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9. ORGANISATIONAL CULTURE
9.1 The changes in legislation and policy in residential child care in the 1990s required staff to gain new knowledge and adopt new approaches to working with the children in their care. That Kerelaw might benefit from a fresh approach appears to have been recognised by Strathclyde Region in the form of at least one appointment to the senior management team in the early 1990s. However, we heard in evidence that, under Strathclyde Region, Kerelaw was seen as somewhat separate from the mainstream, and that some managers and staff had developed a resistance to being told what to do by "outsiders". As a consequence, there appears to have been a culture which made Kerelaw less well placed than it might have been to adapt to new legislative and policy requirements.
9.2 An organisation's culture may be simply described as "the way we do things around here". Management text books abound with more detailed definitions, but Osborne and Brown (2005) 14 capture the essence:
The shared ideas, customs, assumptions, expectations, traditions, values and understandings that determine the way employees will behave
Culture is a product among other things of history, role, attitudes of managers and staff, and their perception of their purpose and self-worth. In the public service, dealing as it often must with some of the most challenging and marginalised client groups, the attitudes of the public to the client group may also influence culture.
9.3 The public can be ambivalent about the kind of challenging client group with whom staff at institutions like Kerelaw have to work. A view that tough discipline and "just deserts" may be appropriate for the most challenging young people may coexist with disapproval of abusive behaviour towards the vulnerable. This ambivalence, sometimes reflected in Government policies and the media, may transfer to some staff and lead to their being confused as to what is expected of them. Some may believe that poor treatment of the client group is excusable, at least from time to time, because the public either considers such treatment to be justified or does not care. Some may think they are doing the right thing when they are in fact doing the wrong thing.
9.4 If staff are unsupported or otherwise undervalued by their employer, for example by being inadequately resourced or trained for the job they do, by seldom seeing senior management, or by having to work in poor surroundings, they may feel isolated and vulnerable. Use of the employer's disciplinary process as a first response to practice issues may increase feelings of vulnerability, to which negative media coverage may add. A feeling that they are themselves subject to a "blame culture" may influence staff behaviours towards clients. At the same time it may nourish the development of an inward-looking, defensive ethos in which loyalty to one's colleagues, or at least to those perceived as being on one's side, takes precedence over other obligations. Solidarity with one another in difficult circumstances may be reinforced where large numbers of staff are recruited from, and live, in the local community, and where there is shift work and shift-based socialisation outside working hours.
9.5 A strong value base is needed to counter negative cultural influences of that kind. Strong leadership, training, supervision and support, and self-evaluation, are key factors in sustaining values, challenging poor practice and creating a culture in which the client's needs are the top priority. In a residential setting for young people, the fundamental requirement is for all workers to embrace a child-centred approach, in which children are listened to, their needs respected and their vulnerabilities understood.
9.6 The concept of the child at the centre is discussed in Chapter 12. Putting this concept into practice when the child is challenging and vulnerable demands a high level of professionalism, skill, and self-control from managers and staff. It depends heavily on role- modelling and standard-setting from the top. It demands from senior managers a shared vision of what kind of organisation they wish it to be, which goes beyond a simple statement of the mission. It requires communication to staff about values and standards, and clarity about what is expected of them. It requires a willingness to question accepted customs and practice and to hold to account those who fall short. It requires a commitment to learning and development to enable workers to adapt to new demands, and respond to changing client needs.
The Kerelaw culture
9.7 There were deficiencies in all the above areas at Kerelaw and negative cultural influences of the kind described. Nevertheless, there were many positive aspects to Kerelaw. There were staff who were child-centred, who had a strong value base, and who did their best in often difficult circumstances. By no means all young people at Kerelaw had a bad experience. Glasgow City Council's own investigations recorded a number of positive comments from young people, for example:
I do not have a bad thing to say about my time in Kerelaw, and not a bad word to say about my staff. I felt they had respect for me.
and so far as one young man was concerned:
in terms of his experience of Kerelaw……he enjoyed it as he was taken to places he would never have been………. "I was treated fairly and we had something to do every night. My two keyworkers …were very good……"
9.8 This was echoed by another male former resident who:
…went on to say that if you were unhappy you knew who you could talk to and who you couldn't. Some staff were good at noticing when someone was about to erupt and would try and help.…[his] key worker…..was good at this.
while a young woman ex resident commented that she:
……felt that some of the staff had looked after them well, some of them were good and could put up with a lot.
9.9 It is right therefore to acknowledge that there were good practitioners at Kerelaw. We heard in evidence that unfortunately some of them did not stay long or, if they did, felt that they would be unable to bring about change. Either way, the exemplary practitioners appear to have been insufficiently numerous or insufficiently influential to make a lasting impact on a culture which, the evidence suggests, laid a very strong emphasis on physical control, and on supporting one's colleagues when this led to complaints or fact-findings. The evidence given to the Inquiry suggests that the description in the Glasgow Report of:
an insular, staff-centred, controlling culture, where young people were not heard or empowered in any meaningful or effective way, made for an environment in which abuse could occur
is a fair commentary on a culture largely driven by the attitudes and behaviours of a core of male employees, who became the main focus of investigations.
9.10 Those behaviours appear to have been replicated to an extent in behaviours towards colleagues who dissented from the cultural norm. We have already recorded at paragraph 7.15 that what sparked off the Millerston investigation in April 2004 was staff complaining of bullying and harassment by a unit manager. This was despite the fact that a report following a Review of Night Care (see paragraphs 10.15-10.16) had recorded 5 years earlier, in March 1999, in a section headed "Culture":
Almost every member of staff interviewed, permanent or temporary, cited examples of bullying/harassment by management. Staff appear to have been disempowered to the extent that they have been unable to challenge practice. This requires attention, particularly given the need to safeguard very vulnerable and damaged young people. Additionally, staff in efforts to protect themselves, have formed powerful sub-groups, which do not enhance an inclusive working culture.
9.11 That Review went on to recommend that the SMT should work with members of staff to promote an inclusive, supportive way of working which positively encouraged the challenging of concerning practice. These findings were taken on board by the then Principal and a paper setting out a basis from which to take work forward was prepared, but we found no evidence that this was adequately followed through in the longer term. Proposed improvements in the formality and frequency of supervision, which would have been a key tool in changing the culture, were not fully implemented.
9.12 Despite the reasonable gender balance in staffing noted at paragraph 4.24, a consistent message from ex-employees and others who gave evidence to the Inquiry was that there was a "macho" culture, into which many new members of staff appear to have been absorbed. Time and again the Inquiry heard from former employees of the strong impression this culture made on them when they were first recruited to Kerelaw. One former member of staff's evidence to the Inquiry echoed that of several others:
Kerelaw was male dominated and a bit macho when she arrived…………The Kerelaw culture had a macho element and many male staff were not used to building relationships and discussing differences of opinion with young people
while a former teacher told us that:
……there was a macho culture …… due to the staff being largely manual workers recruited locally, who did not hold social work values…
9.13 Another former staff member reflected on the staff group he worked with and said that:
there were a lot of 'big guys' employed at Kerelaw and this had been part of the culture…… perhaps being big and strong was seen as more of a priority than having the capacity to write a good report. Staff nicknames reflected this priority ……
9.14 A young person, resident at Kerelaw in 2002, told the Council's investigation team that:
…a lot of staff walked about like hard men in a way which was designed to intimidate the residents…
but a former manager went further, arguing that:
……there was no ethical leadership at Kerelaw and it was managers who were influential in maintaining the macho culture……[but] some staff did realise that things were wrong.
9.15 The Glasgow Report stated that:
Historically, as recently as 25 years ago, it would have been common and acceptable for these young people to be dealt with by means of strict, institutional regimes, characterised by control measures and staffed by predominantly male workers. Young, physically fit males would have been actively recruited as being "hard" enough to deal with the young people in their care.
9.16 Kerelaw's origins as a List D school were cited to the Inquiry several times in evidence. One long-serving staff member observed that:
…… there were issues of culture at Kerelaw where they were trying 'to shoehorn child care practice into a former list D school'
and a professional worker closely involved with Kerelaw over a long period summed up the culture in his oral evidence as:
a macho male dominated culture at Kerelaw particularly in the early days … the ex-mining, agricultural Ayrshire environment placed an emphasis on 'brawn is best' in relation to list D provision, especially for teenage boys,…
although he also suggested that:
… by 1997 ……management were trying to rid themselves of such cultural baggage and ethos. There was interest in training in child protection and…… many staff, especially female managers, were aspiring to improve.
9.17 We were told that the Deputy Head in charge of the Open School at the time of its transfer to Glasgow City Council in 1996 had been appointed in 1993 in an attempt to bring about change. Her aspirations to improve and introduce practices which ran counter to the prevailing culture encountered resistance from some senior management colleagues as well as staff. Opinion among those with whom she worked was mixed. We heard praise for her contribution to introducing training for staff alongside criticism of how she went about things, even from some who supported what she wanted to achieve. She left Kerelaw in early 1999 and resigned from Glasgow City Council the following year, having failed to gain the support needed to bring about lasting change. A common criticism made to the Inquiry was that she "gave the young people too much", itself a comment on prevailing attitudes and culture.
9.18 One former member of staff, referring to the Deputy's attempts to change the culture, noted that:
There was a longstanding control and discipline approach hanging over from Kerelaw's origins as a List D school and the therapeutic approach that [she] was trying to introduce was just alien to them.
9.19 A former female member of staff told the Inquiry that:
In general staff were starting from a pretty basic level in terms of values………[she] remembered talking to HMIE about the basic fundamental issues over staff values. They agreed with her. There had been training but this had not been in basic values……This was a school in the middle of nowhere and the staff had questionable basic values……an institution with dated practices relating to having been an old list D school
and one witness who had been involved in inspecting Kerelaw told us that:
the attitude that came across from staff was that they 'policed the children rather than looked after them'.
9.20 A female former staff member remarked that:
Kerelaw had existed before the Regulation of Care, the Children's Act, and concepts of corporate parenting and so on. But it was a time when organisations and the sector generally were beginning to realise the need to improve the quality of residential care.
9.21 Kerelaw was affected by developments in regulation and needed to improve the quality of care, but we did not in the course of our Inquiry identify a sustained, strong commitment to respond which was shared by the Kerelaw SMT or in Glasgow City Council's Social Work Department. With few exceptions, which we return to in Chapter 10, there was little evidence of a vision of what a different future might be and no overt recognition of a need for a modernisation programme which addressed culture change.
9.22 While we saw evidence of concerns being expressed from time to time in the Social Work Department, we found no evidence there of will or capacity to carry out a root and branch review, or to grasp nettles that needed to be grasped. The fact that plans were slowly being formulated for the redevelopment of Kerelaw, initially on the hypothesis of a new site closer to Glasgow, may have been a factor in this. However, we found no documentary evidence that planning in Social Work HQ included consideration of how to take forward a culture change agenda.
Recruitment
9.23 A recurrent theme during the Inquiry was the extent to which Kerelaw recruited from the local community. As the Glasgow Report recorded, many relatives worked together at the school, as did couples and longstanding personal friends. The Inquiry noted the existence of a range of longstanding animosities too. The local networks and personal connections associated with these relationships and the cliqueishness were cited as reasons why people did not speak up about questionable practices, and why fact-finding investigators expressed concerns that staff were covering for one another. A member of the Personnel function involved with Kerelaw summarised the problem in the following terms:
Kerelaw was a minefield of friendships and relationships that was not conducive to whistle blowing.
9.24 A reliance on local recruitment is not unusual in residential settings, particularly those located at some distance from large settlements. Working patterns and the cost and time involved in travelling tend to militate against recruiting from the labour pools in the Central Belt to the Ayrshire coast. The workforce at Kerelaw was therefore heavily weighted towards the local communities in the Stevenston, Saltcoats, Ardrossan and West Kilbride areas.
9.25 The situation immediately after local government reorganisation did not lend itself to the recruitment of a settled workforce. A freeze on permanent contracts for care workers meant that it was difficult to retain staff, and covering posts was a continual challenge. Kerelaw was accustomed to carrying out its own recruitment, and not all those who found themselves working there did so out of a strong wish to work with vulnerable children and young people. A regular pattern was that people would become involved as sessional workers, would then get a temporary post and later, after the initial freeze on posts was eased, become permanent. It was not until February 1998 that the acting Principal was able to confirm to his managers that Kerelaw could be exempt from the Council policy of not filling vacancies, thus enabling the school to consolidate a number of temporary posts.
9.26 A month later the Principal recorded in a memo to the Depute Director of Social Work that 30% of staff were on temporary contracts. Contractual problems continued. North Ayrshire Council noted in its February 2000 report on an inspection of the Open School in October 1999 that staff still did not have contracts of employment and that the Council needed to address this as a matter of urgency. This was resolved in the course of the year, with North Ayrshire Council's inspection in October 2000 noting that job descriptions were now available for all grades of staff and that they now had employment contracts - some 4 years after local government reorganisation. Given that experience, it would be understandable if employees felt undervalued by Glasgow City Council.
9.27 Until 2001 there seems to have been little attention paid in Glasgow to personnel practices at Kerelaw. Nobody from HQ Personnel had been involved in recruitment exercises before then. When recruitment took place, Kerelaw appears to have provided little or no information to HQ about who was involved or the process used. Kerelaw was inconsistent with the rest of Glasgow in recruiting to sessional positions also. Practice elsewhere in Glasgow City Council was that there were no sessional posts, only temporary posts and permanent posts. At Kerelaw there appear to have been no clear-cut standards or process for moving from one kind of contract to the other.
9.28 In 2001 the Scottish Executive issued guidance in a Toolkit for Safer Recruitment Practice which identified 18 factors for safer recruitment practice, introduced 9 "key capabilities" for the role of residential child care officer and advocated the use of assessment centres for recruitment. Steps were taken to tighten up on recruitment practice across the residential sector and to align Kerelaw with Glasgow City Council's arrangements. Under the new procedures it was decided that Personnel in Glasgow had to be involved. The Inquiry learned that subsequently the outcome of an assessment centre for residential workers at Kerelaw to make permanent appointments was that some long-serving temporary staff failed, mainly because of their attitudes and values which became evident in a group exercise. However, the staff concerned had apparently acquired employment rights as a consequence of their duration of service and releasing them would have had financial implications. Thus, we were told, they were offered instead further 13 week contracts, after which they sat and passed another assessment centre.
9.29 The Inquiry was told by ex-Kerelaw managers and staff that they constantly struggled to attract and retain staff. We were unable to obtain from Glasgow City Council sufficient accessible data on staffing to examine this in detail over the whole period. However, we were able to consider information about the staff establishment for 2000-01 and proposals put to the Council's Social Work Resources Committee of 31 July 2001 (see paragraph 13.9) for an increase in staffing, prompted by inspectors' concerns and by expected Care Commission standards for staffing levels across the residential child care sector.
9.30 Budget figures prepared for 2001-02 show that, of a staff establishment of 109 (excluding teaching staff), there were 16 posts (15%) being covered on a temporary basis - an improvement on 1998 - as a result of long-term sick leave (12), maternity leave (2) and 2 staff away studying for their Diploma in Social Work (Dip SW). The budget figures also set out the costs of proposed administrative and support staff changes that were put to the committee. Other proposals, in respect of residential care staffing, sought an overall increase in staffing of 20 (18%), including consolidation of 7 posts filled on a temporary basis. The paper noted a heavy dependence on the overtime budget, which was 50% overspent.
9.31 This snapshot of Kerelaw's staffing concerns paints a picture of considerable pressure and potential risk. Posts left unfilled by long term sickness alone amounted to 11% and no account was taken of the need to cover for short term absence for training or other reasons. A number of gaps were filled by staff on temporary promotion, which may bring benefits in terms of development but has a downside if too many managers lack experience.
Relationships and behaviour
9.32 We have already referred to close personal relationships among staff and the existence of cliques and factions. The Inquiry was told this in interviews and also picked it up from the way evidence was presented. Divisions among staff were not only personal. They extended to disagreements over practice, over whether programmes were a good idea or not, over training, and over the value of supervision. To the Inquiry, Kerelaw emerged as an unhealthily factionalised institution, afflicted by divisions within units, between units, between open and secure provision, between night staff and day staff, within the Kerelaw SMT, and between Glasgow City Council HQ and Kerelaw. As we shall see from our discussion of external management in Chapter 13, there were also divisions in the Social Work Department in Glasgow.
9.33 We noted earlier in this Chapter evidence from former employees which pointed to a "macho" culture. We were told that a core of staff who had worked at the school for some time set the tone as Kerelaw moved from its list D status. We understand those workers were close personally and appear to have shared a professional ethos based first and foremost on control. At that stage residential workers were generally not well trained and we were told of a "turnkey" and "brother officer" mentality. The language of "decking" was heard on more than one occasion by the Inquiry, from both former staff and residents. We were told that a small number of staff had established in the Secure Unit at Kerelaw what some saw as an influential, overly controlling and authoritarian regime.
9.34 In 1993 the new Deputy Head (Open School) tried to instigate change in the regime, and we describe at paragraphs 10.3-10.6 some of the tension this created. We were told that a small core of staff struggled to come to terms with a new, more child-centred ethos and actively sought to undermine change. More women were employed and there was an emphasis on care arrangements and associated staff training. The implications of these changes and the fall-out for staff and managers is significant. A divided management team was evident from the mid-1990s and a significant energy and resources were employed in disputes and conflict between key members. We shall return to this in Chapter 10.
Gender issues
9.35 Women were increasingly employed in both managerial and care positions at Kerelaw from the mid-1990s. This coincided with attempts to move towards more care-oriented, relationship-based and resolution-focused practices. Many former staff members we spoke to, including a number of men, welcomed this development. We noted attempts to challenge prevailing norms and practices by particular female staff, although by no means all. Certain gender stereotypes appear to have continued into the later years of Kerelaw's existence and it was difficult for women to challenge established norms. Those who did not fit in appear to have been marginalised. We were told that one female worker was referred to pejoratively as a "child crusader" for trying, on the face of it, to be child-focused. One male staff member commented that:
… females really had to shine to be noticed - they really had to be very "in your face" to get on. It was almost a given that the female staff would get the messages and would do the primary care stuff - washing and ironing.
Professional jealousies
9.36 A recurrent feature of life at Kerelaw appears to have been the schism between the Secure Unit and Open School. Staff in the Secure Unit were described by some as elitist and insular and an "us and them" culture was said to have developed between the two. This became particularly acute after changes in the management and staffing of the Secure Unit were made by the Principal in late 1999. This was reflected in low morale in the Open School and a perception that the Secure Unit was prioritised for resources and staff training. A number of professional jealousies, rivalries and personal animosities developed around this issue. Workers talked openly about the emergence of "camps" within the staff group.
9.37 These divisions became fault lines which began to define the school and set the context for a number of the professional and personal relationships which developed. Managers across the Open School and Secure Unit, and often between units within those settings, appeared to be split, and no coherent vision for the school was evident. Managers had been given significant autonomy to run their units following a review of staffing in 1994 undertaken by Strathclyde Region. We were told this was with a view to developing leadership capacity at team leader level. Unit managers were supposed to take on some cross-establishment roles although that does not appear to have happened. Instead, a degree of competition among units was encouraged. The rationale for this lay in providing a stimulus to raising standards, but the downside was that it appeared to work against building the unified, inclusive approach to taking the school as a whole forward which was required.
9.38 The impact on a day-to-day basis was important and the Inquiry was surprised by the accounts provided by a range of former employees. We heard that some managers bullied and undermined staff. Favourites were identified and those whose faces did not fit told us they felt excluded and scapegoated. A general lack of trust appears to have existed across the campus, with attitudes being displayed which were inappropriate. Some of those who gave evidence alluded to a culture of fear and blame within which cliques appear to have thrived. A number of staff talked about not being welcomed when they started at the school or when they moved from one unit to another. The negativity and unpleasantness associated with this behaviour was troubling for staff and, we deduce, for residents too.
9.39 Divisions were evident between night staff and day staff. We heard of the isolation of the night staff, who were often not considered to be an integral part of the care team workforce. They did not have the same access to training or development as the day staff and the important work they were tasked to undertake was largely unacknowledged. However, serious concerns were evident about the practices of the night-shift at different points, and it was believed by many day staff that night staff closed ranks when it suited them. The Inquiry considers that factionalism led to collusive behaviours which hindered an effective resolution of concerns about certain night-shift staff.
9.40 The Inquiry heard evidence of undermining behaviour, with some managers playing workers off against one another. There appears to have been continual gossip and rumour-mongering at the expense of particular staff. Some of those we spoke to talked about being ignored by peers, insulted or given pejorative nicknames. Such behaviour does not appear to have been effectively challenged and in many cases was condoned. Two workers described more sinister attempts to undermine them, including being "set up" and placed at physical risk during shifts. An indication of how difficult it must have been for people to speak up about matters of concern was given by ex-employees who said they had been called "grasses" or were believed to be "plants", placed by Glasgow City Council.
Personal relationships
9.41 The factionalism among staff was reinforced by personal and familial relationships. We were told that particular staff groups regularly socialised together and formed close and intimate relationships. Family members and friends drawn from the local communities were often employed together. We were told in evidence of an occasion when a manager would have been involved in assessing a close family member for promotion but for the intervention of a member of the Personnel Department in Glasgow. Some staff told us that access to training and career progression opportunities had been corrupted. Staff associated with powerful or influential cliques were said to benefit unfairly from such opportunities, although we found no documentary evidence to support that claim. One witness talked of "power play" with overtime, which for some was a welcome opportunity to earn more.
9.42 Professional boundaries were compromised, as young people were often aware of inappropriate relationships between staff. Relationships of this kind swayed professional judgement and got in the way of work. We learned of one case where a resident was confronted by a worker over behaviour which had been directed not to the worker himself but to his domestic partner.
Impact on safeguarding children
9.43 Some staff talked about the difficulty of "raising their head above the parapet" over concerns they had. Some said they did not know whom to go to with concerns about peers as personal connections meant that confidentiality could not be guaranteed. That being so, there was a fear that their "card would be marked". There appears to have been a lack of faith that managers would investigate and resolve concerns. Some talked about a reluctance to raise issues or support young people. It was stated that they would face disapproval from colleagues and possibly direct sanction and disadvantage. Many offered examples of concerns about child care practice which had not been properly addressed, and it was suggested that personal allegiances and loyalties had played a part.
Whistleblowing
9.44 The Edinburgh Inquiry, the Fife Inquiry 15 and the Kent report all identified the need for clear whistleblowing policies and procedures for staff and complaints procedures for children. Despite the fears and anxieties noted above, some staff in Kerelaw did use the whistleblowing procedures. Whistleblowing led to the Millerston investigation, although the initial concern was about bullying of staff, not young people. The Inquiry was surprised at the number of people who described themselves as being "the" whistleblower, in the sense of having brought major allegations out into the open. We were not able to establish how many employees used formal whistleblowing procedures, nor indeed how many understood what those were. The culture at Kerelaw could not be described as open, but certain determined staff did find ways to sound the alarm at different times, although without any lasting impact until 2004, when senior staff in Glasgow took action in response to the information they received.
9.45 Some Kerelaw employees were dismissive of the accounts given by whistleblowers and those who gave evidence at subsequent disciplinary hearings. It was asserted by some that such accounts had been affected by personal loyalties and that they lacked credibility. Some people who were subject to fact-finding and disciplinary procedures stated that they were maliciously implicated in abuse because of the factional, skewed interpersonal agendas at play. The Inquiry was struck by the extent to which personal animosities and resentments against others came through in the evidence of certain individuals and by the determination of some former workers to minimise and disparage the whistleblowers. It is clear that it would not have been easy to be a whistleblower at Kerelaw, and that considerable courage would have been required to raise and sustain complaints about colleagues.
Performance management
9.46 In the 1990s there was no effective performance management or staff appraisal system at Kerelaw of the kind that was already in place, or becoming established elsewhere. In this respect Kerelaw was not unique in the social care system.
9.47 There are a number of obvious difficulties involved in developing formal performance management systems for social care staff, or teachers, whose work is firmly centred in the field of social and human interaction. What outputs, outcomes, indicators, objectives and targets may be appropriate or desirable is a complex question which has given rise over the years to much debate and will continue to do so. This report is not the place to continue that debate. Deciding the extent of an individual's own personal contribution to delivering outcomes and meeting objectives or targets can also be a challenge where the client group has complex needs, and where responsibilities are shared with others.
9.48 Whatever difficulties there may be in defining and assessing measurable outcomes for complex services, or agreeing the contribution of different agencies to the desired results, defining the responsibilities and setting out the objectives of a manager is potentially more straightforward. Giving direction, setting and communicating standards, obtaining and using management information, monitoring trends, ensuring staff have the skills to do their jobs, complying with corporate policies, and budget management are among the generic requirements of the management role, particularly at senior level, regardless of the business or service involved. Personal performance plans should be capable of reflecting aims, objectives and accountabilities within such generic managerial responsibilities, and should be able to provide a basis for performance management and review.
9.49 For managers at Kerelaw, however, personal performance plans, with clear responsibilities and agreed aims or objectives capable of assessment and review by more senior managers, were not a feature. Yet the question of what exactly were the responsibilities of individual senior managers was at the heart of much of the argument in the consideration by the Employment Appeals Tribunal in 2008 of the Principal's appeal against dismissal. The Inquiry considers that the lack of a robust performance management framework for senior managers at Kerelaw was a serious weakness, which contributed to the failures there.
Supervision
9.50 The practice of professional supervision in social work is well recognised, fully documented and often researched. For social care staff at Kerelaw, and for managers at Kerelaw and externally, as elsewhere, supervision would be important in developing and controlling the quality of the service, taking account of the needs and rights of the young people and staff performance. Unison in 2006 described professional supervision in Social Work as "the key process for balancing professional autonomy with responsibility to the client, professional ethics and standards along with accountability to the agency and society at large".
9.51 Through supervision, the line manager is expected to meet regularly with staff to address certain organisational, professional and personal objectives. These objectives are competent, accountable performance, continuing professional development and personal support. Formal supervision involves recording what has been discussed and following this up at subsequent sessions.
The importance of supervision
9.52 The emotional impact of working with challenging and vulnerable young people is considerable. There is a risk of staff burn-out, with the attendant potential risk of a "hardening" in approach. Stress or upset in the personal lives of care staff may have a greater impact on their work than in some other occupations less dependent on at times sensitive human interaction. Staff at Kerelaw would have needed to be supported emotionally as well as practically. They had to be able to react appropriately to all kinds of emotionally challenging circumstances. Good supervision can help a worker to process and reflect, learn new ways to respond and - importantly - send a message to the line manager that he or she is not coping.
9.53 Morrison (1993) 16 suggested that the pace of change in social work, coupled with constant and acute resource problems, made it hard to sustain supervision to reasonable standards. He noted that some senior managers, especially those from outside social work, questioned the meaning and value of supervision. At the same time, the drive for better quality assurance, competence-led training and messages from child abuse inquiries all demanded higher standards of professional competence and public accountability. Morrison argued that this could only be done through effective supervision of staff:
The management of rapid change and the development of a skilled, confident and adaptable workforce, whose task is to deal daily with pain, poverty and powerlessness, will only be fully realised if staff are regularly and skilfully supervised.
Staff supervision at Kerelaw
9.54 The evidence to the Inquiry was that staff at Kerelaw did not receive formal supervision on a regular basis. Some former staff told us there had been times when they had received no formal supervision at all. Others said they had supervision infrequently, in one case only 3 times over a period of many years. Most of the former residential care staff who talked about supervision were aware of its purpose and recognised this was a real deficiency at Kerelaw.
9.55 One former manager told us that she had been sent on a training course and this enabled her to offer better supervision to her staff. However, another former senior manager at Kerelaw expressed the view to the Inquiry that formal supervision within residential care was not as important as in fieldwork, as the residential task often took place in the presence of line managers. This represents a very limited view of the nature and purpose of supervision which ignores the individual support and challenge staff need to receive in private.
9.56 A former senior manager in Glasgow City Council expressed a similar view about supervision in the fieldwork setting. He considered supervision could reinforce poor practice and suggested that the informal daily, and sometimes hourly, contact social workers had with their line managers was better. This seems to the Inquiry also to be a narrow view of the potential of formal supervision. With disagreement among managers as to the value of supervision, it is hardly surprising that the institutional commitment at Kerelaw to making supervision happen and to its quality appears to have been poor.
9.57 The Inquiry read examples of supervision notes. They were very brief, followed a set pro forma and lacked detail. We noted that many had been prepared as part of portfolio submissions for Scottish Vocational Qualifications ( SVQs). Questions about the regularity of supervision were raised with the Principal by the external manager in March 1998 following statements about its deficiencies by staff in fact-finding interviews. Lack of supervision was also a significant issue identified in the Review of Night Care carried out that year. The absence of regular formal supervision was noted in inspection reports over the years. North Ayrshire Council had noted deficiencies in their inspections of the Open School in 1997 and of the Secure Unit in 1998. In his paper on a "New Kerelaw" in early 1999 (see Chapter 10) the recently appointed Principal noted that supervision:
…should have regular dedicated time, be recorded and be thorough. High quality supervision and high quality practice are inextricably linked.
9.58 Towards the end of 1999 an action plan following up the Night Care Review included improving supervision at Kerelaw. A training day for unit managers and deputy unit managers took place at the beginning of September the following year. Two months later new guidelines for supervision set out how frequently this was supposed to happen for all staff. Henceforth supervision was to be pre-planned and monitored by line managers on what was termed a "look-see" basis.
9.59 It is not clear what sustained improvement took place, although there seems to have been some increase in frequency. However, in the report of its inspection of the Secure Unit in March 2001 North Ayrshire Council noted that the planned programme of supervision was not being applied consistently, and in its inspection of the Open School in July of the same year it noted that poor records made it difficult to tell if formal supervision took place. In its inspection of the Secure Unit in February 2002, North Ayrshire Council noted that there were still deficiencies in supervision. Even when inspectors found evidence that supervision was taking place, it was generally not happening often enough nor recorded appropriately.
9.60 In May 2002, a Management Review and Development Day identified revision of the format of supervision and its incorporation in staff development plans as one of a number of priorities for action. We were not able to establish from written records or oral evidence the extent to which this was implemented. In the Care Commission/ HMIE inspection of August 2004, the arrangements for formal supervision of care staff were evaluated as unsatisfactory. To what extent that reflected the removal of a number of managers and staff in 2004 it is not possible to say. It may be that, as with a number of other proposed changes over the years at Kerelaw, disagreements, operational pressures and a lack of sustained management follow-through, got in the way.
The potential of supervision
9.61 The 21 st Century Social Work Review Changing Lives17 suggested that one of the strengths of social work in the past had been using professional supervision to challenge practice and discuss solutions to complex problems. There was concern during the review that some social work managers were using supervision to take accountability for social workers' actions rather than promoting and enabling personal and professional accountability on the workers' part. Many social workers reported that supervision had become little more than workload management.
9.62 Changing Lives sets out a new approach to supervision. It suggests that "consultation" better describes a process which supports and challenges, rather than merely supervises, professionals. The new term "consultation" includes 3 core elements: performance management; staff development; and staff support. Its aim is to enable practitioners to deliver high standards of practice and improved outcomes for service users. However, the effectiveness of "consultation", like "supervision", will be dependent on the commitment of managers at all levels to engage with appropriate frequency and professionalism. That commitment was not evident at Kerelaw even though deficiencies in supervision had been identified by Inspectors and plans were made to improve practice. Nor was this commitment evident from external managers of Kerelaw. The Inquiry considers that robust performance management and supervision are key to reducing the risk of circumstances similar to those at Kerelaw occurring elsewhere.
Conclusion
9.63 The culture at Kerelaw, with its emphasis on control, and the physical capacity to enforce it, was an important factor in the circumstances which led to abuse taking place largely unchecked over a prolonged period. This culture was readily reinforced by a local workforce with shared attitudes and behaviour. There was no effective system of performance management or appraisal, and failures in supervision played an important part in what went wrong at Kerelaw
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