Clare Lodge

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

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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.

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Information about this secure children’s home

There were 4 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 manager has been in post since February 2026. Ofsted has not yet received a complete application to register.

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Overall experiences and progress of

children and young people, taking into account

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requires improvement to be good

Children’s education and learning good Children’s health good How well children and young people are helped and protected requires improvement to be good

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requires improvement to be good

The effectiveness of leaders and managers inadequate Inspection report for secure children’s home: SC033362 2 The secure children’s home is not yet delivering good help and care for children and young people. However, there are no serious or widespread failures that result in their welfare not being safeguarded or promoted.

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requires improvement to be good

Date of last inspection: 10 February 2026

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requires improvement to be good

Overall judgement at last inspection: inadequate

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Enforcement action since last inspection:

The home was judged ‘inadequate’ at the full inspection on 10 and 11 February 2026. Following that inspection, 2 compliance notices were served, under regulation 13, the leadership and management standard, and regulation 12, the protection of children standard. Ofsted also served a notice restricting the accommodation.

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Enforcement action since last inspection:

Ofsted carried out a monitoring visit on 25 March 2026, and determined that the compliance notice under regulation 12 was met. The compliance notice under regulation 13 was reissued.

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Enforcement action since last inspection:

Ofsted carried out a further monitoring visit on 5 May 2026 to explore the action taken by leaders and managers to meet the steps in the remaining compliance notice. Not all steps in the compliance notice were fully met, but due to sufficient progress the notice was not reissued. The notice restricting accommodation was also lifted. Inspection report for secure children’s home: SC033362 3

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Inspection date Inspection type Inspection judgement

10/02/2026 Full Inadequate 07/05/2025 Full Requires improvement to be good 23/04/2024 Full Requires improvement to be good 25/07/2023 Full Good Inspection report for secure children’s home: SC033362 4

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Summary of findings

Children benefit from positive support regarding their health and education. These areas are managed by strong leaders who know the children and their progress well. While there have been some improvements regarding the care children receive, there are still areas for development. The management of care, both internally and in relation to wider local authority oversight, is weak. Children have been exposed to risks due to staff not following risk assessments and a lack of action following incidents of self-harm or damage to property. There is not always clear information about incidents, with managers holding different pieces of information and failing to work collaboratively to ensure that incident reporting is transparent and clear. This is confusing for children and for staff.

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improvement to be good

Children are now making some progress from their starting points. This is driven by strong and effective leadership in health and education. However, children’s progress is hindered by a culture of overly restrictive risk care management practices and unnecessary constraints. For example, one child’s request for a basketball hoop was refused due to ‘health and safety matters and possible rust’. This impacts on children’s ability to experience manageable levels of risk. This limits the opportunities for them to develop essential skills in taking responsibility for their own safety, wellbeing and overall welfare.

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improvement to be good

Some language used and written by staff is not child centred. Use of terms such as ‘unit’ and ‘on the floor’ do not reflect a nurturing and homely environment. This can further marginalise children in care. This language does not promote children’s dignity or sense of belonging.

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improvement to be good

While there have been improvements to the overall cleanliness of the home, some areas are in need of maintenance. One outdoor area is unkempt and is not an inviting space for children to relax or spend time in. Furthermore, facilities intended to support children’s recreation and enjoyment are frequently unavailable. This limits the range of enriching activities available to children, particularly during the evening and at weekends.

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improvement to be good

Children regularly access community-based activities, including going shopping, dining out, going for walks and work experience opportunities. These experiences are helping children to develop the skills to spend time safely in the community. This is helping them to prepare for their future moves.

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improvement to be good

Children are beginning to benefit from improvements in the delivery of interventions. The interventions team is developing and is starting to bring together information from Inspection report for secure children’s home: SC033362 5 children’s health, education and care plans. One child’s formulation has been used to guide their intervention plan. This has been successful in increasing the child’s engagement.

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Children’s education and learning: good

Senior leaders provide strong leadership in education. They know the children well and have positive relationships with staff. Leaders have an accurate understanding of key strengths and take prompt action to address emerging weaknesses. Leaders have remedied the main weaknesses identified at the previous inspection. They have improved the processes for monitoring and then supporting children’s progress.

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Children’s education and learning: good

Leaders assess children’s starting points promptly and use an appropriate range of information, including education, health and care plans, to establish precise targets and adapt the curriculum to meet the needs and interests of the children.

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Children’s education and learning: good

Teachers have the necessary knowledge and skills to work effectively with the children, and leaders ensure that they receive training to develop their teaching skills further and update their subject knowledge. Education staff build trusting and respectful relationships with children and create a purposeful learning environment.

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Children’s education and learning: good

In nearly all subjects, teachers design, plan and order the curriculum in a sensible and coherent way. However, on the science, technology, engineering and mathematics (STEM) course, teachers do not provide children with a well-planned set of learning activities. Children do not understand the connections between lessons and cannot remember what they have been taught.

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Children’s education and learning: good

Most teachers explain key ideas clearly and demonstrate practical activities competently. They provide children with opportunities to practise their new knowledge. Teachers adapt their teaching strategies appropriately to meet the needs of children with special educational needs. Children make substantial progress from their starting points in education.

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Children’s education and learning: good

Children are proud of their work and produce well-presented folders, and pictures of their practical work. They gain external accreditation in recognition of the progress they have made. Children find this highly motivating.

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Children’s education and learning: good

Leaders encourage high attendance in education. When children miss a lesson, staff work closely with care staff to identify the reasons for the absence, provide education in the home and achieve a swift return to school. Education staff work effectively with the health team to improve children’s understanding of healthy lifestyles and relationships.

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Children’s education and learning: good

Leaders organise interesting visits to workplaces which reflect children’s interests. Children enjoy them and they improve their confidence and teamworking skills. Leaders provide children with access to regular high-quality careers advice and guidance, which prepares them well for their next steps. Inspection report for secure children’s home: SC033362 6

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Children’s health: good

Children’s physical and mental health needs are assessed promptly on admission using comprehensive health assessment tools which are then reviewed and expanded as required thereafter. These assessments provide detailed information to better inform care and treatment planning. This is translated into practice and means that children make measurable progress in both their physical and emotional wellbeing.

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Children’s health: good

Foetal alcohol spectrum disorder initial assessment training is provided to healthcare staff, with further pathways and interventions training planned. This will improve treatments to children who might previously have had undiagnosed needs. This overlaps with neurodevelopmental assessments, when required, and ensures that additional care and support are in place to improve overall outcomes for children.

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Children’s health: good

Multidisciplinary functional analysis meetings regarding individual children are detailed, especially, for example, where there have been increased incidents of self-harm. Predisposing factors, early warning signs and immediate triggers to behaviour highlight to all staff what they need to do to keep the child safe and reduce personal risks associated with their behaviour.

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Children’s health: good

Following incidents at the local hospital where children had become dysregulated, health leaders identified a need and contacted the transitions lead there for their input. The lead has now visited children at the home to discuss with them their specific needs and triggers to dysregulation. This has resulted in plans shared between the home and the hospital so that all staff will be better aware of those triggers to dysregulation and so better meet children’s needs during sometimes stressful situations.

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Children’s health: good

Health practitioners, in particular assistant psychologists, work closely with children to develop personalised and highly individual workstreams according to their needs, likes and dislikes. Further to these, health promotion sessions in conjunction with education, including eating well, dental hygiene and how to access community medical services, are provided to children. These help them better prepare and understand how to look after themselves and keep themselves safe when they move on.

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Children’s health: good

A new dental commissioning agreement supported by NHS England ensures that children can access more time with a dentist before treatment, taking into account their needs relating to neurodiversity and better influencing their engagement and ownership of their oral health needs .

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improvement to be good

There have been incidents when care staff have not intervened in a timely manner to prevent harm to children. For example, staff did not intervene fast enough during an incident of self-harm with a knife, and did not seek medical advice in relation to a leg wound. When the health team was made aware the following day of the leg wound, appropriate action was taken for the child to attend hospital, where they required Inspection report for secure children’s home: SC033362 7 stitches. This incident is being investigated in relation to the actions of care staff but there have been delays with this.

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improvement to be good

Poor-quality risk assessments impact staff practice, as some risk assessments lack detail for specific situations. For example, one child experienced a non-epileptic seizure in the car and then attempted to leave a non-secure area. This has not been added to their risk assessment to ensure staff are aware of this risk. Staff do not consistently follow existing plans. For example, one child has full access to toiletries despite their risk assessment requiring items to be stored away and dispensed to the child on paper plates.

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improvement to be good

A review of documentation and CCTV footage indicates that some incidents are avoidable. Specifically, children frequently experience periods of boredom due to a limited choice of available activities. CCTV footage of one incident shows a staff member allowing a child to go into their bedroom, knowing that they had medication on them which was not authorised. While these incidents have been identified, it is unclear if managers and staff have taken learning from them to improve practice.

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improvement to be good

Children do not experience lengthy use of physical restraint. When restraint is used, it is for the minimum time necessary. Records of restraint practice reflect the CCTV footage of the incidents. The number of incidents of restraint has reduced for some children.

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improvement to be good

Single separation is not used regularly and is appropriate when used. There has been no use of managed away. This shows that staff are supporting children to manage their behaviours without additional restrictions being required.

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The effectiveness of leaders and managers: inadequate

The leadership of health and education is strong and effective; however, management of care is weak. Wider local authority oversight is ineffectual and has failed to identify continuing shortfalls and to address them. An interim manager started in February 2026 but has yet to successfully submit an application to register with Ofsted. Actions taken to address shortfalls identified in previous inspections have not all been made in a timely manner.

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The effectiveness of leaders and managers: inadequate

Not all information is clear and easily available. Inconsistencies were found during the inspection about information being provided. The management team often all hold different pieces of information relating to the same incident, and this does not always match the available written records. For example, a child was able to access medication. The record of a meeting held the following day stated that the medicines cabinet door was faulty. Managers have explored this but there continue to be inconsistencies regarding this incident which have not been able to be confirmed. This means the formal records still state there was a faulty door which led to a child being at risk of potential serious harm. There is a lack of a coordinated approach to fully explore the incident and all aspects of it to understand how it happened.

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The effectiveness of leaders and managers: inadequate

Management oversight does not always identify shortfalls. Following one serious incident, there was mention of a child having a piece of metal but there was no follow- Inspection report for secure children’s home: SC033362 8 up about this. Managers had signed off this record without identifying this shortfall. In another incident, management oversight did not identify that the record did not contain full details about when a child was able to tie a ligature around their neck and how long this was on for. Managers are not ensuring records are detailed and that staff are being supported to develop their recording skills.

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The effectiveness of leaders and managers: inadequate

Care staff are not all trained in specific issues related to children. The majority of staff are not trained in autism or attention deficit hyperactivity disorder, despite children having these diagnoses. This means staff do not have relevant training to support children’s known needs. There are regular workshops for care staff offered by the health team and education team, and they say these are helpful.

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The effectiveness of leaders and managers: inadequate

Managers do not always take timely action to explore concerns. Following an incident when care staff did not seek medical attention when a child harmed themselves, there was a delay in staff being spoken to, to establish that they understand their safeguarding responsibilities. While some conversations took place and a referral was made to the local authority designated officer (LADO) in relation to one staff member, the other staff involved were not spoken to for almost 3 weeks. This could mean that staff may not fully understand their safeguarding responsibilities but are continuing to work with children.

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The effectiveness of leaders and managers: inadequate

Not all serious incidents have been notified to Ofsted. In one incident, a child was able to harm themselves with a knife, and their risk assessment was not followed regarding seeking medical attention. This incident was not notified to Ofsted. This limits oversight by the regulator. During the inspection, a delayed referral was made to LADO.

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The effectiveness of leaders and managers: inadequate

The local safeguarding children partnership (LSCP) has not carried out a review of restraint as defined by the Children’s Homes Regulations 2015 and included its review in its annual report, as set out in ‘Working together to safeguard children 2023’. Therefore, the LSCP does not have a clear view on whether practices at the home are appropriate, so that staff can learn and improve practice as necessary.

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The effectiveness of leaders and managers: inadequate

Staff are positive about their roles and said they feel supported by managers. Staff receive regular supervision sessions, which they feel are helpful. Supervision sessions include discussions about the children and reflection on incidents the staff may have been involved in. There is a new wellbeing space for staff which provides a relaxed environment where staff can receive support. This room is available for all health, care and education staff.

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The effectiveness of leaders and managers: inadequate

The average occupancy level at the home has been at 29%. The number of children living at the home at the time of the inspection was below the number of available places. The occupancy level was affected by low staffing levels, staff skills and experience and poor management arrangements and oversight. Ofsted had imposed a restriction of accommodation notice between 13 February 2026 and 5 May 2026. Inspection report for secure children’s home: SC033362 9

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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

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)(b)) 14 August 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

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

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; and 14 August 2026 Inspection report for secure children’s home: SC033362 10 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)(c)(e)(f)(h))

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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

treat each child with dignity and respect;

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Requirement Due date

provide to children living in the home the physical necessities they need in order to live there comfortably. (Requirement 6 (1)(a)(b) (2)(b)(iii)(vii)) 28 August 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)) 14 August 2026

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Recommendations

 The registered person should ensure that the ethos of the home supports each child to learn. Leaders should ensure that the science, technology, engineering and mathematics (STEM) curriculum is planned and taught in a way that meets the needs of the children. (‘Guide to the Children’s Homes Regulations, including the quality standards’, page 29, paragraph 5.18)

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Recommendations

 The registered person should work with the local safeguarding children partnership (LSCP) to remind it of its duty to carry out a review of restraint practice at the home and include its review in the LSCP’s annual report. (‘Working Together to Safeguard Children’, page 108, paragraph 41) Inspection report for secure children’s home: SC033362 11

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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 12

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Secure children’s home details

Registered provider: Peterborough City Council

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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

Leanne Lyon, Social Care Inspector (lead) Gemma McDonnell, Social Care Inspector Jo Birtwhistle, Social Care Inspector Dave Carrigan, Social Care Inspector Daniel Carrick, Children’s Services Inspector, Care Quality Commission Martin Ward, His Majesty’s Inspector, Further Education and Skills Jo Stephenson, Regulatory Inspection Manager, Quality Assurance Manager Inspection report for secure children’s home: SC033362 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,

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Inspectors

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Inspectors

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Inspectors

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