Children's Home run by Cambian Childcare Limited in Suffolk

Assurance inspection report for children's home: 2707907 1 Registered provider: Cambian Childcare Limited

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Inspected under the social care common inspection framework

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Information about this children’s home

This home is privately owned. It provides care for up to 5 children who experience mental health difficulties and may not be able to live in the community without support.

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Information about this children’s home

At the time of this inspection, 5 children were living at the home.

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Information about this children’s home

The manager registered with Ofsted in February 2025.

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Information about this children’s home

There is a separately registered school on site. The inspectors only inspected the social care provision.

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Inspection date: 2 March 2026

Date of last inspection: 8 September 2025

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Inspection date: 2 March 2026

Judgement at last inspection: requires improvement to be good

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Inspection date: 2 March 2026

Enforcement action since last inspection: none

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Information about this inspection

At this inspection, the inspectors evaluated:

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Information about this inspection

 the care of children  the safety of children  the effectiveness of leaders and managers. Inspectors have looked closely at the experiences and progress of children, using the social care common inspection framework. This assurance 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’. Assurance inspection report for children's home: 2707907 2

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Findings from the inspection

We identified serious and widespread concerns in relation to the care and protection of children at this assurance inspection.

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Findings from the inspection

This inspection was carried out because Ofsted had received a regulation 44 report stating that children were at risk of accidental death. An external agency had also shared information about 2 incidents of concern which had not been notified to the regulator.

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Findings from the inspection

On the day of the inspection, 3 staff, including 2 managers, were suspended for failing to keep children safe. There is an apparent culture in the home where staff do not understand risk assessments, their roles or responsibilities in respect of protecting children, which places children at risk of harm.

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Findings from the inspection

Staff do not understand how to fulfil safeguarding expectations. Children subject to legal orders have defined staffing ratios for their care and protection. Staff do not understand safe practice. As a result, children have been able to harm themselves.

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Findings from the inspection

Staff fail to intervene when children are harming themselves. They cannot identify situations where risks may increase. One child had a risk assessment plan detailing that staff needed to always be with them and to be able to see what they are doing. However, the child was able to burn themselves using hair straighteners and the next day, took an overdose of 16 ibuprofen. As a result of staff failings, children have been exposed to increased levels of harm and have been enabled to hurt themselves. Despite this happening nearly a month ago, the manager has not followed this up with the staff member involved, meaning that she has not promptly sought to understand what has happened and what needs to be resolved to prevent this happening again.

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Findings from the inspection

Managers are not skilled at identifying when incidents suggest safeguarding concerns. One incident report details that staff hurt a child when a car door closed on their leg. The child is reported to have been crying and in pain. Staff did not take any action in response. This was evaluated by the manager, but she did not identify any shortfall.

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Findings from the inspection

On occasions when managers have made referrals to safeguarding partners, there has not been sufficient consideration of action that could prevent incidents occurring again. One referral to safeguarding partners met the threshold for harm. The staff member involved remained working in the home and still had decision-making responsibilities. This does not keep staff or children safe.

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Findings from the inspection

A child protection investigation is currently underway in relation to staff’s poor response to a child leaving the home. The record of this incident is poor. This initially limited the action that safeguarding partners were able to take. There has been no follow-up with the staff involved, or the team, to demonstrate what good records Assurance inspection report for children's home: 2707907 3 look like. Staff are unable to accurately record what they have done and how they have done it. This reduces their accountability.

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Findings from the inspection

During the inspection, 2 children explained that a manager left them with a sharp kitchen knife. The children were able to provide evidence of this. One of the children has a high risk of self-harm. They also said that the staff did not check on them regularly. This information was not recorded by the staff involved. This means staff cannot be trusted to provide a clear account of the actions they have taken. Managers have also not shared full information about incidents with Ofsted. This suggests a closed culture that is not conducive to effective safeguarding practice.

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Findings from the inspection

Leaders and managers’ oversight is weak. Managers are overwhelmed by the number of incidents taking place and the documentation required as a result. The responsible individual has been assigned to support the manager; however, she has said that she only spot checks documents and does not provide full scrutiny. This strategy is ineffective. When incidents are monitored, they are completed as paper exercises and not evaluated through a safeguarding, trauma-informed lens. This means managers are not identifying poor staff practice that may require referring to safeguarding partners. Staff are also not being told where they need to improve, leading to repeated poor practice.

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Findings from the inspection

Leaders and managers have not ensured that staff are provided with appropriate support to learn from practice errors and improve their capability. Another of the provider’s homes on this same site recently had its registration suspended. Staff from that home, and other homes that are also poorly managed, are working in this home. Senior managers who have oversight for all the homes have not ensured that processes are in place to help staff learn from previous safeguarding errors. Some staff have risk assessments that mean they cannot lone work. The strategies to manage this are identical for all staff, despite the rationale in each case being different and the staff having different roles. Managers have not taken any of these processes seriously. This does not keep children or staff safe.

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Findings from the inspection

Leaders and managers do not ensure that staff use the prescribed therapeutic model of care. There is no evidence that staff respond to children in trauma-informed, therapeutic ways. It is not clear if managers know what therapeutic practice should be and they have not identified the failings in this area. The service described in the statement of purpose is not being delivered. This is misleading for social care commissioners.

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Findings from the inspection

Managers do not have appropriate oversight of medication practice. A notification was received stating that a child was given nearly 50 times the prescribed dose of medication. During the inspection, this was explored. The dosage is not clearly stated on records, and the manager was unable to explain what had happened, however, it was possible there was an underdose. This means it is unclear if the child received the right medical attention at the time. Assurance inspection report for children's home: 2707907 4 There have been several occasions when children have been restrained. There is a lack of information in reports, including the type of hold used, the reason for the hold being used and what staff did beforehand to try to prevent this from happening. Following the use of restraint, the manager does not have discussions with children or staff to explore what happened and how they are feeling. Oversight

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Findings from the inspection

from the manager is either lacking in detail or absent entirely. This means the manager has not considered whether the need for the use of restraint or the type of restraint used are proportionate or safe.

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Findings from the inspection

Ofsted is not reassured that managers are able to keep children safe. As a result, a restriction of accommodation notice has been served to prevent any further children moving in.

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Inspection date Inspection type Inspection judgement

08/09/2025 Full Requires improvement to be good 07/05/2024 Full Good 27/06/2023 Full Good Assurance inspection report for children's home: 2707907 5

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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 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

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

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

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)(e)(f)(h)))

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Requirement Due date

Ensure that effective systems are in place to provide appropriate day-to-day management oversight.

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Requirement Due date

Ensure that leaders and managers identify safeguarding matters and poor staff practice, taking necessary action where appropriate.

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Requirement Due date

Ensure that staff redeployed from other homes are provided with effective inductions to equip them with the knowledge and skills to work with high-level and complex risks. This requirement is restated. 19 April 2026 Assurance inspection report for children's home: 2707907 6 *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

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

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Requirement Due date

Ensure staff understand, and are attuned to, situations where children might be at risk of harm.

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Requirement Due date

Ensure that, when these situations occur, staff intervene appropriately to minimise risk and harm to children.

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Requirement Due date

Ensure that when staff fail to intervene, that managers identify this and take prompt action.

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Requirement Due date

Ensure that staff provide clear and accurate reports of incidents. 19 April 2026 Assurance inspection report for children's home: 2707907 7 All incidents and physical intervention reports should be reviewed and any necessary action, including referrals to safeguarding professionals, should be taken. Managers should take steps to ensure that all relevant information is recorded in the reports and shared with relevant professionals.

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Requirement Due date

The care planning standard is that children—

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Requirement Due date

receive effectively planned care in or through the children’s home.

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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

that each child’s relevant plans are followed. (Regulation 14 (1)(a) (2)(c))

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Requirement Due date

In particular, leaders and managers must ensure that staff follow the instructions in children’s care plans.

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Requirement Due date

This requirement is restated. 19 April 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;

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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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Requirement Due date

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

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Requirement Due date

understand and apply the home’s statement of purpose;

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Requirement Due date

understand and apply the home’s statement of purpose;

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Requirement Due date

protect and promote each child’s welfare;

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Requirement Due date

treat each child with dignity and respect; 19 April 2026 Assurance inspection report for children's home: 2707907 8 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)(a)(b)(i)(ii)(iii)(iv))

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Requirement Due date

In particular, ensure that staff deliver the care described in the statement of purpose.

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Requirement Due date

Ensure that staff understand and implement trauma- informed working and relevant therapeutic models.

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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. (Regulation 23 (1) (2)(b)) 19 April 2026

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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

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

a description of the measure and its duration;

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Requirement Due date

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

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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; 19 April 2026 Assurance inspection report for children's home: 2707907 9 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 (1)(b) (3)(a)(iv)(v)(vii)(viii)(b)(i)(ii)(c))

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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 risks associated with young adults over the age of 18 will be managed in a home with children. They should explain, for example, how a young person bringing alcohol into the home would be managed and whether staff have received protection of vulnerable adults training. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 42, paragraph 9.7) Assurance inspection report for children's home: 2707907 10

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Children’s home details

Registered provider: Cambian Childcare Limited

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Children’s home details

Registered provider address: 4th Floor, Parkview, 82 Oxford Road, Uxbridge UB8 1UX

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Inspectors

Hannah Phillips, Social Care Inspector Sarah Orriss, Social Care Regulatory Inspection Manager Assurance inspection report for children's home: 2707907 11 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 children looked after, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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Inspectors

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