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13. GLASGOW CITY COUNCIL'S STEWARDSHIP OF KERELAW
13.1 Local government reorganisation could not have come at a more unhelpful time for Kerelaw or for social work in Glasgow. Faced with the challenge of responding to major changes in legislation and regulation, senior managers in Glasgow City Council found very significant time tied up with managing the consequences of reorganisation. This included requiring staff from the former Strathclyde Region to be matched into Glasgow City Council posts in extremely difficult financial circumstances.
Financial pressures
13.2 Financial pressures were a major preoccupation for the Council. There were particular pressures on social work budgets as a result of how Glasgow's financial settlement was calculated. Balancing the budget against staff costs was a significant problem, not least because of the Council's policy of no compulsory redundancies. The Inquiry was reminded that there were poor relations between Social Work Services and the Council's management, with demonstrations in George Square and Council meetings disrupted. There was a crisis in social work staffing, with qualified social workers leaving to work for other authorities, and a general shortage of such staff lasting for some years.
13.3 The pressure on the Social Work Department from the scale of social problems which the Council faced, and still faces, was particularly acute. Discussions of budgets and restructuring were major, recurring items on the agendas of meetings in the Department and at corporate level in the Council, and took up much senior management attention. With financial problems preoccupying senior managers and the restructuring of Council services changing management responsibilities, it is unlikely that the needs of an institution 30 miles away, of which there was little understanding at the centre, would be a high priority in the first few years. As noted previously, the immediate impact on Kerelaw was a freeze on recruitment, which had later to be eased for residential units to enable them to function.
13.4 Residential accommodation is expensive, and it is clear from the records and from evidence to the Inquiry that the Council baulked at the cost of placing young people in residential care offered by other providers when this was more expensive than Kerelaw. A Best Value Review of Kerelaw, undertaken in 2000, which focused on the proposed rebuild and redevelopment based around the Secure Unit (see paragraphs 13.42-13.44), rather than the existing facility, recorded the cost of a placement in the Open School at £1,125 compared with £1,361 to £1,699 in residential facilities run by other agencies, and up to £2,900 in a close support environment. Kerelaw's Secure Unit costs were stated to be £2,093 a week compared with up to £2,749 elsewhere. The Review noted that:
Increasing the usage of the resource clearly carries a cost benefit to the Council if this is offset by a reduction in usage of more costly alternative provision in Scotland.
13.5 It recommended that as a matter of policy Glasgow City Council should increase its user share to 60%, thereby generating a saving in the cost of purchased places elsewhere, although a review of staffing agreed by committee in July 2001 proceeded on the basis of a figure of 50%. Kerelaw was both a cost and a potential source of revenue from other placing authorities, and it appears that significant priority was given to keeping Kerelaw's costs under control. At local government reorganisation in 1996, Kerelaw was organised as joint resource among all ex-Strathclyde Regional Council user authorities, reporting through a Joint User Committee ( JUC), which agreed staffing levels and budgets. In 1999 the JUC was disbanded, leaving Glasgow City Council with sole responsibility for the management of the budget and the setting of weekly rates. A former member of Kerelaw's SMT asserted that:
Glasgow was reluctant to raise fees and the related authorities were unwilling to pay more - even while complaining about the poor standard of Kerelaw.
13.6 The Council disputes that statement, but cost control was clearly important not only as good housekeeping, but also as a demonstration to other providers that it was possible to operate at a lower cost than theirs. A former external manager told us about:
… a dispute involving COSLA over residential school charges. The schools wanted to raise their fees. There was something of a stand off with Glasgow who refused to pay extra fees. Budgetary control at Kerelaw was then tightened to keep down cost and to demonstrate to other providers that residential schooling could be provided at a lower rate…this did affect Kerelaw at the time but… it was later recognised as not sustainable and investment increased…
or as it was put more bluntly by another witness:
Glasgow didn't want to use the independent sector as it was cheaper to use Kerelaw. Kerelaw's fees had been kept low to put a gun to the independent sector schools - to help keep the costs down.
13.7 Obtaining adequate resources for Kerelaw was therefore not easy for local management or for the Head of Service in the Social Work Department, where we learned there were numerous disagreements over funding priority between children and families services and community services. A review of staffing requirements by Strathclyde Regional Council in late 1994 had recommended restructuring and staffing reinforcement at Kerelaw. Staff numbers were supposed to rise from 80 to 97 at cost of nearly £300,000. Senior management was to be slimmed down, but 7 unit manager posts with some corporate responsibilities were to be created, along with 7 deputy manager posts. Night staffing was to be strengthened, with supervision added in. The Social Work Department was said to have contingency money for some of this, but the remainder was to be implemented when budgets allowed. It appears that budgets did not allow. Unit management was strengthened, but by 2001 the recommendations had still not been fully implemented. This had led to sickness and annual leave cover having to be met through overtime.
13.8 Although limited funds were provided from time to time to improve living conditions, concern about budgets was a regular feature of inspection reports, even before local government reorganisation. Following its inspection of the Secure Unit in May 1995, SWSI referred to a failure to establish an adequate budget, although an HMIE report on the Secure Unit later in the same year commented more favourably on the education resources. North Ayrshire Council's report in January 2001, following its inspection in October 2000 of the Open School, expressed concern that staffing levels were insufficient to meet the needs of young people and that there were potentially dangerous situations.
13.9 A case for additional staffing put together by the Principal in 2000 did not succeed, because planned increases in charges to pay for it were not agreed with COSLA. However, a paper reviewing staffing requirements for Kerelaw was submitted to committee at the end of July 2001. This referred to the adverse comments in Inspection reports about staffing levels and, by reference to the Waterhouse and Edinburgh Reports, to the need for extra staff to safeguard young people. It noted that a substantial increase in charges would now be required for 2001-02 to provide additional resource for Kerelaw. A number of additional care-related posts were approved and as noted at paragraph 10.35 these were successfully filled. These were welcome new resources, although two years later the Principal was again expressing concern that staff numbers were low.
External management
13.10 While the management churn at senior level within Kerelaw which we described at Chapter 10 militated against consistent leadership at a time when such leadership was becoming ever more necessary, deficiencies in internal leadership and management at Kerelaw cannot be viewed in isolation from deficiencies in external management. If vision was lacking at Kerelaw, it was no more in evidence in the Council, where a policy aspiration to reduce the use of residential accommodation for young people seemed to co-exist with a reliance on Kerelaw as a disposal of last resort for the most problematic client group.
13.11 Prior to 1996, external management of Kerelaw was provided through the District management of Strathclyde Regional Council's Social Work Department. We were told by some that the arrangements worked reasonably well, and that an external manager would regularly attend senior management meetings at Kerelaw. Others were more critical. As might be expected in relationships between a distant HQ and its field operations, there were from time to time budget issues and other points of friction, but the Inquiry was told that the external managers broadly understood Kerelaw and its needs. HQ, however, seemed largely to leave Kerelaw alone. We were told that senior people from Regional HQ in Glasgow tended to visit very infrequently.
13.12 At the transition of external management from Strathclyde Region to Glasgow City Council, Kerelaw became the responsibility of the Council's North and West District, and the District Manager became the external manager. He had a large workload and delegated responsibility for the day-to-day external management to his assistant District Manager. The latter was responsible for external management of all the residential establishments in North and West District and did not have a specific job description regarding Kerelaw. We heard in evidence that, although he had regular meetings with the acting Principal of Kerelaw, these were roughly every 6 weeks, less frequent than under the previous arrangements.
13.13 As we noted at paragraph 10.7, the external manager became acting Head of Kerelaw towards the end of 1997. Following restructuring within Glasgow City Council, formal external management responsibility then lay with the Head of Children and Families (Head of Service). She delegated day-to-day management tasks to an assistant principal officer, residential child care, who had previously worked as an assistant district manager and had extensive involvement in child care services. This was not welcomed by the individual concerned, who considered that she could not do the job justice. Kerelaw was only one component of her remit and she felt that, for legitimate personal reasons, she could not adequately undertake the on-call responsibilities or oversight of a large residential estate.
13.14 While the new external manager aimed to visit Kerelaw once every 2 to 4 weeks, in her year in post (she left Glasgow City Council in 1999), the Inquiry was told that she managed to visit all aspects of the Open School only once and the Secure Unit 3 times. She attended only one full staff meeting and participated in parts of senior management team meetings. Her early focus was said to have revolved around outstanding grievances and rumblings from certain staff. These rumblings included the concerns previously raised by the Deputy (Open School) about practice, which she believed related to allegations of physical assault of children by staff, unacceptable restraints and the way staff talked to children. However, it appears that these particular concerns were not followed up, although both the Head of Service and the Depute Director had been involved, as noted at paragraph 10.8, in consideration of the implications of fact-finding into allegations of assault by a young person placed by another authority.
13.15 With the departure of the external manager in 1999, her responsibilities fell back on the shoulders of the Head of Service, whose own position had become more stretched when the Depute Director of Social Work became Director and was not immediately replaced. This coincided with the implementation of the Children (Scotland) Act 1995 and the first round of Children's Services Plans - a substantial piece of work. In 2000 she was given the additional responsibility of Criminal Justice Services, and had to cover for the vacant Depute Director post. There were therefore few visits by the external manager to Kerelaw, although the new Principal appointed at the end of 1998 did maintain frequent and close contact with her, and there are records of exchanges between them on a number of matters, including concerns about Kerelaw expressed by external users.
13.16 Particular difficulties arose when in 2001 the Principal, having become Head of Service following the latter's promotion to Depute Director, appointed a Principal Officer with no experience of residential child care to be external manager. We were told that workload issues were the main reason for this delegation of management responsibilities, but we also heard that the Head of Service considered it unfair to the new Principal of Kerelaw to have the former Principal as his external manager.
13.17 This particular appointment was to be the source of continuing and growing resentment on the part of the management at Kerelaw. The Principal did not consider it appropriate for two main reasons: the individual's lack of relevant experience; and his junior position in pay and grading terms in relation to the Principal. To the Principal, this was a downgrading of external management. Although in time a working relationship was established, it was not helped by the external manager's role in "instructing" Kerelaw to take difficult young people from Glasgow in such numbers as to exceed the understanding, to which we have referred at paragraph 13.5, that residents from Glasgow would not exceed 50% of the available places.
13.18 In late October 2003, staff petitioned the Principal to have what they regarded as a particularly challenging young person removed from Kerelaw. This led to the external manager recording his concern with the Principal about how this young person was being managed. While in no way condoning inappropriate responses by employees to the problems they were facing at Kerelaw, the Inquiry considers that more should have been done by Glasgow City Council to support Kerelaw management in what was becoming an increasingly difficult position in 2003. The staff petition should in the Inquiry's view have been a signal that it was time for more robust senior intervention by Social Work managers.
13.19 A further problem in the relationship between Kerelaw and the Social Work Department was a familiar one - the external manager's workload, and his lack of visibility in Kerelaw. We were told that the view in the Social Work Department was that, following the work done by the previous Principal, Kerelaw was now on a solid footing, and that in consequence it took a lower priority than some other work. It is hard to imagine how much lower priority it could achieve. Initial arrangements for monthly "supervision" sessions involving the Principal appear not to have been sustained, which is perhaps not surprising, since following staff changes the external manager's responsibilities were widened to cover all Glasgow City Council children's units. He was also required to act up as Head of Service for a period in 2002.
13.20 In all cases after 1996, external managers to whom responsibility was delegated did not visit Kerelaw enough to walk round units, to speak to residents, and to see for themselves what was going on. Although comprehensive oversight of a large campus like Kerelaw would have been more difficult than for smaller units, they should have visited more frequently and spent more time there. Set against the requirements of external management contained in The Children (Scotland) Act 1995 Regulations and Guidance Volume 2, to which we have drawn attention at paragraphs 5.9 and 5.10, Glasgow City Council's external management performance failed to meet acceptable standards.
13.21 We appreciate that the size of individual workloads made the proper discharge of external management responsibilities difficult but, if Kerelaw had occupied a higher position in the Council's priority list, more care might have been taken to ensure better quality of stewardship. It was put to the Inquiry that the low priority attached to Kerelaw was due partly to its not really being seen as part of Glasgow City Council, and partly to a view that Kerelaw had on site a senior management structure sitting above what were in effect 7 units in the Open School and Secure Unit of a size comparable to small units elsewhere. That being so, it was suggested, the Principal and his senior team might be regarded as a form of external management. We were not able to establish if this kind of thinking was formally articulated. Whether it was or not, it was seriously flawed.
13.22 A further factor in the low priority given to managing Kerelaw may have been that as the plan was to redevelop Kerelaw in the light of A Secure Remedy, it was not worth devoting too much time and energy to it. However, we were not able to find documentary evidence to support that view, apart from a letter to HMIE noting in follow-up to an inspection report on the Secure Unit that, with redevelopment in view, there was no likelihood of resources being provided to do what HMIE recommended with regard to the curriculum (see paragraph 10.24).
13.23 The Inquiry heard evidence that the Head of Service who took up post in May 2002 maintained the arrangements for external management that he inherited, but identified a need to integrate Kerelaw into the Social Work Department's management structure. He sought to increase Finance and HR involvement in Kerelaw, and invited the Principal to attend senior team meetings. The records show that the Principal was present at a number of Children and Families/Criminal Justice Services management meetings until June 2004, although we gained the impression that the opportunity cost in terms of time involved in travelling to Glasgow for such meetings was seen as a disincentive to attendance on every occasion.
13.24 We were told by several witnesses that the Principal was resistant to closer external management although, as we noted at paragraph 10.34, in a memo in May 2002 he referred to the need to locate Kerelaw firmly within the spectrum of child care and staff support which Glasgow offered, and suggested the re-establishment of the Kerelaw Management Group. The alternative view is that his main concern was about the grading of those identified for the external management task. Around the middle of 2002, a move to strengthen external management of Kerelaw by the appointment of an additional Residential Services Manager with experience of residential child care was effectively vetoed by the Principal, who said he had concerns about the remit for the job, which the individual concerned had been asked to draw up. We were told in evidence that she did this by reference to Glasgow City Council's own prescriptions as to the role of external managers. Following the objections of the Principal, the appointment was not pursued.
13.25 The Inquiry obtained a copy of a report dated July 2002, written by two Glasgow City Council Principal Officers who had completed a fact-finding investigation of a complaint by a member of the SMT against a senior colleague. The complaint, which was not related to the treatment of any Kerelaw resident or former resident, was upheld and disciplinary action was recommended. The purpose of the separate report, which was addressed to the Depute Director, the Head of Service, and the external manager of Kerelaw, was to raise concerns about a number of wider issues brought to investigators' attention by a variety of staff. These concerns related to the management styles and abilities of a number of managers, and to a perceived lack of clear direction and leadership from the SMT. The paper raised questions around staff recruitment, professional boundaries, attitudes, and confidentiality. It concluded that these management issues should be addressed and that action was needed. The authors sought an early meeting with those to whom the report was addressed to discuss their concerns.
13.26 We found no evidence that this report received a response or was followed up. We saw no record of any meeting having taken place although, as we noted above, the Principal began to attend senior management meetings in the Social Work Department. The Inquiry was not able to establish whether this was a response to the report or not. Although disciplinary action was taken against the subject of the original complaint (the recommended disposal was reduced by the Head of Service on appeal), the Inquiry was unable to establish whether the wider concerns expressed in the report were ever followed up.
13.27 In August 2003, as difficulties at Kerelaw grew, the Principal put forward proposals of his own for external management support. This resulted in the assignment of an Assistant Residential Services Manager with residential child care experience as an external "consultant" as described at paragraph 10.44. This assignment was made with a view to his being on site at least one day a week. We were told that some staff were puzzled by his remit as they were not used to someone outside the school being involved in management. Some unit managers were said to be suspicious, although they were not, apparently, obstructive. As provided by his remit, the new consultant attended unit managers' and some SMT meetings, and spent time in units looking at their records, which he found to be in need of improvement.
Relationships in the Social Work Department
13.28 Meanwhile, the Social Work Department had its own problems. We heard in evidence that more or less from 1996 to 2002, relationships between two successive Depute Directors with responsibility for Children and Families/Criminal Justice and senior colleagues in the Social Work Department of Glasgow City Council were difficult. These difficulties arose not only from differences over structures, staffing and budgets, but also from differing management styles. It is on record that the Depute Director for Children and Families/Criminal Justice appointed in 2001 took out a grievance against the Council. Her charges of bullying and harassment were not upheld and she left in 2005.
13.29 From what we heard, it appears that aspects of the culture in the Social Work Department during what was a period of regular restructuring of Council Services, staff changes and budget pressures, were little better than at Kerelaw. The behaviours of some senior social work managers appear not to have been conducive to teamwork or collective problem-solving, and did not contribute to an environment in which a manager with operational problems to resolve could have exposed those to view, far less seek help. Against that background, and given the other preoccupations of senior managers in Glasgow, there will have been little incentive to probe too deeply into how an institution, some considerable distance from Glasgow, was being run.
Investigation of external management
13.30 In Spring 2005, after the closure of the Open School, an investigation into the external management of Kerelaw was ordered by the Chief Executive of the Council following concerns expressed by elected members who had begun to hear appeals by employees against dismissals. This led to a report to committee in December 2005. The report concluded that external management was handicapped because line management responsibility was discharged at an insufficiently senior level. It considered the decision by the Head of Service to delegate external management, as described at paragraph 13.16, "unusual" and the management structure put in place at that time to be "flawed". However, the Inquiry found no evidence of the Head of Service's decision having been challenged at Depute Director or Director level. The investigation concluded that, although there were deficiencies in external management of Kerelaw, internal management was largely responsible for the issues which came to light in 2004. It also expressed surprise that the Principal had been permitted to exercise a veto on proposals to strengthen external management in 2002. We share that surprise.
13.31 In its report to the Minister dated August 2007, Glasgow City Council conceded that from 1996 external management was not sufficiently resourced to oversee the functions and performance standards within Kerelaw and that there was limited insight into management and staff behaviours and cultures. The Inquiry regards this as an understatement. After local government reorganisation, external management of Kerelaw was increasingly neglected. Responsibility was passed around a number of individuals, some of whom did not want it. Within the Council, there seems also to have been a lack of clarity as to who had responsibility for certain issues which arose at Kerelaw. This lack of clarity was noticeable in some of the interviews with witnesses. Although there was evidence that the Head of Service in 1998 and 1999 tried to review violent incidents and follow up on complaints, external monitoring seems to have largely faded away until concerns escalated in late 2003.
13.32 While external management failed, and deserves to be criticised, its failures do not excuse internal management deficiencies at Kerelaw or relieve senior managers there of their own responsibilities. We agree that internal management - over a period of years - was largely responsible for the issues which came to light in 2004. The evidence of problems which built during 2003 and erupted in the Spring of 2004 had been there for a considerable time. Even in 2003, complaints and concerns were being considered in isolation and no one appeared to be putting together a wider picture. There had been attempts at improvement by certain individuals, as we have seen, but they were not sustained when the individuals moved on. Managers at all levels from Kerelaw to the senior reaches of the Social Work Department must take their share of responsibility for the way in which young people in their care were let down.
Placements
13.33 We have described the arrangements for placing children at Kerelaw at paragraphs 12.20-12.26, and have noted a number of weaknesses in this aspect of Glasgow City Council's stewardship of Kerelaw and its residents.
Education at Kerelaw
13.34 Most of the former residents who gave evidence to the Inquiry related poor experiences of education at Kerelaw. Some described spending most of their time in class watching videos or colouring in. Some expressed regret that they had not achieved educationally as well at Kerelaw as they might have done at mainstream school. However, a few former residents told us they had good educational experiences and achieved qualifications, including Standard Grades. Some former residents have gone on to further education.
13.35 Some former residents talked of classes being disrupted because pupils were able to come and go as they pleased. A former teacher confirmed that this had been the case in the Secure Unit but had changed around 1999, and pupils were expected to stay in classes until the lesson was over. Former teachers to whom we spoke talked of significant challenges. For example, the shifting population of children made it difficult to teach to certificate level. Many children arrived at Kerelaw having missed a lot of schooling and teachers spent a lot of time on basic literacy and numeracy. Records from previous schools would apparently take weeks to arrive. They also noted that an older age group of 15/16 year olds presented greater educational challenges.
13.36 Former teachers highlighted a number of positive aspects of their experience at Kerelaw. They could opt to work overtime in the residential units and in that way could get to know their pupils in a different environment, which had positive effects in the classroom. Some teachers organised activities for children in the evenings, such as woodwork and cooking. Teaching staff also took young people on outdoor activities such as hill walking, which helped them develop better relationships and provided a new learning experience.
13.37 We heard that over the years Kerelaw had become more academically oriented. Some teaching staff saw this as progress but others suggested it was at the expense of more vocational opportunities. HMIE raised concerns about the structure of the curriculum a number of times over the years. For example in 1999 HMIE evaluated the structure of the curriculum in the Secure Unit as unsatisfactory. However, by February 2003 a joint inspection ( HMIE, SWSI, Care Commission and SEHD) found the effectiveness of educational provision to be good.
13.38 The 2001 inspection of the Open School evaluated a number of indicators as "fair", including the structure of the curriculum, the quality of teachers' planning, the quality of pupils' learning and the effectiveness of promoted staff and senior teachers. As we described in Chapter 10, HMIE remained involved with Glasgow City Council and Kerelaw to support them in preparing their action plan, which appeared to be problematic. Despite this support, very little progress had been made before the first integrated inspection of the Open School in 2003.
13.39 Classes were small, with a maximum of 6 young people in the Open School and 4 in the Secure Unit. Teachers faced challenging behaviour from young people on a daily basis. One teacher suggested that he spent more time managing behaviour than teaching. He described using rewards like time on the computer or a promise of free time on a Friday to keep children motivated and learning. We read minutes of education staff meetings and found them dominated by concerns about pupils' behaviour. Many of the teaching staff were trained in TCI.
13.40 We heard that recruitment of teachers posed the same difficulties as that of care staff. Teachers often started off as supply teachers and then applied for a permanent post. We heard from a senior teacher that recruitment of teachers was difficult and promotions were usually internal. Although some teachers actively chose to work at Kerelaw with children who had social, emotional and behavioural difficulties, we were told that others ended up there by chance, through the supply list. Nevertheless some came to enjoy the challenges of the setting and went on to complete specialist training, for example the Certificate in Special Educational Needs.
13.41 There were 19 teachers at Kerelaw in 2000: 1 Deputy Head Teacher, 4 Principal Teachers, 5 Senior Teachers and 9 teachers. This is a relatively small staff group, which must have made it difficult to offer a broad range of subjects to young people. The structure of education staff changed over time and by 2003 there were two Heads of Education - one for the Secure Unit and one for the Open School. The two "schools" - Open and Secure - seem to have operated quite separately.
The redevelopment of Kerelaw
13.42 As noted at paragraph 10.13, only 3 months after Glasgow City Council became responsible for Kerelaw, the then Scottish Office published A Secure Remedy: a review of Secure Care in Scotland. This Scotland-wide review of secure care listed a number of serious problems with the accommodation in Kerelaw's Secure Unit. It criticised among other things the building's two-storey structure, its ventilation, space shortages, and lack of adequate separation for girls. It noted that the location was over 30 miles from Glasgow and recommended that Kerelaw should be redeveloped on a site closer to Glasgow.
13.43 The Director of Social Work recommended that a new Secure Unit should not be developed in isolation from other provision and it was agreed within the Council that a redevelopment based on a new Secure Unit with "close support" but "open" units alongside would be an appropriate model. In 1997 Glasgow City Council approved the preparation of a submission for funding to the Secretary of State for Scotland. The question of how a new facility might be financed then became the subject of protracted correspondence and discussion, first with the Scottish Office, and subsequently, following Devolution in 1999, with the Scottish Executive.
13.44 Consideration then moved at what can only be described as snail's pace. Throughout the period covered by the Inquiry there was a presumption that Kerelaw would at some stage be redeveloped. By the time the Scottish Executive agreed in 2003 to contribute to funding the rebuilding of the Secure Unit, this was going to take place on the existing site in Ayrshire. An Implementation Group was set up in 2003 to take the project forward and met regularly, right up to the eve of the announcement in 2004 that Kerelaw would close. It may be that the redevelopment of Kerelaw would have proved a stimulus to cultural change, although the focus was on the Secure Unit. However, since there seemed to be no shared view of the future in the SMT, it is hard to see how change would have been achieved even in a new, redeveloped, Kerelaw without changes in the establishment's senior management, a willingness by senior Social Work managers to push for a new approach, and a closer relationship between the institution's managers and external managers in Glasgow.
Lessons from other Inquiries
13.45 There have been two major inquiries into abuse in residential child care in Scotland: Edinburgh's Children: The Report of the Edinburgh Inquiry into Abuse and Protection of Children in Care - published in 1999; and the Fife Council Independent Inquiry following the conviction of David Logan Murphy for the sexual abuse of children - published in 2002.
13.46 The Edinburgh Inquiry made 135 recommendations and the Fife Enquiry 41. There are common themes in the recommendations in the two reports. Both highlighted the need for improved practice in recruitment and selection of residential child care staff, the importance of "whistleblowing" and complaints procedures, the safeguarding role of external people visiting units, and the use of restraint. All these were issues at Kerelaw, as this Inquiry has shown. We saw in the files that Glasgow City Council was aware of those reports, and of others over the years in England, and considered the implications for its own services. There were references to previous Inquiry reports in the Staff Code of Conduct. In 2001 attention turned to recruitment, and procedures at Kerelaw were tightened and brought into line with the Council's policies. But we did not see or hear much evidence that at Kerelaw itself these Inquiries had much impact. We have already seen at paragraph 12.19 that, while the Council reviewed its complaints procedures, Kerelaw seemed to be able to opt out. We have already noted the insufficiency of external management, the concerns of CROs, the drift in refresher training for TCI and the lack of a central overview of the use of restraint.
Conclusion
13.47 Glasgow City Council's stewardship of Kerelaw was unsatisfactory. local government reorganisation in 1996 was a factor, in that Glasgow City Council faced extremely serious budgetary problems which preoccupied senior management and diverted attention from other priorities. Partly as a result of that, Kerelaw did not receive from external management the attention it should have had. While the findings of other Inquiries were considered by the Council, the lessons appeared to have little impact at Kerelaw. External management was insufficiently proactive in ensuring that they were followed up. External management responsibility was also delegated inappropriately and inadequately resourced and its failures were an important contributor to what went wrong. These failures were compounded by poor relationships at senior level in Social Work HQ.
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