Children's Home run by Institute of Integrated Systemic Therapy in Norfolk

Inspection report children's home: SC065792 1 SC065792 Registered provider:

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Full inspection Inspected under the social care common inspection framework

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Information about this children's home

The home is run by a private provider and provides care for up to 8 children who experience social and emotional difficulties.

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Information about this children's home

The manager registered with Ofsted in December 2025.

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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.

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inadequate

Overall judgement at last inspection: outstanding

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inadequate

Enforcement action since last inspection: none Inspection report children's home: SC065792 2

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Inspection date Inspection type Inspection judgement

06/08/2024 Full Outstanding 10/05/2023 Full Good 18/01/2023 Full Good 20/12/2021 Full Good Inspection report children's home: SC065792 3

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Overall experiences and progress of children and young people: inadequate

Eight children were living at the home at the time of this inspection. Five children have continued to live at the home since the last inspection. Four new children have moved in, and 3 children have moved out. Five children were seen as part of this inspection and 3 children were spoken with. Despite some excellent opportunities and some good progress for children there was a significant shortfall in the help and protection of children which has limited the overall judgement.

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Overall experiences and progress of children and young people: inadequate

Children’s moves in and out of the home are well managed. One child who turned 18 was supported to move into a setting suitable to support them into adult life. Another child, who was reaching independence, and living far away from their local area, was supported to move closer to family. Of the 4 new children who have moved in 3 have settled and remained living at the home. However, one child who moved in, moved out quickly as staff were not able to meet their escalating needs.

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Overall experiences and progress of children and young people: inadequate

Staff know children well. They build positive relationships with children over time. Children have trusted adults they can speak with. Staff regularly talk to children about how they are feeling and help them to think about different ways to explore their feelings. These relationships are supported by the in-house therapist.

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Overall experiences and progress of children and young people: inadequate

Most children are in education or are being supported to attend alternative education placements in the community or have tutors at the home. One child is not currently in any education or training, this is despite efforts from the manager to support and sustain a college placement. The manager challenges education plans for children to ensure that children’s educational needs are tailored to them. Some children now receive more educational support as a result of this challenge.

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Overall experiences and progress of children and young people: inadequate

Staff create great memories for children by preparing summer and winter themed days. They decorate the home, dress up and invite external entertainers or food stalls to contribute to any festivities. Staff plan lots of activities for children in the school holidays including trips to theme parks, London and the theatre. The manager supported the children to attend a theatre outreach group in London that focuses on wellbeing. This is helping children to build confidence and self-esteem.

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Overall experiences and progress of children and young people: inadequate

Children have exciting and new experiences. All children and staff have been on a group holiday to Paris. Children have also been on holidays in the UK and spent time camping and staying in caravans. This helps children to benefit from new experiences.

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Overall experiences and progress of children and young people: inadequate

Since the last inspection, several children have been building relationships with their family and spending more time with them in the community. Family relationships are well supported by staff who specialise in family work with children. This is helping children to build life-long relationships. Inspection report children's home: SC065792 4 The home environment is going through some change, with decoration and improvements throughout different areas of the home that are not yet complete. Children have contributed ideas to a new mural in the home. Children have personalised bedrooms, but some children require support to ensure their bedrooms remain clean and suitable to meet their needs.

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

Since the last inspection a serious shortfall occurred regarding an incident relating to how well staff keep children safe and how leaders and manager’s respond. This has resulted in the inadequate judgement.

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

A serious incident occurred when a child was at risk of serious harm. Staff did not seek medical attention for this child. The information was not clearly shared with any on-call support, therefore there were ineffective safeguarding measures to monitor the child and ensure their welfare immediately after this event. This does not keep children safe.

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

The recording of this incident did not help leaders and managers to track other occurrences of similar events to appropriately monitor and manage any future risk. Leaders and managers did not identify that immediate medical attention was not sought and did not share this information with the professional network quickly. This information was not shared with the local authority designated officer to consider the shortfalls in staff practice nor was it shared with Ofsted. This does not help external professionals to have a good understanding of incidents and consider any action that may need to be taken as a result.

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

Following this event, leaders and managers did take some learning forward, information was shared with the staff team a week later to make some changes to staff practice and the child’s risk assessment was updated to reflect these concerns. Support was later sought from the child’s GP and there are now support services in place to more effectively meet this child’s needs. However, the shortfalls immediately after the event are significant.

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

Children have sometimes needed to be held to keep them safe. Holds are often necessary and proportionate. The manager has identified some shortfalls in practice after using alternative restraint techniques. These issues did not reoccur. However, following holds, there is not always timely and effective reviews with staff and children about the use of the hold and if this was effective, or if children had any concerns. This does not help leaders and managers to assure themselves that staff practice is safe.

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

On two occasions, children have been given the wrong dosage of medication. This is despite additional training to monitor medication administration. Leaders and managers have reviewed this incident but have not made changes to medication administration in a timely way.

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

Despite the significant shortfall in practice, staff generally support children to keep safe. Inspection report children's home: SC065792 5 Children rarely go missing from home. In a brief period when there were several incidents of children going missing from the home together staff searched for the children and appropriately reported them missing to the police. Staff encouraged children to come home and supported them with nurture when they returned home.

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

Staff are helping children to think about their risks online. Since the last inspection, several children have more free time on electronic devices and with less restrictions. There are safety measure in place for each child who uses the internet and these are individually agreed. Children are encouraged to talk to staff about any worries that they may have and staff regularly talk to children about their safety online.

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The effectiveness of leaders and managers: inadequate

Since the last inspection, the registered manager left the home. The deputy manager who has worked at the home for many years and who is well known to staff and children stepped into the manager’s role.

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The effectiveness of leaders and managers: inadequate

The manager and deputy managers have high aspirations for children and want children to have excellent experiences when they move to the home. However, some shortfalls have resulted in ineffective responses to safeguarding by leaders and managers. As part of this inspection, the manager has identified actions to address these shortfalls.

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The effectiveness of leaders and managers: inadequate

Leaders and managers do not yet have effective monitoring systems in place to help them track serious incidents, physical interventions or other concerns.. Although records exist, these are not reviewed as a whole to make sense of situations and to assure leaders and managers that staff are making changes or have taken effective action to keep children safe. The manager’s review of some records is not completed quickly after events which does not help the manager to understand children’s immediate safety and wellbeing.

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The effectiveness of leaders and managers: inadequate

Staff generally receive regular training and are trained in the home’s model of care and therapeutic approach. However, staff do not always receive specific training quickly in relation to children’s needs. Staff did not receive any training for seven months on a specific risk-taking behaviour that was known for a child, this is after several incidents of this behaviour over several months. This does not give staff the skills to keep children safe and does not assure the manager that staff will have the necessary skills or be able to take swift action if there are concerns for a child.

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The effectiveness of leaders and managers: inadequate

Staff receive regular supervision sessions with a relevant person. However, when there have been practice concerns about staff it is not clear if staff are spoken with quickly after these issues to address concerns. Supervision sessions are undertaken by several different senior members of the team. Therefore it is not clear how the manager is tracking these issues to ensure staff practice remains consistent and learning needs are identified and met.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have now outlined learning from the serious event and have identified steps they will take to improve children’s safety and well-being in the future. Inspection report children's home: SC065792 6 Inspection report children's home: SC065792 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, 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

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 (Regulation 12 (1) (2)(a)(v)(vi)(vii)) 6 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—

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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

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; 19 June 2026 Inspection report children's home: SC065792 8 use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (1)(a)(b) (2)(c)(f)(h))

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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

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. (Regulation 35 (a)(vii)(viii) (b)(i)(ii) (c)) 19 June 2026

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Requirement Due date

The registered person must notify HMCI and each other relevant person without delay if—

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Requirement Due date

there is any other incident relating to a child which the registered person considers to be serious. (Regulation 40 (4)(e)) 6 March 2026

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Recommendations

 The registered person should ensure that care must be taken to ensure prescribed medicines are only administered to the individual for whom they are prescribed. Medicines must be administered in line with a medically approved protocol. ('Guide to Children's Homes Regulations, including the quality standards', page 35, paragraph 7.15)  The registered person should ensure that the home is a nurturing and supportive environment that meets the needs of children. In particular, that all children's Inspection report children's home: SC065792 9 bedrooms are kept clean and are well-maintained. ('Guide to the Children's Homes Regulations, including the quality standards', page 15, paragraph 3.9)

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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: SC065792 10

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Children's home details

Registered provider address: 91-95, Southwark Bridge Road, London SE1 0AX

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Inspectors

Rebecca Hannell, Social Care Inspector Thembie Mzila, Social Care Inspector Inspection report children's home: SC065792 11 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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