Children's home run by F2L Investments Limited

Inspection report children’s home: 2748820 1 Registered provider: F2L Investments 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 home is privately run and provides care for one child who may experience social and emotional difficulties.

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Information about this children’s home

The manager registered with Ofsted in April 2024.

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Information about this children’s home

At the time of the inspection, one child was living at the home.

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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 widespread failures that mean children and young people are not protected, their welfare is not promoted or safeguarded and 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: following an assurance inspection in March 2025, three compliance notices and a restriction of accommodation notice were issued. Progress against these has been monitored and evaluated within this full inspection. Inspection report children’s home: 2748820 2

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Inspection date Inspection type Inspection judgement

30/07/2024 Full Good Inspection report children’s home: 2748820 3

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Overall experiences and progress of children and young people: inadequate

The child’s experiences and progress are significantly hindered by the poor quality of care and support provided. The home environment does not offer the warmth or nurture expected in a setting that should replicate family life. The removal of all personal touches has resulted in an environment that is stark and institutional. The lack of access to basic personal care items, including the requirement to request toilet paper, compromises the child’s dignity and autonomy. The child’s bedroom is missing important things, such as curtains and a TV, which makes it feel cold and unwelcoming. This kind of environment does not support the child’s emotional needs or help them feel safe at home.

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Overall experiences and progress of children and young people: inadequate

The child is uninterested and unenthusiastic when talking about their experiences at home. The child is still upset by the use of physical restraint and said it makes them feel sad. There is insufficient evidence that the emotional impact of such restrictive interventions is being recognised or addressed by staff.

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Overall experiences and progress of children and young people: inadequate

Staff have not made clear to the child what the behaviour expectations are at home. The child spoke of losing access to their television for not ‘behaving’, but was unable to articulate what specific behaviours were expected of them. This lack of clarity indicates that behaviour management strategies are not being implemented in a way that supports the child’s understanding or helps them to make progress. Instead, current practices appear punitive and inconsistent.

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Overall experiences and progress of children and young people: inadequate

The child is disappointed that they have been prevented from attending a gymnastics club, an activity they were interested in pursuing, due to staff being unable to remain present. This demonstrates a failure to provide inclusive opportunities that support the child’s social and emotional development. Staff have not shown the flexibility or commitment required to ensure the child is able to engage in meaningful activities suited to their interests and needs.

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Overall experiences and progress of children and young people: inadequate

Together, shortfalls contribute to an experience that is failing to meet the child’s individual needs. The lack of a nurturing, child-centred approach is having a detrimental impact on the child’s well-being and progress. The provider feels unable to meet the child’s needs and has asked the local authority to find a suitable alternative without delay.

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

Risk assessments are not used effectively to safeguard the child. While there have been some updates to the child’s risk assessment, such as identifying self-harm as a high risk, the document lacks the necessary clarity, specificity and responsiveness to be effective. Key sections are outdated, including the incident log, which has not been revised since March 2025, despite notable incidents in April and a formal review in May. This undermines staff ability to manage emerging risks safely and proactively. Inspection report children’s home: 2748820 4 Serious safeguarding concerns arise from the failure to reflect known incidents. For example, a staff member was bitten by the child, yet this is not recorded in the ‘risk to staff’ section of the care plan. This omission demonstrates a lack of oversight and reduces staff preparedness, placing both the child and staff at risk of further harm.

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

Records of physical interventions are poor. Incident reports lack essential detail, including timelines, antecedents and descriptions of the holds used. Several entries use vague or generic language that fails to show whether the use of restraint was necessary, proportionate or safely applied. This lack of transparency undermines both the safety and accountability of practice in the home.

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

Staff debrief discussions are superficial and fail to explore incidents in a meaningful way. In one case, the child reported experiencing chest pain following restraint, but there was no recorded analysis of how this may have occurred or consideration of potential injury. Staff did not document the force or positioning used, instead relying on non-specific justifications, such as ‘staff had no choice’, which limits reflective safeguarding practice. Failure to acknowledge and respond to a child experiencing chest pain is a serious concern.

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

There is little evidence of trauma-informed care or child-centred safeguarding. Staff reports include dismissive comments, such as describing the child’s disclosures as ‘false accusations’ without supporting evidence or professional curiosity. This approach fails to acknowledge the child’s emotional experiences and does not support safe or trusting relationships.

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

Some supervision practices are overly restrictive and lack clear justification. In one example, the child was prevented from using the bathroom independently at night and was required to leave the door open, despite no risk assessment mandating this. The lack of privacy, combined with a stripped-down bathroom and no lock on the door, compromises the child’s dignity and infringes on their rights.

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

Medication procedures are unsafe. Records are inaccurate and not subject to effective oversight or auditing. Given the child’s epilepsy and significant mental health needs, this presents a serious risk. There is no assurance that medication is being managed safely, further highlighting weaknesses in the home’s safeguarding systems and leadership oversight.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not taken sufficient or effective action to address the shortfalls identified in compliance notices. There is little evidence that the requirements set out by Ofsted have been fully understood, implemented or monitored. This lack of progress demonstrates weak leadership and an absence of urgency in driving necessary improvements. Inspection report children’s home: 2748820 5 Staff are not aware of the specific concerns raised at the last inspection or the actions required to address them. Team meeting records contain no reference to the identified shortfalls, nor do they evidence any reflective discussion or learning from recent incidents. This significantly limits the opportunity for collective improvement or shared accountability within the staff team.

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The effectiveness of leaders and managers: inadequate

The manager does not demonstrate a clear understanding of her role in monitoring and evaluating the quality of care. She is unable to describe any robust systems for oversight, instead stating that most of what she needed to monitor was ‘in her head’. This approach to monitoring does not provide the structure, transparency or consistency required to assure effective leadership.

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The effectiveness of leaders and managers: inadequate

Although the responsible individual has supported the manager by producing an action plan, the majority of the planned actions have not been implemented. This highlights a failure of leaders to ensure that identified improvements are followed through. Where external support has been provided, it has not been used effectively to secure any significant change.

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The effectiveness of leaders and managers: inadequate

Staff report feeling supported and enjoy working in the home. However, they lack a thorough understanding of the regulatory concerns raised. This suggests that communication from leaders has been insufficient in promoting a culture of accountability and improvement. As a result, there is a disconnect between staff morale and the reality of the workforce’s performance.

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The effectiveness of leaders and managers: inadequate

External professionals report that the home is not meeting the child’s needs. The local authority is actively seeking alternative provision. There is a concern that specialist advice provided to the staff team has not been acted on in practice. This further reflects the leadership team’s failure to ensure that professional input leads to improved outcomes for the child.

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The effectiveness of leaders and managers: inadequate

Although supervision discussions are taking place, they lack depth and do not promote meaningful reflection or learning. Training around physical intervention, identified as an area of concern at the previous inspection, has not been prioritised or improved. In addition, the staffing structure remains weak, with two unqualified support staff appointed to senior roles. This includes one staff member whose qualification was misrepresented by the manager during inspection. These decisions raise serious concerns about the competence and judgement of leaders in making safe and appropriate staffing choices. Inspection report children’s home: 2748820 6

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Statutory requirements

This section sets out the actions that the registered person 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

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

(Regulation 12 (1) (2)(a)(i)(v)(vi)(vii))

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Requirement Due date

This specifically relates to ensuring that risk assessments are updated in line with the needs of the child. 2 June 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

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Requirement Due date

In particular, the standard in paragraph (1) requires the registered person to— 2 June 2025 Inspection report children’s home: 2748820 7 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 have the experience, qualifications and skills to meet the needs of each child;

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Requirement Due date

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

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Requirement Due date

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

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Requirement Due date

use monitoring and review systems to make continuous improvements in the quality of care provided in the home.

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Requirement Due date

(Regulation 13 (1)(a)(b) (2)(a)(c)(g)(ii)(h))

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Requirement Due date

This specifically relates to ensuring that staff employed in the home are considered to have appropriate qualifications, experience and skills. It also relates to ensuring there is appropriate monitoring and oversight of the home and that learning from incidents is embedded.

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Requirement Due date

*The registered person must prepare and implement a policy (“the behaviour management policy”) which sets out—

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Requirement Due date

how appropriate behaviour is to be promoted in the children’s home; and

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Requirement Due date

the measures of control, discipline and restraint which may be used in relation to children in the home.

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Requirement Due date

within 24 hours of the use of a measure of control, discipline or restraint in relation to a child in the home, a record is made which includes—

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Requirement Due date

details of the child’s behaviour leading to the use of the measure;

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Requirement Due date

the date, time and location of the use of the measure; 2 June 2025 Inspection report children’s home: 2748820 8 a description of the measure and its duration;

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details of any methods used or steps taken to avoid the need to use the measure;

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Requirement Due date

the name of the person who used the measure (“the user”), and of any other person present when the measure was used;

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Requirement Due date

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

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Requirement Due date

a description of any injury to the child or any other person, and any medical treatment administered, as a result 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.

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Requirement Due date

(Regulation 35 (1)(a)(b) (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii)(c))

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Requirement Due date

This specifically relates to ensuring that all records of physical intervention are recorded with sufficient detail, that debriefs with the child and staff involved in physical interventions occur within the correct timescales and that there is clear management oversight of physical interventions.

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Requirement Due date

The registered person must make arrangements for the handling, recording, safekeeping, safe administration and disposal of medicines received into the children’s home.

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Requirement Due date

In particular, the registered person must ensure that—

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Requirement Due date

medicine which is prescribed for a child is administered as prescribed to the child for whom it is prescribed and to no other child; and 2 June 2025 Inspection report children’s home: 2748820 9 a record is kept of the administration of medicine to each child. (Regulation 23 (1) (2)(b)(c))

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Requirement Due date

This specifically relates to ensuring clear and accurate recording of medication administration and auditing occurs in the home.

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Requirement Due date

the privacy of children is appropriately protected;

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any limitation placed on a child’s privacy or access to any area of the home’s premises—

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Requirement Due date

is kept under review and, if necessary, revised; and

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Requirement Due date

allows children as much freedom as is possible when balanced against the need to protect them and keep them safe.

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Requirement Due date

This specifically relates to ensuring any measures taken to supervise the child while in the bathroom are regularly reviewed based on a frequently assessed level of risk. 2 June 2025

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Requirement Due date

*These requirements are subject to a compliance notice.

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Recommendation

 The registered person should ensure that staff are familiar with the home’s policies on record-keeping and understand the importance of careful, objective and clear recording. Staff should record information on individual children in a non-stigmatising way that distinguishes between fact, opinion and third-party information. Information about the child must always be recorded in a way that will be helpful to the child. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 62, paragraph 14.4) Inspection report children’s home: 2748820 10

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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 children’s home: 2748820 11

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Children’s home details

Registered provider: F2L Investments Limited

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Children’s home details

Registered provider address: 1 Bosworth Way, Leicester Forest East, Leicester LE3 3QQ

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Inspector

Lauren Barwell, Social Care Regulatory Inspector Inspection report children’s home: 2748820 12 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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Inspector

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Inspector

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Inspector

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