18. ANALYSIS AND CONCLUSIONS
Did abuse take place on the scale suggested by Glasgow City Council?
18.1 The Inquiry believes that abuse of young people did take place at Kerelaw after 1996. Court convictions and the records of disciplinary action taken by Glasgow City Council point to abuse having taken place over a number of years before then as well. The Inquiry found no grounds for concluding that sexual abuse was widespread or institutional, but cannot rule out that sexual misconduct took place to a greater extent than has been proven and is in the public domain. To say it cannot be ruled out is not to imply that it must have happened. We believe that to draw an inference from Glasgow City Council's report on its investigations that 40 staff might have been involved in sexual abuse over a lengthy period, and that a much larger number knew about it and did nothing, would not be justified.
18.2 The position as regards physical and emotional abuse is complex. By no means all staff engaged in such activity. There were good and dedicated staff who worked hard for young people. Many young people testified to that, and said that they had a positive experience at Kerelaw. The Inquiry considers nonetheless that physical and emotional abuse did take place over a period and was associated mainly with a particular core of staff. Although their practice gave cause for concern to some of their colleagues, it went largely unchecked until brought into the open in 2004, when the investigation of allegations of bullying and harassment of staff against the manager of the Millerston Unit was put in hand. It is regrettable that it was staff complaining about their own treatment, rather than the treatment of young people, which led to the fact-finding that then uncovered allegations by residents and ex-residents of ill treatment and abuse.
18.3 Physical abuse took a number of forms: poor practice; inadvertently clumsy restraints; deliberately painful restraints masquerading as consistent with approved procedures; and common assaults which owed nothing to guidelines, procedures or acceptable behaviour. Emotional abuse included threatening behaviour towards young people, shouting and swearing, and the use against them of their own life histories to disparage, devalue and among other things discourage complaints.
18.4 Those who physically abused young people will not have done so all the time, and some will no doubt have believed that what they were doing was not abuse, or was justified by the behaviour of young people they faced on a daily basis. For some, what became recognised as abuse in later years might not have been considered abuse when they first began working in residential child care. Nevertheless, it was abuse and should not have occurred.
18.5 We do not consider that the outpouring of allegations made to investigators in 2004 and 2005 can be explained away on the grounds that residents and former residents saw the investigations as an opportunity to win compensation. It is possible that a desire for compensation may have been a factor in some allegations, but the statistics for those who have submitted claims do not suggest that this was a significant motivator. Most of the claims for compensation were lodged after the outcome of the trial of the teacher and manager in 2006, and only a small number of those interviewed by Council investigators had made claims by the end of March 2009.
The circumstances that led to the abuse
Culture
18.6 The circumstances in which abuse was able to take place reflect a complex mix of factors, of which culture was particularly important. An emphasis on control, and the physical capacity to enforce it, originating in Kerelaw's history, lived on longer in a workforce which was heavily drawn from the surrounding local communities than it might have done in a wider labour pool with less of a tendency to close ranks round shared attitudes and behaviours. Ties from familial and other relationships reinforced this tendency.
18.7 The cliques and loyalties associated with those relationships were intimidating to staff who were concerned about what they saw, and were therefore a disincentive to challenge or whistleblow, although eventually some staff overcame their hesitations and spoke up. Many, however, did not, or left rather than report colleagues.
18.8 Differences and rivalries reduced the effectiveness of the senior management team, and made the pursuit, far less the achievement, of cultural change unlikely. The regular changes in senior management after 1996 also predisposed against any sustained attempt to challenge existing practice and bring about new approaches. The leadership based on shared values and clear vision which staff should have been given by their senior managers was largely absent. The opportunity to bring about change was lost in senior management churn.
Capacity for change
18.9 There was limited capacity for change within Kerelaw. Some senior people understood the need to challenge the prevailing culture and there were attempts at change, but these either failed to gain traction or ran out of steam. Two individuals at different times recognised that change was needed. Such aspirations as there were to bring about a more inclusive culture in which people put aside rivalries and worked more constructively together came to nothing.
18.10 The appointment from outside Kerelaw of a Principal with a potentially different perspective was an opportunity for change. The period from late 1998 to the end of 2000 was one of some change and modest improvement. Resistance to change from some staff and managers was evident but, with time, training, and probably changes among senior managers and some residential staff and teachers, lasting improvements might have been achieved. It is, however, difficult to say. Tentative steps towards a different, more inclusive culture, fit for a new, redeveloped Kerelaw, with a shared vision supported by management development and training, and by regular supervision, monitoring and accountability, were not sustained after his departure.
Training and development
18.11 Many staff came to Kerelaw without any prior training, although some others arrived already professionally qualified. Over the years, training developed in the residential sector, in which Kerelaw participated successfully in that many staff obtained qualifications. For some the learning was important and led them to consider their practice. However, the potential of this was never fully realised at Kerelaw. The Inquiry considers that the main reasons for this were the lack of a consistent or sustained overall shared vision for Kerelaw to which learning and development should have been linked, and a lack of process for embedding new learning and assisting staff to put their training into practice. There was also a resistance on the part of some individuals to learning new approaches stemming from a belief that no-one outside really understood their task.
18.12 Weaknesses in training for TCI contributed to poor practice, which was often abusive. How to restrain, as opposed to how to avoid having to restrain, appears to have been over-emphasised. Insufficient attention was paid to refresher training, which would have picked up developments in the system and misunderstandings by staff, until 2003, by which time some staff had received no updated training for 6 or 7 years. This meant that an over-emphasis on physical control was not challenged, and it reduced the ability of staff to respond safely to the increasing pressures they were facing from the client group.
Poor supervision and lack of performance management
18.13 There was no effective system of performance management or appraisal in relation to Kerelaw which would have required the senior management team to agree clear individual objectives and accountabilities with the Principal, or which would have required the latter to sit down with the Head of Service and agree what was expected of him. It meant that there was no real framework which required the Principal and his line manager to review formally the former's performance against agreed plans.
18.14 All care managers and staff should, however, have been subject to a formal system of supervision, familiar to social work practitioners, designed to support staff and enable practice to be reviewed and improved. This was inadequately applied. Successive inspection reports and reviews found it deficient and, although the need for improvement was recognised, and some improvements introduced, supervision took place inconsistently and was of variable quality. Failures in supervision played an important part in what went wrong at Kerelaw.
Complaints system
18.15 Although some complaints by residents were followed up rigorously when external placing authorities were involved, the complaints system was less than effective when kept in-house. While many of the outward manifestations of a complaints system were present, inspection reports regularly raised concerns about record-keeping and feedback. Many young people had no idea that complaints could be made outside the school and that the Principal was not the final arbiter. In some cases it was not clear to young people that complaints could go beyond their residential unit manager.
18.16 There were significant disincentives to young people to complain. Some saw no point because they received no feedback. Some were reluctant to make complaints in case staff lost their jobs. Some even seem to have accepted a level of violence against them as a normal part of the lives they led both in and outside Kerelaw. Some thought they brought it on themselves. Others were intimidated by their peers not to make complaints in case treats were withdrawn. Still others were told by staff that no one would believe them because of their history and behaviour. In short, the complaints system did not work adequately at the front end - the complainer, or at the back end - the follow-up stage.
Inspection
18.17 Inspection did not stimulate culture change at Kerelaw. This is not surprising. HMIE appear not to have inspected the Open School for 17 years after 1984. There was insufficient coordination of inspection, with HMIE, SWSI and North Ayrshire Council all involved. Only North Ayrshire Council in its inspections until 2002, when the Care Commission took over, gained a regular overview of Kerelaw as a whole. Over the years North Ayrshire Council raised a number of concerns, although not to the point of advocating closure of the school. All 3 inspection agencies gave credit where it was due - and it was due in a number of regards - but they were also clear that improvement was required. However, the common features of inspection activity until after 2003 were insufficient, consistent follow-up within Kerelaw and insufficient attention from external management.
18.18 The inspections of Kerelaw resulted in mixed reports over the years. Good points were highlighted and progress noted. However, far from indicating there were no problems, reports consistently raised concerns about staffing levels, the state of the buildings, lack of supervision, poor record-keeping, particularly in relation to complaints, and care staff-education staff interactions. Some concerns and criticisms expressed privately among inspectors did not find their way into published reports. There is some evidence of engagement by senior Social Work Department managers in receiving feedback and in following up recommendations, but follow-through was extremely poor. Little consistent interest appears to have been taken by the Council's Education Department in HMIE findings.
18.19 It is not justified to contend, as some have, that the poor report of the repeat inspection carried out by HMIE and the Care Commission in August 2004 was a bolt from the blue. The integrated HMIE/Care Commission inspection in November 2003 which preceded it raised a number of serious concerns, including deficiencies in the follow-up to a report of an inspection of the Open School carried out by HMIE over 2 years earlier, in September 2001. A number of those concerns were around issues that had come up on more than one occasion over the years. Internal papers from the Summer of 2004 suggest that individuals in the Care Commission had for some time harboured serious reservations about how Kerelaw was being run, yet there was no indication as to the seriousness of these in the report on the November 2003 inspection carried out jointly with HMIE.
18.20 Our overall conclusion, like that of other reports, is that inspection alone cannot be relied upon to bring about change and improvement. Even where problems and concerns are identified, and it is for consideration whether inspection methodologies are sufficiently tuned to allow cultural inferences to be drawn, only appropriate follow-up and management action can bring about improvements. Both internal and external management at Kerelaw failed in that respect.
Glasgow City Council's stewardship of Kerelaw School
Local government reorganisation
18.21 There were serious deficiencies in the internal management of Kerelaw over the years, but they alone do not explain why things went so badly wrong. If for many residents the stewardship of Glasgow City Council was inadequate, the same might be said for the employees of Kerelaw also. The transition from Strathclyde Regional Council to Glasgow City Council ownership was not an easy one. Personnel had to be matched to posts in the new Council and many people left. To deal with this and the budgetary dilemmas which the Council faced, recruitment was frozen and this had an effect on Kerelaw. A number of staff had to remain on temporary contracts for a long time, and some simply left when permanent opportunities arose elsewhere.
18.22 The migration to new systems was not straightforward and Kerelaw had simply to get on with the job. Although there was in due course a relaxation in restrictions on recruitment to residential homes, it took considerable time for staff to be given new contracts of employment at Kerelaw. The uncertainty that entailed would have meant staff did not feel valued. Despite observations by Inspectors and concern on the part of Kerelaw management it took 4 years for the contractual position of all staff to be resolved.
18.23 Budgets were a constant problem. The minutes of senior management meetings in the Social Work Department show the extent to which budgets occupied management time week after week and month after month. This will have made it harder to give the close attention to front-line services such as Kerelaw than might otherwise have been the case. Many services were cut, experienced staff were lost, and social workers were difficult to recruit. In those extremely difficult financial circumstances, there was no appetite for investment or spend to save. Successive Kerelaw managers had to fight for money to improve facilities, fund staff, and establish programmes for young people. Moreover, as Glasgow City Council had an interest in maintaining Kerelaw as a low-cost residential facility by comparison with other providers, winning an increase in budget would have been doubly problematic.
External management
18.24 Kerelaw could not be ignored, but it did not receive from external management the attention that it should have had. Other priorities and heavy workloads meant that external managers had difficulty establishing or maintaining the physical presence at Kerelaw that was required. Kerelaw managers for their part were at best ambivalent about, and at worst resistant to, more involvement by Glasgow City Council or indeed scrutiny by external agencies or individuals. The long-embedded inclination of Kerelaw to distance itself from many of the managing authority's policies and procedures and "do its own thing" should not have been condoned.
18.25 It is difficult to escape the conclusion that Glasgow City Council did not regard putting effort into managing Kerelaw as a high priority. External management responsibility was delegated inappropriately to individuals at a lower grade than the Principal of Kerelaw, and this was bound to be a problem with an institution that was sensitised to "outside interference". This took on more importance from 2001 onwards. While, in less challenging circumstances, and with regular supervision by the Head of Service, this would not necessarily have been unworkable, it was not an arrangement which encouraged proper partnership working between local management and Council HQ. The role of the external manager in determining admissions also created tension.
18.26 In summary, external management was insufficiently resourced, insufficiently senior, and insufficiently visible at Kerelaw to do its job. Its failures were an important contributor to what went wrong.
18.27 These failures were compounded by a dependency on Kerelaw as a placement of last resort for certain young people, which would probably have militated against radical measures by Social Work HQ. But even if external managers had wished to be more proactive, the culture in the Social Work Department would not have encouraged them to share with colleagues the kind of problems which Kerelaw posed. While different Directors of Social Work took different approaches to the resolution of conflict at senior level within their Department, the picture which emerges is of disagreement over policies, priorities, budgets and spending control. In those circumstances the exposure to colleagues of operational problems or of a need for help would not have been easy. The temptation "to let sleeping dogs lie" must have been strong.
Redevelopment
18.28 After the publication of A Secure Remedy in 1996, Glasgow City Council engaged in a protracted negotiation with central government over who would pay for a new Kerelaw, based, as it was intended to be, on a Secure Unit serving national needs with some form of close support units around it. Given the budget problems faced by the Council from 1996, it is not surprising that cost would be a major issue, and both sides would no doubt be determined to put as little of their own money as possible into the project. Eventually, agreement was reached on a central government contribution to the cost, some 7 years after Kerelaw's secure facilities had effectively been declared unfit for purpose. It is hard to escape the conclusion that, with a major redevelopment in view on an albeit distant horizon, there was no great incentive to the Council to make the investment in buildings or in human resources that Kerelaw required. However, the Inquiry found little documentary evidence to that effect, and any conclusion that it was an important factor would be speculation.
The arrangements for children who were placed in and accepted by Kerelaw
18.29 The arrangements for placing children at Kerelaw and the planning for them when they were there left much to be desired. Although there were procedures for planned admissions to Kerelaw, many took place on an emergency basis. Placements were not always matched to needs, and in some cases were inappropriate. This reinforced the view of many Kerelaw workers that it was a dumping ground for young people with particular problems or who had "failed" in other placements. With so many children placed on an emergency basis social workers had little opportunity for care planning prior to admission. In a number of case files the recording was so poor it was impossible to establish the frequency of contact between the fieldworker and the young person. Nor was it always clear what work was being carried out. Kerelaw files which were reviewed contained a range of care planning materials, and recorded information on children's progress, but there was little sense of joint working between the placing social worker and Kerelaw staff. There were also weaknesses at the end of placements, with little in the way of effective throughcare work taking place. Our conclusion is there were significant weaknesses in the arrangements for children who were placed in, and accepted at, Kerelaw.
Investigations and disciplinary process
18.30 The presentation in June 2004 to the Directors of Social Work and Education of the report containing the outcome of the Millerston investigation and other material collated over a period of several months produced a strong reaction. The Council clearly decided that it could leave no stone unturned within Kerelaw in establishing what had happened and in bringing perpetrators to book. The joint investigation team which was put in place faced a formidable challenge. While there was experience within the team of individual fact-findings, and of child protection, no-one had been involved in an investigation of such a scale before. As the team began its work alongside a police investigation into allegations of sexual abuse, it had a sense of moving into uncharted waters.
18.31 Aware of the personal relationships and other issues at Kerelaw identified in the June report, and with a belief that young people had been let down at the front of their minds, the team pursued their investigations with vigour. As allegations involving the same names which had come up time and again over the years multiplied, and as the team itself encountered the personal loyalties and connections which appeared to have hampered previous fact-findings, its determination not to be deflected resulted in an aggressive pursuit of evidence which left many staff feeling intimidated and devalued. While in the circumstances the end may well be thought to have justified the means, for many of those being investigated the presumption of innocence until proven guilty seems to have been lost along the way. As a result, a large number of staff who were not found to have a case to answer, including some who had themselves spoken out against abuse, considered that they had in turn been abused, by the process.
18.32 The joint social work-education investigation started with concerns for child protection, but it was in fact a disciplinary investigation. The scale and complexity of the task were evidenced by the expansion of the team in early 2005 and the length of time it took to complete its work. Despite the complexity, and the wish to proceed without undue delay to disciplinary action, more care should have been taken to quality control the recording of statements, to check available records, names and dates, and to pull together reliable written evidence. More care should also have been taken to abide by the Council's own procedures in respect of making available relevant written information to staff and their representatives. Disciplinary hearings should not have been scrabbling around for evidential productions on the day. The Inquiry also had some concerns that the investigation was not as all-embracing as it should have been between education and social work.
18.33 The Inquiry was left with the feeling that differences in the team between those who felt that in some cases they were dealing with poor practice rather than deliberate abuse were never fully resolved. It would perhaps have been helpful if more senior management guidance had been provided. It seems also that the investigation team might have been better supported by corporate HR and legal services. While we found no evidence of overt pressure on team members from elected members or senior managers to amass enough evidence to dismiss staff, it is not difficult to imagine in the circumstances an unspoken agenda to ensure that the Council could not be accused of being soft on child abuse. It would not be beyond imagining either that the Council would have wished to be seen to hold senior management at Kerelaw to account as well as more junior staff. However, the withdrawal by the Council of two cases being defended at Employment Appeals Tribunals because of admitted weaknesses in processes, and the loss of two actions, raises questions about the quality of scrutiny and advice.
18.34 The Inquiry does not believe that the Council took as much care to keep in touch with suspended employees as it should have done, to comply with its own procedures. The numbers involved may have been a factor, but too many people were kept in a state of uncertainty for too long. The impact of suspension and discipline procedures on the wellbeing of individuals and their families should not be underestimated. Employees facing allegations about their conduct in relation to young people in their care will feel anxious and may also experience fear, anger, sadness, resentment and hostility. It is incumbent on their employer to keep them informed throughout the process and to provide appropriate support. The Inquiry considers that the Council fell short of meeting its obligations in that regard. The Inquiry also considers that the members of the investigation team should have had formal debriefing by managers following the completion of their work.
Support for young people
18.35 The Council did not adequately anticipate or plan for the support needs of ex residents who gave evidence to the police and/or the joint investigation team. Although Barnardo's were commissioned late in the day to provide support to those who were involved in the Court process, some were over the age limit of 25 and were ineligible for the service. The investigation team was left to arrange for such support as was required for others. This was inappropriate. The Inquiry considers that independent, easily accessible support should have been built into the process. The Council should also have considered the support needs of the wider group of residents who had been in Kerelaw over the years. The Inquiry accepts this would have been a significant piece of work, but found no evidence that it had been considered.
Record-keeping
18.36 The Inquiry believes it is important to reflect on the quality of information provided by Glasgow City Council and on the keeping of that information. We acknowledge that maintaining records in good order when two simultaneous investigations were under way must have had its challenges and that certain information might be held elsewhere while a Court Appeal and various Employment Appeals Tribunals were in hand. Nevertheless, we were concerned about the Council's inability to furnish the Inquiry with complete and accurate records relating to the people at Kerelaw - in particular the residents, but also the staff. This undermines confidence that the Council has improved in its attention to record- keeping in relation to complaints, allegations and other incidents in residential child care establishments.
Leadership and management failure
18.37 There were significant changes in legislation and policy in residential child care in the 1990s. These changes required residential child care staff to gain new knowledge and adopt new approaches to working with the children in their care, and should have been the driver for a major programme of culture change at Kerelaw. The absence of a sustained drive for culture change, the poor follow-up of inspection reports and fact-findings over a long period, inadequate attention to supervision, weak systems, a lack of rigour in monitoring key indicators, and a reluctance to take difficult decisions involving key staff, point to leadership and management failures both within Kerelaw and in Glasgow City Council from 1996. At local level those failures were not helped by lack of continuity in the SMT. But they also reflect a lack of insight into what was required.
18.38 The failures identified relate not only to the period leading up to the events which unfolded in 2004. There appears to have been over the years no shared vision of the future, either within the SMT at Kerelaw or within external management in the Council's Social Work Department. Although the Council was having to adjust to new regulation, we found no evidence of drive to ensure that Kerelaw was moving with the times. Too much faith appears to have been vested in local management's capacity to appreciate what was required and to respond.
18.39 Kerelaw's flaws came to a head after 2001, when the pressure from an older, more challenging population of residents began to build. A more imaginative response by internal and external managers to the consequences of that would have included a thorough review of Kerelaw's fitness for the role it was expected to discharge and a willingness on the part of Social Work Department management to address concerns about the capacity of local management to bring about the change that was required.
18.40 While it is frequently a challenge to achieve the appropriate balance between empowering well-paid, qualified individuals to get on with their jobs, and the oversight necessary for accountability and compliance with corporate policies, there was too great a willingness to defer to the autonomy of local management. There was systemic failure over a long period to ensure that policies, procedures and guidance were being implemented at Kerelaw. The will to follow through appears to have been lacking. Although individual Heads of Service followed up a number of specific issues over the years, lack of clarity as to what was expected of the Principal of Kerelaw, and over-delegation of external management resulted in a woeful lack of performance management by the Social Work Department in terms of holding senior Kerelaw managers to account.
DWCL
18.41 The referral of ex-Kerelaw staff by Glasgow City Council to the DWCL raises a number of concerns which have implications for child protection and the rights of referred individuals. These concerns relate to: the quality and quantity of information on which the Council's referrals initially were based; the referral of ex-employees on the basis of uninvestigated allegations and the Council's unwillingness to confirm in the absence of an investigation that it would have considered dismissal had it investigated at the time; and the length of time it has, and is, taking to conclude on referrals.
18.42 It was difficult for DWCL officials to process referrals quickly with incomplete information. While the Council's child protection intentions were sound, if consideration had been given to completing its investigations before making a referral the whole picture, including any interdependencies between individuals, would have been made available at once. This would have distinguished between witnesses and those who needed to be referred, and it would have avoided double referrals.
18.43 As the DWCL has no investigatory powers and must rely on information provided by others, the quality of information is crucial. Where an ex-employee has left voluntarily, the legislation requires the ex-employer to confirm that he or she would have dismissed, or considered dismissing, an individual had he or she been investigated and the allegation proved at the time. Without that confirmation, the DWCL has no alternative but to treat a referral as legislatively incompetent under the Act. That raises obvious risks in relation to child protection. A lengthy provisional listing without an investigation or clarity in relation to the allegations also raises concerns in relation to the rights and employability of referred individuals. In guidance issued in January 2008, the DWCL made clear that an ex-employer should consider whether the tests for competence of a referral would have been met if the incident had been investigated at the time.
18.44 Some individuals referred by Glasgow City Council have remained provisionally listed on the DWCL for 2 and sometimes 3 years without a decision about their unsuitability to work with children. This is in the Inquiry's view an unsatisfactory state of affairs. Most often extensive delays have resulted from the intervention of other proceedings, such as Court cases and Employment Appeals Tribunals, where the DWCL waits for an outcome before taking forward its listing consideration. We were told that there are not many individuals provisionally listed who continue to work with children, even though they are able to do so. Nevertheless, the possibility that someone who is provisionally listed and who may go on to be listed can continue to work with children for a protracted period after referral prolongs the risks in relation to child protection.
18.45 The Inquiry was told that, under the Protection of Vulnerable Groups legislation, individuals might be considered, on a case-by-case basis, for listing more quickly without awaiting the outcome of legal or disciplinary proceedings. We welcome the improvements in the protection of children that will derive from the new legislation. However, this is not an opportunity for complacency - the onus will remain on the employer to maintain good records of allegations, complaints and incidents involving individual staff, and on the employer or ex-employer to be efficient in the investigation of such matters. Such investigation will lead to delays in some cases, and it is important that the employer makes efforts to keep individual employees informed about progress during that time and remains vigilant to the risks that remain while those who are provisionally listed may continue to work with children.