keys INVESTIGATION -- REPORT COMPILED -- DATE COMPILED: 4.8 16 The following investigation process was commissioned in response to a letter of concern received on 26.7 16 Concerns relate to a number of notifications of serious events over recent months which raise Concerns about behaviour management and safeguarding within the home 1. Children attemptiong to steal the homes vehicle, and setting fire to the carpet in the home 2016) 2. Unknown "Young man" found in child's bedroom at23.50 on (27"'june 2016) 3. Stanley knife and makeshift weapon made from toothbrush and Stanley knife blade handed in by child (27"'june 2016) 4. Child requiring hospital treatment folloWIng cutting his thumb in his bedroom with large industrial hedge cutter 3'djuly 2016) 5. Three children arrested following an incident which involved a Child throWIng urine at a peer, a Child exposing himself to staff and peer and damage to children '5 property (5m july 201 6) In addition seriosu incidents continue to occur within this home, the most recent notification is Police involvement following a child causing significant damage to the home, and making threats to kill the deputy manager who was on shift with three agency workers (16July 2016) What I found: Incident no 13.6.16; 1. Registered manager identified 3 key areas of concern in this incident Young people attempting to climb out of bedroom windows after removing window restrictors and climbing down from windown on make shift ladder made from bedding . Action taken Maintenace team contacted new window restrictors put in place morning of 14.6.16 Keyworking session undertaken with young people to discuss the dangers of attempting to climb out of windows, explaining consequences of a fall, ie: life changing injuries. Vehicle key being stolen from office environment, resulting in an attempt to steal the homes vehicle, consequence of this could have had serious implications to young people, other road users and pedestrians in the event they had managed to take it. Action Taken Maintenace team contacted and new key safe put in office so keys can be locked away . Investigation Identifed that key for vehicle had been left on office desk. All staff informed of the requirement to ensure keys locked away after use. Fire starting incident -- Potentially could have resulted in the home catching fire, potential for life changing injuries being sustained or death, and property damage. Action taken Fire safety Equipment Contractors contacted to replenish fire extinguishers used to put out the fire. The morning of the 14.6.16 Contacted-- Behaviour Management Keys Group and- Therapist Keys Childcare Group to discuss behaviours being presented and strategies used to manage them. Contacted Maintenace team to visit and repair door alarm systems as young people had tampered with the alarms, so staff were not alerted to them exiting the building. Risk assessments updated accordingly Staff informed of all new risk assessments and strategies for behaviour management What we found Incident no 2; 27'" june 2016 Registered manager identified from investigation into this incident that one staff member was on phone informing EDT of Young person's safe return 2"'1 staff member was on the phone to 101, to inform them of Young person's safe return. Waking watch staff member was on the landing after supporting another young person with settling in their bedroom and identified unknon young person in the home. Staff responded speaking to young person, ascertaining that he had been thrown out of his home, staff offered to contact EDT Halifax to try and find a suitable placement for him overnight. Reported to Safeguarding team following morning Social workers contacted to request strategy meeting . Maintenance contacted to attend the home the morning of the 28.6.16, as it is suspected that the alarms have been tampered with again as they were not alarming when doors opened to alert staff to young people attempting to exit building and in relation to attempting to let unknow people in the home. Risk assessment updated in relation to home security. Follow up key working session undertaken with young person to explain consequence of bringing unknown individuals into the home, explaining consequences of allegations of a sexual nature and the implications this could have on him. Discussed consequences of unknown people in the home, risk of theft of home property. What we found Incident no 28.6.16 Registered manager identified that young people had purchased stanley knife blades whilst out in community on free time, this had been disclosed following incident. Room searches implemented for young people, although- 5 curently having room searches undertaken 2 daily due to previous incident with ligature. Keyworking session with all three young people about the consequences of knife weapons in relation to street crime and the consequences of being found in possession of such articles by the Police, discussion in relation to impact this could have on their current YOT order, their placements and their liberty. Social workers notified request for strategy meetings to discuss behaviours. Police contacted in relation to visiting the home to speak with young people, in relation to the severity of this issue, and to confiscate the makeshift weapons and dispose of them. Risk assessments implemented in relation to fashioning of weapons, all staff informed of new assessments. -- Therapist Keys Childcare contacted in relation to behaviours exhibited. What we found Incident no 3.7.16 Registered manager identified that staff responded to first indication of young persons injury, ensuring urgent attention at Calderdale hospital Accident and Emergency Unit. Parent, and social worker informed of the incident. Further discussion with young person confirmed that he had brought the hedge trimmer in covertly, he admiited to returning from free time the previous evening, having something to eat and retiring to his room later, he then explained he had used the second set of stairs, and gone out and collected the hedge trimmer sneaking it into the home without staff being aware and hiding it in his bedroom. Once inside he again locked the door and went back to his bedroom without detection by staff. Maintenace contacted to ask them to attend the home and check the door alarms as they are not alarming when opened, therefore not alerting staff to young people exiting the building or entering the building. Police informed due to the electrical equipment (Hedge Trimmer) being the industrial type and young person acquiring them. Police asked that we keep hold of the equipment and they will collect. Request for camera's to be positioned around the outside of the home, to asist with security of the building. What we found Incident no 5.7.16 Registered manager identified during investigation into the incident that Young people had been excitable and giddy in mood, staff suspect it is about trying to establish a hyerachy Young people had been pranking each other, and although staff had tried on numerous occasions to stop this behaviour escalating it did. During the incident one young person exposed hsi genital area to staff and another young person. Staff agree that this was not in a sexual manner morover in a joking manner albeit in poor taste). Behaviours continued to escalate whilst staff were dealing with one young person in an extremely heightened mood, threatening to pour boiling water mixed with sugar over another as a weapon, and for them to close the kitchen door to prevent this occurring. One young person utilised this opportunity to run upstairs and cause damage in the other young persons room. Staff responded to the continued heightened mood of all young people, trying to diffuse using all verbal de-escalation techniques. Closing the kitchen area to minimise the potential for further risks in respect of kitchen implements being used to harm Due to the severity of the behaviours being displayed and risks to young people and staff police called to the home. Due to all three young people still being heightened in mood, on arrival of police, and their refusal to calm down, police had not alternative other than to arrest the young people and take them into custody We have increased staffing on waking watch to 2 staff with one sleep over duty, and 3 staff on 9am -10pm shifts each day. Risk assessments updated and a new risk assessment in respect of Deprivation of Liberty - Locking the kitchen area at times when young What I found Incident no Duke Street Registered manager found in her investigation into incident involving agency staff member assualting Young person was addressed immediately ,Young person offered appropriate support due to the traumatic nature of the incident Staff member immediately asked to leave the home. Incident reported to all appropriate parties Police, LADO, OFSTED, Keys childcare, Uber support Agency, Parents of young person.