Transition Care Peterborough Ltd v Ofsted

In our judgment, there would, at present, be a material risk of harm to children if the Restriction was not in place. The relevant threshold relating to risk is met. The Restriction is, at present, objectively justified as proportionate to the risk identified and/or, to put it another way, as a proportionate means of achieving a legitimate aim. We consider the Restriction to be necessary, in other words, at present, to keep children adequately safe.

We set out some further reasoning below. What follows is not designed to cover all the matters touched on in the Bundle or the other documents before us. It is, however, designed to be sufficient to clarify the core reasons why we reached our decision.

Bearing in mind the principles set out further above, and without going as far as to find facts, we reached the following views on the limited evidence before us. Stepping back and looking at things in the round, we are satisfied that, as of today, there are sufficient reasonable grounds to believe that the provision of service by the Appellant would or may expose children to a material risk of significant harm. We rely on the following in support of this view.

First, the evidence from the Respondent in relation to the First Inspection, and to concerns identified in the course of that inspection, appears to us to be credible, reliable and persuasive.

The Respondent appears to have carried out a relatively full inspection between 27 and 31 January 2025. It seems likely to have formed a genuine view, on what appear likely to us to be rational and reasonable grounds, that there were indeed some serious and relatively widespread issues in the service. The Respondent made it clear that urgent action was required to address such matters and that a further inspection would take place within six months or so.

For example, there is direct evidence – from Mr James’s statement in particular – which tends, in our view, to suggest the following:

Other issues identified included, for example, that safeguarding or child protection information was not always shared with relevant professionals, partners or agencies; and that one or more of the children had a high level of missing-from-home incidents and that support in relation to that risk was insufficient.

We had due regard to the two compliance notices issued, on 7 February 2025, following and as a result of the First Inspection:

We place on record, though, that the Respondent’s conclusions were not uniformly negative. The Respondent noted in the inspection report, for example, that: “all staff” were “committed to helping children to try and make progress”; partner agencies had fed back that staff “genuinely cared” about the children; and staff appeared to have a good understanding of ways to communicate with children.

It seems clear that the Monitoring Visit was relatively successful in the sense that the Appellant was able, at that point, to persuade the Respondent that it had (apparently) made sufficient progress in relevant respects. To take one important example, the Respondent recorded, in the outcome document, that a “robust process” was now in place for managing referrals and children will only be admitted if their assessed needs can be properly met. Various other relevant improvements, to process and practice, are also noted/perceived.

Consequently, at a subsequent case review meeting on 27 March 2025, the Respondent concluded that the Appellant had made sufficient progress to meet the steps set out in the compliance notices. That said, the Appellant was, it appears, still required to take some further actions related to relevant standards.

However: it is important to note, in our view, that, at the time of the Monitoring Visit, the Appellant had not, it seems, admitted any additional children to the service since the First Inspection. As a consequence, the decision to lift the compliance notices was, in essence, based on assurances provided by the Appellant that it had sufficiently improved its systems, processes, and practice. It was also, according to the statement of Mr Woodbridge, based on two referrals not being accepted during that period by the Appellant due to the children having been deemed unsuitable for supported accommodation. The Appellant, according to the Respondent, had agreed that it had previously accepted children to the service who were not suitable for supported accommodation; but appeared to, by then, have recognised that as an issue and was now in a position, therefore, to prevent it from re-occurring in the future.

The evidence from the Respondent in relation to the Second Inspection, and indeed in relation to the Monitoring Visit, also appears to us to be credible, reliable and persuasive.

The Second Inspection had always been planned and anticipated, as indicated above, to have occurred within (approximately) a six month period. We note that it was conducted, once again, by Mr James (who also, we note, conducted the Monitoring Visit). We also note the evidence that Ms Pearson played a relatively significant support role in relation to the Second Inspection.

One of the main problems faced by the Appellant in this appeal is that the balance of the evidence before us tends to indicate that, at the time of the Second Inspection, there were probably still a number of significant issues with the service, including some of those already identified in the First Inspection. That, if correct, would suggest a pattern of problematic service provision, and a potentially serious issue relating to the Appellant’s capability (or willingness) to effectively implement, embed and sustain necessary changes and improvements.

The relevant concerns are summarised in the Notice and set out in the witness statements provided by the Respondent.

One important area of concern related, again, to the management of admissions/ referrals. The balance of evidence indicates that there were genuine concerns, on what appear reasonable grounds, that the Appellant’s process or decision-making in relation to admissions/referrals was not being (and/or would not be) conducted in line with good safe practice and the relevant regulatory framework. The Respondent’s evidence suggests that out of three children admitted recently, two were considered by the Respondent to have been inappropriate, at the point of admission, for supported accommodation such as that provided by the Appellant:

Moreover, the concerns arising from the Second inspection were noted limited to referrals/admissions. The evidence indicates that the Respondent had genuine concerns on what again appear to us to be reasonable grounds in relation to the following beliefs:

The above matters led to the Respondent forming a view that the Appellant’s leadership/management did not have effective oversight of the service; that, among other things, they were failing to identify and remedy weaknesses in the admission process, children’s plans, support work, and the requirement to submit notifications of serious incidents. There was a risk, in its view, that if allowed to accept further admissions, there would be a risk of harm to those children, and also to the children already accommodated. The Respondent concluded that the Notice was required, until the provider was/is able to demonstrate it understands sufficiently the regulatory framework for supported accommodation and is both willing and able to apply it in practice.

Compliance notices were also served, with the compliance date of 7 September 2025, to address the shortfalls and issues identified.

We note that, within the Bundle, there is evidence of a subsequent monitoring visit by Cambridgeshire County Council. This appears to have been triggered by the outcome of the First Inspection and to have taken place on 18 July 2025. It appears to have involved a discussion with the nominated individual regarding the First Inspection, a review of an action plan produced by the Appellant (see below), a review of files, a tour of the premises, and a discussion with one service user. The associated report of the visit indicates, in broad terms, that, at least in relation to some important respects, the Appellant is (or, more accurately, was as at 18 July 2025) still in the process of reviewing processes (such as those relating to referrals/admissions), making changes and improvements, etc. The report also indicates that the local authority found that some important documents, such as daily logs and instant logs, varied in detail and quality. Record keeping and “targeted support” were identified as areas for improvement. The Appellant was expected to provide regular further updates, in relation to its action plan, to the local authority, as part of the latter’s “continuous monitoring” of it as a provider. We also note, however, as we do above, that there were positive observations, including those in relation to the director’s “dedication and commitment to the young people”.

We note the action plan in the Bundle. While the date of the version before us is not entirely clear, Mr Williams’s statement suggests it’s a version from 10 July 2025. Again, in broad terms, it appears to indicate that the Appellant has put a plan together designed to address the concerns raised by the Respondent in the Second Inspection but that, in several significant aspects, is still in the process of delivering against that plan. There is no or no persuasive evidence before us, for example, from the Appellant, that (1) the plan is now fully implemented and (2) is sufficient to address all of the significant concerns raised by and relied on by the Respondent.

We further note, and have taken into consideration, a document called “Minor clarification or factual accuracy form”.

Finally, we note the information contained within or associated with Mr Williams’s more recent witness statement. The statement is very brief, covering just two pages. It does not, in our view, really address the issues/allegations most relevant to the Appeal. It repeats the complaint or concern about the alleged approach adopted by Mr James to the Second Inspection in particular. But the issues raised, in relation to that, are not sufficiently relevant, detailed, supported, or persuasive to drive us towards upholding the Appeal. There was very little in the statement about the crucial issues in this case or the current position, in relation to them, that the Appellant is now in. Having sought a paper-based hearing, there was no opportunity for us to ask Mr Williams further questions or (to the extent that it would have been fair procedurally to have sought to do so) to assist him in providing some further relevant evidence about key issues.

Overall, we are satisfied that there was reasonable cause to believe that a material risk was present at the time of the Notice and that it continues, today, to be so. The evidence from the Respondent on that appears to us to be relatively strong (if untested in court); and there is little evidence, in practice, from the Appellant to undermine it or to establish recent sufficient improvements etc. The reality appears likely to be that the Appellant was operating in such a way that may well (if unintentionally and despite good intentions) have put children at material risk of harm and that, while it is in the process of seeking to make changes to address relevant matters, it has yet to get to the point where the relevant risk can be properly said, objectively, to have been reduced to a level that is acceptable. We have kept in mind the following from the Guide: “Where young people of this age have needs that would best be met in a children’s home or foster care placement, that is where they should be placed… Supported accommodation caters for children aged 16 and 17 who have relatively high or increasing levels of independence, who are ready to gain further skills in preparation for adult living, and who do not need or want the degree of care or type of environment provided in the children’s home or foster care”. We are persuaded that there are significant ongoing risks, arising not just from the Appellant’s admissions/referrals practice but also from the service provided to children once admitted.

In all the circumstances, we are further satisfied that the Restriction is objectively justified as proportionate.

First, we have formed the view that the harm contemplated is more than merely trivial or minor: it is, in our view, significant and potentially very serious. It could, realistically, include a significant level of physical, sexual, emotional, financial or developmental harm. We also think that the likelihood of the risk materialising is relatively high (or, at least, not low): the evidence before us suggests a potential pattern of actual issues in recent months; and there is no longer-term history, for this service, of strong and reliable previous compliance. We have though, we stress, had regard to the positive documentary evidence in support of the Appellant including, for example, the evidence about Mr Williams’s personal dedication etc but, at this point in time, in light of the other evidence, those things are not sufficient to reduce the risk profile enough. The fact that the potential impact of the risk is relatively high, and that the likelihood of occurrence is not low, means that the Restriction is more readily justified as proportionate to the risk.

Second, there is a legitimate aim engaged. It is important. It is relates, ultimately, to the protection of vulnerable children from the risk of significant harm. The Restriction relates, directly, to the pursuance or achievement of that aim. Its immediate purpose is to keep children safe during a period in which the Appellant (or the Respondent) takes necessary steps to reduce the relevant risk to an acceptable level. Again, the importance of the aim means that the Restriction is more readily justified as proportionate.

Third, we have tried to have careful regard to the adverse impact of the Restriction on the Appellant and any other relevant people. We can see that the matter, generally, may well have an adverse impact on the Appellant and some people related to it. But there is a lack of direct or persuasive evidence from the Appellant about the nature and degree of that impact. There is no sufficient evidence before us that the Appellant, or any relevant children or others, are, as a result of the Restriction, disproportionately impacted. We are content that the importance of the legitimate aim(s) being pursued outweighs the adverse impact; and that it is proportionate at present. In forming that view, we had in mind the limited time period of the Restriction and the obligation on the Respondent to actively keep it under regular review (and to lift it should the Appellant demonstrate a sufficient material change in the situation etc).

Fourth, we are further satisfied that the legitimate aim(s) cannot realistically be achieved adequately by any less-restrictive measure. The evidence indicates that, in essence, other less-restrictive measures have already been tried – and have probably not been sufficiently effective. It therefore appears both appropriate and reasonably necessary, in our view, to take the next step up: i.e. to put, and to keep, in place the Restriction. The Respondent might potentially have considered going even further but elected to restrict the nature of the intervention to a time-limited restriction. That, in our view, continues to be proportionate overall. Our decision is based, as it must be, at the time of the Hearing and on the basis that the Restriction is due (in principle at least) to end relatively shortly (on 3 October 2025).

In our judgment, therefore, the Decision was rational, proportionate, and lawful; and it continues – for now at least – to be so.

The Appeal is dismissed. The Decision is confirmed.