What happened
Care Focus Limited ran a private children’s home for up to four girls with social and emotional difficulties. Ofsted brought its full inspection forward to 22 and 23 July 2024 to address specific concerns about the home, Ofsted URN SC477900.
Inspectors found that a child had been held in a ground hold for 30 minutes, and had said during it that they could not breathe properly. No debrief with the child is recorded afterwards.
The hold sat inside a wider pattern. Staff had not always offered children medical assistance after a restraint. Records of physical intervention did not always carry the information oversight needs. Children’s and staff’s views of restraint were not always recorded.
The outcome
Ofsted judged the home inadequate in all three domains, including how well children are helped and protected. The report says there are “serious failures that mean children and young people are not protected and their welfare is not promoted or safeguarded.”
Statutory requirements were imposed on supervision and professional development, and on the statement of purpose, due by 30 August 2024. Two were subject to a compliance notice. One was met by 3 September 2024; the second was re-issued and met by 14 October 2024.
No prosecution or civil claim is recorded. The provider entered administration on 29 January 2025 and the registration is closed.
What went wrong
The child’s sentence was the finding. A person held down who says they cannot breathe properly is describing a medical emergency. The response is to end the hold and get them assessed. Neither happened, and the report says opportunities to learn and develop safe practice were missed.
The home also could not show that an allegation about a member of staff being too forceful in a restraint had been referred to the local authority designated officer, and other allegations were not followed up. Police were called to manage behaviour on occasions, and not every serious incident reached Ofsted without delay. There had been no registered manager since September 2023.
What it teaches
Half an hour on the floor is not one decision. It is a hold that has outlived its purpose, repeated by the people in the room, with nobody ending it.
A child’s words are clinical information. “I cannot breathe properly” is not defiance. It is the point at which the hold stops and an assessment starts, and staff should have heard the sentence in training before they hear it on a floor.
The debrief is the only thing that turns an incident into safer practice. Without it the child’s account is lost and the next hold runs the same way.
A home that had gone without a registered manager since September 2023 does not have a paperwork problem. It is a home where nobody owns the standard.
Questions for the room
- A child says they cannot breathe properly while you are holding them. What happens in the next two minutes, and who is called?
- Could a manager who was not there reconstruct the hold from your records?
- Who in your setting can end a hold that someone else started?
Evidence and limits
Confidence: probable. The account rests on Ofsted’s inspection report of 23 July 2024, summarised in the case précis and vault record; I did not open it myself. It carries a section 45A restriction, the child is not identifiable, and the restraint is undated, so no date is given here.
The provider is named because the report names it. No member of staff is named and none was charged. The separate police-investigated matter concerns mobile phones, not the hold, and is not described.
Our restraint reduction training covers how services build restraint out, rather than getting better at applying it.
Sources
Reviewed 20 October 2026.