Children's Home run by KDB Care Ltd in Sandwell

Inspection report for children’s home: 2813382 1 Registered provider: KDB Care Ltd

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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 privately owned and provides care for up to 3 children with social and emotional difficulties. At the time of inspection, one child was living at the home, and two children had moved out. The child living at the home was spoken to briefly during the inspection. However, they requested that their views be communicated via the adult caring for them.

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Information about this children’s home

The home registered with Ofsted in January 2024. Since that time, there has been a significant turnover of management and staff. At the time of the inspection, the manager’s post was vacant. The responsible individual has been in post for 3 weeks and has applied to Ofsted.

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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 or their welfare is not promoted or safeguarded, 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: 2813382 2

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Inspection date Inspection type Inspection judgement

08/04/2025 Full good Inspection report for children’s home: 2813382 3

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Summary of findings

Children are not safeguarded effectively in the home. Managers and staff do not demonstrate they have the necessary skills and experience to keep children safe. They do not always understand or assess children’s risks effectively. Children’s unrestricted access to social media and unsupervised free time has not been appropriately assessed, this has exposed 2 children to risk of significant harm.

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Summary of findings

Managers and staff do not have sufficient oversight of the quality of care to ensure children’s safety and wellbeing. They do not maintain safe and effective care for children. A frequent turnover of managers and staff within the home impacts on children’s continuity of care.

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Summary of findings

Leaders and managers have not effectively developed staff skills to ensure children’s safety. Poor monitoring systems fail to review staff practice. Staff are not helped to develop to improve their learning and practice.

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Overall experiences and progress of children and young people: inadequate

Children’s safety has been compromised due to significant weaknesses in safeguarding practice and ineffective management oversight. On occasions, these failings have placed children at risk of significant harm.

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Overall experiences and progress of children and young people: inadequate

Two children living in the home experienced instability and abrupt endings. Ongoing concerns about staff’s inability to protect children from a known risky adult in the home, led to the placing authorities removing the children to a safer environment. Plans were made to take the children to an activity nearby to the alleged perpetrator’s address. Risk assessments did not consider this risk, neither did it consider previous missing episodes. Staff also failed to provide consistent structure, routines and planned activities, resulting in children spending unstructured time within risky areas in the local community. As a result, unplanned moves and a lack of stability, potentially has a negative impact on children’s sense of belonging and emotional wellbeing.

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Overall experiences and progress of children and young people: inadequate

Children have experienced significant instability due to a high turnover of staff. Retention of the core staff team within the home has been inconsistent. Furthermore, managers have relied on the use of 18 different agency staff on multiple occasions to cover the shortfalls in staffing. These significant changes have impacted on the continuity of care children receive. As a result, children feel unsettled and uncertain about expectations within the home. Inspection report for children’s home: 2813382 4 Children’s care and support plans are not always reviewed and updated with the relevant information and guidance for staff to keep children safe. This shortfall in staff knowledge about emerging risk and what action they need to take, impacts on the quality and continuity of care children receive and increases their vulnerability to further harm.

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Overall experiences and progress of children and young people: inadequate

Children’s wishes and feelings are not consistently sought or responded to in a meaningful way. For example, when children have raised concerns about the care they receive, this is not always investigated. Furthermore, managers and staff do not consult and show professional curiosity, when children report they are feeling anxious, this is a missed opportunity to explore children’s views and feelings and ensure they have the right support. As a result, children feel they are not listened to, and managers and staff do not take their concerns seriously to take the appropriate action.

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Overall experiences and progress of children and young people: inadequate

Leaders and managers fail to ensure that staff provide children with clear and consistent boundaries and routines. Children have poor sleep patterns and remain awake until the early hours of the morning, this significantly impacts on them participating in education and other daily routines. Educators said children’s attendance is very concerning, one child’s attendance was 20%. Leaders and managers have not developed a culture of high aspirations for children. This is demonstrated through the failure of support children receive from staff to engage in learning and opportunities offered to them.

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

Inspection report for children’s home: 2813382 5 Managers and staff do not understand or assess children’s associated risks effectively. While an allegation made by a child was appropriately reported, the immediate risk was not effectively assessed. For example, staff lacked professional curiosity by leaving children with unsupervised access and time on their electrical devices, where they were exposed to harm. Insufficient management oversight within the home contributed to the shortfall not being identified much sooner and appropriate action taken. This resulted in continued exposure to harm that may otherwise have been prevented.

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

Leaders and managers did not ensure that staffing arrangements were reviewed in line with one child’s mental health needs and associated risks. Sufficient staffing arrangements were not in place, despite incidents escalating, and resulting in physical intervention. Furthermore, staff do not have the required training to undertake physical intervention, and incidents were not consistently recorded. This limits the ability of leaders and managers to monitor practice, identify patterns or evaluate whether interventions are being used proportionately and safely.

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

The home is warm and welcoming and comfortably furnished. However, leaders and managers have not ensured that environmental risk assessments provide sufficient guidance about one child’s known history and risks. As a result, ligature risks are present within the home. This shortfall placed the child at risk of harm. The failure to identify and mitigate known environmental hazards meant the child was not protected.

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

Staff do not always follow missing from care protocols. When one child went missing, staff failed to escalate their concerns in contacting the relevant authority and agencies to reduce the perceived risk of harm the child was exposed to. This undermined effective safeguarding for the child.

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

Staff rarely monitor children’s access to online social media, despite known risk and vulnerabilities. For example, one child had unsupervised access to 2 mobile phones, and another child was not supported by staff offering sufficient supervision when they were online. Furthermore, children are not helped to understand online risk in accordance with their age and understanding. This increases children’s risk to unsafe online interactions and harmful materials, limiting their ability to recognise and respond to potential harm.

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The effectiveness of leaders and managers: inadequate

Since the last inspection, the home has been managed by 4 interim managers and 3 responsible individuals. The current deputy manager has remained committed and has continued to oversee the running of the home during a prolonged period of instability. In the absence of effective leadership and management oversight, the deputy manager has been required to undertake duties and responsibilities that have been beyond his experience and skills. A lack of support has contributed to significant shortcomings in Inspection report for children’s home: 2813382 6 leadership oversight and adversely affected the safety and quality of care children receive.

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The effectiveness of leaders and managers: inadequate

Leaders and managers have not effectively developed staff skills to ensure children’s safety. Poor monitoring systems fail to review staff practice. They are not helped within their learning and development to improve their practice. Staff feedback indicates that there is limited unity within the team, with inconsistent approaches to practice, decision- making and communication. This has resulted in children receiving a poor standard of care and support, impacting on children’s experience and progress.

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The effectiveness of leaders and managers: inadequate

Children have not received the therapeutic support outlined in the home’s statement of purpose. Although a therapist is now in post, work with both staff and children remains in its infancy. Furthermore, there is a reluctance among staff to engage in reflective practice and to learn from their experiences. This limits opportunities to improve practice and drive high standards of care. This means that children do not received support for their emotional wellbeing and make little progress regarding their overall development.

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The effectiveness of leaders and managers: inadequate

When concerns about staff practice occur, which mean they cannot continue working in the home, managers fail to ensure that restorative work is undertaken, so staff can safely return back to working in the home. This can lead to staff becoming fearful, withdrawn or overly cautious in their practice. Furthermore, without the appropriate repair, relationships can become disrupted within the home, affecting childrens confidence, wellbeing and ability to form secure attachments with the adults caring for them. Inspection report for children’s home: 2813382 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— that staff—

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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

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 designed, furnished and maintained so as to protect each child from avoidable hazards to the child’s health.

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Requirement Due date

(Regulation 12 (1) (2)(a)(i)(ii)(iii)(v)(vi)(vii) and (d)

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Requirement Due date

In particular, leaders and managers must ensure that staff understand risks for children and know how to support them so that they are kept safe. Risk should be assessed and reviewed. 05 July 2026 Inspection report for children’s home: 2813382 8 This includes ensuring the physical environment meets the child’s individual needs. *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 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 has sufficient staff to provide care for 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

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

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

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Requirement Due date

(Regulation 13 (1)(a)(b) (2)(a)(b)(c)(d)(e)(f)(h)) 05 July 2026

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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

if the registered person considers, or staff consider, a placing authority’s or a relevant person’s performance or response to be inadequate in relation to their role, challenge the placing 05 July 2026 Inspection report for children’s home: 2813382 9 authority or the relevant person to seek to ensure that each child’s needs are met.

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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.

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Requirement Due date

(Regulation 5(c)(d)) The positive relationships standard is that children are helped to develop, and to benefit from, relationships based on—

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Requirement Due date

an understanding about acceptable behaviour; and

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Requirement Due date

positive responses to other children and adults.

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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

meet each child’s behavioural and emotional needs, as set out in the child’s relevant plans;

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Requirement Due date

communicate to each child expectations about the child’s behaviour and ensure that the child understands those expectations in accordance with the child’s age and understanding;

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Requirement Due date

help each child to understand, in a way that is appropriate according to the child’s age and understanding, personal, sexual and social relationships, and how those relationships can be supportive or harmful;

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Requirement Due date

strive to gain each child’s respect and trust;

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Requirement Due date

understand how children’s previous experiences and present emotions can be communicated through behaviour and have the competence and skills to interpret these and develop positive relationships with children;

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Requirement Due date

are provided with supervision and support to enable them to understand and manage their own feelings and responses to the 05 July 2026 Inspection report for children’s home: 2813382 10 behaviour and emotions of children, and to help children to do the same.

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Requirement Due date

(Regulation 11 (1)(a)(b)(c) (2)(a)(i)(v)(vi)(viii)(ix)(x) and (b)) The registered person must ensure that—

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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;

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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. (Regulation 35 (3)(a)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(b)(i)(ii) and (c)(iv)) 05 July 2026

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Requirement Due date

* These requirements are subject to a compliance notice. Inspection report for children’s home: 2813382 11

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Recommendations

 The registered person should have a workforce plan, which can fulfil the workforce related requirements of regulation 16, schedule 1 (paragraphs 19 and 20) The plan should detail the necessary management and staffing structure. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 53, paragraph 10.8)

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Recommendations

 The registered person is responsible for maintaining good employment practice. They must ensure that recruitment, supervision and performance management of staff safeguards children and minimises potential risks to them. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 61, paragraph 13.1)

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Recommendations

 The registered person must ensure that all children’s case records must be kept up to date and stored securely while they remain in the home. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 62, paragraph 14.3)

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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: 2813382 12

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Children’s home details

Registered provider address: Avon House, 435 Stratford Road, Solihull B90 4AA

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Inspector

Mandy Wake, Social Care Inspector Inspection report for children’s home: 2813382 13 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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Inspector

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