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17. LESSONS LEARNED BY GLASGOW CITY COUNCIL
17.1 The Inquiry was asked to consider the steps taken by Glasgow City Council to safeguard the children it places in residential care following the closure of Kerelaw. We sought information on the lessons learned by the Council in interviews and examined current documents in order to establish those steps.
17.2 In its report to the Minister for Children and Young People in August 2007 Glasgow City Council noted that it had taken action to strengthen safeguarding for children and young people and had developed an Action Plan to address the findings of the Council's investigation into Kerelaw. This has since been developed further.
The Kerelaw Action Plan
17.3 Responsibility for implementing the Kerelaw Action Plan was taken by the Council's Safeguarding Working Group. This group was established following the Edinburgh Inquiry to oversee safeguarding activity and monitor progress at both local and city levels.
17.4 The original Kerelaw Action Plan proposed actions to be taken under 6 broad themes:
- listening to children and young people
- care planning and care management
- external management and monitoring
- personnel processes
- external scrutiny
- use of restraint
and it appears to the Inquiry that progress has been made in each area. Some tasks are complete and others are ongoing, and some further attention from the Council would be of benefit, as outlined below.
17.5 The Inquiry was told that the Kerelaw Action Plan had been subsumed into the Council's overarching Safeguarding Action Plan, and we accept the logic of that, although examination of the two documents suggested that this was not entirely the case, with some elements of the Action Plan having apparently been lost in the process. We therefore asked the Council to update the Plan to show what progress had been made. This showed progress on a range of actions covering listening to children, care planning, staff training in safe care and integrated assessment, the development of practice standards, complaints logging (but see paragraph 17.10 below) and management, external management and scrutiny, and personnel processes.
Delivering the Action Plan commitments
17.6 The city-wide Safeguarding Action Plan overarches 5 locality-based plans, one in each of the Community Health and Care Partnership ( CHCP) areas. The most recent version of the city-wide plan seen by the Inquiry was dated July 2008. We also examined 2 local CHCP safeguarding plans, one dated April 2008 and the other undated. We understand these are the most recent updates in a stream of safeguarding activity dating back to February 1998, when the Council began to respond to the 1997 Kent review.
17.7 The city-wide Action Plan is large, and examination of the content suggests many actions are out of date, with no changes since 2007 despite the cover date. The two local action plans which we reviewed address important safeguarding issues, but are "work in progress" at this stage; so delivery is not fully measurable. We were told that Council staff accepted that safeguarding could be improved by better streamlining and more effort on implementation.
Purchased provision
17.8 The Inquiry has concerns that effective quality assurance is more difficult for purchased provision than for provided services and that this may increase the potential risks for accommodated children. In fact, the monitoring of purchased residential places appears to rely on the combined effectiveness of local care management by fieldworkers and central contract management arrangements. In interviews we heard that efforts are being made to ensure fieldworkers recognise their particular responsibilities in this regard and this is to be welcomed. In one CHCP this role is supported by practice guidance for staff on care planning and frequency of contact, and we hope that all are aiming to share and adopt best practice. In this context, the Inquiry welcomes the recent development of a Multi-Agency Resource Group, which has assumed responsibility for the review of quality assurance arrangements and for ensuring that placements for looked after children are appropriate.
Oversight of complaints and allegations
17.9 The Inquiry heard that a number of individuals keep records of one kind or another concerning complaints and/or allegations from looked after children. However, it appears that the Council does not keep one comprehensive central record of this information as was proposed in the Kerelaw Action Plan. Work has been going on for some time on an electronic system which can be integrated with existing information systems but, until that is established, an overview is lacking, which makes it difficult for the Council to "join the dots" in relation to complaints and allegations - a deficiency identified as contributing to the failure to identify abuse at Kerelaw over a period of years.
17.10 It appears that the current approach to monitoring is at odds with the Council's procedure Complaints and Allegations - Keeping Children and Young People Safe dating from 2001 and revised in 2004, which requires the Keeper of the Child Protection Register to log all complaints and allegations centrally, and to report 4-weekly to the Head of Service and annually to the Child Protection Committee. In effect, this means there is no independent scrutiny of complaints and allegations, which potentially undermines the credibility of the formal complaints process and the Council's wider approach to child protection. While noting that neither HMIE nor SWIA has raised this concern in recent inspections, Glasgow City Council has acknowledged this gap and has committed to implementing the necessary arrangements. On a more positive note, the Inquiry welcomes the annual reporting of complaints and other key areas of performance within provided services which has now been in place since 2007.
The role of the Child Protection Committee
17.11 The Council's Child Protection Committee was operational throughout the period covered by the Inquiry and has reported annually on its work since 1996-97. We considered a range of material from the Committee and noted few references to Kerelaw, either before or after the school's closure. This raises questions about the extent to which the Committee took an interest in placements at the school or in the outcomes for young people placed there. While the Inquiry can see why Kerelaw may not have featured heavily prior to 2004 - regrettable though that was - it is hard to understand why it did not appear to take an interest in Kerelaw once problems were recognised. As a minimum, the Committee should have ensured reporting of complaints and allegations took place as provided for in the complaints procedures, and more in the way of scrutiny of safeguarding actions and outcomes might have been expected.
17.12 The Inquiry was told that the Council had recently participated in an HMIE Child Protection Inspection and was expecting a good report from that. However, the self- assessment document used by the Council for that inspection contains no references to the lessons learned from Kerelaw or the strategic and operational issues raised. Nevertheless, the Inquiry welcomes the recent positive examples of scrutiny and reporting activity in relation to provided services. Annual reports are now prepared and published in relation to Glasgow City Council's residential units and the service is developing audit activity and Care Commission monitoring procedures.
Children's Rights Services
17.13 The Council has articulated a Listening to Children strategy which seeks to ensure that all agencies and professionals understand their responsibilities to listen to children and to ensure their rights are respected and promoted. Steps have been taken to revise training for fieldworkers to emphasise safeguarding remits and responsibilities.
17.14 The Children's Rights Service has an important role in proofing policies and strategies as well as providing a direct service to the most vulnerable and excluded children, and the Inquiry welcomes the mainstreaming of this service. We note that the service covers a wide range of foster care placements and residential settings and services - often outwith the city - and we were told that the service in Glasgow faces significant pressures as a result. In consequence, we were told, direct one-to-one contact with young people is difficult to sustain. This is a concern, as the quality of relationships young people are able to establish with adults can have an important bearing on their ability and willingness to speak up about worries. This situation echoes concerns expressed by CROs who told us how difficult and time-consuming it was to follow up and take forward specific concerns raised by children at Kerelaw.
17.15 This evidence of significant pressure on the Children's Rights Service raises concerns about resourcing that the Inquiry believes Glasgow City Council should examine. There is moreover a wide variety of purchased and provided advocacy service models across local authorities, which suggests that there may be merit in a national review of best practice in the funding, commissioning and delivery of Children's Rights Services to ensure Scotland maximises quality and value for money.
Wider Strategic Developments in Glasgow City Council
17.16 Senior managers and elected members described to the Inquiry a number of strategic initiatives to recast the approach to children's services in the city. A Corporate Parenting Strategy sets out how the Council and its partners will assume collective responsibility to meet the needs of looked after children. This strategy emphasises the role of elected members as corporate parents, establishes a Champions Board of elected members and senior officials, and clarifies the role of the corporate management team in monitoring and evaluating outcomes for the Council's looked after children. This perspective was lacking in relation to Kerelaw and the Inquiry welcomes this development.
17.17 We also welcome proposals for implementation that include performance monitoring, quality audit, awareness raising, safeguarding training, service redesign, evidence- and research-based interventions, plus an educational attainment working group, annual reporting in relation to looked after and accommodated young people, engagement of children and young people and the involvement of the Multi-Agency Resources Group.
17.18 The Inquiry recognises the work undertaken so far on new strategic planning and service development. However, the challenge for the Council will be to bring about change in how managers and front line workers do their jobs and turn strategic priorities into measurably better outcomes for children. From previous Inquiries and in our own work, it is evident that strategies and policies, while important, are insufficient in themselves to effect change. The Council had numerous policy documents, codes and guidelines throughout the 1990s that did not adequately safeguard young people at Kerelaw. Effective implementation and management of compliance together with clear accountabilities throughout the management line are the key to adequate safeguarding.
External management of provided residential provision
17.19 As discussed at paragraphs 13.10-13.27, weaknesses in external management contributed to the problems at Kerelaw. The Council has restructured the external management arrangements for provided residential child care since Kerelaw closed, so that the number of external managers - which was set at 9 (8 plus a Principal Officer) in early 2002 - has been reduced to 5 posts, plus a Principal Officer. While it was explained to us that this was to provide one per CHCP, allowing the disaggregation of external management to CHCP level, a number of those who gave evidence to the Inquiry considered this reduction in numbers inconsistent with the "strengthening" of external management alluded to in the Glasgow Report. This may be a signal that the Council needs to take soundings from the front line and review the new arrangements.
Impact of Kerelaw on contemporary practice
17.20 The Inquiry met two focus groups - one of residential unit managers and one of social workers who had placed young people in Kerelaw in the past - with a view to gaining an external perspective on Kerelaw and an insight into the lessons learned by the Council following events there. Residential workers told us they believed the situation had evolved over several years of neglect and that it seemed Kerelaw had not been seen as fully part of Glasgow City Council, having been considered by many as discrete and different. We were told that Kerelaw has had a lasting legacy in the Council. Some spoke of a culture of fear among residential staff. They were said to be the group most acutely aware of the importance of safe care, yet they felt the most vulnerable to allegations and scrutiny.
17.21 We heard that a legacy of Kerelaw was that, despite national guidelines in Holding Safely and internal policy on the use of TCI, staff were fearful that if they exercised restraint in any circumstances they were vulnerable to disciplinary action. This stems from the premise that almost any circumstances could be construed as circumstances in which physical restraint was not advised, leaving staff open to challenge on every occasion. It is important that employers recognise their responsibility both for ensuring that residential child care workers are not left in any doubt about where they stand in relation to the use of physical restraint and also for reinforcing that position over time.
17.22 Unit managers told us that they now have much clearer lines of accountability with clear expectations in relation to safe care. Units all have safe care plans which they review regularly with external managers. Monthly audits of care plans are standard practice, and unit managers now expect spot checks, unannounced visits, and scrutiny by external management. A number of returns are required by HQ. All of this was seen as positive, but unit managers stated that the service was stretched and continued to feel that some senior managers have not always understood the dynamic of external management or the need to balance scrutiny with support. They did, however, feel that the balance was improving.
17.23 Unit managers noted there have also been improvements in recruitment through the introduction of assessment centres, although they were concerned that recent attempts to implement a corporate approach linked to a shared service centre could undermine progress achieved by social work services in taking into account applicants' values and attitudes. They believed that the proposed changes were too rigid and competence-focused.
17.24 Residential staff told the Inquiry that there is evidence of more contact between young people in residential care and fieldworkers and more awareness of safe care issues. This was attributed to training and briefings in relation to lessons learned from Kerelaw. However, there were still concerns about the adequacy of placement planning for young people and there are still capacity issues which mean that service aspirations may not be met in full.
17.25 Residential staff believe there is evidence of the complaints system being used in Glasgow City Council units by young people, who were described as being more confident about raising concerns. Unit managers said this was reflected in the relatively high levels of fact-finding investigations they were asked to undertake. Staff spoke about investigations often taking months rather than weeks and, as suspended workers were not replaced, this put pressure on others and had an impact on the work of the unit. There was concern that this additional pressure was not appreciated fully by senior managers.
17.26 There was some criticism of the HR and administrative support which was available, and a variety of concerns, which would be familiar in any organisation, about employment law and the pressures which flow from being involved with disciplinary processes. It is important that central HR and administrative services accord appropriate priority in their own work to ensure that unnecessary delays are avoided. It is sometimes too easily overlooked that delays in fact-finding and disciplinary processes can exact a heavy toll both on service provision and on the individuals who are under investigation.
17.27 Unit managers commented on working with the most challenging children since Kerelaw closed. They now require to deal with problems themselves and can no longer rely on transferring responsibility to Kerelaw on an emergency basis. This is a significant change, but one which we were told is being managed with reasonable success.
17.28 We were told that supervision continued to be a priority for staff, who told us they did have regular supervision, and that it was minuted and focused. However, there was a consensus that supervision could often be the first thing to be abandoned during a crisis, although some unit managers were said to be very creative and had used group supervision for shifts during significant events. Staff told us that Residential Services Managers sampled the supervision notes from their units and that the Care Commission also looked at the notes during inspections.
17.29 We were also told that the introduction of a Code of Conduct for residential workers which was produced in 1998 and updated in 2004, to reflect new structures, had been important in changing the culture. There were positive references to residential care having tried to move on and promote safe care priorities. Encouragingly, there was talk of a reflective self-evaluation culture beginning to develop and drive change. The Inquiry welcomes these positive signals and the arrangements the Council told us they have put in place to monitor, support and, where necessary, challenge contemporary practice.
Conclusion
17.30 Many senior management changes have taken place in Glasgow City Council since Kerelaw closed and a number of strategic and operational initiatives have been developed to improve the safeguarding of looked after and accommodated children. Lessons appear to have been learned from what went wrong in relation to Kerelaw. Action plan commitments have been taken forward as part of a wider safeguarding agenda. The Inquiry concluded that there is scope for more effective and better coordinated implementation in some areas, including quality assurance and monitoring of purchased provision, capacity building within fieldwork services, and complaints procedures, including the monitoring role of the Child Protection Committee. The Inquiry had concerns about the capacity of the Children's Rights Service in Glasgow. We also concluded that wider consultation and communication within the Council on the revised external management arrangements would be beneficial. Strategic priorities and new policies and procedures must now be fully operationalised in working practices and management accountability, from the bottom to the top of the management line.
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