The Scottish Government

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1. EXECUTIVE SUMMARY

The Inquiry

1.1 The Inquiry was commissioned by the Scottish Government and Glasgow City Council in November 2007. Its purpose was to secure comprehensive insight into the circumstances that led to abuse at Kerelaw Residential School and Secure Unit over a period of years, to examine Glasgow City Council's stewardship of the school since 1996 and to consider the Council's investigation of what occurred and the arrangements following closure of the school between 2004 and 2006. The Inquiry was asked to make recommendations to ensure similar circumstances could not arise again and to offer any other insights relevant to the safe care of young people in residential settings.

Our methods

1.2 A small Inquiry team comprising the chairman, 3 further investigators and an office manager examined a large volume of paper and electronic records held by Glasgow City Council. We contacted a wide range of organisations and individuals and conducted 166 interviews. The notes of these interviews formed a central core of evidence to the Inquiry. We received and examined written material and testimony that was of relevance to the residential care of young people or specifically to the operation or staffing of Kerelaw or to residence in the school. We drew on expert advice from a small group of external advisers. The Inquiry took place in private to encourage more open communication on some very sensitive and personal issues, and we committed to anonymise the information provided by interviewees when preparing our report.

Kerelaw Residential School and Secure Unit

1.3 Kerelaw opened in Stevenson, Ayrshire in 1970, initially as a residential school for 72 boys, and later became co-educational. A mixed sex Secure Unit was added in 1983 and extended in 1988 to cater for a further 24 young people. Most were placed under a supervision requirement, with smaller numbers on remand or sentence. All had significant behavioural, emotional and/or educational needs. Education was provided up to statutory school leaving age, and young people had access to a range of specialist support including psychology, psychiatry and addiction counselling. As a result of local government reorganisation, Glasgow City Council took over the running of Kerelaw from Strathclyde Regional Council in 1996. At that point Kerelaw comprised 4 Open School units housing a maximum of 24 boys and 24 girls and the Secure Unit containing 16 boys and 8 girls. Compared with other residential accommodation for young people in Scotland, Kerelaw was the largest local authority-run establishment and catered for some of the country's most challenging and vulnerable young people.

Legislation and regulation

1.4 During Kerelaw's existence there were significant developments in the regulation of care for looked after children and changes in public and professional attitudes towards large residential institutions. During the period covered by the Inquiry there were three legislative developments of particular note - the Children (Scotland) Act 1995, the Regulation of Care (Scotland) Act 2001 and the Protection of Children (Scotland) Act 2003.

1.5 The Children (Scotland) Act 1995 brought conformity with the UN Convention on the Rights of the Child and served to place the child at the centre of official decision-making. It promoted inter-agency co-operation and the development of effective individual care planning for young people. Regulations and guidance outlined the role of external management in relation to looked after children. The Regulation of Care (Scotland) Act 2001 aimed to provide better protection for those in care and created The Scottish Commission for the Regulation of Care (The Care Commission) as an independent body charged with the regulation and inspection of care services. The Act also established the Scottish Social Services Council ( SSSC) as the registration body for social workers and others working in social care, with responsibility for setting standards for qualifications and behaviour of care workers. The Protection of Children (Scotland) Act 2003 provides for the disqualification of unsuitable people from working with children.

Policy trends

1.6 These regulatory changes underpinned policy developments in residential care that would impact on the residents and staff of Kerelaw. A growing ambivalence towards the use of residential care for young people from the early 1990s led to a move towards favouring foster care and a view that resorting to a residential placement was a failure. As fewer young people were placed in residential care, those who were so placed had more complex needs. Such young people were more likely to have experienced one or more failures of care in a different setting. We were told that an increasing number of those placed at Kerelaw had problems with drug or alcohol misuse and, as the complexity of the problems increased, more and more placements took place on an emergency basis. Despite the pressure for change represented by regulatory and policy developments, the pace of change at Kerelaw was slow.

Abuse and physical restraint

1.7 Glasgow City Council reported in 2007 that there were between 350 and 400 allegations from 159 people complaining of emotional, physical or sexual abuse. Two staff were convicted of physical and sexual abuse, and one of physical abuse, as a result of police investigations. A further case of alleged sexual abuse was not proven. It was not the role of the Inquiry to examine individual allegations of abuse, nor to re-run investigations into whether abuse occurred at Kerelaw. However, to fulfil our remit, it was important to understand the range of allegations made and the nature and scale of abuse.

1.8 Some young people testified to Council investigators and to the Inquiry that they had a positive experience at Kerelaw and had never been subject to abuse themselves. Similarly, some former staff said they had never witnessed abuse of young people. Other young people were clear that they had been poorly restrained and hurt as a result, and some said that they had been assaulted without any pretence of a restraint. Some staff admitted to the Inquiry that they had undertaken restraints that were poorly executed and probably caused pain, while others acknowledged that they had taken action in a restraint that they now recognised as inappropriate. Nobody admitted to the Inquiry that they had intentionally assaulted a young person in their care, although some staff and young people did describe having seen one or more members of staff assaulting someone.

1.9 This pattern of restraint and assault must be considered in a context of developing policy in relation to crisis intervention. Until 1995, there was no single, accepted method for managing conflict or violent behaviour, although some staff at Kerelaw said that they had been trained in the 1980s and early 1990s in pain compliance techniques of the kind used in prisons and secure psychiatric hospitals. In 1995, Strathclyde Regional Council adopted the Therapeutic Crisis Intervention ( TCI) model for preventing and managing challenging behaviour in young people. TCI includes restraint methods, but its primary purpose is to de-escalate critical situations and reduce the need for restraint. Nevertheless, a significant number of staff and young people saw TCI solely as a method of restraint and some used physical intervention as a first rather than last resort in dealing with difficult behaviours. Such physical intervention was often inappropriate and poorly executed. Some staff took the view that TCI was not appropriate for the very challenging young people at Kerelaw and that it was not physically possible to restrain a young person in the way described in the training manual.

1.10 We heard about "horseplay" that still took place after policy guidance advised that it was inappropriate, and we heard that language was used that belittled and undermined the already fragile self-esteem of many of the young people at Kerelaw. Some staff developed negative attitudes towards young people which were played out in emotionally abusive terms. The language of failure and "dumping", ridicule about family backgrounds and teasing and bullying seem all to have played a part in the emotional abuse of residents. Appropriate boundaries were not always maintained between young people and their care workers.

1.11 As in other residential child care establishments, there were allegations of abuse and complaints over the years. Some complaints concerned day-to-day issues, such as food or clothing, privileges or entertainment. Many, however, complained of emotional abuse including bullying and of pain inflicted during restraint. Some alleged assault. Some complaints and allegations were investigated and we found some evidence of effective handling and follow-up which reflected concerns about the way Kerelaw was operating and the behaviour of certain staff and managers. However, the system was inconsistent, and we were told by residents and staff that not all complaints were acted upon. We saw evidence that even concerns arising from complaints by placing authorities other than Glasgow were not properly followed through to a conclusion.

1.12 The Inquiry concluded that over a period of years, although a range of allegations, complaints and concerns emerged, and were investigated, there was no systematic overview taken of what lay behind them and such findings as emerged produced no lasting effect. It was not until the Summer of 2004 that this pattern was broken when Glasgow City Council established a joint Social Work/Education investigation team to look into current and historic allegations of abuse at Kerelaw.

Organisational culture

1.13 The regulatory and policy developments of the 1990s required staff in residential care settings to gain new knowledge and to adopt new practices, and there is some evidence from recruitments made to the senior management team of Kerelaw that external managers recognised the need for Kerelaw to adapt and adjust to the new environment. Unfortunately, modernisation initiatives met resistance from within in the form of a culture that promoted the status quo. As a result Kerelaw did not move forward as it needed to do.

1.14 A staff group that is sometimes ambivalent towards the young people it cares for, or that feels poorly equipped, unsupported by management and undervalued by its employer and the wider public is likely to feel isolated and vulnerable, and may be resentful and angry. This can lead to the development of an inward-looking, defensive ethos which puts solidarity with one's colleagues above other priorities. Solidarity with one another in difficult circumstances may be reinforced where large numbers of staff are recruited from, and live in, the local community, and where there is shift work and shift-based socialisation outside working hours. These negative cultural influences were all present at Kerelaw.

1.15 However, such solidarity did not result in a united staff with a common sense of purpose. There were animosities, allegiances, factions and cliques, seemingly based on some very strong feelings, both personal and professional. The culture was described as "macho", not in relation to the gender balance but to attitudes and behaviours exhibited by certain staff. Splits in the staff group were not confined to care workers, but extended to the senior management team. A number of interviewees told us they felt the divides were generated by the factional behaviour of senior managers. One such divide, between the Secure Unit and Open School, was deepened by management changes instigated in 1999. In the mid-1990s unit managers were given increased autonomy in an attempt to promote quality improvement, but which instead generated unhealthy competition between units and a degree of mistrust and resentment. There were also divisions between the night staff and others and, more generally, divisive behaviours by some managers and workers.

1.16 For much of its existence, the recruitment practices operated by Kerelaw did not comply with the policies of Strathclyde Region or subsequently Glasgow City Council, but it was not until 2001 that the school was brought into line and Human Resources ( HR) staff from HQ took an active role in overseeing the recruitment process. Prior to that, practices often resulted in temporary and casual staff, some of whom were related to or known to recruiters, drifting into permanent employment. The relationships they had formed were either sustained or dissolved while they worked together at Kerelaw. Former residents told the Inquiry that the details of staff relationships were common knowledge throughout the school, and it was difficult to raise concerns as people could not be sure whom to trust. We were told by former staff and managers that Kerelaw struggled to attract and retain staff over the years and that vacancies led to significant reliance on overtime and casual staffing, which had implications for the quality of care.

1.17 Despite the considerable pressure from this negative culture, there were good, child-centred staff who succeeded in doing their best for young people in difficult and challenging circumstances. Those individuals were not, however, the predominant cultural influences on Kerelaw.

Capacity for improvement

1.18 Systems and tools existed that could have been used to change the culture at Kerelaw but it was not seriously addressed. Like many other public bodies, Glasgow City Council did not have an effective performance management system during the 1990s. For staff in social care, including senior and external managers of services, a system of professional supervision existed and should have been used to address many of the issues of practice that arose at Kerelaw. Staff working at Kerelaw would have needed the emotional, practical and professional support provided by supervision, but they did not receive it on a regular basis. Some had infrequent supervision, and others told the Inquiry they had none at all.

1.19 Other factors militated against sustained forward progress for Kerelaw. There was significant senior management "churn" at Kerelaw and in Glasgow's Social Work Department from 1996 onwards. There were few senior managers who sought to bring about significant change to the way Kerelaw operated, and those who tried met considerable resistance and a lack of support from colleagues, with the result that new initiatives resulted in little lasting change.

1.20 Staff training and development should have been a key tool in modernising Kerelaw and ensuring that practice kept pace with the changing regulatory and policy framework. There seems to have been little training and development offered to staff at Kerelaw until the early to mid-1990s, when efforts were made to ensure staff received at least basic introductory training in child care. Some were encouraged to pursue professional qualifications. Staff were also trained in TCI, but follow-up refresher training was not systematically provided. While many staff welcomed training and reflected in their evidence to the Inquiry on the benefits this had had for their approach to work, others were said to be dismissive and resistant. Training did not deliver the cultural benefits that would have been expected as it was neither integrated with supervision nor positioned within a clear and unified vision of the kind of organisation Kerelaw should have aspired to be.

Inspection

1.21 A number of different organisations were responsible for the inspection of Kerelaw over the period from 1996 to closure, including North Ayrshire Council, HM Inspectorate of Education ( HMIE), the Social Work Services Inspectorate ( SWSI) and latterly the Care Commission. The Scottish Executive Health Department ( SEHD) was also involved. North Ayrshire Council carried out annual inspections and covered both the Open School and the Secure Unit until 2002. The Secure Unit was also subject to regular inspection by SWSI and HMIE for approval purposes on a 3-year cycle. HMIE inspected the Open School in 2001 and then jointly with the Care Commission in 2003 and 2004.

1.22 Numerous concerns were raised in inspection reports over the years, but there was little evidence of sustained action by Kerelaw or Glasgow City Council to address these. Staffing levels, supervision, training, the fabric of the buildings, privacy and dignity of young people, and the complaints procedure were all subject to criticism. However, while separate agencies conducted separate inspections, there was a distinct lack of overview, a factor in the inadequate follow-up by management. The Care Commission have recognised concerns about the provision of care in residential schools and have made recommendations to improve those services and have taken action to improve the quality of inspection practices.

The child at the centre

1.23 The Inquiry did not gain a sense that the rights, needs and welfare of children were central to the operation of Kerelaw or the actions of all staff who worked there. While some ex-staff told us they encouraged advocacy services, social workers and others to visit young people in Kerelaw, many of the advocacy workers we spoke to expressed concerns about being excluded, obstructed or treated dismissively by some unit staff.

1.24 An effective complaints system is key to safeguarding young people in residential care, but we heard mixed accounts of the system at Kerelaw both from former residents and staff. Problems with the complaints system were regularly raised by inspectors. By some accounts the system worked well and was effective. Others said that complaining was discouraged, that the system worked inconsistently, or that complaints were not followed through so for some there was no point in making them. We were told by some staff that young people could only complain by accessing a form through the unit manager.

1.25 In 2001 Glasgow City Council implemented new complaints procedures that standardised processes for complaints and child protection issues and aimed to distinguish between formal and informal complaints. The new procedures also set down reporting and monitoring requirements. However, Kerelaw was excluded from these new arrangements and central monitoring arrangements did not apply.

1.26 Although the admission of young people to Kerelaw should have been on the basis of formal assessment and planning, the Inquiry learned that many admissions took place on an emergency basis. As a local authority resource, Kerelaw was not in a position to be as selective as other establishments and as a result came to be seen by some as a safety valve for a dysfunctional system. Expectations of the quality of care and positive outcomes for young people resident there were not high. Problems inherent in the school were compounded by poor throughcare and aftercare planning and provision.

1.27 The Inquiry also found a mixed picture of the arrangements for needs assessment and care planning for young people placed in Kerelaw. The large number of emergency admissions, shortages of field social workers and significant caseloads did not facilitate effective care planning. Evidence suggested some effective planning by field social workers, but poor record keeping led the Inquiry to have concerns about the adequacy of care planning and delivery. The importance of care planning was emphasised to staff at Kerelaw from the mid-1990s, and some former employees told us that they welcomed this, although the Inquiry found little evidence to substantiate it.

1.28 Absconding appears to have been routine for many young people at Kerelaw and staff responses varied. Some saw absconding as adding to the complexity and pressure of their jobs, while others recognised the importance of trying to prevent it and of dealing sensitively with young people when they returned, often under the influence of alcohol or drugs. There was no clear evidence of any consideration of the reasons why young people were absconding.

1.29 A number of ex-residents related poor experiences of education at Kerelaw, although some achieved qualifications. Ex-residents described classes being disrupted, while teachers spoke of the difficulties of educating a shifting population of young people, many of whom had missed significant periods of schooling.

Glasgow City Council's stewardship of Kerelaw

1.30 The timing of local government reorganisation in 1996 was not helpful. Senior Council managers found themselves having to respond to major changes in legislation and regulation while under serious financial pressures. In the immediate aftermath of reorganisation, much senior management time in Glasgow was devoted to dealing with the consequences of a financial settlement that created major difficulties for social work services provision. Kerelaw was both a generator of revenue and a drain on resources, and financial issues diverted senior management time in the Council from proper consideration of the quality of provision or the future direction for the establishment.

1.31 Prior to local government reorganisation, the external management of Kerelaw was provided by Strathclyde Regional Council and the Inquiry was told that arrangements worked reasonably well, although a relatively "hands-off" approach to how Kerelaw was run seems to have been the norm. Once responsibility transferred to Glasgow City Council, external management was unsatisfactory. Responsibilities were inappropriately delegated, and burdens on managers meant that they made few visits to Kerelaw. This lack of visibility and oversight was compounded in later years by poor relationships between internal and external managers. Poor relationships within the senior management team in the Council's Social Work Department militated against effective action being taken. The Inquiry concluded that Glasgow City Council did not give Kerelaw the attention it needed or deserved.

Closure of Kerelaw

1.32 The Open School closed at the end of December 2004 and the Secure Unit in March 2006. Some former staff and managers interviewed by the Inquiry suggested that Glasgow City Council was looking for an excuse to close Kerelaw and the uncovering of allegations by the joint investigation team, and subsequent Care Commission/ HMIE inspection, provided it. This suggestion does not fit either with the Council's dependency on Kerelaw for accommodation, or with the evidence given to the Inquiry. There is evidence that in the course of the Summer of 2004 senior management in the Council began to doubt whether Kerelaw should continue, but this was not, so far as the Inquiry could establish, why the investigation was set up or why inspectors were called back in. A formal proposal to close the school was made to committee in October 2004 and agreed by elected members. The decision gave rise to considerable grief on the part of those young people who were still resident at Kerelaw, but the evidence is that planning for the future of those remaining residents was appropriately and professionally handled.

Investigations and disciplinary process

1.33 Glasgow City Council set up its joint Social Work/Education investigation of Kerelaw following an investigation into staff complaints of bullying and harassment by a unit manager. During that investigation a number of other staff and young people came forward with allegations of poor treatment and abuse. Separately, historic allegations precipitated a concurrent police investigation into Kerelaw. As this and the internal investigations continued, and the net widened, more and more allegations were made. The two investigations remained separate, although there was regular communication and information flow.

1.34 The Council's investigations continued for 3 years and resulted in 29 disciplinary hearings, followed by internal appeals against dismissal and in some cases Employment Appeals Tribunals which have now spanned a period of more than 4 years. As a result of the investigations and disciplinary processes, 14 staff were dismissed. Two of the dismissals were deemed unfair by Employment Appeals Tribunals, and the Council withdrew its defence in the case of another two.

1.35 Many ex-Kerelaw staff criticised the handling of the investigation, feeling that the approach was aggressive and the process poorly handled and over-long. Staff felt they were not adequately informed about the allegations against them and that they therefore found it difficult to respond adequately. On the other hand, some were unwilling to cooperate and the joint investigation team faced the challenge of finding a way through the networks of cliques and relationships which they concluded had obstructed a number of fact-findings over the years. The investigation team had a complex and difficult task, but the Inquiry was nevertheless surprised by the lack of attention to detail in some fact-finding reports and the weakness of some paperwork put forward for disciplinary hearings.

1.36 The claim by some that young people were driven to make allegations by the lure of compensation is not borne out by the evidence. Fewer than a fifth of those who were interviewed by internal investigators had by March 2009 made compensation claims. The statistics suggest that the convictions of the teacher and the unit manager following their Court cases in 2006 precipitated compensation claims.

Disqualification from working with children

1.37 A further outcome of the Glasgow investigation was that 31 ex-Kerelaw employees were referred to the Disqualified from Working with Children List ( DWCL). Of these, 9 had been listed and 16 not listed by the end of 2008. Six remained provisionally listed. The emergence of such a large number of referrals early in the existence of the DWCL was as unexpected as the process was new to all concerned. The Council did not investigate some referrals as the individuals concerned had left their employment and there were significant difficulties in relation to such uninvestigated referrals.

Lessons learned by Glasgow City Council

1.38 The Council reported in 2007 that steps had been taken to improve the safeguarding of young people in residential care as a result of their findings in relation to Kerelaw and that an action plan had been drawn up to deliver further improvements. The Kerelaw Action Plan was subsumed into the Council's overarching Safeguarding Action Plan. Some tasks had been completed by the end of 2008 and others were ongoing. Work remains to be done on the central monitoring and scrutiny of complaints, but there has been welcome progress.

1.39 There is a Listening to Children Strategy, but there is pressure on the Children's Rights Service, which raises concerns about resourcing. A Corporate Parenting Strategy sets out how the Council and its partners will assume collective responsibility to meet the needs of looked after children. There is a Champions Board of elected members and senior officials, and the strategy clarifies the role of corporate management in monitoring and evaluating outcomes for Glasgow's looked after children. This was lacking in relation to Kerelaw and is a positive development. It appears that efforts have been made to improve residential care and promote safe care priorities, and the Inquiry heard references to a reflective self-evaluation culture beginning to develop. 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.

Analysis and conclusions

1.40 The Inquiry concludes that abuse of young people did take place at Kerelaw after 1996 and that physical abuse was prevalent, although it did not involve all staff. Weaknesses in TCI training contributed to poor practice that was often abusive. The circumstances that allowed abuse to happen comprised a complex mix of cultural factors, including an over-emphasis on control. There were cliques and factionalism and inappropriate relationships which inhibited challenge and attempts at change, for which there was limited capacity. There was a lack of strategic direction, both in Kerelaw and in Social Work HQ, and no united sense of purpose. Training did not support culture change as there was no shared view of the kind of organisation Kerelaw should be. There was no robust system for performance management and supervision of staff was inadequate. The complaints system was inconsistent and poorly monitored and there was little follow-through from fact-finding investigations of young people's allegations. Inspection did not stimulate culture change at Kerelaw. Criticisms that were made were insufficiently followed through by Kerelaw, the Council or, until after 2003, the inspection agencies.

1.41 Glasgow City Council's stewardship of Kerelaw was lacking in important respects. local government reorganisation created serious financial problems for the Council and distracted senior managers from the real issues at Kerelaw. External management was inappropriately delegated and inadequately carried out. Poor professional relationships at senior level in the Social Work Department compounded the problem. Proposals for the redevelopment of Kerelaw were a long term aspiration from 1996 onwards which may also have been a distraction. The Council's investigations from 2004 onwards were robust, but could have been better handled, and would have benefited from closer quality control of documentation. Staff were not well supported during the investigations and disciplinary processes. The quality of information management by the Council and the adequacy of records relating to young people in care were a cause for concern. Overall, there was a significant failure in leadership and management that led to the relative neglect of Kerelaw and, as a consequence, the dual abandonment of those who lived and worked there. That failure did not occur only in Kerelaw's final years: it grew over many years under changing circumstances and different management regimes.

Recommendations

1.42 Residential child care has moved on since Kerelaw and the protection afforded to young people is being improved. There is no room for complacency, and our recommendations build on those developments. All the strategies in the world will not prevent mistakes or failures. The best protection we can offer young people in care is that everyone, from front line care workers to the most senior managers, takes their responsibilities fully on board, puts the client first, and does their job.

Our recommendations include:

• Improving leadership and management capability by better succession planning; effective recruitment of high calibre candidates; clarifying roles and responsibilities for external management; and accountability for the monitoring and quality assurance of reporting systems.
• Enhancing performance management by introducing personal performance planning for external managers and the heads and other senior managers of residential establishments, and consideration of peer and subordinate appraisal processes.
• Reinforcing the requirements of good supervision underpinned by a supervision policy for every provider and consideration of group-based supervision.
• Better training and learning in mixed groups with appropriate reflection and evaluation of the learning experience; resourced to ensure underpinning of the SSSC registration requirements; and with guidance and refreshing of training in crisis intervention to ensure understanding and appropriate application.
• Improving the avenues for listening to children including easily understood and accessible complaints procedures; effective monitoring and review of complaints; and adequately resourced children's rights and children's advocacy services.
• More rigorous follow-up to inspection by service providers, external management and inspection agencies; and the transfer of historic inspection information to new inspection bodies.
• More effective investigation and disciplinary processes conducted jointly with the police where there is the possibility of crime; and based on sound legal advice and up-to-date expertise in employment law.
• Good record-keeping to underpin effective investigation and discipline and to afford looked after children the dignity and respect they deserve.
• Competent referrals to the DWCL and registration bodies based on thorough and efficient investigation to ensure those who should be disqualified from working with children are disqualified quickly and efficiently.

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