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Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
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5.1
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Brent Social Services had the opportunity to help Victoria on two
separate occasions. The first was on receipt of an anonymous telephone
call expressing concern about Victoria’s safety in June 1999,
while Kouao and Victoria were living at 8 Nicoll Road and supported
by Ealing Social Services. The second was almost a month later,
after Kouao and Victoria had moved in with Carl Manning at 267 Somerset
Gardens. This was when Victoria was taken to the Central Middlesex
Hospital by her childminder’s daughter, Avril Cameron, with
suspected non-accidental injuries. Regrettably, at no time during
Brent’s brief involvement with Victoria did social workers
make any connection between these two referrals. Indeed, the first
time senior managers acknowledged that there had been two referrals
in relation to Victoria was in February 2001, a year after her death
and in the month following the criminal trial of Kouao and Manning
for her murder. Had the link been made at the relevant time it seems
highly likely that events in Victoria’s life would have taken
a very different turn.
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5.2
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The two referrals found their way to a duty team. The Social Services
Inspectorate (SSI) in May 2000 assessed this team to be "failing
to meet basic requirements for an initial response to referrals."
They were operating administrative systems the SSI considered to
have "broken down" and to be "creating serious risks". Overall,
in May 2000 the inspectors found a situation that was "very serious"
and a children's services department that "lacked any clear vision
or sense of direction". This did not happen overnight.
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5.3
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Brent has accepted there were serious shortcomings in the practice
and in professional judgements made at the time, which resulted
in missed opportunities to help Victoria. If the criticism could
be fairly made that senior management took its eye off its 'front
door' children's services in Ealing, the position in Brent was far
more deep-rooted - as the SSI May 2000 inspection was to reveal.
Mike Boyle, the director of social services until April 1999, accepted
that he had 'taken his eye off the ball' in respect of children's
services from 1998.
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5.4
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In fact, at one stage children were so low in Brent's priorities
that children's social work was not even mentioned in the 1999 Corporate
Strategy Update. It was not surprising, then, that in May 2000,
the SSI could find no up-to-date children's plan. The most recent
was dated 1995 and referred to the period 1995-1998. The interim
child protection procedures were still considered 'interim', despite
being over four years old. Jenny Goodall, Brent's new director of
social services appointed in April 2000, went further and said,
"I think there was a period when social services [my emphasis]
somehow slipped below the horizon." Therefore, I make the following
recommendation:
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Recommendation
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Chief executives and lead members of local authorities with social
services responsibilities must ensure that children's services are
explicitly included in their authority's list of priorities and
operational plans.
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5.5
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Responsibility for this sorry state of affairs rests squarely with
Brent's council members, chief executive Gareth Daniel, and his
senior social services officers. Mr Daniel said in evidence both
politicians and management accepted that in 1999 they had plainly
not done enough for children in Brent. This does little more than
state the obvious - especially as the SSI May 2000 inspection was
preceded by critical SSI inspections into the safety of children
looked after in February 1998 and Brent's child protection services
in September 1996. The latter inspection warned of serious deficiencies
in child protection practice and urged a "re-prioritising of management
endeavour" so as to "increase the level of direct support, advice
and direction to team managers and social workers until such time
as practice achieves a consistently good standard".
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5.6
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In 1998, the SSI identified an absence of workload management systems
in the social work teams and said workload pressures had worsened.
They warned, "These pressures could, if allowed to continue or deteriorate,
reduce workers ability to identify and address safety issues for
children.
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5.7
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Mr Daniel, who was appointed to his position in September 1998
after being the acting chief executive from May 1998, said of himself,
"I am a general strategic manager for the authority and that is
my discrete role. It is not my role to be a surrogate for the people
that I directly manage." Mr Daniel then explained that he discharged
his responsibilities by "making sure that the resources are available,
the proper checks are in place and that we appoint people in whom
we have confidence to discharge the statutory responsibilities which
I have to reinforce".
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5.8
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In my view, other parts of the evidence of Mr Daniel cast some
doubt on this assertion. Looking specifically at social services
and children's social work, Mr Daniel said that he thought the leadership
at a high level in the social services department during 1998, 1999
and 2000 was "seriously defective", with staff being "poorly managed
and poorly led". He said, "My impression of the social services
department from a professional distance [my emphasis] in
the town hall is [that] there were a lot of good front-line staff
working in that department putting in very long hours, and there
were senior managers who were certainly doing all of those things,
but I did not feel confident that they were providing the strategic
leadership for the department that it needs." As to how the lack
of good management affected the way children in Brent were looked
after and cared for, Mr Daniel said, "I do not think it assisted
the process. I mean, I think the endeavours of front-line staff
probably rescued us from a lot of crises which may potentially have
arisen. We were very heavily dependent on the integrity and the
commitment of those front-line staff.
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5.9
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In my view, the chief executive can exercise considerable influence
on the quality and effectiveness of front-line social work, and
indeed has a responsibility to do so. In the particular circumstances
in which Mr Daniel found himself in Brent, he failed (during the
period with which I am concerned) to address the shortage of staff
in the children's services and to implement the recommendations
of the SSI reports of 1996 and 1998. He also failed to ensure these
services were adequately funded. These were all matters which had
a major impact on the children's services, for which Mr Daniel must
take personal responsibility. Therefore, I make the following recommendation:
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Recommendation
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The Department of Health should require chief executives of local
authorities with social services responsibilities to prepare a position
statement on the true picture of the current strengths and weaknesses
of their 'front door' duty systems for children and families. This
must be accompanied by an action plan setting out the timescales
for remedying any weaknesses identified.
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5.10
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A fair assessment of the performance of front-line staff in Brent
at the time Victoria needed protection has to be made against the
backdrop of the dysfunctional and administratively chaotic children's
service in which they were expected to work.
|
Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
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5.11
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In 1999, Brent senior management team was structured as follows:
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•
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Gareth Daniel, chief executive
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•
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Mike Boyle, director of social services (and later Ronald Ludgate)
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•
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Lucille Thomas, director of children's social work services
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•
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Branton Bamford, assistant director for finance and administration
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•
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David Charlett, service manager for the duty team and the child
protection and investigation team.
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5.12
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Brent children's social services had two initial assessment teams.
These were the duty team and the child protection investigation
and assessment team (child protection team) - and six teams that
were allocated cases on a long- term basis. The duty team was the
first team to consider referrals received about children, though
this was complicated by the fact that many of these came through
Brent's One Stop Shops. If the referral raised issues of 'a child
in need', the case would remain in the duty team for initial assessment.
But if it was agreed that it contained child protection concerns,
it would be transferred to the child protection team. Both of these
teams were assisted by a duty administrative team, which would log
the referrals into a database and complete checks to find out whether
the child was known to the borough.
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5.13
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The duty child protection and duty administrative teams shared
an open-plan office on the ground floor of the children's social
work building. I heard evidence that the building was "overcrowded",
"grotty", and "neglected". The SSI in 2000 said the accommodation
for duty work needed to be improved to meet health and safety requirements.
The manager of the duty team, Edward Armstrong, and the manager
of the child protection team, Tina Roper, shared a small office
at the end of the room. The seven duty social workers including
Lori Hobbs, Kate Thrift and Yolande Viljoen (née Hurter),
worked at one side of the room and the six child protection social
workers were stationed at the opposite side of the room.
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5.14
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At the time Victoria's case was handled by Brent, all the duty
social workers had received their training abroad and were on temporary
contracts. Several workers in the child protection team were also
recruited on a temporary basis. The fact that so many staff in the
initial assessment teams were agency staff had important consequences
to which I shall return later in paragraphs 5.59 to 5.61. The two
duty senior social workers were Monica Bridgeman and Pauline Phillips,
and the two child protection seniors were Michelle Hines and Christina
Austin. The group administrative officer was Robert Smith. Martin
Punch was one of the administrative support workers. Unlike other
boroughs, Brent did not deploy any of its social workers at local
hospitals.
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5.15
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Mr Boyle was frank in his evidence to the Inquiry on the state
of the duty team. Looking back, he said it was clear to him now
that "the duty team began to unravel during 1998 and 1999. The attention
of senior managers was elsewhere and as a consequence the service
declined to a point that was unacceptable". He believed Victoria's
case demonstrated "individual, collective and institutional failures
in the system [which were] intended to ensure that the needs of
the most vulnerable children are met".
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5.16
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Counsel for Brent acknowledged that the duty team was undoubtedly
"a team under pressure, over busy, very short of permanent and experienced
staff" and Mr Armstrong pointed out that in 1999 the pressure was
particularly acute because of the increase in the number of asylum
seekers. Ms Viljoen described the duty team as "very busy". She
said, "The phones would ring constantly." Mr Punch said the duty
team was "very, very swamped with work". Mr Armstrong said, "It
was concerning to look at working with between 200 to 300-odd cases
per week that was in the backlog system." Given the caseload in
June and July 1999, he said that he barely had time for lunch, let
alone to stand back within his office and look at the systems the
duty team worked under.
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5.17
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Mr Armstrong dated the beginning of the influx of unaccompanied
asylum seekers to 1999. By then, he said, " We lost our ability
to be social workers [my emphasis] because of the time we had
to spend dealing with asylum seekers - there were no additional
resources to cope with it." Mr Armstrong estimated that in June
and July 1999 he was dealing with at least 15 referrals in relation
to intentionally homeless people and asylum seekers each week, and
that at least 50 per cent of social workers' time would be spent
working on cases of unaccompanied minors. By May 2000, the SSI found
that duty staff were overwhelmed with cases of homeless people and
were required to spend up to 80 per cent of their time working on
what might be considered housing and homelessness issues. I can
only question, and not for the first time as will become clear,
why Brent's senior management team failed to act more quickly to
protect the 'front door' of their children's services.
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5.18
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Even more significant than the increase in numbers coming through
social services' door was the inability of the duty team to pass
cases on to the long-term teams, after the initial work had been
completed. Mr Armstrong described how every Wednesday morning he
would attend allocation meetings with the assistant directors and
the child protection team to refer cases for allocation to the long-term
teams. He said, "It had become a common theme for me to go to the
allocation meeting with cases for allocation to a 'long-term' team,
only to return with the same cases because there was insufficient
resource availability in long-term teams to deal with the cases."
He added, "It was something that went on, not for months, for years."
Ms Roper confirmed that the relevant assistant directors and occasionally
Ms Thomas would attend the allocation meeting, so they were perfectly
well aware of the difficulty and the bottleneck in allocating cases
to the long-term teams.
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5.19
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The effect on the duty team staff was immense. Ms Hobbs said it
was a "major problem", which "was frustrating because there was
little let-up". This bottleneck of cases meant that duty workers
would have to carry out work that should have been done in the long-term
teams in addition to each day's new referrals. For Mr Armstrong,
the pressures reached such a pitch that he said, "It got to the
point where I actually filled the boot of my car every Friday evening
to take cases home, in order to get them up to date, bring them
up to date and still report to senior management about what was
happening." To do this Mr Armstrong said he needed Ms Thomas's permission.
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5.20
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Mr Armstrong did not, however, suffer in silence. He raised his
concerns about the workload pressures and staffing with his superiors
on a number of occasions. He said, "I would mention it to all the
senior managers that I came into contact with, but it got to the
point where I felt it was because I kept on doing the work, and
was not falling off sick or going off sick for months on end, that
it became acceptable to senior management." Ms Bridgeman said she
also reported her concerns to members of the senior management team
on numerous occasions. She said, "We were constantly working in
a crisis situation. Senior management knew this."
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5.21
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Mr Charlett, when discussing the problem of allocating child protection
cases to the long-term teams, said, "We could not stop work coming
into the office, but on the other hand, it seemed to be blocked
at that point, and there was no way I could - I had no authority
to order people in the other teams to take on cases." It is difficult
to credit a more ineffectual management response, despite Brent's
action plan following the 1996 SSI inspection stating that they
should take measures to reduce pressures on team managers. Mr Armstrong
said, "Nothing was done to relieve the pressure. Instead the pressure
increased."
|
Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
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5.22
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During the summer of 1999, the duty team also appeared to have
let slip vital administrative functions. Although the administrative
team was a separate unit, there was considerable overlap between
the functions and operation of the two teams, and often a confusion
as to which team bore the responsibility for particular tasks. One
area of contention was the collection and distribution of faxed
referrals and other important communications received by the children's
social work team. In his evidence, Mr Armstrong painted a graphic
picture of faxes at times streaming on the floor and nobody picking
them up. It was not a description that others in the duty team recognised,
though Ms Bridgeman acknowledged she was aware of significant delays
in the distribution of faxes on one or two occasions. When asked
why he himself did not do something about it, Mr Armstrong said,
"It was not my job to pick up the fax from the fax machine. It was
not my role. I had other things to do." He did, however, complain
to administrative colleagues about the problem.
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5.23
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The evidence relating to the tracking of cases within the duty
and administrative teams raised further serious concerns. According
to Mr Armstrong, more than one case was going missing every day
and it was obviously difficult to monitor what was going on in the
missing cases: "Some files were misplaced and some were never found."
Mr Smith believed that it had been known for files to go missing
and never reappear, though this was not his personal experience.
Mr Punch wrote in a later memo: "Retrieving files has become like
the 'National Lottery' with the same odds for finding files." It
was Mr Punch's view that the high number of systems in use at the
time only contributed to the problem. There were just too many routes
and locations in which files could be lost.
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5.24
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There can be little doubt the duty system was in administrative
chaos in 1999. Instead of senior management taking urgent steps
to remedy the sources of the problems, the duty team was left to
devise its own ad hoc solutions that included introducing a number
of manual logging systems. Mr Armstrong said there was no way in
which information could be matched up between the books they used.
For example, the duty book "would not give us as much information
as we require, but it will let us know that that file has been in
the system, is in the system, but is now missing". Therefore, I
make the following recommendation:
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Recommendation
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Directors of social services must devise and implement a system
which provides them with the following information about the work
of the duty teams for which they are responsible:
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• number of children referred to the teams;
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• number of those children who have been assessed as requiring
a service;
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• number of those children who have been provided with the
service that they require;
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• number of children referred who have identified needs
which have yet to be met.
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5.25
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With the heavy work pressure and the presence of so many agency
staff, good supervision and support was essential. The agency social
workers spoke highly of the supervision and support they received
from their seniors and team manager while at Brent, but this was
not carried through at more senior levels. In relation to his supervision
of the senior social workers in his team, Mr Armstrong said, "Due
to the volume of cases which we were handling, supervision arrangements
slipped and certainly did not occur on a monthly basis." He was
supposed to have monthly supervision meetings with Mr Charlett but
Mr Armstrong said he could not say how often these actually occurred,
other than to point out they were less regular than monthly. Ms
Roper said she found Mr Charlett's supervision to be supportive,
but pointed out that his recent experience of child protection matters
was limited.
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5.26
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In view of the regular turnover of staff, the monitoring of the
quality of the work carried out should, in my opinion, have been
a top priority. In fact what actually occurred in Brent was just
the reverse. As Mr Armstrong pointed out, it was obviously difficult
to monitor work in the cases that were lost. In his written statement
Mr Charlett said, "Monitoring arrangements included case records
monitoring, the system of regular staff/case supervision through
the line management system, random monitoring of cases by supervisors/managers,
statistical analysis of referrals and caseloads." However, when
specifically questioned on this, Mr Charlett made a somewhat unconvincing
attempt to outline these processes in practice and it became clear
that there were no formal procedures in place, or at least none
used by him, to monitor cases. On the other hand, Ms Roper said
that she would monitor the progress of cases in the child protection
team and that she carried out an audit of cases once every fortnight.
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5.27
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Despite written procedures in the Brent Quality Protects Management
Action Plan 1999-2000 requiring assistant directors to produce
quarterly reports on individual cases, Mr Charlett said he could
not recall producing such reports routinely for the director of
children's social work. When it was suggested to him that the systems
of monitoring and supervision of cases within his department were
inadequate, Mr Charlett said that he would have to agree, up to
a point. He said, "Certainly they were not what I would have liked,
and what would have been desirable, but as I have pointed out, there
were lots of difficulties with regard to covering just the day-to-day
work." Therefore, I make the following recommendation:
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Recommendation
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Directors of social services must ensure that senior managers
inspect, at least once every three months, a random selection of
case files and supervision notes.
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5.28
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Despite a very heavy workload and several temporary social workers,
in contrast to other teams in the children's social work unit, Mr
Charlett observed, "The child protection team was always more stable,
it had ... more of a team quality about it, and it was a team where
other social workers wanted to join." Mr Charlett said he had a
great deal of confidence in Ms Roper and the other workers in the
team. Child protection team members themselves said they thought
it was a supportive team, with a good manager. Mr Charlett was also
of the opinion that the team was capable of managing its workload.
This may in part have been because the administrative and the long-term
teams would prioritise the cases above those concerning children
in need. In fact, Ms Roper said that on occasion she would volunteer
at allocation meetings to keep some of her cases, in an effort to
allow some duty cases to be allocated.
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5.29
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Mr Charlett said that all child protection workers were meant to
follow a seven-day modular course, but that agency workers were
less able to pursue training courses. Although it was not something
he agreed with, Mr Charlett said, "There was certainly a feeling
that it was sometimes a waste of time training agency staff." Yet
these were the very same workers whose task it was to assess the
most vulnerable of Brent's children, those for whom it had already
been decided, rightly or wrongly, that there were clear child protection
concerns.
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5.30
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Ms Roper said that she would meet with any new worker to the team
and talk them through the processes and systems of the child protection
team and they would initially co-work with other members of the
team. However, there was no formal induction process in place. Ms
Hines said she personally had not received any induction and whether
or not locum workers who joined more recently received an induction
depended upon the staffing of the department at the time. Therefore,
I make the following recommendation:
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Recommendation
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Directors of social services must ensure that all staff who work
with children have received appropriate vocational training, receive
a thorough induction in local procedures and are obliged to participate
in regular continuing training so as to ensure that their practice
is kept up to date.
|
Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
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5.31
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The increased workload in the two initial assessment teams, particularly
the duty team, had a knock-on effect on the duty administrative
team. Yet Brent's response was to understaff this department as
well. According to Mr Bamford, there were three members of the administrative
team during the relevant period, but one of these three was off
sick. He said that the previous fourth position had been notionally
frozen. When the third staff member went on sick leave, Mr Bamford
said he discussed whether to get in additional temporary help. But
after considering the time it would take to train someone and that
they might stay only a short time, Mr Smith agreed to cover until
Brent Social Services' Finance and Administration Department had
a better idea of the length of the sick leave.
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5.32
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Mr Bamford said he was unaware of any administration problems at
the time, other than the staffing issues. While he acknowledged
that "things were not run as smoothly as one would hope", he seemed
totally unaware of any backlog at the time in question and thought
that if there were any problems these should have been brought to
his attention.
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5.33
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I found Mr Bamford's ignorance of the problems facing the team
to be surprising. The administrative problems were numerous and
glaring. In addition to the backlog of referral details waiting
to be inputted because of staff shortages, the absence of a common
database in social services meant that administrative staff had
to complete checks on five or more different databases. As the duty
administrative team staff did not have direct access to most of
these, the time taken to complete a check was unnecessarily lengthened,
which just added to the workload. Child protection cases were prioritised
but the backlog meant that cases not yet on the system could not
be easily searched. Mr Armstrong said referrals that were initially
or wrongly categorised as 'child in need' but later transpired to
have child protection issues, were almost inevitably caught up in
this administrative delay, making it harder and slower to detect
and remedy any mistake, as happened in Victoria's case.
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5.34
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According to Mr Punch, "People were struggling in a very difficult
environment." Ms Hobbs said she could remember cases piled high
and thought the administration staff were under more stress than
anyone. Others described the team as "relentlessly overworked" and
"overburdened". Records for June 1999, the month of Victoria's first
referral to Brent, showed that only 107 referrals (42 per cent)
were logged onto the system within one working week, and 41 (16
per cent) took between four and 12 weeks. Mr Armstrong said, "I
complained week in, week out to the administrative officers about
the backlog, about getting people to come in and clear the backlog,
because the backlog was getting so high it was actually hiding the
administrative staff from the rest of the team." Nor did this situation
appear to be temporary either. In May 2000, the SSI inspected a
duty area where there were "hundreds of case files that had not
been administratively processed, going back four to five months".
Staff, therefore, had to rely on their memories to link new contacts
with past contacts, and there was no system to ensure that repeat
contacts were linked and patterns of referrals identified and responded
to.
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5.35
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Other problems relating to the duty administrative team were raised
in abundance. Ms Bridgeman said that due to work pressures, the
administrative team did not make up a whole file for the duty workers.
Instead they just received the duty manager's action sheet, the
administrative checks sheet and the referral.
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5.36
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Mr Punch also identified the problems of inadequate filing space
and the unusual system of filing by problem type, rather than by
the person's name. On the basis of the evidence of Mr Armstrong,
there appears to have been almost a complete absence of filing closed
cases. Mr Armstrong said that when a file was closed and the administrative
officers had input the necessary information on the database, "Instead
of the files being taken from the duty room direct to the archive
room, they were just put in a corner or on desks around the office,
until the administrative officers had time available on their hands
to get them up there, which could take months. I have known files
which took years to get upstairs."
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5.37
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As team manager for the duty team, Mr Armstrong was clear that
he had no management responsibility for the administration team
or over its systems, yet he was dependent on them for the logging
in of referrals, the checking of databases, and the issuing of appointments,
which were fundamental to the smooth operation of his duty team.
Mr Armstrong said, "Looking back, maybe I should have taken the
view to go above the heads of my senior managers, and possibly maybe
as far as the chief executive.
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5.38
|
I heard much evidence in support of his opinion. Although the administration
failings in Brent deserve my criticism in full, I do not direct
this at the individual administration workers. Mr Punch, for one,
appears to have been conscientious and hard-working and to have
tried his best in the impossible situation management put him in.
Mr Punch considered the position so fragile that even as late as
September 2000, seven months after Victoria's death, he wrote a
lengthy plea to Mimi Konigsberg, the new assistant director for
children's services, Mr Bamford and Mr Smith. He outlined his grave
concerns and suggested ways in which improvements could be made.
In general, he spoke of a particularly "difficult, frustrating and
depressing period of work" during which he had become disheartened
because he felt he was part of a function rather than a team. He
said, "The work of duty admin has generally been under-resourced,
unsupported, unappreciated and not fully understood by other staff
members and even by management." It was not until the instigation
of this Inquiry, and some 14 months after he sent his memo, that
he finally received a substantive reply from Ms Konigsberg. It therefore
came as no surprise to me that the SSI wrote in 2000, "Communication
in the past had been too much top down and staff needed to be listened
to and their contribution to the development of the department recognised
and supported."
|
Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
|
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5.39
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Part of the explanation of how and why Brent children's social
work teams had fallen into such a state of disarray must lie with
the legacy of past council decisions, and a corporate structure
designed to deal with their persistent financial pressures.
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5.40
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Mr Daniel said, "I think children's social work was under-funded,
I think social services were under-funded, and I think Brent council
was under-funded." Mr Boyle believed that the primary difficulties
were Brent's historic debt that had to be met from revenue funds,
the under-funding by government of adult community care services,
the inadequate level of council reserves, and the failure of the
government grant to keep pace with the real costs of inflation.
As such, Mr Boyle said he thought the council was effectively bankrupt.
It had no ability at all to respond to any significant variations
in service demands and was managing in a "financially impossible
position".
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5.41
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The implications were severe. In 1997/1998, the overall social
services budget was fixed at 4.4 per cent below the Government's
Standard Spending Assessment (SSA), while the average total spending
on social services in England was 8.3 per cent above the SSA. Brent
was the second lowest spending authority in London. Children's services
were particularly badly hit. In the financial year 1998/1999, Brent
had a children's SSA of £28.12m (as against £26.5m in the previous
year), but the actual spend was only about £14.5m, up barely £250,000
on the year before. Mr Boyle, who was the director of social services
at the time, said he felt "extreme concern and unhappiness" about
only being allowed to spend half the SSA. In 1999/2000, the SSA
itself decreased by almost £7.5m to £20.65m as a result of the Government's
decision to remove ethnicity from the assessment formula. This sorely
affected Brent, which has a substantial ethnic minority population.
Mr Daniel described his oversight of the budget as a "baptism of
fire" because of the reduction of £7.5m and a budget deficit of
£17.5m that he had to try to bridge. Yet he could not dispute that,
even with the reduction, the council was still not spending the
SSA on children's social work.
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5.42
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Politicians and management were keen to submit that the SSA was
a notional figure or formula for distributing money, rather than
being prescriptive as to what the council should spend. Councillor
Mary Cribbin said that there was real deprivation in the borough
and that the budgeting process was therefore a "balancing act" between
competing concerns. As a result, while spending on children's social
work was under the SSA, other units were being funded in excess
of their designated SSA. I address the issues concerning spending
in relation to Government-set SSA's elsewhere in this Report. It
is enough to say here that I heard no evidence from Brent's senior
managers or lead council members to show that they could justify
spending so little on children's services during the relevant period.
In fact, it became clear that wherever the money was going, the
adequate provision of children's services was certainly not one
of the council's priorities.
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5.43
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The social services committee certainly could not claim it was
unaware of the implications of budget decisions or of the problems
surfacing in children's social work. Mr Boyle said, "There was a
corporate understanding that social services was financially very
challenged indeed." There were the critical SSI reports in both
1996 and 1998 and the committee regularly received information from
its officers. Mr Boyle, as director of social services, wrote to
the social services committee on 4 March 1999. In his letter he
outlined the likely impact of the council's decisions, since September
1998, to reduce the spending plans of the committee by £4m. Mr Boyle
pointed out that the managed reduction in spending had resulted
in "severe pressures and stresses" including long-term illnesses
and absences among a number of service unit directors and front-line
staff. He said that social services were carrying vacancies in all
teams and the Area Child Protection Committee (ACPC) had been advised
for the first time in many years that there were unallocated child
protection cases. Mr Boyle's letter continued:
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"Your officers advised that it is not possible for these savings
to be achieved from 'salami-slicing' and there will be significant
and serious implications for service delivery. I[n] some instances,
we may be expecting staff to manage risks which are unacceptable
and dangerous. Your officers fully appreciate the circumstances
facing the Council but setting unachievable savings targets will
not assist you, or the Committee, in meeting the objectives of the
Council."
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5.44
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The message could not have been clearer. However compelling the
financial pressures may have been at the time, they could not, in
my view, excuse the failure of Brent's council and senior management
to address the problems in their children's services that had become
so evident in the late 1990s.
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5.45
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I was told that alongside the financial pressures, Brent's other
legacy from the previous administration was its corporate structure.
The council had been split into 'core units' with corporate and
strategic responsibilities, 'commissioning units' that dealt with
needs analysis and service planning, and most importantly 'business
units' that were responsible for service delivery. Ms Goodall said
that this structure "did away with everything that I think you would
recognise as traditional local government". She said at one point
there were nine different business units in children's social work
and they were all semi-autonomous, operating without traditional
line management responsibilities. Although the new administration
sought to alter this framework, Ms Goodall observed: "Brent Social
Services really had not sort of thrown off the old business unit
culture. And to a great extent there was not a departmental culture,
there were lots of separate managers, really, doing their own thing."
In Mr Boyle's view, "Many of the difficulties, financial and operational,
encountered in later years arose from the inherent weakness in these
structures established during 1993/1994 and 1994/1995." He said,
"Over a period, the lack of accountability became apparent, complex
cases were not dealt with properly, and financially many social
services units were not able to make a corporate contribution without
compromising the safety of the service.
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5.46
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A clear example of the failings of the independent business units
was the absence of a common database throughout the whole of social
services, let alone the whole council. In 1993, the main system
in use was the Social Services Information Database (SSID) and this
continued to be the predominant database used by adult social services
and the One Stop Shops. In May 1996, when Mr Bamford arrived in
children’s social work, the department had no connection to
SSID after a corporate decision had been made to discard it. He
believed that parts of social services were meant to make their
own alternative arrangements. In so doing, and because SSID was
not generally considered by Brent to be an easy system to use nor
did it lend itself to reporting information on children, Mr Bamford
decided that children’s social work would use Filemaker as
their primary database. This database was only accessible by administration
and not practitioner staff. In addition to Filemaker, Mr Punch,
who was responsible for inputting practically all the child protection
referrals, had his own system specifically catering for child protection
cases. Mr Bamford explained that the operation of five or more different
systems in social services “was not an ideal situation”,
with the consequence that telephone calls would have to be made
to different departments to find out whether or not a family was
known. Worse still, the out-of-office-hours team, which operated
the out-of-office hours social work, could only consult the child
protection register and had no access to either the SSID or Filemaker
database to find out whether children not on the register were known
to Brent. It was not until September 1999 that SSID was actually
reintroduced to children’s services, and the out-of-office-hours
team and practitioner staff could access this information. Therefore,
I make the following recommendation:
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Recommendation
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Local authority chief executives must ensure that only one electronic
database system is used by all those working in children and families'
services for the recording of information. This should be the same
system in use across the council, or at least compatible with it,
so as to facilitate the sharing of information, as appropriate.
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Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
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5.47
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Accompanying the introduction of the business units was a reduction
of general, non-operational support services. Mr Daniel described
the devolved culture in Brent by saying:
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"On the whole we have a minimalist corporate centre - as a
deliberate policy choice between 1991 and 1996, support services
in the authority were stripped down to the bare minimum, and that
meant quite a lot of central support functions, particularly in
areas like HR or information gathering, were either reduced to a
skeletal basis or eliminated altogether ... a lot of our capacity
to gather information about the organisation became somewhat limited."
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At a departmental level, by the late 1990s Mr Ludgate said that
social services had lost all of its human resources and training
staff.
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5.48
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According to Mr Boyle, "A further feature of the new arrangements
was a general belief that the council, and social services, was
over-managed. Consequently, significant reductions were made in
non-operational budgets resulting in the loss of a number of key
management posts." The effect was to significantly reduce the strategic
and management capacity of the organisation. The posts of both senior
policy manager for children's services and the service development
director were frozen or deleted in late 1997. According to Mr Boyle,
by 1997 the effects of this policy prompted the then chief executive
to describe the council as suffering from "institutional anorexia".
Reductions nevertheless continued and as a result, when practice
began to deteriorate, Mr Boyle said, "The management infrastructure
was not in place to identify that that was happening."
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5.49
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Front-line children's services did not escape the cutbacks. Despite
increasing pressures on the department, in August 1997, service
reductions resulted in 10 children's social work posts being deleted
and a further 13 vacancies frozen. The SSI in 1998 recognised that
"Staff reductions had had a debilitating effect." From inside, Ms
Roper observed, "The whole of Brent children's social work was running
with a large number of vacancies." In June 1998, the director of
social services reported to the Committee: "Eight social workers
have been recruited to ease caseload pressures and to reduce the
number of unallocated cases." However, overall that only placed
the council, in the words of Councillor Cribbin, "down 23 and up
8".
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5.50
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In his evidence, Mr Daniel was critical of the strategic leadership
of the directors of social services and of children's social services
at the time.
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5.51
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Certainly Ms Thomas, as director of children's services, held a
key position in the management framework. The absence of a witness
statement and her inability to give evidence to this Inquiry due
to ill health has made it more difficult to assess fairly her contribution
to the state of affairs in Brent's children's services. Ms Thomas's
ill health also caused her to be absent from work on sick leave
for five or six weeks during the summer of 1999. I heard evidence
that as non- front- line posts were deleted from children's social
work, Ms Thomas, along with other managers, were consequently expected
to carry a much larger and more varied workload, in her case a workload
that was both strategic and operational. Brent's Management
Action Plan in mid 1999 was heavily criticised by the SSI,
in particular reflecting that the service "lacked any clear vision
or sense of direction". The previous post of senior policy officer
for children's services had been deleted, and Mr Daniel considered
this to have created a "critical weakness" in the senior structure
of the department. I can only assume this was a view he held with
hindsight, otherwise once again I am left asking why he did nothing
about it once in post as chief executive.
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5.52
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Mr Boyle, talking of his time as director of social services, said,
"Throughout 1998/1999, most senior management time was spent on
financial matters, either in trying to align actual spending with
the budget available, or in making plans to deal with the financial
shortfall in 1999/2000." Mr Boyle said that he thought the turning
point came in 1998 when "Social services senior managers began to
take on more and more work and took their eye off the ball, I think
particularly with the director of children's social work services
... because of the extra work that she was required to do ... as
a consequence ... strong management attention on the service, which
the SSI pointed out in 1996 was required, did not occur and the
service deteriorated from that point onwards." Mr Boyle said that
he had "very serious concerns" about what was happening in social
services in 1998/1999, "not just with children's services ... but
also with the increasing effect of concentrating social services
provision, both in children and on adults, on those at the most
risk". Looking back, he said, "In truth, the funding problems for
Brent and in social services were there even before I arrived. I
was just unable to stop the position deteriorating year on year."
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5.53
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Despite his own admission that it took him some time to "come up
to speed" with children's social services as it was not his "area",
Mr Ludgate (appointed acting director of social services in April
1999) appeared to be well aware of the problems facing children's
social services. The level of children's services they were able
to provide caused him concern because of:
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•
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the very high proportion of agency and temporary workers;
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•
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the imbalance of too many complicated cases and too few experienced
social workers;
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•
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not having the training and development staff to bring locum workers
up to speed fast enough on policies and procedures;
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•
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the fact that child protection and children-looked-after cases
were being held by teams without appropriate manpower.
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Mr Ludgate said, "Managers and social workers were responding
to the highest need and highest risk presenting at the time."
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Paragraphs: 5.1 - 5.10
| 5.11 - 5.21 | 5.22 - 5.30
| 5.31 - 5.38 | 5.39 - 5.46
| 5.47 - 5.53 | 5.54 - 5.64
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5.54
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In March 1999, following a series of meetings between the SSI,
council members and senior managers, Brent council accepted proposals
involving the release of £170,000 from reserves in 1999/2000 and
£250,000 in 2000/2001 into children's social services. The extra
funds were in part to improve the infrastructure of children's services,
to re-establish the post of assistant director for children's services
and positions within human resources, to appoint three family support
workers, and to pay for scarcity and honorarium payments. Mr Daniel
said, "At the time, I have to say that was a very difficult decision
for the members to take, given the overall financial position of
the council, and the low level of our reserves, so it was a very
significant tide of political commitment, I think, to start at least
the process of addressing the problems that were beginning to be
identified." In fact, as shall become clear, it was a matter of
'too little too late'.
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5.55
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In view of the staffing crisis, Mr Ludgate said that during his
tenure as acting director he "was willing to pay for any social
worker we could get hold of. So no posts were being frozen in terms
of operational staff". But the decision to recruit was only the
start. Filling posts was not so simple. Difficulties in recruiting
social workers was a London-wide problem, but Brent was particularly
badly affected because of the terms and conditions offered. Also,
according to Mr Charlett, "There was a residual kind of perception
of Brent as not a very attractive place to come to, so I think you
were starting with a disadvantage anyway."
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5.56
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In May 1999, the issue was discussed by the Area Child Protection
Committee (ACPC) as the staffing crisis was contributing to the
number of unallocated cases. Dr Bridget Edwards, the Brent ACPC
vice chair, subsequently wrote to Councillor Cribbin on 8 June 1999
"to express serious concerns about children's social work unit's
ability to recruit and retain qualified and experienced social workers".
Dr Edwards said:
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"You'll be aware that recruitment and retention of staff in
children's social services have been a problem for quite some time
now. However, it seems there has been a particularly high level
of staff turnover in the past few weeks, not helped I think by the
introduction of new pay and conditions of services, on top of the
already low level of London weighting payments in Brent."
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Dr Edwards continued:
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"As safety of children is an important issue when cases remain
to be allocated, I wonder if you would consider improving the existing
package of pay and conditions to enable children's social services
to attract new staff as well as to keep experienced staff."
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Dr Edwards could not recall receiving a reply to her letter. This
was further evidence of the lack of impact of ACPCs.
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5.57
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It appears that Brent council did little to help itself ease the
problem. In 1999, along with other local authorities across the
country, Brent was required to implement the 'single status agreement'
which equalised the terms and conditions of existing manual and
office staff. However, the decision was taken that new staff coming
to Brent should not receive the higher London weighting. Instead
the inner-London weighting was preserved for existing staff by way
of "honorarium payments". Mr Charlett said, "This was obviously
not very attractive to people from outside ... I thought it was
plainly ridiculous, but that was part of the council's cost cutting
- saving strategy. So that made it difficult with agencies who frankly
told us we were uncompetitive in the job market." He added, "It
meant there was a kind of two tier system ... but it also meant
that compared to neighbouring boroughs, Brent was paying less money
and expecting people to work longer hours, in arguably worse conditions.
It seemed to me quite a potent factor, if I had been looking for
a job myself." Councillor Cribbin disagreed: "We made a political
decision because of financial restraints, and it was a method of
saving money." She said that she did not think "that a matter of
a few hundred pounds would be a deterrent to a social worker coming
to work in a borough".
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5.58
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Brent was not alone in experiencing problems with the recruitment
and retention of social workers. Evidence as to the scale of the
problem emerged clearly in Phase Two of this Inquiry, as well as
from looking at social services provision in Ealing and Haringey.
While pay and conditions were clearly a factor, albeit not the only
factor, I question whether this at least might be addressed through
the implementation of a national pay structure.
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5.59
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The approach taken by Brent, ironically designed to save money,
led to the recruitment of a large number of agency staff, costing
approximately 30 to 40 per cent more per employee than permanent
staff. When asked about the recruitment of temporary staff, Councillor
Cribbin said, unconvincingly, one of the reasons Brent was not able
to fill the vacancies was because "we had decided we were only going
to employ the best staff". This was perhaps an unrealistic goal
for a council offering among the worst pay and conditions in London.
A comprehensive recruitment package was not finalised in Brent until
October 2001.
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5.60
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The teams most affected were the duty and child protection teams
because Brent Social Services had made a policy decision in 1996
that in an effort to ensure that all long-term cases were held by
permanent social workers, it would manage the initial duty response
through agency and temporary staff where necessary. As a result,
Mr Armstrong said the duty team he managed, in mid 1999 at a time
of high workload pressures and when the two referrals relating to
Victoria passed through his team, was staffed entirely by agency
workers who had not qualified in England. He agreed it was not acceptable
to have people on short-term contracts at the front-line of contact
with very vulnerable children but said, "It was what we were doing
and what we were working. There were occasions where a person will
get off a plane in the morning, arrive in the office just after
lunch, be interviewed and start work either in the duty team or
the child protection team. It was happening very, very often." Mr
Charlett said, "I thought the fundamental problem was there were
just not the resources available. There were just not the people
there that stayed long enough for the continuity that was desirable,
and to familiarise themselves properly with the work, and become
a true team ... it seemed to me that there were obvious disadvantages
in having a team composed of people who are purely agency staff."
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5.61
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Mr Charlett's concerns at the time were well justified. Because
of the bottleneck in passing cases on to the long-term teams, the
very same short-term agency staff were left holding cases on a long-term
basis. Also, as agency staff they did not stay long enough to be
trained and their induction was varied or non-existent. Inevitably,
as both Mr Armstrong and Mr Charlett pointed out, the agency staff
were less familiar with the procedures and the local area and therefore
took longer to carry out their tasks. Although hesitant on the subject,
Mr Charlett said that it was likely that the reliance on agency
workers caused the service in the duty team to suffer. Mr Armstrong
said that he was told by one of the assistant directors within children's
services that the financial cost of a week's worth of induction
outweighed the financial cost of the workers being allocated cases
immediately.
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5.62
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If help was needed, the newly arrived duty workers would and did
turn to the support of other staff members and their seniors. Ms
Hobbs said that she felt well equipped to do the work, but that
was mainly due to the extra support she received from her seniors
and manager. She said, "I think they had to provide a lot more than
they should have if there had been a more formal induction process."
Ms Thrift also spoke very highly of the help from those around her,
but said, "I did feel, though, maybe I should get a little bit more
time to understand Brent procedures."
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5.63
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In fact, the length and complexity of the procedures and policies
existing at the time, namely the interim child protection periods
of 1996 and Volume C of Brent Social Services' Children's Services
Manual of Procedures, meant they were of limited help. Dr Edwards
said the local authorities' child protection procedures and guidance
could be voluminous. She found them quite daunting and thought it
was "quite difficult to grapple with so many sheets of paper". Ms
Hines said she would not say the procedures were "user friendly",
while the SSI in 2000 found them to be "inadequate and in need of
a major revision".
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5.64
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Overall, it is difficult to draw any other conclusion than front-line
staff in Brent Social Services, whose actions and decisions affected
Victoria in mid 1999, were working in an under-resourced, understaffed,
under-managed and dysfunctional environment. The SSI in 2000 and
again in 2001 remained highly critical about a number of the deep-rooted
problems that were apparent in 1999, such as the over-reliance on
agency staff, the tracking of cases and the transfer of cases to
the long-term teams. Senior managers and elected members were either
unaware of or unable to tackle these deep-rooted deficiencies within
the organisation, and for that they must take responsibility.
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