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Paragraphs: 4.1 - 4.11
| 4.12 - 4.20 | 4.21 - 4.31
| 4.32 - 4.46
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4.1
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Between the end of April and early July 1999, Kouao attended Ealing
Social Services on no less than 18 different occasions. She was
accompanied by Victoria on at least 10 of these visits. Together
they had dealings with six social workers, one group support assistant
and one housing officer. Yet by the time Ealing closed Victoria's
file on 7 July 1999, they knew virtually no more about Victoria
than when Kouao first visited the Ealing Homeless Persons' Unit
on 26 April 1999 to seek help with her housing needs.
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4.2
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Ealing Social Services have acknowledged from the outset that the
quality of their social work in Victoria's case was unacceptable.
In particular, they "failed to address Victoria's needs as an individual
and instead treated her as a part of ... Kouao's homelessness case".
To Ealing's credit they did not lay the blame on a lack of resources.
Indeed, Judith Finlay, senior commissioning manager at the time,
was quite clear when she said, "I cannot say that resources were
an issue because we paid more than probably we would have if we
had done a proper assessment and we certainly took longer about
it."
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4.3
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Even more disturbing, Ealing could not be sure that the total inadequacy
of Victoria's assessment was a one-off because they had no proper
systems in place for tracking cases through the referral and assessment
stage. This was a serious failing. I strongly believe that Victoria's
case could and should have started and finished in Ealing - a conclusion
to which I shall return later.
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4.4
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To a large extent, the weakness in Ealing's referral and assessment
process in early 1999 had been highlighted in a highly critical
Social Services Inspectorate (SSI) report that Ealing received in
December 1997 relating to the safety of the children they looked
after. Ealing Social Services were subsequently placed on special
measures in June 1998. Significantly, that report concluded that
children in care and on the child protection register "were not
considered by any measure to be adequately safeguarded". The SSI
commented on the "culture of hopelessness" within the social services
department, the serious deficiencies in assessment and care planning,
and the fact that 45 per cent of the staff were temporary agency
staff.
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4.5
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The report led to a radical shake-up of senior management and organisational
structures. The director of social services at the time resigned
and was replaced, initially on an interim basis, by Norman Tutt
in June 1998. Together with a new assistant director for children's
services, John Skinner, Mr Tutt oversaw the creation of a new specialist
children's team structure by the end of 1998. The team brought together
fieldwork and residential and daycare services. However, the housing
and social services departments were at that time two separate directorates
and were not finally to merge until January 2001.
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4.6
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Two specialist referral and assessment teams - one in each district
office - were established to build up an expertise among staff in
short-term assessment work. In addition, there were a number of
long-term teams split between the two districts, the most relevant
to the Inquiry being the 'child in need' teams, which focused on
work with children in need of protection and support services. During
the relevant period, Ms Finlay was the operations manager responsible
for all children's services provided from the Acton area office.
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4.7
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In preparation for the restructuring, initiatives were taken to
audit 'child protection' and 'looked-after-children' files to assess
the quality of work done. Managers who were performing poorly were
not reappointed. Any action taken was quick and decisive. "In all,
the restructuring took some three months. It was a very difficult
and demanding time," said Mr Skinner, "for both the organisation
and for staff. A massive amount of change took place within a very
condensed timetable". There was "enormous drive to improve standards
within children's services". Although the disruption caused by such
wholesale restructuring did have an impact on staff morale, Mr Tutt
told the Inquiry that he believed the overall effect was positive.
He said he targeted those managers whose performance was below standard:
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"They were recognised by their colleagues as not performing,
so having somebody deal with it raised morale ... The unions were
not at all happy about it ... I made it quite clear that in the
light of the SSI report, my job was to make sure children were safe
in the borough of Ealing, and if members of staff were not able
to be compatible with that aim or objective I was quite happy to
defend my position in whatever forum might be appropriate."
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4.8
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That it was achievable in such a short timescale Mr Tutt put down
to political backing: "[The leader of the council] ... met me, I
think, on the first day and said that he would back whatever needed
to be done.
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4.9
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It paid dividends. A further SSI inspection in March 1999 noted
a significant improvement in services, recognised that there was
a strategy for development and that basic systems were in place
at least for children being looked after. The SSI commented, "We
found that the culture of hopelessness we referred to in the previous
report had been replaced by one of expectation.
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4.10
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There had also been an impressive turn around on staff recruitment
and retention. According to Mr Tutt, Ealing social workers were
paid less than comparable boroughs and they progressed up the salary
ladder more slowly. That was addressed in June 1998 and continued
to be addressed. By spring 1999, 85 per cent of staff in the department
were permanent, and some teams had virtually no agency staff. The
referral and assessment team that Victoria was referred to was "a
reasonably solid team of social workers". Although there were some
locum workers, there was no great turnover and staff sickness was
not an issue.
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4.11
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Mr Tutt attributed the improvement to greater managerial responsibility
for employment, improving culture and speeding up the recruitment
process. He put great emphasis on the work ethos of the children's
services department:
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"The way we have tried to tackle it is by stressing that we
believe in a very high standard of work and we do not accept less
than that, and most social workers actually want to work in a department
which will support them to achieve the best for children."
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Paragraphs: 4.1 - 4.11
| 4.12 - 4.20 | 4.21 - 4.31
| 4.32 - 4.46
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4.12
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However, gaps remained. In particular there were gaps in the competence
of staff, problems in the identification of potentially serious
child protection matters with further training required, and an
"inadequate management information system". Significantly, problems
remained with regards to assessment. There were also a number of
steps in the authority's action plan, dated March 1999, that were
still waiting to be carried out by the time Victoria arrived in
Ealing in late April 1999. A review of the deployment of staff in
the referral and assessment teams was still incomplete and not all
cases held on duty had "a named worker to progress the work within
identified timescales". Ms Finlay went on to state:
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"We were working intensively with managers to ensure that cases
were allocated quickly. That involved a change in culture and a
change in understanding of the work, and we did not get there straightaway
... We should have had work allocated immediately, but we did not."
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4.13
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In practical terms, Mr Skinner told the Inquiry, he thought it
was virtually impossible in the spring of 1999 to have allocated
all work coming into the referral and assessment team. He said,
"We had a backlog of work and also we were overwhelmed with new
referrals, so the possibility of allocating all that work immediately
was unrealistic.
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4.14
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Failure to allocate Victoria's case early was almost certainly
to prove critical in contributing to a lack of any clear focus and
continuity in handling. Most importantly, and surprisingly, only
allocated cases were the subject of supervision. Yet Ms Finlay said
that at the time, "We relied on the team managers and senior practitioners
to undertake the assessments, to undertake the supervision of social
workers and to make sure that the assessments were completed." She
admitted that by April 1999 senior managers had not got to the stage
of auditing the referral and assessment team. As a result, there
were no arrangements in place to ensure that assessments were properly
carried out by those teams. Therefore, I make the following recommendation:
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Recommendation
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Managers of duty teams must devise and operate a system which
enables them immediately to establish how many children have been
referred to their team, what action is required to be taken for
each child, who is responsible for taking that action, and when
that action must be completed.
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4.15
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Mr Tutt confirmed that assessment processes were poor before the
introduction of the National Assessment Framework: "One of the problems
until the framework was produced was that there was no clear definition
of how assessment should be undertaken at the point of entry." Discussing
assessments in April 1999, Ms Fortune said, "To be quite honest
with you, we did not have any kind of grounding for assessments."
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4.16
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In fact, social workers had little by way of up-to-date manuals
to guide them in their day-to-day practice. The fieldwork manual
'current' in early 1999 which dealt with matters other than child
protection (and was therefore relevant to Victoria at the time she
made contact with Ealing Social Services), amazingly predated the
Children Act 1989. Understandably, it was described by Mr Tutt as
"grossly inadequate" and "indefensible". This was particularly so
in relation to agency staff, who might have expected to place heavy
reliance on up-to-date manuals, and to new staff who could not be
sure of receiving proper induction training. New child protection
procedures were implemented in February 1999 and the eligibility
criteria for children's services were being developed, but a manual
of child protection practice guidelines, which should have been
finalised in April 1999, was marked "interim". Significantly, it
was to retain that status through to at least the end of the Phase
One hearings of this Inquiry, in February 2002. Mr Skinner acknowledged
that a new member of staff to the Department, such as Sharmain Lawrence
in spring 1999, who received no induction training when she arrived,
would have had "an incomplete set of procedures" and "would struggle
as a consequence". Therefore, I make the following recommendation:
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Recommendation
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Directors of social services must ensure that staff in their children
and families' intake teams are experienced in working with children
and families, and that they have received appropriate training.
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4.17
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The Area Child Protection Committee (ACPC), chaired by Mr Skinner
from January 1999, ought to have been the driving force for regeneration
and renewal among the child protection agencies. However, according
to Mr Skinner its agenda had been dominated by Part 8 reviews and
other responsibilities, and so this received little or no attention.
It appears that the ACPC had all but become detached from front-line
staff, and its policies, procedures and guidelines were out of date.
In fact, it was the social services child protection procedures
that were adopted by the ACPC in 1999 as a temporary measure - and
there was little or no real investment in developing an effective
inter-agency child protection partnership. This was the first of
several concerns I was to hear about the ACPC arrangements.
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4.18
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When the SSI returned for a follow up children's services inspection
in December 1999, some five months after Ealing had closed Victoria's
case file, they found that progress had continued but they highlighted,
yet again, the need to continue to improve standards in the referral
and assessment teams. Initial assessments were seen as being "of
variable quality, particularly for lower priority cases".
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4.19
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It was accepted to be fair criticism. In evidence, Mr Tutt was
quite clear that his first and second priority had to be children
in need of protection and children looked after because "the most
serious criticism of the SSI had been that no child could be guaranteed
to be safe in the borough". That meant that other areas, such as
referral and assessment team initial services, received a lower
priority. As Mr Tutt said, this area of work "was not the highest
priority, certainly".
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4.20
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Along with other social services departments, Ealing struggled
with the quality of some of its front-line staff. According to Mr
Tutt, "Many of the staff coming into post were relatively inexperienced
in that they had not many years post qualification experience and/or
were from [overseas]." In the referral and assessment teams, managers
knew that "a lot of work had to be done with individual members
of staff around core basic skills".
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Paragraphs: 4.1 - 4.11
| 4.12 - 4.20 | 4.21 - 4.31
| 4.32 - 4.46
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4.21
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The intake team was dealing with a wide range of referrals, not
least homeless families like Kouao and Victoria, coming from abroad.
Mr Tutt told the Inquiry, "They come with a whole range of health
and other problems and present in our offices although they have
no status legally within our country." Many were asylum seekers.
Some, like Kouao, were travellers under the Treaty of Rome - people
without a documented history. Pamela Fortune, the social worker
eventually allocated to Victoria, thought that perhaps 60 to 70
per cent of referrals came from abroad. The difficulty, according
to senior practitioner Ms Lawrence, was that "there were not very
clear protocols and guidance for dealing with people that were presenting
from abroad and presenting as homeless, and quite often I felt that
people were left to rely on ... professional judgement".
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4.22
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The policy at the time was to give a weekly subsistence sum to
those who came from abroad without the means to support themselves.
Ms Fortune explained, "If there were issues about accommodation,
if they could not get any help via housing services, we would have
to offer a service." Financial assistance would continue if they
appealed their habitual residency status and those appeals could
take years.
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4.23
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By 26 April 1999, the Acton referral and assessment team, which
consisted of one team manager, Sarah Stollard, one senior practitioner,
Ms Lawrence, nine social workers, one social work assistant and
three group support assistants, had already received 388 referrals
that month. Ms Stollard said:
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"It was a very busy team ... There was varied experience in
the team. Some of the social workers had hardly any experience,
and some had quite a number of years experience. It was also a new
team and a new structure, so people did not have experience of working
in a referral and assessment team, necessarily ... when I took over
that team, we had a backlog of 200 cases ... we continued to take
in cases, so I would say it was a team that was under quite a lot
of pressure, and we did have a number of agency staff."
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4.24
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There were no workload management systems in place in 1999. The
general expectation was that social workers would carry between
12 and 15 allocated cases on top of their duty commitments. An audit
in July 1999 indicated that staff in the Acton referral and assessment
team had on average 11.25 allocated cases. Ms Fortune described
workloads as "high but not unmanageable". Deborah Gaunt, another
social worker in the Acton referral and assessment team, thought,
"The workload was challenging but I felt that it was appropriate
for my level of experience and that I could handle it."
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4.25
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Social workers took turns being on duty for one week in three.
In theory, they were supposed to work on duty for the whole week.
However, Ms Stollard explained that "reality and practicality dictates
that they are not always the same three workers on for the whole
week". It was explained that social workers on duty worked on duty
cases, assigned daily, downstairs in the Acton office. Social workers
not on duty worked upstairs on 'allocated' cases.
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4.26
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A referral could be by letter, telephone or in person. According
to the level of risk or concern, the referral would either be taken
straight to the duty manager or would be dealt with on the spot
by the duty social worker. If the duty manager was not available,
social workers would go to a more senior manager, such as the operations
manager (Ms Finlay). If not dealt with immediately (and not urgent),
the social worker would write an action plan and leave that, together
with the referral form, in a basket on the duty manager's desk.
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4.27
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Ms Stollard alternated with her senior practitioner, Ms Lawrence,
as duty manager on a "one week on, one week off" basis, although
she also line managed Ms Lawrence. As a result, accountability for
case management decisions was not clear. It was demonstrated in
Victoria's case that it was possible for the two managers to take
opposed views when it came to their 'turn' to manage the case.
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4.28
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Ms Stollard summarised the differences in their roles as follows:
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"I was the overall manager ... I suppose the last decision
would be mine if it was felt necessary to come to me, to seek my
view on something. In terms of ... the practicalities of how it
worked, Sharmain was, I suppose, like a deputy team manager ...
and I would not get involved in her decision making unless something
was brought to my attention where I thought I needed to, or where
she wanted to ask me what I thought about something."
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4.29
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It was the job of the duty manager to review all the work in the
duty basket on a daily basis, but according to Mr Skinner, assistant
director of children's services, "That was an aim not always achieved."
Regular payments, similar to those made to Kouao, had to be signed
off and managers would take the opportunity to consider those cases
as the payments fell due - although there was no formal review.
However, Ms Stollard acknowledged that some files were not reviewed
as regularly as they should have been. The safety net, such as it
was, was almost totally reliant on her memory of the case details
as well as the paper tracking system that she devised and only she
felt fully confident in using. It was certainly no way to run a
busy duty system that began the year with a backlog of 200 cases
and where case allocation, if it happened at all, was such a hit-and-miss
affair.
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4.30
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If no further action was required for the time being on a particular
file it would be stored in the A-Z cabinet. Cases requiring action
were placed in the 'pend' cabinet to be allocated to the duty social
workers on the relevant dates. Progress was certainly made in moving
cases on. Of the backlog of cases Ms Stollard inherited at the beginning
of the year, only 30 or so were left on the duty system by the end
of 1999. However, there was nothing in place to gauge whether the
scope and timeliness of the intervention offered was in any way
appropriate to the needs of the children concerned.
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4.31
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Mr Tutt told the Inquiry that the A-Z system was almost totally
reliant on the memory of one manager. Ms Stollard said that the
entire system depended on her initiative, intellect, memory and
physical review of the files in the cabinet. Although Ms Finlay's
understanding was slightly different, the difference was more a
matter of semantics. Ultimately in the absence of a proper, electronic
tracking system, knowledge of those priorities relied once again
on the diligence, hard work and memory of the duty managers.
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Paragraphs: 4.1 - 4.11
| 4.12 - 4.20 | 4.21 - 4.31
| 4.32 - 4.46
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4.32
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By December 1999, according to Mr Tutt, an electronic database
that could track cases was in place. But in March 1999 Ms Stollard
relied on a manual paper system which she had devised and which
amounted to no more than "simply a sheet of paper where details
of up to 10 cases could be summarised - that is updated on a weekly
basis and you hope that cases fall off by the end of the week because
they have either been disposed of finally or allocated".
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4.33
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It was a system described variously as "adequate", "basic and had
flaws", "on a basic level ... barely adequate" and "fairly crude".
However, Ms Lawrence was quite clear that she did not find it easy
to use.
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4.34
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At the end of the duty week, cases were supposed to be reviewed
and possibly closed or allocated. According to Ms Stollard, cases
were allocated "if the case was looking more complex or it appeared
that a longer piece of work needed to be carried out, or if a case
conference was needed or the child became a looked after child".
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4.35
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Allocation was the key to whether or not a case was discussed in
supervision. Each member of staff in the referral and assessment
team was to be supervised once a month as a minimum. Ms Stollard
aimed for fortnightly supervision but at least once every three
weeks for allocated cases. Supervision records relating to individual
cases were placed on each case file. In relation to duty cases,
I was told by Ms Finlay that "supervision was informal in that social
workers would approach the duty manager to discuss aspects of a
duty case upon which they [my emphasis] felt they
needed support or guidance". That meant there might be no supervision
at all if a case was open and shut while a social worker was on
duty. Significantly, in Victoria's case it took over two months
to allocate her case, and it was subsequently closed one week later.
Therefore, there was no formal supervision discussion and no supervision
record appears on the file.
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4.36
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Handover between the two managers at the end of the duty week was
only thought necessary for cases that were of particular concern.
Where a conversation was not possible, notes would be left or conversations
would be had on another day or simply not at all. Nonetheless, Ms
Finlay regarded the system as adequate and Ms Lawrence felt the
whole process was assisted by her and Ms Stollard's "professionalism".
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4.37
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But this, too, was to come under some strain during 1999. Ms Stollard
had concerns about Ms Lawrence "as a result of [her] poor performance
and a lack of commitment". In particular she was concerned about
Ms Lawrence's frequent absences, and she felt Ms Lawrence was undermining
her as team manager.
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4.38
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Matters came to a head in September 1999. Ms Stollard returned
from annual leave to find the referral and assessment services in
what she considered to be a "dangerous state". She pursued the matter
with Ms Finlay in writing.
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4.39
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During the management investigation which lasted from October 1999
to March 2000, Ms Lawrence was removed from her role as senior practitioner
and invited to remain at home "in her own interests".
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4.40
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The outcome of the management investigation led ultimately to Ms
Stollard leaving Ealing Social Services in July 2000. Ms Lawrence
in the meantime returned to work and was subsequently promoted to
the position of team manager.
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4.41
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It is far from clear what impact the process of investigating these
complaints had on service delivery. Ms Stollard said the interviews
with the team were lengthy and "very disruptive". She did not think
there was any impact on the way service users were dealt with, although
she later said:
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"Inevitably team members found the investigation distressing
and of interest. It was a matter of significant office gossip and
although I never spoke to staff about the investigation, it was
a matter of considerable discussion which was a diversion to the
task at hand. Time was obviously spent encouraging people to make
complaints and all of this would have had an impact on the provision
of service to clients."
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4.42
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Mr Skinner was not aware of any "visible impact" on service delivery,
although there was a "degree of tension" among staff as they became
more aware of the difficulty.
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4.43
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All, however, were at pains to point out that the problems between
Ms Stollard and Ms Lawrence arose after Victoria's time at Ealing,
and so had no adverse impact on the way her case was handled. I
am unwilling to accept such firm assurances.
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4.44
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Although Ms Lawrence, as senior practitioner, would not have been
the allocated social worker for Victoria, Victoria's case remained
on the duty system for some two months. If Ms Lawrence had any concerns
about her management of the case, which she undoubtedly did, supervision
would have provided the opportunity for her to air those concerns
with her team and line manager. But as Ms Lawrence admitted, supervision
arrangements with Ms Stollard were a bit "ad hoc" and at least initially
were not "adequate". Therefore, it seems possible that the worsening
relationship between the two, and which senior managers were certainly
aware of from the spring of 1999, might have hindered the effective
duty system handover at the end of each week and could have contributed
to the prolonged and differing approach that each took in relation
to Victoria's case.
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4.45
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It certainly provided added reason, if reason was needed, to get
a management grip of a duty system that was seriously deficient.
The senior management team at the time failed to do this. When asked
to identify defects in the duty system team, Ms Stollard referred
to "changes in plan, different people getting involved ... situations
getting slightly lost", while Ms Lawrence said she was "perturbed"
by the number of unallocated cases. She thought it was "Very difficult
to work with the volume of cases there was on the duty system ...
it was difficult to monitor all the cases on duty." Victoria's was
just one of those cases.
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4.46
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There is no excuse for failing to have in place a system for efficiently
managing the workload in a social services team dealing with children
and families.
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