The Elms

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Children and young people were not protected from avoidable harm whilst living at The Elms. Staff failed to protect children and young people from known risks and when incidents occurred, action was not taken to prevent these recurring. Most children and young people using the service were always supervised by staff due to the risk they posed to themselves. However, children and young people were still able to self-harm, swallow batteries, get on the roof, and jump from a bridge which endangered their safety. We observed that staff did not always supervise children and young people appropriately. For example, one child was supposed to be supervised by 2 staff who let them leave a room and did not follow. Two children told us staff did not always supervise them as they were supposed to. This was corroborated by feedback from external professionals and the Police. Children and young people had access to items which posed a known risk to them, for example knives and items they could ligature with. Action was not taken following incidents to reduce the risk of repeat incidents. The provider, director, deputy manager and clinical lead displayed a lack of concern for the serious incidents that were occurring and did not take action to reduce these. The service was not clean, with a smear of blood observed on a door and general lack of cleanliness throughout.

This service scored 3 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders did not learn from previous incidents and take action to protect children and young people from repeat incidents. In discussion with the deputy manager, they displayed a lack of concern about two incidents where staff placed one child at risk of falling from a bridge on two occasions. They had not taken any action after the first incident to ensure the child was prevented from going to or near bridges. No amendments had been made to care planning or risk assessment where this would have been appropriate. As a consequence, the child could have died or come to serious harm falling from the bridge in the second incident. The provider displayed a lack of concern or understanding of the seriousness of the incidents occurring at the service. Despite being made aware of concerns before our assessment visit, they had not taken action to ensure the vulnerable children and young people they cared for were protected from avoidable harm.

Processes in place to protect children and young people from harm were inadequate. Whilst incidents were recorded and reviewed by senior staff, action was not always taken where this would have been appropriate. This placed children and young people at risk of avoidable harm.

Children told us that staff did not keep them safe and protect them from avoidable harm. For example, children and young people were supposed to be supervised by staff at all times because of the risk they posed to themselves. However, children told us and we observed that staff did not always maintain this supervision. This allowed children and young people opportunities to harm or endanger themselves. One child told us how they had been admitted to hospital after swallowing batteries and staff did not follow them when they tried to leave the hospital which placed them at risk. Police said this feedback was confirmed by CCTV they reviewed from the hospital. Children told us staff did not always listen to them and this compromised their safety. For example, one child stated they told staff about a fire they had set but staff failed to take any action.

Staff and leaders did not protect children and young people from avoidable harm. Senior staff, including the provider, demonstrated a lack of concern about incidents occurring which placed children and young people at risk of harm. In communications with us, they did not recognise the seriousness of concerns raised with them before our assessment visit and after it. They failed to take prompt action to safeguard children and young people.

Processes in place to safeguard children and young people were inadequate. There was a procedure in place to record, review and analyse incidents. However, staff completing these reviews failed to take appropriate action in response to incidents to prevent recurrence.

Staff and leaders failed to safeguard children and young people from harm and recognise their role in keeping children and young people safe. Leaders and senior staff failed to take action in response to safeguarding concerns and displayed a lack of concern in discussions with us. Staff told us that staffing levels meant it was difficult to keep children and young people safe and that a lack of regular staff impacted on the care provided to children and young people.

We observed that staff did not always take actions to keep children and young people safe. For example, one child was supposed to be supervised by 2 staff at all times for their safety. Despite this, we observed them leave the room without their staff following them to supervise. This placed them at risk of avoidable harm. In addition, we observed that children and young people had access to items of known risk to them such as a battery on the floor outside, ligatures and knives.

The processes in place did not protect children and young people from the risk of avoidable harm. For example, incidents were recorded and reviewed but action was not always taken to prevent recurrence.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Children and young people told us there were not enough staff to meet their needs and provide support when they required it. One child stated they should have a daily walk and they found this helpful for their mental health recovery. However, they said this rarely took place as the staff were often busy supporting other children and young people. Two children told us that staff did not always supervise them when they should be supervised at all times for their safety.

The deputy manager told us they were currently using a lot of agency staff to cover shifts in the service and that they did not have enough regular employed staff to support children and young people without using agency. They also told us they currently had no cleaning staff employed, until new staff started in over 4 weeks time. Cleaning was supposed to be carried out by support staff but we observed this was not taking place and it was unclear whether the time required to keep the service clean had been factored into the overall staffing level.

We observed that there were not enough staff to support with incidents whilst also maintaining supervision of those who required constant supervision for their safety. We saw an incident occur with one child who was displaying distressed behaviours. All staff went to support with this incident and left the children and young people they should've been supervising alone. This placed them at risk.

There were insufficient processes in place to manage staffing in a safe, effective way. The service failed to deploy enough staff to meet the needs of all children and young people using the service. This includes enabling those using the service to access meaningful engagement and to ensure the premises was kept clean and tidy for children and young people.

The deputy manager took us on a walk around the service and we pointed out cleanliness issues to them. They told us it was blood we could see smeared on one door. They also stated they did not currently have any cleaning staff employed until new staff started in over 4 weeks time. They said support staff should be carrying out cleaning duties and there was a rota for this, but it was clear this was not happening.

The premises was dirty, unkempt and neglected. In one bathroom we saw dirt around the toilet, shower and sink. There was no soap and there were the cardboard centres of 7 toilet rolls on the floor by the toilet. This indicated the lack of attention to cleanliness had been going on some time. There was also a smear of blood on the door in one bathroom.

There was insufficient monitoring of cleaning by senior staff. If monitoring had been taking place, they would have seen the condition of the premises and been able to take action to rectify this. Five hours after we pointed out cleanliness issues to the deputy manager, no action had been taken to rectify this.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.