Clare Lodge

Inspection report for secure children’s home: SC033362 1 Clare Lodge

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Clare Lodge Secure Children’s Home, 8 Lincoln Road, Glinton, Peterborough PE6 7AW

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Inspected under the social care common inspection framework

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Information about this secure children’s home

This home is operated by a local authority and is approved by the Secretary of State to restrict children’s liberty.

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Information about this secure children’s home

The home provides care for up to 16 girls aged between 10 and 17 who are placed by local authorities, under section 25 of the Children Act 1989. There were six children living in the home at the time of this inspection.

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Information about this secure children’s home

Admission of any child who is under 13 years old requires the approval of the Secretary of State.

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Information about this secure children’s home

The commissioning of health services at this home is the statutory responsibility of NHS England, under the Health and Social Care Act 2012. Education is provided on site in dedicated facilities.

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Information about this secure children’s home

The registered manager post is vacant. A manager was appointed in December 2025 but has yet to register with Ofsted.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

Children’s education and learning not judged

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inadequate

How well children and young people are helped and protected inadequate Inspection report for secure children’s home: SC033362 2 The effectiveness of leaders and managers inadequate

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inadequate

There are serious and widespread failures that mean children are not protected or their welfare is not promoted or safeguarded and the care and experiences of some children are poor.

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inadequate

Overall judgement at last inspection: requires improvement to be good

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inadequate

Enforcement action since last inspection: none Inspection report for secure children’s home: SC033362 3

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Inspection date Inspection type Inspection judgement

07/05/2025 Full Requires improvement to be good 23/04/2024 Full Requires improvement to be good 25/07/2023 Full Good 29/11/2022 Full Requires improvement to be good Inspection report for secure children’s home: SC033362 4

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Overall experiences and progress of children and young people: inadequate

Care managers and care staff failed to follow a child’s risk plan and advice from health professionals and failed to intervene to protect and safeguard a child from serious risk of harm. As a result, this child required urgent medical support from emergency services. This is set out in more detail in the ‘how well children and young people are helped and protected’ section of this report. The judgement about ‘how well children are helped and protected’ is a limiting judgement. This means that, if inspectors judge this area to be inadequate, then the ‘overall experiences and progress’ judgement will always be inadequate.

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Overall experiences and progress of children and young people: inadequate

Staff have not been consistently sensitive to a child’s preferences in the use of pronouns. When children have specifically asked to be addressed in a particular way, this is not carried out by staff nor consistently recorded in their care plans so that all staff are aware. This means children do not feel valued or respected.

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Overall experiences and progress of children and young people: inadequate

Placing social workers said that they are not always informed about incidents or concerns about the children promptly. They say that incident reports that are sent to them are not always sufficiently detailed and leave them having to contact the home for further information and clarifications. Some family members also shared concerns about the lack of communication from staff.

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Overall experiences and progress of children and young people: inadequate

Children are encouraged to share their views about their care and the running of the home. Regular key-work sessions and recently introduced ‘lounge meetings’ provide opportunities for children to discuss their experiences and raise issues that are important to them. Children understand how to make a complaint and are supported to do so when needed. Leaders provide feedback to children through a monthly newsletter so that children know how their views have been considered. For example, following a request for more animals to visit, a mobile zoo was arranged.

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Overall experiences and progress of children and young people: inadequate

Leaders have recently introduced a new intervention team. Intervention workers are positive and aspirational about the support they provide to children. Although the role is still being embedded, they have increased the range of activities, direct work sessions and lounge meetings. They use feedback from children to inform and target their work. For example, they are supporting children to personalise drawers in their bedrooms to store paperwork and drawings confidentially. This demonstrates that staff listen to children’s ideas and seek safe and appropriate ways to put them into practice.

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Overall experiences and progress of children and young people: inadequate

One child has made measurable progress due to coordinated support from the health team and care staff. Staff use positive relationships and creative approaches to deliver this work in a child-centred way. Children are also progressing with their mobility plans and are accessing the community more frequently, preparing them for the future. For one child, staff have developed an independence plan alongside the mobility plan to support the child to develop skills for independent living. Inspection report for secure children’s home: SC033362 5

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Children’s health: inadequate

Children’s health is inadequate due to an incident where care staff and care managers failed to protect and safeguard a child. This significantly impacted on the child’s health and wellbeing. Care staff and care managers failed to work with health professionals to manage risk. This is set out in the ‘How well children and young people are helped and protected’ section of this report.

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Children’s health: inadequate

Children’s physical and mental health needs are assessed promptly on admission through initial comprehensive health assessment tools and then reviewed regularly thereafter. These assessments provide comprehensive information to inform care and treatment planning. As a result, children make measurable progress in relation to their physical and emotional wellbeing.

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Children’s health: inadequate

Leaders use adapted outcome measures to evaluate children’s progress. Formulation (planning) goals focus on children’s engagement, understanding of their circumstances, achievements and ability to regulate their emotions. Children make progress against shared objectives that support their social, emotional and mental health needs.

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Children’s health: inadequate

Leaders review existing attention deficit hyperactivity disorder and autism assessments and seek reassessment when appropriate to ensure that diagnoses remain accurate and relevant. Where children do not already have a neurodivergent diagnosis, appropriate referrals are made. Learning disability assessments are also undertaken. This ensures that children can access the right support during their stay and when they return to the community.

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Children’s health: inadequate

Leaders recognise that foetal alcohol spectrum disorder can be underdiagnosed. They are in the process of securing appropriate training and accreditation so that children can be assessed and, where appropriate, diagnosed. This will strengthen the home’s ability to provide tailored care and support.

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Children’s health: inadequate

Partnership working with health professionals has improved. Children’s immunisations are monitored and kept up to date. Specialist nurses visit the home at flexible times to provide advice and administer vaccinations.

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Children’s health: inadequate

Occupational therapy self-assessments are written in a child-friendly format. This supports children to take ownership of their plans and promotes engagement. Staff use this information to prioritise meaningful areas of work.

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Children’s health: inadequate

The clinical lead for health is proactive in developing opportunities to improve children’s social interaction. During the inspection, inspectors observed a meeting between the clinical lead, an NHS England commissioner and representatives from a football club. This meeting explored opportunities for children to engage in structured activities and Inspection report for secure children’s home: SC033362 6 where they can develop new skills. This demonstrates leaders’ commitment to broadening children’s experiences and supporting positive outcomes.

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

Social care managers and staff have failed to protect a child from serious risk of harm.

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

A child with a known history of serious self-harm was left alone in a lounge area for a protracted period of time. Staff were observing on CCTV, but the child was almost completely out of sight of staff throughout. The child tied a ligature around their neck to the point of becoming unresponsive. This is despite the child’s safety plan and health professionals’ advice stating that she required increased and close supervision. When staff did eventually check on the child, her condition was such that on-site health professionals were requested to attend urgently. Emergency services were called and the child was taken to hospital. The child was discharged after hospital care. The centre manager was aware of the incident as he walked past the lounge area on two occasions but did not take any action.

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

Not all children’s risk assessments provide clear strategies to guide staff in effectively supporting and safeguarding children, particularly those who are new to the home. The quality of these assessments is inconsistent. In some cases, not all relevant assessments are updated when new risks emerge. This limits staff’s ability to respond appropriately to children’s needs.

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

Some documents contain language that is child-blaming. This is unhelpful and does not reflect a child-centred approach. For example, in one child’s records it describes the child as having an ‘unhealthy interest in men’, when the child has been the subject of sexual exploitation.

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

When physical intervention is necessary it is used appropriately. Following these incidents, children are able to share their views and receive support to ensure they are safe and well.

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

Single separation (a child locked into an area alone, usually their bedroom, due to serious risk to self or others) is used infrequently, appropriately and as a last resort.

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The effectiveness of leaders and managers: inadequate

There have been three different centre managers since February 2025. Centre managers have failed to develop a good-quality service for children and have not established effective and collaborative working relationships with their heads of departments.

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The effectiveness of leaders and managers: inadequate

Social care leaders and care managers failed to demonstrate professional curiosity when a child was clearly struggling, despite being advised on more than one occasion by on- site health professionals that the child required increased close supervision and support. The centre manager saw that a serious incident was taking place and had the opportunity to intervene yet failed to take appropriate action to safeguard a child. Other Inspection report for secure children’s home: SC033362 7 leaders did not identify or address significant practice shortfalls through effective management oversight.

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The effectiveness of leaders and managers: inadequate

The team manager responsible for reviewing incidents on CCTV and overseeing other safeguarding duties is committed to his role. As part of his work, he is required to view distressing footage of incidents involving children. Currently, there are no formal emotional support processes in place for him.

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The effectiveness of leaders and managers: inadequate

A quality improvement manager started work at the home very recently to help support leaders to improve the quality of care for children, safeguarding processes and to develop staff skills to ensure that the home runs effectively and safely. As this role is very new, it is not possible to assess its impact.

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The effectiveness of leaders and managers: inadequate

The recommendations raised at the last full inspection relating to the education provision were not assessed at this inspection. They will be reviewed at the next full inspection.

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The effectiveness of leaders and managers: inadequate

The home has been at 50% occupancy in the last 12 months. This is due to ongoing recruitment to bring staffing up to full complement and to ensuring that staffing levels are sufficient to provide care and support for children with complex needs. Inspection report for secure children’s home: SC033362 8

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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

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

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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;

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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. (Regulation 12 (1) (2)(a)(i)(iii)(v)(vi)(b)) 23 March 2026

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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— 23 March 2026 Inspection report for secure children’s home: SC033362 9 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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Requirement Due date

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

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Requirement Due date

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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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

research and developments in relation to the ways in which the needs of children are best met; 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. (Regulation 13 (1)(a)(b) (2)(a)(b)(c)(e)(f)(i)(h))

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Requirement Due date

In meeting the quality standards, the registered person must, and must ensure that staff—

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Requirement Due date

seek to involve each child’s placing authority effectively in the child’s care, in accordance with the child’s relevant plans;

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Requirement Due date

seek to develop and maintain effective professional relationships with such persons, bodies or organisations as the registered person considers appropriate having regard to the range of needs of children for whom it is intended that the children’s home is to provide care and accommodation. (Regulation 5(a)(d)) 23 March 2026

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Requirement Due date

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; 23 March 2026 Inspection report for secure children’s home: SC033362 10 use this understanding to deliver care that meets children’s needs and supports them to fulfil their potential.

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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

treat each child with dignity and respect; and

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Requirement Due date

provide personalised care that meets each child’s needs, as recorded in the child’s relevant plans, taking account of the child’s background. (Regulation 6 (1)(a)(b) (2)(b)(iii)(iv))

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Requirement Due date

In particular, the registered person must ensure that children’s preferences in the way they are addressed and cared for are recorded in plans and delivered in practice.

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 The registered person should ensure that staff have the knowledge and skills to understand each child’s education and training targets and their next steps for learning. They should ensure that staff receive the training and support they need to improve their subject and pedagogical knowledge. (‘Guide to the Children’s Homes Regulations, including the quality standards’, pages 27 and 28, paragraph 5.11)  The registered person should ensure that children have a clear plan to continue their education, training or employment once they leave the home. Measurements of progress should include qualitative information such as how well the child is being prepared for the next stage. Plans should include rewards and recognition of achievements, improvements in attendance and, when appropriate, reduction in behavioural incidents including exclusion. The child’s personal circumstances, individual needs and educational history are relevant in considering what might

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Recommendations

constitute progress; but should not limit aspirations for them. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 26, paragraph 5.2

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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 secure children’s home: SC033362 11

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Secure children’s home details

Registered provider address: Sand Martin House, Bittern Way, Peterborough PE2 8TY

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Inspectors

Gemma McDonnell, Social Care Inspector, Lead Inspector Shaun Common, His Majesty’s Inspector, Quality Assurance Manager Leanne Lyon, Social Care Inspector Jo Birtwhistle, Social Care Inspector Daniel Carrick, Children’s Services Inspector, Care Quality Commission Inspection report for secure children’s home: SC033362 12 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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