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12. THE CHILD AT THE CENTRE
Children's Rights
12.1 The Inquiry considered what life was like on a day-to-day basis for young people at Kerelaw and the extent to which those responsible for their care exercised their duties appropriately and placed the needs, welfare and rights of children at the centre. In 1997 Kerelaw's statement of objectives noted:
Rights are now viewed as an everyday concern for staff and residents alike. This has been brought about through training and open access to local authority's rights workers and Who Cares? Negotiation, support, responsibility, mediation and active listening are central to this issue and at every level there are opportunities to voice concerns.
12.2 A number of former staff told the Inquiry that Kerelaw encouraged CROs and other advocacy staff to visit children placed by their authorities. They appeared to recognise the importance of such services in safeguarding children in their care. However, inspections of the Open School in 1999 and 2000 by North Ayrshire Council reported that:
information regarding external advocacy services and children's rights was not available throughout the units and young people displayed a lack of awareness about how to access this information.
and:
inconsistency regarding the display of information about children's rights across the school……..Some young people seemed to have no access to their local authority Children's Rights Officer.
12.3 The Inquiry interviewed a number of CROs who had worked with children placed at Kerelaw. We also interviewed "Who Cares?" staff. All the advocacy workers we spoke to expressed concerns about Kerelaw. They were not always made welcome and sometimes were treated dismissively or ignored by staff. They also faced obstruction as they attempted to carry out their work. For example, one cited being denied access to key operating procedures without reasonable explanation. This made it difficult for advocacy workers to challenge particular working practices or advise children.
12.4 The Inquiry also heard that some staff at Kerelaw did not seem to understand the role of the CRO or indeed the centrality of children's rights in the "looked after" system. This was illustrated by the example of a member of staff asking "what about our rights?" The Inquiry was told of one CRO having to explain that children's rights were not dependent on their responsibilities, although it did not mean children had no responsibilities. We heard of one young person being told by staff that there was no point in talking to the CRO as the latter could not change anything. However, not all the staff at Kerelaw were unwelcoming to advocacy workers or resistant to embracing children's rights. In some units they were made welcome, private space was made available, and young people were encouraged and supported to approach them.
Complaints
12.5 An effective complaints system is of fundamental importance to the safeguarding of children, and the principle that young people in residential care require visible and accessible complaints procedures is widely accepted. There was a complaints procedure at Kerelaw. Documentation from 1997, 2000 and various points thereafter refer to such a procedure, and mechanisms were in place for both informal and formal complaint and allegation handling. Formal complaints leaflets appear to have been in place from at least 1997 and Glasgow City Council complaints procedures should have applied. Although all inspection reports from 1996 to 2004 acknowledge there was a procedure in place, various issues were raised as to how this was working in practice.
12.6 The Inquiry heard mixed accounts of the complaints procedure from both ex-staff and ex-residents. Some said it was well-used and effective. Others said making complaints was discouraged, the process was inconsistent and too slow, and outcomes were poorly communicated. Inconsistency in the way complaints were dealt with from one unit to another is evident in inspection reports. Generally, over the years, young people told inspectors they were aware of their right to complain and the procedure they should follow. However, inspectors noted that records of complaints and their outcomes were not always as detailed as they should have been and young people did not always receive written feedback. Responses and outcomes to some complaints were extremely brief and at times barely legible. Inadequate records of feedback raised questions about the effectiveness of the complaints system.
12.7 Most former staff who gave evidence to the Inquiry were aware, as they should have been, of the complaints procedure. Some elements appear to have been well understood. Some ex-staff talked about supporting young people to write complaints as they recognised that this was important in terms of safeguarding and promoting children's rights. Others appear to have considered it a matter of operational requirement rather than good practice. Staff attitudes to complaints were raised in two inspection reports. In one there was concern that young people were discouraged from submitting complaints because of a belief that these would not be treated seriously due to the "jokey" stance of the staff. In another report inspectors noted that complaints in one unit were treated in a minimalist fashion.
12.8 Access to complaints forms was also inconsistent. The Inquiry heard that it was standard practice for complaints paperwork to be distributed only by a duty manager. This meant that children could not raise issues anonymously or choose whom best to complain to. There were many pressures on young people not to make complaints. We were told of complaints often being withdrawn by young people. The Inquiry saw a form which had been drawn up for this purpose. Sometimes there would be a genuine change of mind, perhaps after the young person had reflected on the issue. However, in one well documented case we heard of a complaint being withdrawn because of peer pressure as a promised outing had allegedly been cancelled because staff had to attend fact-finding interviews. Peer pressure was a common disincentive. In the opinion of one external advocate, who had strong views:
The internal complaints procedure at Kerelaw was wholly inadequate. Complaints were not acknowledged in writing and young people did not receive responses verbally or in writing. ……young people were intimidated by staff (and other young people) when they did make complaints and some were later withdrawn as a result……young people feared intimidation and reprisals so much that the whole complaints procedure was undermined.
12.9 The Inquiry concluded that some staff and young people had little confidence in the complaints system. One young person interviewed by Council investigators encapsulated a prevalent view that:
…there was no point in complaining as nothing was done…
while another was more specific:
…… he had completed a complaints form several times about being hurt in restraints and passed them to his unit manager … he had not received any acknowledgement of his complaints. No one had spoken to him about his complaints, nothing had been done.
12.10 Kerelaw managers stated in evidence that they were told to do different things by Glasgow City Council at different points in time, but maintained that they always passed allegations outside the school, and often arranged for joint investigations to be carried out with external placing authority representatives. There is documentary evidence to support that: some complaints and allegations did make it out of Kerelaw, but by no means all. When they did, rights workers, parents or in some cases fieldwork staff were generally instrumental in ensuring they were followed up.
12.11 We are aware of two local authorities raising significant concerns about the manner in which allegations of mistreatment were handled by both Kerelaw and the Council over a number of years. These allegations included emotional, verbal and physical abuse as well as concern about how practices like strip searching, single separation and restraint were carried out. A number of investigations were conducted involving external fact-finders. However, the Inquiry is aware of one occasion where the Principal refused to cooperate in a joint investigation because he did not agree with the choice of investigator and insisted the individual was replaced. The Head of Service agreed to this and appointed a different fact-finder.
12.12 The Inquiry read documents and spoke to staff from a placing authority which had removed children from Kerelaw following child protection investigations in 2000 and 2002. The Director of Social Work of this authority followed up with senior managers in Glasgow City Council and assumed incorrectly that the authority's concerns were being followed through at the highest level.
12.13 In 2001, Glasgow City Council implemented new procedures for complaints and allegations entitled Complaints and Allegations - Keeping Children and Young People Safe. This followed a review of the Council's complaints-handling practice in line with the findings of the Edinburgh Inquiry in 1999 and the Kent Report of 1997. The Waterhouse Report 21 in 2000 had also recommended the vigorous promotion by local authorities to children and staff of its complaints procedures for looked after children.
12.14 Keeping Young People Safe defined separately complaints (expressions of dissatisfaction about services) and allegations (concerns raised about possible abuse or harm) and set out different responses: a standard complaints procedure route and a child protection route. It made a distinction between informal and formal complaints. It emphasised the value of trying to achieve resolution at as early a stage as possible, and provided for informal complaints to be addressed at a local level with negotiation and dialogue aimed at securing resolution without the need to invoke formal mechanisms. Within the informal route the young person was able to choose to formalise his or her complaint if he or she was not satisfied with the response.
12.15 The procedures included standard forms of paperwork covering among other things provision of information to young people and residential staff. Timescales for investigation, providing feedback and appeals mechanisms were set down and there was provision for monitoring complaints and allegations. The Keeper of the Child Protection Register in the Council was charged with responsibility for recording all complaints and allegations on a central log and was required to report to the Head of Children and Families and Criminal Justice every 4 weeks, and to the Child Protection Committee on an annual basis.
12.16 Even after the 2001 procedures were distributed some ambiguity remained as to what constituted a complaint. Some senior staff at Kerelaw refused to acknowledge a complaint unless it had been written down on paper and signed off by a resident. We were told that on one occasion external fact-finders arrived at Kerelaw to investigate an oral allegation of mistreatment, and were sent away on the grounds that the allegation was not recognised as a valid, recorded complaint. The Inquiry heard from advocacy workers that much perseverance and determination were required to follow up on complaints and allegations made by young people. Many people who gave evidence to the Inquiry said that the default position within Kerelaw was that there was no case to answer.
12.17 Kerelaw was excluded from the complaints monitoring and recording arrangements introduced within the 2001 procedures for other Glasgow units. It operated its own separate system for recording complaints and allegations and relied on the external manager to provide oversight and monitoring. The Inquiry was unable to locate the relevant logs. The requirements placed on the Keeper of the Child Protection Register in the Council to record all complaints centrally, to report to the Head of Service and to the Child Protection Committee did not include Kerelaw. The new arrangements included the introduction into residential units of boxes into which complaints could be posted. The boxes would be emptied by an administrator from outside the unit. Kerelaw apparently did not accept the boxes and it seems that although their introduction was supported by external management, the matter was not pressed or, it seems, implemented until 2004.
12.18 The Inquiry acknowledges that even those who had negative comments to make about aspects of Kerelaw's approach accepted that some staff and systems worked for some children on some occasions. Some complaints and allegations were investigated and recorded appropriately. The outcomes in such instances may well have been beneficial for children and for developing professional practices. As we have noted, some staff supported children in expressing themselves and complaining either formally or informally. Such staff made constructive efforts to respond to children's concerns speedily and in a manner which offered resolution without the need for formalisation.
12.19 In 2002 SWSI, in its follow-up inspection of the Secure Unit, recommended that the complaints procedures, which were correctly those of the managing authority, needed to reflect specific arrangements at Kerelaw. This was recorded as having been achieved in the November 2003 integrated inspection, although it was noted that Kerelaw still needed to set these procedures out clearly in the information pack supplied to placing authorities. The Care Commission inspection reports of 2003 and 2004 note that Kerelaw was not displaying the details nor including them as part of the complaints procedure, and the final integrated inspection of the Open School in 2004 noted that the complaints procedure did not meet regulatory requirements.
Admission arrangements
12.20 Although there were procedures for planned admissions to Kerelaw, we heard from a number of different sources that many, and at times most, admissions were on an emergency basis. We read correspondence and minutes of meetings which confirm that emergency admission was the most typical route. In 1997, 40% of all admissions were made on that basis. Pre-placement meetings occurred for some young people, but we heard about children often being dropped off by social workers, the police or the standby service at a point of crisis. High numbers of emergency, rather than planned admissions, can often have a detrimental effect on the care of a group of young people as there is no opportunity to ensure the mix is appropriate. Children arriving on an unplanned basis, often in crisis and sometimes in the middle of the night, is unsettling for those already in placement.
12.21 A secure screening group met weekly in Glasgow to prioritise admissions to secure care. A central prioritisation group met to allocate placements within residential schools, and would often ratify admission decisions in retrospect. Kerelaw managers were directly involved in both processes. Fieldworkers and residential care staff told the Inquiry that the process did not facilitate the matching of placements to children's needs. Kerelaw was often used because it had more capacity than other establishments, and Glasgow City Council as managing authority was able to direct admissions to a greater extent.
12.22 Some suggested that Kerelaw, as a local authority resource, was not in a position to be as selective as other establishments and took more than its fair share of inappropriate admissions. The lack of alternative specialist resources, in particular for young people with mental health problems and learning difficulties, also led to many inappropriate placements. Expectations of quality care and positive outcomes were not high, but Kerelaw fulfilled a purpose. There was a frequently reported view that Kerelaw was no more than a dumping ground for young people who had particular problems or who had "failed" in other placements. Most Council managers who gave evidence to the Inquiry conceded that Kerelaw was not ideal and some said that it functioned as a "safety valve in a dysfunctional system".
12.23 We heard from different people and read evidence suggesting that there were also occasions when children were accepted on a respite basis. At times this involved their sleeping in beds only temporarily empty due to other children being on home leave. This was highly inappropriate and communicated a lack of care to both the child on leave and the child on respite.
12.24 The Inquiry was told that the age profile of the young people in Kerelaw increased over the years, with many young people over the age of 16 placed there. Minutes of screening groups we read indicated that a shortage of supported aftercare placements meant that those who had started at Kerelaw at 14 or 15 had to remain there much longer than had been planned. Children who are brought up at home with their families are rarely ready to leave home at 16, and keeping them within the children's system until they are at least 18 can be good practice. However, the right support needs to be in place to prepare them for moving on. This was one of the challenges in caring for a group of young people whose age range was steadily increasing.
12.25 At times, Kerelaw was able to offer dedicated staff to this group to help them prepare for the future. In the mid-1990s the Deputy Head (Open School) designated unused accommodation for independent living as a base for preparing young people over the age of 16 for leaving Kerelaw. This was not resourced properly and relied on staff working extra hours to keep it operational. Some of those who spoke to the Inquiry praised the initiative as innovative and necessary. Others considered that the arrangements were badly thought out and poorly managed. As we noted at paragraph 10.20, the facility was ended in early 1999, following concerns about a budget overspend, although the Deputy Head (Open School) tried unsuccessfully, including through a direct intervention with the Depute Director of Social Work, to keep the initiative alive.
12.26 At other times, young people approaching adulthood were largely left to their own devices and little in the way of effective throughcare work appears to have taken place. There is some evidence that young people were discharged in an emergency when their Kerelaw placement broke down. Thus both the routes in and out of Kerelaw for young people were often when they were experiencing significant difficulties. This is bound to have had a negative impact on the atmosphere and stability of the care setting.
Needs Assessment, Care Planning, Interventions and Review
12.27 The Inquiry considered the arrangements for assessment and care planning for children placed in Kerelaw. We read the available fieldwork and residential files for a sample of 30 young people who had been placed at Kerelaw between 1996 and 2006. We found a mixed picture. With so many young people placed on an emergency basis, social workers had little opportunity for care planning prior to admission. Glasgow City Council fieldworkers had significant caseloads. One former senior child care manager said that in the early 2000s only about 30% of looked after children in Glasgow had care plans, and that some child care fieldwork teams were running with 50% vacancies. This is not surprising given the severe shortage of qualified social workers which the Council was experiencing at the time, and it meant that many children in care did not have an allocated worker. The Inquiry is concerned at the impact this must have had on effective care planning, safeguarding and review for children in care.
The role of fieldworkers
12.28 Fieldworkers should have had a central role in ensuring that placements in Kerelaw were appropriate, planned and purposeful. Glasgow City Council set out responsibilities in terms of care planning and review procedures in 2002 in response to the Looking after Children In Scotland, Good Parenting Good Outcomes material. These procedures superseded review procedures established by Strathclyde Region and amended in 1990 and 1995. In 2004 the Council updated the 2002 procedures.
12.29 From our file sample we concluded that recording practices varied considerably in scope, quality and accuracy. We were particularly concerned about the lack of attention to detail evidenced for example by different spellings of children's names and different dates of birth for the same child. This lack of quality control may lead to problems retrieving data in the future. The Inquiry found this careless approach to recording important information about children under the care of the Council disconcerting, and would be concerned if the lack of attention it implied had been replicated in direct engagement with young people. In some case files the recording was so poor it was not possible to establish the frequency of contact between the worker and the child. Nor was it always clear what work was being carried out.
12.30 We were able to draw some conclusions about the progress of care plans from reports provided for Children's Hearing and Looked After Children reviews. However, we noted that there was rarely a complete set of Looked After Children review paperwork. Often papers had not been tabled in advance of reviews and we assume had therefore not been discussed with the young person. We found it difficult to track progress between reviews, mainly because of the similarity of information presented on each occasion. We found little detail in the files of focused or specific interventions whether by fieldworkers, care staff, education staff or specialist services.
12.31 In the papers sampled, a lot of care planning activity seemed to be about home leave negotiations. The use of home leave was encouraged by Kerelaw. It was used as a way to help children retain contact with family and community life as well as a process of developing independent living capacity. Its cancellation was used as a sanction. We saw little reference to specific needs assessment, risk assessment or planned interventions, and the impression gained was of action planning being more about sustaining the Kerelaw placement, rather than addressing particular issues or behaviours which had contributed to the decision to accommodate the young person there in the first place. The Inquiry recognises that this approach may be appropriate for some young people at key times in their placement journey, but the apparent lack of other action planning was unsatisfactory.
12.32 Fieldworkers we talked to said they would assess and draw up care plans, but because they did not have the necessarily resources, they could not deliver the plan. Day-to-day implementation of the plan was generally up to Kerelaw staff. We did see evidence of prolonged social work involvement with young people and their families prior to admission to Kerelaw. There was evidence that attempts had been made to support young people when they were in the community. Some had been supported at home or in foster care or residential care before placement at Kerelaw. Referrals to other agencies and projects for community support, group work and addiction services were evident. When a young person moved to Kerelaw, access to support services revolved round the school, and meaningful links with community services was minimal.
12.33 The Inquiry reviewed a small sample and we appreciate this may not be fully representative. However, it was clear that poor recording made it difficult to judge the appropriateness of fieldwork responses or establish the extent to which fieldworkers were able to drive care plans or follow through on safeguarding concerns. We also found unrelated files mixed in with the sampled files, which suggested that, should a young person ever wish access to his or her file in the future, he or she would be most unlikely to obtain the "misplaced" material. This is poor administrative practice and has an echo of the unsatisfactory record-keeping which was an important deficiency identified by Tom Shaw in his report on systemic child abuse in Scotland published in 2007 22
The role of Kerelaw staff
12.34 Ex-staff from Kerelaw told us that the concept of care planning within the school was emphasised following the arrival of the new Deputy Head (Open School) in 1993. The 1997 statement of objectives clarifies the Kerelaw approach to care planning as follows:
Individual care planning is the important building block for all young people referred to Kerelaw. Planning is undertaken by the key worker in collaboration with teacher, social worker, young person and family from the first stages of pre admission, to through care planning in the final phase. The care plan is promoted through weekly planned supervision sessions between key worker and resident and monthly with the key teacher. The Child in Care Review is the appropriate forum for significant modification to the care plan and these follow the local authorities approved format
12.35 The Inquiry heard that staff welcomed this new emphasis and were involved in care planning with young people. Many recognised that as key workers they could develop good relationships with young people and make progress with care planning objectives. From our review of Kerelaw files, we found a range of proformas, care planning materials and recorded information on young people's progress. We were told that individual units developed different approaches and would adapt the forms, but that between 1999 and 2000 common care plans were introduced. However, we gained little sense of joint working between the placing social worker and Kerelaw staff. There was often no direct correlation between formal Looked After Children care plan actions and objectives, and the day-to-day personal plans and records held in the residential unit.
12.36 Specialist addiction counselling, offending behaviour programmes and cognitive skills training were offered at Kerelaw, but we saw no written evidence of this work within individual records we sampled and can therefore make no judgement on its impact. Some fieldworkers said there was very little therapeutic intervention at Kerelaw and that, despite much being said by the school about its programmes, little was evident in reality. We did not find evidence on which to judge the accuracy of such assertions.
Absconding
12.37 Absconding appears to have been a regular and routine part of life for many young people at Kerelaw. Responses to children missing from placement varied. Some staff would try to prevent young people absconding, and would sometimes search the immediate area to try to get the young person to return. On other occasions, staff would simply record the absconding, notify the police, and await the young person's return.
12.38 All of the above responses may be appropriate, depending on the circumstances. Responses to absconding have changed over time within the residential sector. The Council's Missing from Placement Procedure issued in 2000 and updated in 2004 differentiates between a "missing child" and a "failure to return". The procedure acknowledges that placement staff need to exercise judgement as to response, depending on the assessed needs of and risks to the young person concerned, and his or her pattern of absconding. The procedure prescribes administrative arrangements for alerting Social Work HQ, notifying the police, the fieldworker and the child's parents.
12.39 The Inquiry heard from a number of former staff of the challenge of assessing risk and intervening appropriately. Some former staff took the view that, on a child's return, often late at night, and under the influence of alcohol or drugs, they had a duty to ensure the safety and wellbeing of the child. Some spoke sensitively about balancing the need to assess the risk the young person posed on return to himself or herself, and to others, with the need to ensure he or she was fed, made comfortable and brought back into the life of the unit. Conversely, we heard about punitive attitudes among night staff who saw their job as simply getting the returning absconder off to bed. This limited interpretation of their role seems not to have stretched to consideration of needs or risks, although we did hear that night staff felt overwhelmed at times having to collect absconders from distant locations, or search the grounds for absconders while maintaining sufficient presence in the units.
12.40 Some young people ran away because of incidents at the school or confrontations with staff or other residents. Absconding became a particular problem in late 2003 and early 2004, but we found little or no evidence of monitoring absconding rates across units, across shifts or across time periods to establish reasons. A significant increase in absconding in late 2003 appears to have been ascribed largely to the nature of the young people being sent to Kerelaw who, as we note at paragraphs 7.12 and 10.30, seemed by then to have become more challenging. But it is hard to escape the conclusion that there was over the years a degree of complacency on the part of the school and Glasgow City Council, and a lack of concern for what the young people involved might have been trying to say. A number of former staff told us that, with hindsight, they had asked themselves, not simply where did the young persons run to, but why did they run, and whether they were running from something that was happening at Kerelaw.
Conclusion
12.41 There were deficiencies in the way in which the interests of young people were protected at Kerelaw. Many of them were placed on an emergency basis which meant that there was often inadequate care planning prior to admission and a level of disruption and instability when they arrived. There were weaknesses in the arrangements for children who were placed in, and accepted at, Kerelaw and little joint working between placing social workers and Kerelaw staff. The rights of young people were not adequately upheld. The complaints system did not work effectively and there were pressures on young people not to make complaints at all. This important safeguarding issue was continually raised in inspection reports and was not properly followed up. The Inquiry's conclusion is that the arrangements for children placed at Kerelaw were insufficiently child-centred, despite the kind of Mission Statement described at paragraph 4.11.
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