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11. INSPECTION

11.1 We recorded at paragraphs 4.29 and 4.30 that a number of different bodies were responsible for inspecting Kerelaw School and Secure Unit from 1996 until its closure in 2006. In addition there were significant changes in legislation on regulation and inspection during the period, including those deriving from the (Regulation of Care (Scotland) Act 2001).

Inspections between 1996 and 2006

11.2 North Ayrshire Council carried out yearly inspections of Kerelaw Open School until 2002, when it handed this over to the newly established Care Commission. The Care Commission was expected to carry out one announced and one unannounced inspection each year, and in February 2003 it carried out its first full announced inspection of Kerelaw.

11.3 There were inspections by HMIE in 1979 and 1984 focusing on educational provision, but, as stated in the HMIE letter of 21 September 2007, to the Minister for Children and Early Years, there are no records of the Open School having been inspected by HMIE between 1984 and 2001. In 2001 HMIE carried out an abbreviated inspection of the Open School as part of a national sample of provision for pupils with special educational needs. In November 2003 HMIE and the Care Commission carried out their first integrated inspection as part of their new programme for residential schools.

11.4 The Secure Unit continued to be subject to three-yearly inspections for approval purposes. Inspections of the Secure Unit took place in 1995, 2000, 2002 and 2003 led by SWSI and including a medical professional from the SEHD. HMIE were obliged to inspect the education provision for approval purposes and they did this separately from SWSI and SEHD in 1995 and 1999. In 2002 SWSI and HMIE simultaneously inspected the Secure Unit. This inspection was not joint or integrated. In February 2003 SWSI, HMIE and the Care Commission carried out the first integrated inspection of the Secure Unit. That integrated inspection was the last one SWSI and SEHD were involved in before responsibility for inspecting secure care services passed to the Care Commission.

11.5 Correspondence in 1998 between Glasgow City Council and the Scottish Office highlights some problems with the inspection programme for the Secure Unit. Although SWSI and HMIE were carrying out the three yearly inspections to satisfy the approval process, SWSI suggested to Glasgow that local authority inspection units should also be inspecting twice yearly. After some debate about whether it should be Glasgow or North Ayrshire Registration and Inspection Unit, North Ayrshire was asked to do it.

11.6 In August 2004 the Care Commission and HMIE undertook a joint inspection of both the Open School and the Secure Unit. This inspection led to a very negative report and resulted in the Care Commission issuing an Improvement Notice in October 2004 in respect of the Open School and a Condition Notice in respect of both the Open School and the Secure Unit. The Council decided to close the Open School and did so at the end of the year. HMIE and the Care Commission continued to inspect the Secure Unit until it closed in March 2006.

11.7 The Inquiry had access to HMIE, SWSI, North Ayrshire Council and Care Commission inspection reports since 1996 as well as a number of background files, inspection notes, correspondence and action plans. Changes in the inspection process over time are reflected in the various reports. This complicates attempts to identify improvements or otherwise over time. The various agencies took different approaches and used different quality standards. There was no formal integration of inspections until 2003 following the setting up of the Care Commission. Inspections of the Open School in particular highlighted a number of problems and concerns over the years, some more than once. These problems and concerns led to recommendations for action. Some were acted on, others were not, and there was little evidence of sustained, systematic follow-through by local or external managers in a number of important respects.

11.8 It appears that very limited information from their annual inspections was passed on by North Ayrshire Council to the newly established Care Commission in 2002. This meant that the Care Commission was not in a position to follow up a number of significant issues. In addition North Ayrshire Council's practice of inspecting the Open School and the Secure Unit in alternate years led to Kerelaw as a whole being subject to less inspection than other residential schools.

Concerns raised in inspections

11.9 A number of concerns were raised in inspection reports over the years with little progress being identified. These related to:

• Staffing: not enough staff, not enough qualified staff, many staff on temporary contracts, initially as a result of the freeze on recruitment to permanent posts imposed by Glasgow City Council immediately following local government reorganisation. Contractual issues were regularly identified by North Ayrshire Council until resolved in 2000. The need for more staff, recognised by Kerelaw management, but only partially responded to by Glasgow City Council, was also a recurrent theme.
• Supervision : lack of formal supervision, or inconsistent supervision, which we have discussed in Chapter 9.
• Fabric of the building: damaged toilets were a particular source of criticism in the inspections undertaken by North Ayrshire Council, and although improvements were noted, and some attempts were made to brighten up and redecorate living units, there is a theme of unsuitable and decaying accommodation.
• Privacy and dignity: linked with this were regular references to poor toilet, shower and bathing facilities, with broken fittings and doors which did not lock. Although some progress was noted over time, these basic living conditions were not improved quickly enough.
• Training : although some improvements were noted over time there were throughout issues about access and record keeping, and about refresher training in TCI, which was not kept up to date, as we have noted in Chapters 8 and 10.
• Complaints procedure: a poor, ineffective complaints process and lack of evidence of feedback to young people were a theme in several reports. This should have been a warning sign, but was not followed through.
• Private access to a phone: although the lack of this was noted on a number of occasions, this was still not available in all units. This is crucial to safeguarding, although we recognise there may need to be limits as some calls may have to be monitored; but the risks should be assessed on an individual basis.

11.10 File notes suggest that some inspectors had concerns which did not always find their way into published reports. This may have been because they could not always be checked and corroborated. An internal memo following the HMIE inspection of the Secure Unit in September 1999, which focused on the curriculum and made a number of criticisms of leadership and staff development, described the inspection as a "profoundly depressing experience" and said that education had risked being judged unsatisfactory, but for some committed and effective teachers. There was said to be an urgent need for inspection of residential care and that it would be important to alert SWSI. There were references also to a "general air of unrest" in the Unit which were subsequently not included in the report.

11.11 The Inquiry found no written evidence that concerns expressed by inspectors to one another in the course of inspections were consistently addressed in feedback to the Council, although we were told that "soft" information would usually be reported. We also saw internal Care Commission briefing material for the inspection carried out jointly with HMIE in August 2004. This listed a catalogue of perceived failings at Kerelaw which seemed to have been developing over some time and which were in the Inquiry's view valid. However, these had not been exposed in the report of the integrated inspection carried out by the Care Commission and HMIE in November 2003, because, we understand, the authors felt there was insufficient "hard" corroborated evidence to include them. We return to this "soft information" at paragraphs 14.4 and 14.5.

Lack of overview

11.12 A significant contributory factor in the continuing deficiencies at Kerelaw over many years was the lack of any person or body having the whole picture. The Open School and the Secure Unit appeared to function as two separate institutions, a situation exacerbated by the changes in management introduced by the then Principal in 1999 (see paragraph 10.21), although there is evidence that, following the management changes referred to above, there were improvements in secure care. They were inspected as separate entities despite having one overall manager in the person of the Principal. The reason for this is that legislation, both previously and currently, required them to be separately registered and inspected.

11.13 Relationships between staff in the Secure Unit and the Open School were described as tense at times, but differences between the two parts of Kerelaw were not the only divide. Relationships between education and care staff were also described in inspection reports at times as poor. This picture may be mixed, however, as other references describe these relationships as positive, or at least as improving between inspections. There is some evidence in reports of strained relationships between care staff working in the units and the senior managers. Tensions were also evident between the managers in the school and their external managers in Glasgow.

First integrated inspection

11.14 In November 2003 the first integrated inspection of the Open School was carried out by the Care Commission and HMIE as part of a new programme of integrated inspections of residential schools. The inspection was, as previously noted, led by the Care Commission, but as it was an integrated inspection, it was collated and edited by HMIE in accordance with the HMIE and Care Commission protocol. This report was published in April 2004. Of the 5 recommendations for action 3 referred directly to education provision, one to the management and organisation of the school as a whole and one to residential accommodation.

11.15 Despite the weaknesses highlighted in the report, which we have described at paragraph 10.39, and although as we have noted, the Head of Education in the Open School raised concerns with the external manager, this report appears to have been regarded by some senior managers at Kerelaw as not unsatisfactory so far as care and child protection were concerned. The inspection did, however, result in requirements that the recruitment of care staff should be carried out timeously to improve the safety of young people, and that the Principal should improve the consistency of management in the residential units to ensure young people's needs were being met.

11.16 The report noted concerns relating to basic personal care. For example, in some units bathrooms and shower rooms did not provide enough privacy for young people, an issue raised on more than one occasion in previous reports. Also, residential units did not have security systems in place for visitors. Yet again staffing levels in the units were considered to be inadequate. This report referred to a number of areas where the recommendations of the previous HMIE inspection had not been implemented. For example, the school did not yet have a suitable management structure to support educational developments there, and inspectors were sufficiently concerned to attach the action list from the previous HMIE inspection with a note on what progress had been made.

Lack of follow-up

11.17 Contrary to the views of some Kerelaw managers who have suggested that inspection reports were positive over the years from 1996, a number of serious deficiencies in basic personal care were being picked up and reported on. This included some highlighted in the Children's Safeguards Review (1997), such as the handling of complaints and staff supervision.

11.18 There are various reasons why these issues were not systematically followed up.

• External managers were not always actively involved in this process. They did not always attend the oral feedback meetings. They did not take an active role in making sure that recommendations were implemented. Sometimes they disagreed with them.
• Internal managers did not always take inspection seriously. On at least one occasion, attempts were made to refuse inspectors entry to the school.
• Inspection agencies did not always pursue the resulting action plans.
• Prior to 2003, Kerelaw was not inspected as often as it should have been, resulting in lengthy gaps between inspections and consequent difficulties in tracking progress.
• The inspection regime changed over the years and the transitions lacked handover or overlap.
• Prior to 2002 the inspection regime did not have regulatory powers over local authority services.
• There was fragmentation of inspection, with up to 4 different agencies involved at a time.

And no-one was pulling all the information from inspections together. This was not happening within Kerelaw, Glasgow City Council or indeed in the inspection agencies until 2003, from which year there was a joint inspection process by the Care Commission and HMIE, involving SWSI as appropriate.

Inspections did not pick up abuse

11.19 Young people are unlikely to confide in inspectors that they are suffering abuse. They will often not tell anyone while they remain in the placement and they are most likely to confide in someone they know well and with whom they have an ongoing relationship. However, child abuse is not only uncovered when a young person is able to tell an adult about it. Adults working with children need to be aware of the signs and be assertive in seeking out explanations. Inspections need to look in detail at the operation of the mechanisms in place to protect children and young people. The complaints procedure would be key here, as would fully trained and well-supervised staff. Hazards should also be identified: for example, lone working, staff working excessive hours and poorly defined boundaries between staff and young people. As we have noted, warning signs had been present at Kerelaw over the years and were being identified, but no-one in the management chain seemed to take a rounded view or took ownership of following them up.

The Care Commission's response to the Glasgow Report

11.20 The Care Commission in its report for the Minister for Children and Early Years suggested that Glasgow City Council did not give enough attention to inspection reports and requirements or recommendations. It also noted that the service did not have robust self- assessment and performance management systems in place. It pointed out that the inspection regime prior to 2002 did not have regulatory powers over local authority services and considered this to have been a weakness in that system. It went on to say that regrettably not all service providers respond fully and timeously to recommendations or requirements. As a result, the Care Commission does have to take formal legal enforcement action to secure the required improvements. It noted that in 2006-07 it took enforcement action against 3 out of 35 residential schools/secure services, or 9%. It pointed out that this was a high level of enforcement when compared with other types of services regulated by the Care Commission and indicated that the internal and external management of these services needed to improve. During the same period, the corresponding figure for levels of enforcement for all regulated services was just 1%.

11.21 In the Care Commission report The Quality of Care Services in Scotland (2007 - information from inspections to April 2006), it noted that there were significant concerns in more than 1 in 3 special residential schools. These concerns, all of which have resonance with weaknesses the Inquiry identified at Kerelaw, related to:

• the care and welfare of pupils
• risk management
• lack of security in accommodation
• insufficiently robust child protection arrangements
• inadequate care planning for young people
• lack of continuity between care and education
• a lack of good leadership on the part of some services

Next steps

11.22 In March 2008 the Care Commission published Protecting Children and Young People in Residential Care: Are We Doing Enough? Because of the number of serious allegations of past mistreatment in residential care and the concerns noted above, the Care Commission set out to check on the safeguards for young people and to encourage better practice in child protection. The report looked at 3 important areas of practice in residential care of young people: protecting children; planning for their care; and using physical restraint.

11.23 The report gathered together what the Care Commission had learned from their regulation of the quality of practice in each of the above 3 areas. Although inspections found a number of services using good practice, over 50% of services needed to improve aspects of their practice in one or more of these areas. The report made the following recommendations:

• Local authority staff responsible for placing young people in residential care services and care service staff need to make better assessments of young people's needs before they are placed in residential services, to ensure services are able to deal with challenging behaviour without excessive use of restraint.
• Care services need to consider and respond to the detailed recommendations in the report to improve practice in child protection, care planning and the use of physical restraint.
• The Scottish Government, COSLA, appropriate professional organisations, service providers and the Care Commission should work together to promote the use of a standardised system for recording when physical restraint is used and to consider the merits of introducing a national accreditation system for training in de-escalation (calming situations down) and the use of physical restraint.

11.24 On the basis of the Inquiry's findings, we support those recommendations.

Improving inspection of residential schools

11.25 In September 2008 the Care Commission issued supplementary guidance on inspection of residential care for children. This followed a review of inspection methodology and management arrangements for regulating special schools and secure services, and took account of the responses from HMIE and SWIA to the Minister for Children and Early Years in relation to the abuse at Kerelaw School and Secure Unit. In addition they took account of the findings from A review of residential services for young people with harmful sexual behaviour (2007) ²⁰.

11.26 This prompted a more robust approach to inspections, incorporating greater collaboration with SWIA and HMIE. The Commission reviewed and strengthened their joint inspection approach with HMIE and the Inquiry was told that they were focusing inspections on key processes designed to examine the quality of outcomes for young people. In April 2008 the Commission introduced grading for all inspections, supported by requiring services to produce robust self-evaluation, involving young people, their carers and other relevant stakeholders such as placing social workers and independent advocates. Included in the revised inspection process is the "case tracking" model that specifically focuses on the young person's needs being met, taking account of inputs and how these impact on positive outcomes.

11.27 It is too early to assess the impact of this new methodology. However, it does represent a more holistic approach to inspecting the quality of service being offered to children and young people in residential care, and we welcome and support that.

Conclusion

11.28 Inspection did not stimulate change at Kerelaw, partly because of insufficient coordination and overview, and partly due to lack of proper follow-up by internal and external management. Inspections resulted in mixed reports over the years, with good points and progress noted, alongside consistent concerns around staffing levels, the state of the buildings, lack of supervision, poor record-keeping, particularly in relation to complaints, and care staff-education staff interactions. It is clear to the Inquiry that inspection alone cannot be relied upon to bring about change and improvement, which can only be achieved through appropriate follow-up and management action.

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