Children's Home run by Children of the Mangrove Limited in Merton

Inspection report for children’s home: 1235653 1 Registered provider: Children of the Mangrove Limited

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Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This privately owned home provides care for up to five children with social or emotional difficulties.

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Information about this children’s home

There were three children living in the home at the time of this inspection. Two children were spoken to.

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Information about this children’s home

The home registered with Ofsted in April 2016 and the manager registered in April 2021.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

There are serious and/or widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded and/or the care and experiences of children and young people are poor, and they are not making progress.

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inadequate

Overall judgement at last inspection: good

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inadequate

Enforcement action since last inspection: none Inspection report for children’s home: 1235653 2

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Inspection date Inspection type Inspection judgement

30/07/2024 Full Good 13/09/2023 Full Good 02/08/2022 Full Good 22/02/2022 Full Good Inspection report for children’s home: 1235653 3

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inadequate

Children’s experiences and progress are limited by inadequate safeguarding practice, ineffective staff supervision and poor management.

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inadequate

Children experience instability in the home. Since the last inspection, three children have moved out. Leaders and managers ended two of the children’s placements because staff were unable to manage children’s behaviours and risks. One child asked to move after they were assaulted by another child because they did not feel safe in the home.

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inadequate

Despite this, the children currently living in the home said that they are happy living there. They have positive relationships with some staff members and enjoy the food that the chef cooks, which one child described as ‘banging.’ The children particularly like their generous weekly allowance, which they use for different activities, including go-karting and trips to the funfair.

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inadequate

Children make limited progress in their education. Despite staff’s efforts to encourage engagement with education, all three children living in the home have sporadic attendance.

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inadequate

Staff do not provide children with clear and consistent boundaries. Although there are some staff members who are skilled at working with children and advocate well for them, their ability to make an overall impact is restricted by the wider challenges of using agency workers and inexperienced staff. One child’s social worker said that they are concerned that staff struggle to manage the dynamics between children, staff, and other children. As a result, there have been incidents in the home and children have presented risks to each other.

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inadequate

Children’s complaints are not managed effectively. One child’s complaint about another child led to an updated risk assessment and the child being spoken with. However, it is unclear what the outcome was as they were not given a written response. Another informal verbal complaint was not investigated, and the registered manager was unaware of the complaint. This means children do not feel heard and are not reassured their concerns are being addressed.

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inadequate

Some areas of the home are in poor condition. There are damaged and marked walls, stained carpets, recently broken furniture, and damaged doorways. Staff could not explain what had caused a crack in the children’s bathroom window or a very large stain on the outside of one child’s bedroom window. One child’s bedroom overlooks a flat roof, which is littered with bottles and cigarette ends. Children’s bedrooms are very untidy, with clothes and bedding strewn around. One child’s bedroom had smoking detritus beside their bed and smelt of cannabis. Inspection report for children’s home: 1235653 4

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How well children and young people are helped and protected: inadequate

Safeguarding practice is inadequate. Staff do not supervise children safely in the home. Despite children having known risks of physically challenging behaviours and substance misuse, they have been able to regularly enter each other’s bedrooms, where safeguarding incidents have arisen. For example, one child was able to go into another child’s bedroom and assault them. This led to a child needing hospital treatment and the abrupt ending of their placement in the home.

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How well children and young people are helped and protected: inadequate

The home’s missing-from-home procedures do not keep children safe. Missing episodes are not well recorded and indicate that concerns about children’s presentation and risks are not fully explored. One missing-from-home record had two separate recordings for the same date that described different incidents. This makes it difficult to track the actions staff have taken and the outcomes for children. Staff do not consistently request return home interviews from placing authorities when children return. On one occasion, a child with a known risk of substance misuse left the home at 3am and returned at 5am. Staff did not follow them, and they were not reported as going missing in the middle of the night.

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How well children and young people are helped and protected: inadequate

Staff have not reduced the risk of children misusing alcohol and substances. They have not put clear boundaries in place to reduce this risk, and as a result, a culture of substance misuse has emerged. One social worker is concerned that staff do not understand the extent of drug activity happening in the home and between the children. Children regularly smoke cannabis in the home, and on one occasion, three children locked themselves in a room and took substances together. Another incident involved a staff member buying alcohol for a child who requested it. Although the staff member said that they did not realise that this was an alcoholic drink, it is a concern that this happened.

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How well children and young people are helped and protected: inadequate

Children’s risk assessments are not always updated to reflect new risks. Although they include details about known risks and behaviours and provide interventions to reduce risks, it is not easy to determine which is the most up-to-date assessment. One child has 19 separate risk assessments, which does not help new staff or agency staff who work in the home and need to quickly understand the main risks and concerns to support children.

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How well children and young people are helped and protected: inadequate

Staff do not follow children’s plans and risk assessments as required. For example, following significant concerns, one child’s safety plan stated that there should be daily bedroom searches. Despite the high level of risk, these searches were not undertaken. Children are not routinely debriefed following bedroom searches. Furthermore, there is no management oversight of bedroom searches.

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How well children and young people are helped and protected: inadequate

Staff engage children in regular key-work sessions. Records of these sessions are sensitively written and discuss children’s feelings, behaviours, and incidents. Appropriate actions are agreed. However, staff do not always discuss the most recent or pressing concerns raised. For example, there were no key-work sessions for one Inspection report for children’s home: 1235653 5 child about being under the influence of substances, despite recent concerns about this.

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The effectiveness of leaders and managers: inadequate

Effective management is not in place. Leadership and management arrangements in the home are confusing. The registered manager is supervised by a consultant. A manager from another home has provided some support for the registered manager and deputy manager. This arrangement means there is no clear line of management and tasks are not always delegated or followed up. The responsible individual does not regularly visit the home, which limits their oversight of staff practice and children’s experiences.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not met the requirements from the last inspection. Children’s records are not uploaded in a timely way and are not being kept under regular review. Recording systems are confusing, and there are gaps in recordings. Physical restraint records do not always detail what led up to an incident or what the incident was. There are no records of debriefs with children or staff, and management oversight is often missing. This limits opportunities to assess the reason for the intervention and if the restraint is proportionate. Poor recording undermines safeguarding practice in the home, and it is unclear what actions have been taken during significant incidents.

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The effectiveness of leaders and managers: inadequate

Staff supervision is not effective. Leaders and managers do not provide the frequency of supervision set out in the home’s statement of purpose. New staff do not have an increased level of supervision during their probation period, and one night staff worker has not received any supervision at all. Managers and staff do not discuss children’s risks or the plans to reduce risk. Staff do not have clear actions set in their supervision, and there are some delays in providing staff with their written supervision records. This means that staff do not have consistent guidance and supervision of their practice.

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The effectiveness of leaders and managers: inadequate

Staff turnover is high. As a result, there has been a high use of agency staff, which has reduced the opportunities for children to develop positive relationships with consistent adults. Agency staff have often worked at night when safeguarding incidents have occurred that have not been safely managed. For example, one young person under one-to-one supervision filmed themselves smoking cannabis in the kitchen. Children have also reported incidents of waking night staff locking themselves in the front room and sleeping.

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The effectiveness of leaders and managers: inadequate

The registered manager is unclear about the threshold for notifying Ofsted about serious incidents. This has led to some late regulation 40 notifications, which limits external oversight of the home.

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The effectiveness of leaders and managers: inadequate

Due to the concerns raised at this inspection, a notice restricting accommodation has been issued and two compliance notices. Leaders and managers have provided Inspection report for children’s home: 1235653 6 Ofsted with an immediate action plan with the actions they are taking to protect children and improve the quality of care that they receive. Inspection report for children’s home: 1235653 7

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet the Care Standards Act 2000, The Children’s Homes (England) Regulations 2015 and the ‘Guide to the Children’s Homes Regulations, including the quality standards’. The registered person(s) must comply within the given timescales.

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Requirement Due date

*The protection of children standard is that children are protected from harm and enabled to keep themselves safe.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to ensure—

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Requirement Due date

assess whether each child is at risk of harm, taking into account information in the child’s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child;

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Requirement Due date

help each child to understand how to keep safe;

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Requirement Due date

have the skills to identify and act upon signs that a child is at risk of harm;

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Requirement Due date

manage relationships between children to prevent them from harming each other;

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Requirement Due date

understand the roles and responsibilities in relation to protecting children that are assigned to them by the registered person;

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Requirement Due date

take effective action whenever there is a serious concern about a child’s welfare; and

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Requirement Due date

are familiar with, and act in accordance with, the home’s child protection policies;

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Requirement Due date

that the home’s day-to-day care is arranged and delivered so as to keep each child safe and to protect each child effectively from harm;

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Requirement Due date

that the premises used for the purposes of the home are located so that children are effectively safeguarded; 30 April 2025 Inspection report for children’s home: 1235653 8 that the premises used for the purposes of the home are designed, furnished, and maintained so as to protect each child from avoidable hazards to the child’s health; and

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Requirement Due date

that the effectiveness of the home’s child protection policies is monitored regularly. (Regulation 12 (1) (2)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(b)(c)(d)(e))

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Requirement Due date

In particular, leaders and managers must ensure that staff provide safe and consistent boundaries for children, particularly around the use of alcohol and substances, spending unsupervised time in each other’s bedrooms and general behaviour management. Children’s risk assessments must be kept under regular review and must be updated to reflect new risks, and staff must follow children’s safety plans. Staff must carry out direct work with children to help them understand their risks and develop strategies to reduce them.

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Requirement Due date

the effectiveness and any consequences of the use of the measure;

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Requirement Due date

within 48 hours of the use of the measure, the registered person, or a person who is authorised by the registered person to do so (“the authorised person”)—

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Requirement Due date

has spoken to the user about the measure; and

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Requirement Due date

has signed the record to confirm it is accurate; and

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Requirement Due date

within 5 days of the use of the measure, the registered person or the authorised person adds to the record confirmation that they have spoken to the child about the measure. (Regulation 35 (3)(a)(vi)(b)(i)(ii)(c))

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Requirement Due date

In particular, leaders and managers must ensure that when behaviour management measures are used, they are recorded accurately and evaluated to review their effectiveness. Leaders and managers must ensure that children are spoken to about the incident and that their views are taken into account. 30 April 2025

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Requirement Due date

*The leadership and management standard is that the registered person enables, inspires, and leads a culture in relation to the children’s home that—

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Requirement Due date

helps children aspire to fulfil their potential; and 30 April 2025 Inspection report for children’s home: 1235653 9 promotes their welfare.

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to—

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Requirement Due date

lead and manage the home in a way that is consistent with the approach and ethos, and delivers the outcomes, set out in the home’s statement of purpose;

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Requirement Due date

ensure that staff work as a team where appropriate;

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Requirement Due date

ensure that staff have the experience, qualifications, and skills to meet the needs of each child;

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ensure that the home has sufficient staff to provide care for each child;

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ensure that the home’s workforce provides continuity of care to each child;

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understand the impact that the quality of care provided in the home is having on the progress and experiences of each child and use this understanding to inform the development of the quality of care provided in the home;

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demonstrate that practice in the home is informed and improved by taking into account and acting on—

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research and developments in relation to the ways in which the needs of children are best met; and

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feedback on the experiences of children, including complaints received; and

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use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b) (2)(a)(b)(c)(d)(e)(f)(g)(i)(ii)(h))

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Requirement Due date

In particular, leaders and managers must ensure that the staff team has the skills to manage children’s behaviours and have effective oversight of staff practice. Leaders and managers must ensure that the staff team provides consistency for children. Leaders and managers must ensure that all staff have regular and effective supervision. Leaders and managers must ensure that they have effective monitoring and reviewing systems and accurate records of significant incidents. Inspection report for children’s home: 1235653 10 The quality and purpose of care standard is that children receive care from staff who—

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Requirement Due date

understand the children’s home’s overall aims and the outcomes it seeks to achieve for children;

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Requirement Due date

use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

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In particular, the standard in paragraph 1 requires the registered person to—

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ensure that the premises used for the purposes of the home are designed and furnished so as to—

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enable each child to participate in the daily life at the home. (Regulation 6 (1)(a)(b) (2)(c)(i)(ii))

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Requirement Due date

In particular, leaders and managers must ensure that children’s bedrooms are well maintained and that damage to the property is promptly repaired. 15 May 2025

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Requirement Due date

Subject to paragraph (6), the registered person must establish a procedure for considering complaints made by or on behalf of children.

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Requirement Due date

The registered person must ensure that a record is made of any complaint, the action taken in response, and the outcome of any investigation.

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Requirement Due date

The registered person must supply to HMCI, at HMCI’s request, a statement containing a summary of any complaints made during the preceding twelve months and the action that was taken in response to each complaint. (Regulation 39 (1) (3) (5))

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Requirement Due date

In particular, leaders and managers must ensure that children’s complaints are taken seriously and responded to. 15 May 2025

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Requirement Due date

*These requirements are subject to a compliance notice. Inspection report for children’s home: 1235653 11

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Recommendations

 The registered person should ensure that records are kept detailing all individual incidents when children go missing from the home (regulation 36 (schedule 3(14)). Evaluation of missing incidents should be undertaken to identify any gaps in training, skills, or knowledge for staff or to record and retain evidence of what worked well. (‘Guide to the Children’s Homes Regulations, including the quality standards,’ page 46, paragraph 9.31)  The registered person should ensure that all serious events are notified within 24 hours to the appropriate people. (‘Guide to the Children’s Homes Regulations, including the quality standards,’ page 63, paragraph 14.13)

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people, using the social care common inspection framework. This inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with The Children’s Homes (England) Regulations 2015 and the ‘Guide to the Children’s Homes Regulations, including the quality standards’. Inspection report for children’s home: 1235653 12

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Children’s home details

Registered provider: Children of the Mangrove Limited

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Children’s home details

Registered provider address: Chester House, Fulham Green, 81-83 Fulham High Street, London SW6 3JA

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Children’s home details

Responsible individual: Knowlton Crichlow

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Inspectors

Jo Mitchell, Social Care Inspector Christine Kennet, His Majesty’s Inspector Inspection report for children’s home: 1235653 13 regulates and inspects to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children’s social care and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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