The Children's Trust - Tadworth

The Children's Trust provides a residential children's home for children and young people with profound and multiple learning disabilities, a residential rehabilitation service for children and young people with acquired brain injury and a Short Breaks service. There are seven houses at The Children’s Trust and we inspected Chestnut House.

People’s experience of using this service and what we found

Children and young people in Chestnut House were safe and well cared for by committed staff who knew them well.

Staff developed clear, detailed and child-centred care plans from the child or young person's perspective.

Effective systems and processes were in place for safe medicines management. Advice and support from the onsite pharmacist provided good oversight of medication use.

One parent told us what a lovely place Chestnut House was for their child to live and how homely the staff had made their child’s bedroom. They said they knew their child was safe and being well looked after.

Rating at last inspection

The last rating for this service was Outstanding (published 27 March 2020)

Why we inspected

CQC have introduced targeted inspections to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We undertook this targeted inspection in response to information received which raised concerns about staffing and how children and young people in Chestnut House were being kept safe. The concerns raised suggested care plans were not being followed, that staff were not all properly trained and there was a disproportionately high rate of medicines errors.

We found no evidence during this inspection that people were at risk from these concerns. Please see the safe section of this full report. The overall rating for the service has not changed following this targeted inspection and remains Outstanding.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Children’s Trust on our website at www.cqc.org.uk.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Children’s Trust – Tadworth provides a residential children’s home for children and young people with profound and multiple learning disabilities, a residential rehabilitation service for children and young people with acquired brain injury and a Short Breaks service. The Children’s Trust offers a wide range of services, and at the time of our inspection 49 children and young people were in receipt of care. They can accommodate 61 children and young people across seven houses.

Children and young people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Those using the service received planned and co-ordinated child-centred support that was appropriate and inclusive, and helped them to gain new skills in preparation for adulthood.

The Children’s Trust had up-to-date, comprehensive and service specific policies and procedures to support effective practice.

Staff knew the children and young people they cared for well, including information about their prescribed medicines. However, records did not always fully reflect the excellent care, treatment and intervention received.

Not all staff received level three safeguarding children training in accordance with updated intercollegiate guidance.

All houses and communal areas were clean. Hygiene standards, infection prevention and control were maintained to a high standard.

Children and young people benefitted from exceptional care provided by a wide range of highly skilled, committed and passionate staff.

The Children’s Trust had a comprehensive understanding of the needs of children and young people when they return home or transfer into adult services. Planning for discharge began before admission.

Children and young people receiving intensive rehabilitation at The Children’s Trust were supported by excellent staff who were committed to supporting achievement and success. The progress children and young people made was visible.

Staff were committed, dedicated, passionate and professional. We observed kind and caring staff treat children and young people with dignity and respect. Staff were passionate about the work they did to support children and young people to lead fulfilling lives.

All discussions with staff included the child or young person whenever they were present. Staff understood the requests of children and young people who found it difficult to verbally communicate.

We saw many examples where children and young people were at the heart of everything. We saw positive interactions between children, young people and staff at all levels. We saw strong evidence of children and young people achieving exceptional outcomes.

Staff developed child-centred care plans from the child or young person’s perspective. Voice of the child was very strong throughout the assessments and plans that we reviewed.

Arrangements for social activities were innovative to meet children and young people’s individual needs, so they could live as full a life as possible.

The Children’s Trust had a strong process for seeking, responding to, and making improvements from; feedback, complaints and compliments.

Governance structures, accountability frameworks and monitoring of quality and improvement was strong and well-embedded throughout the service.

Effective processes and systems were in place for pharmaceutical supply and advice within the service, providing good oversight of medication use.

Staff told us they felt well supported by leaders at different levels and felt confident in raising concerns. Senior leaders were highly visible and available to staff through ‘visible leadership’.

The standard of record keeping was variable across all aspects of The Children’s Trust, reaching just the minimum requirements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was outstanding (published 11 January 2018).

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Children’s Trust - Tadworth on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Children's Trust Tadworth is a charity that works with children and young people who as a result of an acquired brain injury have multiple disabilities and complex health needs. They offer a range of services which include rehabilitation for children and young people and respite care which is accessed via the child's local authority. They also offer rehabilitation for children who have long term disorders of consciousness and attend The Children's Trust School.

The Children's Trust offers an online information hub which includes education and advice concerning aspects of caring for children with acquired brain injuries. This service is a national resource and openly accessible to people and professionals in the community. Additionally there are two support teams, one based in the community and the other based in key NHS hospitals across the country offering advice and support within their local geographical areas. There is also an onsite school providing education to children and young people. The school is regulated by Ofsted (the regulator for education and children services).

The Children's Trust offers accommodation for children and young people within seven units/houses. For those children for whom The Children's Trust is effectively their permanent home, three houses are registered jointly with Ofsted. The remaining four houses are registered with only the Care Quality Commission (CQC) as the children have limited stays, albeit with high medical needs. At the time of our inspection 44 children were in receipt of care. Throughout this report children and young adults will be referred to as ‘people or person.’ At the time of writing this report decisions were being made about who the primary regulator should be and which regulated activity would be inspected by Ofsted and CQC.

At the previous inspection in September 2016 we identified a breach in relation to medicines and how records were stored. At this inspection this had now improved.

Staff worked creatively with people and their relatives to involve them in the management of their medicines. They employed a pharmacist who worked with other health care professionals, people and relatives to help streamline the management of their medicines. Staff ensured that people received their medicines on time, as intended and in a safe way. Staff engaged with health care professionals to review people’s medicines. Research about the causes of medicines incidents had taken place and their findings and recommendations were discussed with staff.

The Trust undertook research in a number of ways to ensure that only the best care was being provided. The service contributed to the development of best practice and good leadership with other agencies. Learning took place from the research and changes made to how care was delivered. There were a whole range of health care professionals that worked at the Trust that ensured they were up to date with best practice and current guidance. Comprehensive training was provided to all staff. Relatives were also provided with training around the equipment that their family member needed.

People and their relatives felt that the care that was provided exceeded their expectations. Staff demonstrated a real empath for people they cared for. Staff involved and treated people and relatives with compassion, kindness, dignity and respect. We saw staff treat people in a caring way. People's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy and dignity were respected and promoted when personal care was undertaken. People and relatives felt that staff went the ‘extra mile’ in relation to the care that was provided. For example one person was supported by staff to have their dream holiday abroad.

Staff used innovative ways of involving people and their relatives in care and support. People's needs were assessed when they entered the service and on a continuous basis to reflect changings in their needs. Care plans were detailed and provided staff with guidance on how to provide the most appropriate care. People and their relatives were heavily involved in care planning and felt listened to. Staff used a variety of methods to communicate with people and were creative in their approach to this. People and relatives were supported with their religious and cultural needs including supporting one person to have their Bar Mitzvah (a Jewish celebration) and supporting another person to pray when they needed to.

Staff and management were committed to a supportive approach to caring and found ways to make sure that every person using the service were happy and comfortable. People were treated as individuals whose life and experiences mattered to the staff. Visions and values were imbedded into the organisations and staff understood the importance of them. The Trustees at the service worked alongside staff to gain a better understanding of how care was delivered. People and the relatives were highly complementary of the leadership and all staff at the service. Staff felt privileged to work at the service and felt listened to, supported and valued.

The service had a strong, visible person centred culture and is exceptional at helping people to express their views so they understand things from their points of view. People, relatives and staff were heavily involved in the running of the service. Various methods were used to ensure that their voices were heard including focus groups, online discussions, meetings and surveys. All of these were used to make improvements at the service. There was joint working with external organisations and professionals who were invited to open days at the service to gain an understanding of the injuries that people were living with.

The service used innovative ways to manage people's risk and keep people safe, whilst ensuring they had a full and meaningful life. People said that they felt safe at the service and relatives had peace of mind their family members were kept safe. Staff understood the importance of empathy supporting people to challenge themselves whilst supporting their life style choices. Risk assessments took place with people and staff understood what to do to reduce the risks of incidents. Incidents and accidents were recorded and action taken to reduce the risks of incidents reoccurring.

People were able to alert staff when they needed to and there were sufficient numbers of staff available to support them. People were involved in the recruitment of staff. Only suitable staff that had gone through rigorous recruitment checks were appointed. There were plans in place for each person should an emergency occur. In the event of an emergency such as a fire or a flood there was a service contingency plan in place.

Staff were knowledgeable on infection control and what they needed to do to reduce the risks of infections. People and their relatives felt the service was clean and tidy. Staff were competency assessed regularly to ensure that they were providing the most appropriate care. All the health care professionals had to revalidate to ensure that they remained fit practice.

People and their relatives told us that they liked the food at the service and that their preferences were catered for. People that were unable to eat orally had support from staff to ensure that they were provided with adequate nutrition. People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment.

Staff at the service communicated effectively to ensure the best delivery of care. There were teams of health care professionals that attended multi-disciplinary meetings to decide on the most appropriate care for people. People and their relatives told us that health care professionals were always on hand for support that had a positive impact on the person’s recovery. Staff understood the impact on the recovery of people in relation to their input in their care.

Staff were up to date with current guidance to support people to make decisions. Where people had restrictions placed on them these were done in their best interests using appropriate safeguards. Staff had a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) as well as their responsibilities in respect of this.

The service went the extra mile to find out what people had done in the past and evaluate whether they could accommodate activities that there important to people. There were a range of activities available within the service and outside. People were supported to move to other services or back home to their families at the end of their stay at the service.

People and relatives were encouraged to voice their concerns or complaints about the service. Concerns were used as an opportunity to learn and improve the service. There was a comprehensive system of audits that were being used to improve the quality of care. Each audit included an action of things that required improvement and time scales for these improvements.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had informed the CQC of significant events. Records were accurate and kept securely.

The Children's Trust Tadworth is a charity that works with children and young people who as a result of an acquired brain injury have multiple disabilities and complex health needs. They offer a range of services which include rehabilitation for children and young people and respite care which is accessed via the child’s local authority. They also offer rehabilitation for children who have long term disorders of consciousness and attend The Children's Trust School.

The Children’s Trust offers an online information hub which includes education and advice concerning aspects of caring for children with acquired brain injuries. This service is a national resource and openly accessible to people and professionals in the community. Additionally there are two support teams, one based in the community and the other based in key NHS hospitals across the country offering advice and support within their local geographical areas.

There is also an onsite school providing education to children and young people. The school is regulated by Ofsted (the regulator for education and children services).

The Children’s Trust offers accommodation for children and young people within seven units/houses. For those children for whom The Children’s Trust is effectively their permanent home, three houses are registered jointly with Ofsted. The remaining four houses are registered with only the Care Quality Commission (CQC) as the children have limited stays albeit with high medical needs. This inspection was conducted at the same time as Ofsted, but ran in parallel as the purpose and role of each regulator is different.

At the time of the inspection The Children’s Trust there were 49 out of a maximum of 77 children or young people accommodated at the service in Tadworth. Because of difficulties associated with finding suitable alternative placements for young people older than 18 years within their home local authorities, a number of young adults were accommodated by The Children’s Trust between the ages of 18 and 23.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Whilst we acknowledge the large volume of medicines administered safely by the service on a daily basis, there were some areas of concern. Refrigerator temperatures for the storage of some medicines did not include a maximum and minimum measurements. This meant we could not be sure medicines were stored correctly. Also a dose of a medicine dispensed and labelled for one child was administered to another child under the supervision of a doctor.

The Children’s Trust maintains dual records for children and young people, either as paper records or computer based. This dual system sometimes led to incomplete information which meant current and up to date information about children was not always available. We found some daily records were not always contemporaneous, and on occasions therapists updated care plans but had not always signed or dated them so it was unclear when or who had updated them.

We identified two breaches of the Health and Social Care (Regulated Activities) Regulations 2014 during our inspection. You can see what action we told the provider to take at the back of the full version of this report.

People we spoke with were positive about the care and support they and their children received from The Children’s Trust. Staff were knowledgeable about the children and young people they supported. Levels of staffing were sufficient to ensure the needs of children and young people were met.

Staff received extensive training which was refreshed regularly. They were supported by team meetings and one to one supervision meetings, so they could reflect on their practice and consider their professional development. There were recruitment procedures in place to make sure only suitable staff and volunteers were recruited into post.

The Children’s Trust employed a range of healthcare professionals which meant children’s and young people’s needs were assessed and met promptly. Children and young people also had access to community healthcare professionals as and when they needed them. Their nutritional needs were assessed and monitored closely so these were met.

The service worked collaboratively with professionals in the child’s home local authority to ensure that suitable alternative placements were located closer to where they lived. The staff also worked with health and social care professionals to consider transitional arrangements from children to adult services.

Staff used a variety of communication methods to ascertain the views of children and young people they worked with. Where this was not possible they worked with parents to consider best options. The service worked within the framework of the Mental Capacity Act 2005 to ensure they protected the rights of young people.

Children and young people received personalised care and support in line with their wishes and that of their parents. There were many practical measures in place to assist families in caring for their children as well as advice and support.

Managers were open and transparent. They encouraged people to comment on the quality of the service. There were a number of audits and governance systems in place. There was learning from accidents and incidents. In this way, the provider was continually monitoring the quality of the service and looking at ways to identify improvements.

People told us they felt The Children’s Trust was a safe place. Staff knew what action to take if they thought children and young people were at risk of abuse or harm. Risks to health and safety were assessed and strategies put in place to minimise them. There were regular maintenance and safety checks of the premises. The provider also had appropriate arrangements to ensure risks from the spread of infection were minimised.

People spoke very positively about The Children's Trust. Family members told us they felt involved with their children's care, both during the assessment and delivery stages of care provision. One person said "They look after us all very well. I feel that my child is safe and I can trust the staff to look after my child when I am not here". Another person said "If I have a problem I can speak with a staff member; sometimes it is a matter of mis-communication between the teams but the staff work hard to resolve any problems very quickly".

Staff told us that the organisation was going through managerial change which was, on balance a "Positive move for the organisation".

We found that children's needs were assessed and care and treatment was delivered to ensure the safety and welfare of the children who used the service.

The location was found to be clean and tidy; the service had taken action to resolve areas of previous non-compliance with infection control processes.

Staff received training, support and supervision on a regular basis.

There were appropriate quality assurance systems in place which evidenced that the Provider was taking action to improve the quality of the service provided by listening to people's feedback.

At the time of this inspection this service did not have a Registered Manager in post as the existing post-holder had recently left the organisation. The Provider was taking action to appoint a new Registered Manager to oversee the Regulated Activities to which this service is registered for as per the conditions of their registration.

As part of this inspection we were required to speak with representatives from Ofsted, the Regulator who is responsible for inspecting and regulating services who provide care for children and young people and those providing education and skills for learners of all ages. The School for Profound Education is located on the main campus and forms part of the Children's Trust and is currently regulated by Ofsted. We were asked to consider whether the School for Profound Education should be jointly registered with Ofsted and CQC due to the changing needs of the children and young people who use the service. Ofsted are responsible for regulating the social care needs of children and young people whilst the Care Quality Commission (CQC) are responsible for regulating the health needs of children, young people and adults.

We will continue to work with the Provider and Ofsted to determine whether the School for Profound Education should be jointly registered with both Regulators.

Therefore, this report details our findings associated with the care provided within the Rehabilitation Service which is located at The Children's Trust, Tadworth and is exclusive of the care provided at The School for Profound Education.

Relatives we spoke with told us they always felt included in any decisions about care and treatment for their child. One relative told us that the staff 'Always discuss the possible side effects of any treatment.'

We observed that staff provided care with patience and in a way that made children feel relaxed. All of relatives we spoke with thought that the care that the staff provided was excellent. One member of staff we spoke with told us that 'All of the staff go above and beyond' to provide care.

The relatives we spoke with told us that the service was always clean and tidy. However we found that not all of the infection controls were in place. There were no schedules or rotas that directed staff to what needed cleaning or what had been cleaned.

We saw that there were adequate numbers of qualified staff at the service on the day of our inspection.

The service had systems in place that monitored the quality of the service and identified when things needed to be improved.

One child told us that she was enjoying her speech therapy session when we visited her there. Another expressed himself with a thumbs up sign during his physiotherapy session. Another made head movements during his music therapy session that he was enjoying it.