Conclusions of the inquiry

Clwyd

Sexual abuse

(1) Widespread sexual abuse of boys occurred in children's residential establishments in Clwyd between 1974 and 1990. There were some incidents of sexual abuse of girl residents in these establishments but they were comparatively rare.

Local authority homes

(2) The local authority community homes most affected by this abuse were (a) Bryn Estyn, where two senior officers, Peter Norman Howarth and Stephen Roderick Norris, sexually assaulted and buggered many boys persistently over a period of ten years from 1974 in the case of Howarth and about six years from 1978 in the case of Norris and (b) Cartrefle, where Norris continued, as Officer-in-Charge, to abuse boys similarly from 1984 until he was arrested in June 1990

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(3) The Tribunal heard all the relevant and admissible evidence known to be available in respect of the allegation that Police Superintendent Gordon Anglesea committed serious sexual misconduct at Bryn Estyn but we were not persuaded by this evidence that the jury's verdict in his favour on this issue in his libel actions was wrong

(4) In addition to the abuse referred to in (2) there were other grave incidents of sexual abuse of boy residents by male and female members of the residential care staff between 1973 and 1990 at five local authority homes in Clwyd, namely, Little Acton Assessment Centre, Bersham Hall, Chevet Hey, Cartrefle and Upper Downing

Private establishments

(5) There was widespread sexual abuse, including buggery, of boy residents in private residential establishments for children in Clwyd throughout the period under review. Sexual abuse of girl residents also occurred to an alarming extent.

(6) The most persistent offender in the Bryn Alyn Community was the original proprietor himself, John Ernest Allen, who was the subject of complaint by 28 former male residents and who was sentenced to six years' imprisonment in February 1995 for indecent assault on six former residents. One other member of the staff was convicted in 1976 of sexual assaults on boys and another was under police investigation for alleged sexual abuse during the Tribunal's hearings and until his death in August 1998. The Deputy Headteacher of the Community's school was also convicted in July 1986 of unlawful sexual intercourse with a girl resident under 16 years and sentenced to 6 months' imprisonment.

(7) Richard Ernest Leake, formerly of Bersham Hall, who was the first Principal of Care Concern's Ystrad Hall School from 1 July 1974 and later Director of the organisation, is awaiting trial on8 November 1999 on charges of indecent assault on boys between 1972 and 1978. The Tribunal is aware of 16 male former residents of Ystrad Hall School who have complained of sexual abuse by members of the staff (six have been named). The Deputy Principal, Bryan Davies, was convicted in September 1978 of three offences of indecent assault against two boys and placed on probation. We were unable to hear the evidence in respect of Leake because of the continuing police investigation and the evidence that we heard in respect of other members of the staff was insufficient to justify a finding, except in respect of Davies.

(8) There was persistent sexual abuse, including buggery, of not less than 17 boy residents at Clwyd Hall School between 1970 and 1981 by a houseparent, Noel Ryan, for which he was sentenced in July 1997 to 12 years' imprisonment. Richard Francis Groome, the former Officer-in-Charge of Tanllwyfan, who was Head of Care and then Principal at Clwyd Hall School between November 1982 and July 1984, has been committed for trial oncharges of sexual offences against boys, some of which relate toformer boy residents at these establishments. His trial will take place early in 2000.

(9) There was yet again persistent sexual abuse of boy residents of Gatewen Hall, which was a private residential school prior to its sale to the Bryn Alyn Community in 1982. The abusers were the two proprietors from 1977 to 1982, Roger Owen Griffiths and his then wife, now Anthea Beatrice Roberts, who were convicted on 4 and 5 August 1999 in the Crown Court at Chester. Griffiths was sentenced to eight years' imprisonment and Roberts to two years' imprisonment.

Voluntary homes

(10) There were complaints of sexual abuse from six former boy residents of the only voluntary home that we investigated, namely, Tanllwyfan. They were directed against a former care assistant at the home, Kenneth Scott, who was there from 1974 to 1976 and who was sentenced in February 1986 to eight years' imprisonment for buggery and other offences against boys committed in Leicestershire between 1982 and 1985. We have no reason to doubt the accuracy of the two complainants who gave evidence of indecent assaults on them by Scott during his period at Tanllwyfan. There is one charge against Richard Francis Groome in respect of his period as Officer-in-Charge of Tanllwyfan.

Gwynfa

(11) Allegations of sexual abuse during the period under review at Gwynfa Residential Unit or Clinic, an NHS psychiatric hospital for children, were made by ten former residents to the police and involved four members of the staff. One former member of staff was convicted in March 1997 of two offences of rape of a girl aged 16 years committed in 1991, when she was a resident but not in care. Allegations against another member of staff, Z, were being investigated by the police in the course of the Tribunal's hearings and some of them were made by former children in care but the decision has now been taken that Z should not be prosecuted. We have not attempted to reach detailed conclusions in relation to Gwynfa for reasons that we explain.

Physical Abuse

(12) Physical abuse in the sense of the unacceptable use of force in disciplining and excessive force in restraining residents occurred at not less than six of the local authority community homes in Clwyd, despite the fact that it was the policy of Clwyd County Council throughout the period under review that no member of staff should inflict corporal punishment on any child or young person in any circumstances. It occurred also at most of the other residential establishments for children that we have examined.

Local authority homes

(13) Such abuse was most oppressive at Bryn Estyn, where Paul Bicker Wilson was the worst offender. There was a climate of violence at the home in which other members of the staff resorted to the use of impermissible force from time to time without being disciplined for it. Bullying of residents by their peers was condoned and even encouraged on occasions as a means of exercising control.

(14) Physical abuse was less prominent in the five other community homes referred to in (12), namely, Little Acton, Bersham Hall, Chevet Hey, Cartrefle and South Meadow, but was sufficiently frequent to affect a significant number of residents adversely. The use of force was often condoned and its effects were aggravated by the fact that some Officers-in-Charge from time to time, such as Pe
ter Bird, Frederick Marshall Jones and Joan Glover, were themselves the perpetrators

Ysgol Talfryn and Gwynfa

(15) Physical abuse occurred also from time to time at a local authority residential school, Ysgol Talfryn, and at the NHS residential clinic for children, Gwynfa.

Private establishments

(16) Physical abuse was prevalent in the residential schools/homes of the Bryn Alyn Community in its early years and to a lesser extent at Care Concern's Ystrad Hall School. John Ernest Allen himself was a prominent offender in this respect at the former but impermissible force was used by other members of the staff quite frequently.

Abuse in foster homes

(17) There were comparatively few complaints of abuse in foster homes in Clwyd but the evidence before the Tribunal disclosed major sexual abuse in five such homes, in respect of which there were convictions in four of the cases (the fifth offender hanged himself before his trial).

Failings in practice etc

Complaints etc

(18) It was a serious defect nationally that complaints procedures were not introduced generally until the late 1980s. In Clwyd, there were no complaints procedures in any of the residential establishments that we have examined in detail between 1974 and 1991 when the major incidents of abuse occurred.

(19) Few resident children made complaints of abuse (except at Park House, where long term residents felt freer to do so). Those who did complain were generally discouraged from pursuing complaints and recording of complaints was grossly defective. It was, however, the complaint of a boy resident at Cartrefle to a sensitive member of staff that led to the first convictions of Stephen Roderick Norris.

(20) There were no procedures in any of the establishments to enable members of staff to voice matters of concern and, in many of them, complaints by staff were strongly discouraged.

(21) The worst exemplar of the "cult of silence" on the part of staff was Bryn Estyn, where there were grounds for suspicion and gossip about Howarth's "flat list" activities for many years but the Principal, Arnold, threatened staff with dismissal if they gave currency to the rumours. Arnold was responsible also for covering up the true circumstances in which a resident had been injured and both he and Howarth were seriously at fault in failing to deal with Wilson's oppressive conduct.

The quality of care

(22) The quality of care provided in all the local authority homes and private residential establishments examined was below an acceptable standard throughout the period under review and in most cases far below the required standard. Those well below the standard were Bryn Estyn, Little Acton, Bersham Hall, Chevet Hey, Cartrefle, Park House, the Bryn Alyn Community and Clwyd Hall School. The quality of care was also well below standard at Ysgol Talfryn by 1993.

Secure units

(23) There was misuse of the secure units provided (but not approved for use as such) at Bryn Estyn and Bersham Hall.

Education

(24) The provision of education was inadequate in all the local authority community homes with educational facilities and in the private residential schools at Bryn Alyn and Clwyd Hall.

Recruitment

(25) There were many breaches of approved practice in the appointment of residential care staff, most notably at Bryn Estyn, where several members of the staff were recruited informally without references and without any adequate investigation of their past records.

(26) Manifestly unsuitable residential care staff were appointed to some vacant senior posts in community homes without any adequate assessment of their suitability for those posts. This was most blatant at Cartrefle with the successive appointments of Stephen Roderick Norris and Frederick Marshall Jones.

Police checks

(27) Checks upon the records of potential employees and foster parents held by the police, the Department of Health and the Department of Education were not made routinely before appointments were confirmed. In the particular case of the foster parent Roger Saint the North Wales Police were at fault in failing to explain to the Social Services Department the narrow limits of their check on Roger Saint's record of convictions in August 1978; and the Department itself was at fault subsequently in failing to make a further check in 1982 at the request of Tower Hamlets and in failing to take any appropriate action when informed of his conviction in 1988.

Training

(28) Training opportunities and practice guidance for residential care staff were grossly inadequate and no instruction was given to them in proper measures of physical restraint.

Recording

(29) The recording of events within residential establishments was frequently of poor quality and on occasions knowingly false.

Visiting

(30) Visiting by field social workers was in too many cases both irregular and infrequent and recording standards were very variable; in general, the quality of contact was poor.

Care planning

(31) There were deficiencies in care planning and in the statutory review process for each child on a similar scale. Too often reviews were paper exercises carried out without the involvement of the child and much later than they should have been.

Leaving care

(32) There were no adequate arrangements for preparing children for leaving care.

Supervision by other authorities

(33) The supervision of children from outside Clwyd by the placing authorities, whether in a residential establishment or in a foster home, was generally inadequate.

Management

(34) The arrangements for the oversight of the operation of the Social Services Department at the most senior levels in the County Council were inadequate.

Leadership

(35) The Social Services Department failed to provide at the most senior level effective and positive leadership to ensure that, in relation to decisions affecting each child in their care, first consideration was given to the welfare of the child and to foster a climate in which that principle was followed.

Structure

(36) The senior management of the Social Services Department in relation to children's services was subjected to frequent changes and remained confused and defective without adequate expertise at the highest level and clear lines of responsibility and accountability.

Planning

(37)The Social Services Department failed to establish any strategic plan for the provision of residential placements following the demise of the Regional Plan for Wales.

Inspection and monitoring

(38) There were no coherent arrangements by Clwyd Social Services Department for the management, support and monitoring of the authority's community homes and for supervision and performance appraisal of residential care staff for most of the period under review. This grave defect had its most serious impact on Bryn Estyn where, despite the existence of a management committee charged with responsibility for it and two other Wrexham community homes, the Principal was left to run the home without any effective supervision or guidance.

Complaints and discipline

(39) The response by senior management, particularly by Geoffrey Wyatt, to complaints was discouraging and frequently inappropriate; and the implementation of disciplinary procedures was fundamentally flawed.

Response to reports

(40) The Social Services Department failed to respond positively to successive adverse reports on individual community homes, most of which were of county-wide relevance in relation to the management of the residential sector and the st
ate of the community homes.

Information to the SSC

(41) The information supplied to members of the Social Services Committee by officers, including the contents of reports on inquiries, was inadequate and, on occasions, positively misleading.

The role of councillors

(42) Members of the Social Services Committee prior to 1990 failed to discharge their parental responsibilities to the children in their care by informing themselves adequately about the state of children's services in the county and insisting that officers supplied appropriate information to them about matters of concern.

Visits by councillors etc

(43) Visits to community homes by councillors and headquarters' officers were grossly inadequate for most of the period under review.

The Cartrefle and Jillings reports

(44) Clwyd County Council cannot fairly be blamed for failing to publish the Cartrefle and Jillings reports before it ceased to exist, having regard to the continuing police investigation at that time and its contractual duty to its insurers; but it is desirable that the Law Commission should consider the legal issues that arise in relation to the conduct of inquiries of a similar kind initiated by local authorities or other public bodies and publication of the reports of such inquiries.

Gwynedd

The reason for the inquiry

(45) Without Alison Taylor's complaints about Nefyn Dodd there would not have been any public inquiry into the alleged abuse of children in care in Gwynedd. In general terms, she has been vindicated.

Complaints generally

(46) Of about 120 complainants to the police who were former residents of one or more of the five local authority community homes in Gwynedd that we have investigated, about half (58) made complaints that they had been abused by Nefyn Dodd; and all but six of the latter alleged abuse by him at Ty'r Felin.

Sexual abuse

Local authority homes

(48) We have not received acceptable evidence of any persistent sexual abuse in any of the local authority homes in Gwynedd. We did, however, hear perturbing evidence of incidents of alleged sexual abuse at different times by two women members of the staff (X and Y) at Queens Park community home involving one (different) resident only in respect of each. The allegations against X were inadequately and inappropriately investigated and, in effect, suppressed. The allegations against Y were not made until 1996. In the absence now of any supporting evidence in respect of either set of allegations we are unable to find that they have been proved.

Private establishments

(48) There were some isolated incidents of sexual abuse at two of Paul Hett's establishments, namely, Do®l Rhyd School and Ysgol Hengwrt. The five alleged abusers were all male members of the staff involved with one victim each; three of the victims were boys and two were girls. Four of the abusers left the staff shortly after complaints had been made but the fifth was not the subject of complaint until 1993, over four years after the victim had run away.

Physical abuse

Local authority homes

(49) Physical abuse in the sense that we have defined it in (12) occurred frequently at Ty'r Felin during the regime of Nefyn Dodd as Officer-in-Charge between 1978 and 1990 but was less frequent in the last three or four years of that period. There were 75 complainants to the police who alleged physical abuse there. The worst offenders were Nefyn Dodd himself and John Roberts. We have not been persuaded that either June Dodd or Mari Thomas was guilty of physically abusing residents.

(50) There was no persistent physical abuse at any of the four other local authority community homes in Gwynedd that we have investigated and comparatively few complaints of such abuse were made to the police about Ty Newydd (paras 34.08 to 34.12), Queens Park and Cartref Bontnewydd. There were more (11) complainants to the police who alleged that they had been physically abused by a named abuser at Y Gwyngyll and four of them named Nefyn Dodd; but any incidents of physical abuse that occurred were isolated and were not the subject of complaint until many years afterwards. We accept, however, that Nefyn Dodd did use excessive force to residents at Y Gwyngyll on a limited number of occasions.

Private establishments

(51) We did not receive any complaint of physical abuse at Hengwrt Hall School but there were complaints by the Spastics Society in 1988 and by a Senior RCCO in 1990 of incidents of alleged abuse, which gave rise to concern.

(52) 15 former residents of Paul Hett's establishments complained of physical abuse by identified members of the staff but most of their complaints related to Ysgol Hengwrt between 1986 and 1990. We have no doubt that excessive force was used to residents quite frequently by largely untrained staff in the absence of any clear guidelines.

Other abuse

Nefyn Dodd

(53) The regime imposed by Nefyn Dodd and, to a lesser extent, John Roberts upon staff and children at Ty'r Felin was autocratic, oppressive and contrary to the best interests of the residents.

Abuse in foster homes

(54) Both sexual and physical abuse of children in care occurred in a small number of foster homes in Gwynedd during the period under review.

(55) Complaints of sexual abuse were made by four foster children placed in Gwynedd, but two of them were placed there by Clwyd Social Services Department. One of the foster parents of a Clwyd child (Malcolm Ian Scrugham) was sentenced to ten years' imprisonment in April 1993 for rape and other offences against the foster child. Gwynedd foster child C1 was sexually abused by the eldest other child in her foster home, for which he was fined in 1984. We are not satisfied that the two other foster children were sexually abused .

(56) Two foster children placed by Gwynedd were subjected to physical abuse in their foster homes. In the case of M, the foster father and one of his two sons were eventually convicted in July 1993 of assaults many years after they occurred; but there were many breaches of good practice by the Social Services Department earlier in dealing with M's complaints. It is likely also that C1 and her two brothers were subjected to bullying in the foster home.

Failings in practice etc

Similarities to Clwyd

(57) Although the extent of abuse of children in care in Gwynedd was much less than it was in Clwyd the failings in practice were of a similar order or degree.

(58) The following failings in practice mirrored those in Clwyd:

Complaints

(1) There were no complaints procedures in any of the residential establishments between 1974 and 1991.

(ii) The few residents who complained were discouraged and their complaints generally suppressed

(iii) There were no procedures for staff to voice matters of concern and complaints by staff were strongly discouraged.

The quality of care

(iv) Quite apart from the oppressive nature of Nefyn Dodd's regime at Ty'r Felin referred to in conclusion (53), the quality of care provided in all the local authority community homes was below an acceptable standard.

Education

(v) The provision of education at Ty'r Felin was inadequate (paras 33.54 and 33.55).

Visiting

(vi) Visiting by field social workers was in too many cases both irregular and infrequent and the quality of contact was poor.

Care planning

(vii) There were serious and persistent deficiencies in care planning and in the statutory review process.

Leaving care

(viii) There were no adequate arrangements for preparing children for leavin
g care.

Supervision by other authorities

(ix) The supervision of children from outside Gwynedd by the placing authorities, whether in a residential establishment or in a foster home, was generally inadequate.

(59) Monitoring by social workers of the quality of individual boarding out placements was inadequate and there was confusion of responsibility for this.

(60) The child protection procedures and the provisions of the Boarding Out Regulations 1955 were not used for that purpose in some cases.

Management

Retention and advancement of Nefyn Dodd

(61) Major causes of Gwynedd's failure to eliminate abuse in its residential homes for children were the failure to recognise Nefyn Dodd's shortcomings as Officer-in-Charge of Ty'r Felin and his advancement to a position of control over all the county's community homes.

(62) As in Clwyd:

Leadership

(i) The Social Services Department failed to provide at the most senior level effective and positive leadership in the provision and monitoring of children's services.

Structure

(ii) The senior management structure of the Social Services Department in relation to children's services was subjected to frequent changes and was confused and defective without adequate expertise at the highest level and clear lines of responsibility and accountability.

Planning

(iii) The Social Services Department failed to establish any strategic plan for the provision of residential placements.

Inspecting and monitoring

(iv) There were no coherent arrangements for inspecting community homes and for monitoring the performance of residential care staff for most of the period under review. The effect of this was to leave Nefyn Dodd in sole control, accountable to himself alone.

Response to complaints

(v) The response by senior management to complaints, in particular to those made by Alison Taylor, was discouraging and generally inappropriate.

Response to reports

(vi) The Social Services Department failed to respond to successive adverse reports on the community homes, most of which were of county-wide relevance in relation to the residential sector and the state of the homes.

Information to the SSC

(vii) The information supplied to members of the Social Services Committee by officers was inadequate and, on occasions, positively misleading.

The role of councillors

(viii) Members of the Social Services Committee failed to discharge their parental responsibilities to the children in their care by informing themselves adequately about the state of children's services in the county and insisting that officers supplied appropriate information to them.

Visits by councillors

(ix) Visits to community homes by councillors were grossly inadequate.

Financial allocation to children's services

(63) Inadequate financial resources were allocated by Gwynedd County Council to children's services throughout the period under review and the adequacy of the allocation was never re-appraised by reference to children's needs.

Leadership

(64) Prior to 1991 the managerial arrangements at the most senior levels in the County Council were outdated and failed to provide an adequate oversight of the operation and performance of the Social Services Department in relation to children's services.

The Welsh Office and Central Government

Legislation

(65) Too many changes were imposed in the organisation of local government in Wales and of social services in too short a time span.

Leadership and guidance

(66) At a time of major upheaval in local government in Wales and in the organisation of social services, the Welsh Office failed to provide leadership and guidance to ensure that the provision and administration of social services were given appropriate priority and failed to inform itself adequately about what was happening in relation to those services in North Wales.

Bryn Estyn's change of status and control

(67) The Welsh Office failed to give Clwyd County Council (or its predecessor, the then Denbighshire County Council) any guidance in relation to the management, administration, supervision and running of Bryn Estyn Community Home following its change of status from an approved school controlled by the Home Office.

Staffing

(68) The policy and inspectorate branches of the Welsh Office were inadequately staffed with officials of sufficient experience in children's services to support and monitor the provision of those services by local authorities in Wales effectively.

Strategic planning

(69) Following the demise of regional planning in 1984, the Welsh Office failed to ensure that there were adequate strategies for the provision of residential accommodation for children in care in North Wales (including placements outside Wales) and that such strategies were implemented.

Private children's homes

(70) Central government failed to take any action before the Children Act 1989 to regulate private children's homes despite the provision for this in the Children's Homes Act 1982 on the initiative of a Member of Parliament.

Regulation and inspection of residential establishments for children

(71) The regulatory and inspectorial regimes for community homes and for private residential schools were defective and the findings of inspectors were insufficiently publicised.

Training

(72)Insufficient priority was given to the need for appropriate training for residential care staff (including guidance on appropriate methods of physical restraint), despite a succession of reports drawing attention to the need for such training.

Alison Taylor's complaints

(73) Although the Welsh Office did not become aware of allegations of mistreatment of children in care in Gwynedd until September 1986 and of persistent sexual abuse in a Clwyd community home until August 1990, its response to Alison Taylor's complaints was inappropriately negative and inadequate.

The North Wales Police

Investigations generally

(74) Save for the investigations in Gwynedd from 1986 to 1988 of Alison Taylor's complaints, there was no significant omission by the North Wales Police in investigating the complaints of abuse to children in care that were reported to them prior to 1990. This finding includes the investigation of Gary Cooke (and Graham Stephens) in 1979.

(75) The evidence before the Tribunal does not justify severe strictures on the police for their response to individual alleged complaints by children in care, including absconders, but it does underline the need for vigilance and sensitivity by police officers when dealing with such complaints.

1986/1988 investigations in Gwynedd

(76) The investigations in Gwynedd between 1986 and 1988 of Alison Taylor's complaints were defective in many respects and may fairly be described as "sluggish and shallow". The role played by Detective Superintendent Gwynne Owen was inappropriate and the size of the investigating team inadequate. There was no liaison with the Social Services Department and relevant documents were not seized. The reports on the investigation were one-sided and regrettable in tone; and the oral report to the Director of Social Services was inadequate.

The Cartrefle investigation

(77) The investigation of sexual abuse at Cartrefle in 1990 led by Detective Inspector Cronin was thorough and he pursued it as far as could reasonably be expected on the basis of the information before him; but the mode of access to social services files aff
orded to the police was unsatisfactory.

The major investigation from 1991

(78) The major police investigation of child abuse in Clwyd from 1991 onwards was carried out thoroughly. It was also carried out sensitively according to most of the complainants, although a small number were critical of the method of approach to them.

An outside force

(79) The decision by the Chief Constable not to request that an outside police force should take over the major police investigation was justified.

Re-opening the Cooke 1979 investigation

(80) The decision of the senior investigating officer not to re-open the 1979 investigation of Gary Cooke (and Graham Stephens) was also justified.

Freemasonry

(81) Freemasonry had no impact on any of the police investigations and was not relevant to any other issue arising from our terms of reference.

Inter-agency review of major police investigations

(82) It would be timely now to arrange a comprehensive inter-agency review of the conduct of major police investigations into the alleged abuse of looked after children.

Paedophile ring

(83) During the period under review there was a paedophile ring in the Wrexham and Chester areas in the sense that there were a number of male persons, many of them known to each other, who were engaged in paedophile activities and were targeting young males in their middle teens. The evidence does not establish that they were solely or mainly interested in persons in care but such youngsters were particularly vulnerable to their approaches.

The Successor Authorities

Need for co-ordinated action

(84) The number and size of the new local authorities responsible for social services in North Wales give rise to special problems, some of which can only be solved by co-ordinated action.

New management structures

(85) The new management structures for social services in some counties do not all provide a single officer at senior management level who is both dedicated to and responsible for children's services and who is of sufficient seniority to influence adequately the allocation of resources to those services.

Financial resources

(86) There is cause for continuing concern about the adequacy of financial resources allocated to children's services. A fresh assessment of the needs of these services on an All Wales basis is highly desirable.

Recruitment at managerial level

(87) Difficulties are being experienced by some authorities in recruiting officers of appropriate ability and experience in child care services at senior and middle management level and there has been little cross-fertilisation of ideas and practice. Provision for appropriate management training is required.

Recruitment of residential care staff

(88) The recruitment of suitable residential care staff for children is a widespread problem that needs to be addressed urgently.

Residential care establishments

(89) The provision of residential care establishments in North Wales is inadequate and needs to be reviewed, together with the use of out of county and private establishments, with a view to co-operative action.

Fostering

(90) There is a shortage of foster parents with requisite skills and a similar review of the availability and quality of fostering services is needed.

Inspection

(91) The present organisation of inspection units needs revision. Any National Unit should have a local base within North Wales. Inspection should include also the provision and quality of fostering services.

Whistleblowing

(92) There is real danger that the discouragement of "whistleblowing" may persist and positive action is required to ensure that the new procedures are implemented conscientiously and that any fear of reprisals is eliminated.

Independent visitors

(93) The need for independent visitors requires re-assessment, as do the pre-conditions for their appointment.

Awareness of signs of abuse

(94) Vigilance by everyone who has contact with looked after children is of great importance and this applies particularly to teachers, members of the medical profession and police officers.

Leaving care

(95) The problems for children leaving foster care may well be as severe as those facing children leaving residential care and the forms of assistance that they need may be wide ranging. The implementation of leaving care strategies will need continuous monitoring.

Postscript

55.11 This inquiry has revealed that many of the aspirations of policy makers in the 1960s in relation to children's services were not realised in the following two decades. Reorganisation of local government and social services led to a dissipation of specialist skills and knowledge in child care, which were not replaced. Moreover, the intention of the Children and Young Persons Act 1969 that delinquent children, whose misbehaviour was seen as a consequence of deprivation and disturbance, should receive the same programme of care and treatment as children who had suffered similarly but who had not offended was not effectively implemented.

55.12 It must also be said that, in terms of crime prevention, the care system in Clwyd and Gwynedd was notably unsuccessful. From the records available to us in respect of all but two of the 129 complainants who gave oral evidence to the Tribunal, it appears that 52 had convictions before they entered care but 85 were convicted of offences whilst they were in care and 85 are known to have been convicted after they left care; and the figures for both counties were proportionately broadly similar. It would be a mistake to attach great importance to unanalysed statistics of this kind but they do underline the gravity of the problems that local authorities face.

55.13 One of the many explanations for this sorry record may be that delinquent children saw themselves as being more severely punished than their predecessors because they were now subject to orders that could continue up to the age of 18 years instead of orders for shorter specified periods. On the other hand, some children who had not offended before were introduced to delinquency and to harsh regimes in which they were treated by some staff as "little criminals". Neither category of child received a service that could be described as remedial or therapeutic and some regimes encouraged absconsion and increased offending. It is not surprising in the circumstances that many regarded themselves as lost in care.

55.14 Despite what we have said, however, a significant number of children regarded life in care, even at Bryn Estyn, as distinctly better than life at home and did not want to return to their family of origin. They were fed and clothed regularly and preferred a more predictable life to the unstable and sometimes dangerous one that they had known. We do not subscribe, therefore, to the view that children should be kept out of care at all costs, even though radical improvements in children's services may take some years to achieve.

Recommendations of the inquiry

(1) An independent Children's Commissioner for Wales should be appointed.

(2) The duties of the Commissioner should include:

(a) ensuring that children's rights are respected through the monitoring and oversight of the operation of complaints and whistleblowing procedures and the arrangements for children's advocacy;

(b) examining the handling of individual cases brought to the Commissioner's attention (including making recommendations on the merits) when he considers it necessary and appropriate to do so;

(c) publishing reports, including an annual report to the National Assembly for Wa
les.

Children's Complaints Officer

(3) Every social services authority should be required to appoint an appropriately qualified or experienced Children's Complaints Officer, who should not be the line manager of residential or other staff who may be the subject of children's complaints or complaints relating to children.18 to 21

(4) Amongst the duties of the Children's Complaints Officer should be:

(a) to act in the best interests of the child;

(b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child;

(c) thereafter to notify and consult with appropriate line managers about the further handling of the complaint, including:

(i) any necessary interim action in relation to the affected child, the complainant and the person who is the subject of complaint, including informal resolution of the complaint, if that is appropriate;

(ii) consideration of the established procedures to be implemented, such as child protection and disciplinary procedures and including any necessary involvement of the police and/or other agencies;

(d) to ensure that recourse to an independent advocacy service is available to any complainant or affected child who wishes to have it;

(e) to keep a complete record of all complaints received and how they are dealt with, including the ultimate outcome;

(f) to report periodically to the Director of Social Services on complaints received, how they have been dealt with and the results.

Response to complaints

(5) Any decision about the future of a child who is alleged to have been abused should be made in that child's best interests. In particular, the child should not be transferred to another placement unless it is in the child's best interests to be transferred.

Complaints procedures

(6) Every local authority should promote vigorously awareness by children and staff of its complaints procedures for looked after children and the importance of applying them conscientiously without any threat or fear of reprisals in any form.

(7) Such complaints procedures should:

(a) be neither too prescriptive nor too restrictive in categorising what constitutes a complaint;

(b) encompass a wide variety of channels through which complaints by or relating to looked after children may be made or referred to the Children's Complaints Officer including teachers, doctors, nurses, police officers and elected members as well as residential care staff and social workers;

(c) ensure that any person who is the subject of complaint will not be involved in the handling of the complaint.

Whistleblowing procedures

(8) Every local authority should establish and implement conscientiously clear whistleblowing procedures enabling members of staff to make complaints and raise matters of concern affecting the treatment or welfare of looked after children without threats or fear of reprisals in any form. Such procedures should embody the principles indicated in recommendation (7) and the action to be taken should follow, as far as may be appropriate, that set out in recommendation

Duty to report abuse

(9) Consideration should be given to requiring failure by a member of staff to report actual or suspected physical or sexual abuse of a child by another member of staff or other person having contact with the child to be made an explicit disciplinary offence.

Field social workers

(10) An appropriate field social worker should be assigned to every looked after child throughout the period that the child remains in care and for an appropriate period following the child's discharge from care.

(11) Field social workers should be required by regulation to visit any looked after child for whom they are responsible not less than once every eight weeks. In the case of older children, they should be required also to see the child alone and at intervals away from their residential or foster home.

(12) Any arrangements made for the provision of residential care or fostering services should expressly safeguard the field social worker's continuing responsibilities for supervision of the placement and care planning.

Awareness of abuse

(13) Area Child Protection Committees should arrange training in sexual abuse awareness for social services staff and for those from other departments, agencies and organisations in their area.

(14) Steps should be taken through training and professional and other channels periodically to remind persons outside social services departments who are or may be in regular contact with looked after children, such as teachers, medical practitioners, nurses and police officers, of their potential role in identifying and reporting abuse, the importance of that role and the procedures available to them.

Police log

(15) A log of all incidents, disturbances, reports, complaints and absconsions at a children's home should be kept at an appropriate nearby police station and made accessible, when required, to officers of the Social Services Department.

Absconders

(16) Police officers should be reminded periodically that an absconder from a residential care or foster home may have been motivated to abscond by abuse in the home. They should be advised that, when apprehended, an absconder should be encouraged to explain his reasons for absconding and that the absconder should not automatically be returned to the home from which he absconded without consultation with his field social worker.

(17) It should be a rule of practice that any absconsion should be reported as soon as possible to the absconder's field social worker and that the absconder should be seen on his return by that social worker or by another appropriate person who is independent of the home.

Strategy on investigation of complaint

(18) When a complaint alleges serious misbehaviour by a member of staff, the Director of Social Services should appoint a senior officer to formulate an overall strategy for dealing with the complaint, including such matters as liaison with the police in relation to investigation and with other agencies as appropriate, the impact on the child and other residents, any links with other establishments, the handling of any disciplinary proceedings, treatment of any looked after children who are or may become abusers themselves, the management of information for children and parents, staff, elected members and the public.

Liaison with police

(19) Whenever a police investigation follows upon a complaint of abuse of a looked after child, the senior officer referred to in recommendation (18) or another senior officer assigned for the specific purpose should establish and maintain close liaison with the senior investigating officer appointed by the police for that investigation and the local authority's officer should be kept informed of the progress of the investigation.

Disciplinary proceedings

(20) Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any other investigation. In this context it should be emphasised to personnel departments and other persons responsible for the conduct of disciplinary proceedings within local authorities that:

(a) police or any other independent investigation does not determine disciplinary issues;

(b) disciplinary proceedings may well involve wider issues than whether a crime has been committed;

(c) the standard of proof in disciplinary proceedings is different from that in criminal proceedings; and

(d) statements made to the police by potential witnesses in disciplinary proceedings, including statements by a complainant, can and shou
ld be made available to local authorities for use in such proceedings, if consent to this is given by the maker of the statement.

(21) Personnel departments and other persons responsible for disciplinary proceedings within local authorities should be reminded that:

(a) in deciding whether or not a member of staff should be suspended following an allegation of abuse to a looked after child, first consideration should be given to the best interests of the child;

(b) suspension is a neutral act in relation to guilt or innocence;

(c) long periods of suspension are contrary to the public interest and should be avoided whenever practicable;

(d) depending upon the gravity of the allegation of abuse, the employment of a member of staff in another capacity not involving contact with children or other vulnerable persons may be an appropriate decision at the time of suspending or finally, having regard to the importance of protecting looked after children from abuse.

Review of procedures in major investigations and guidance

(22) In the light of the recent experience gained in both England and Wales in major investigations of alleged wide ranging abuse of children in care/looked after children, an inter-agency review of the procedures followed and personnel employed in those investigations should now be arranged with a view to issuing practical procedural guidance for the future. In any event guidance is required to social services departments and police forces now in relation to:

(a) the safeguarding and preservation of social services files;

(b) the safeguarding and preservation of police records of major investigations, including statements and the policy file;

(c) access by the police to social services files;

(d) the supply of information about alleged and suspected abusers by the police following an investigation; and

(e) the sharing of information generally for criminal investigation and child protection purposes.

The prevention of abuse

Recruitment of staff

(23) Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee; and compliance with them by individual local authorities should be audited from time to time.

Approval of foster parents

(24) Similar vigilance should be mandatory in relation to all applications for approval as foster parents. In particular, any application to foster by a member of a local authority's child care staff should be stringently vetted by a social worker who is not known to the applicant.

Induction training

(25) Social Services Departments should ensure that appropriate and timely induction training is provided for all newly recruited residential child care staff.

Training generally

(26) The Tribunal endorses all five of the most recent recommendations of Sir William Utting in "People Like Us" in relation to the content and provision of training for staff in children's homes and the care units of residential special schools and recommends that they should be implemented as expeditiously as possible.

(27) It should be a requirement that senior staff of children's homes (including private and voluntary homes) must be qualified social workers or, if that is not practicable before appointment, that it should be a condition of their appointment that they undertake qualifying training within a specified period.

(28) Central government should take the initiative to promote and validate training in safe methods of restraint with a view to making such training readily available for residential child care staff and foster parents.

(29) Suitable specialist training in child care at post-qualifying level should be made widely available and, in particular, to the senior residential care staff of children's homes and to field social workers.

Attracting suitable staff

(30) There should be a national review of the pay, status and career development of residential child care staff and field social workers to ensure as far as possible that there is a sufficient supply of candidates for such posts of appropriate calibre.

The quality of care

Assessment

(31) Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.

(32) All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.

Care planning

(33) The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.

(34) An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.

Foster carers

(35) Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us".

Leaving care

(36) The daily regime in residential establishments and foster homes should encourage and provide facilities for the acquisition of skills necessary for independent living.

(37) A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for further support.

(38) The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so as to ensure that placing authorities provide the level of support to be expected of good parents, including (where appropriate) help to foster parents to provide continuing support.

Fostering breakdowns

(39) Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director of Social Services.

Compliance with safeguards

(40) Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:

(a) the allocation of a designated social worker to each looked after child;

(b) compliance with fostering and placement regulations;

(c) statutory review requirements; and

(d) rota visits by elected members.

Private children's homes and residential schools

Registration of homes

(41) All private children's homes should be required to register with the independent agency referred to in recommendation (47).

Governing body

(42) The owner of a private children's home and the owner of a private residential school approved generally for SEN children or receiving SEN children with the consent of the Secretary of State should be required, if the establishment is above a size to be determined, to appoint an appropriately constituted governing body under arrangements approved by the relevant regulatory authority, to include representation from the local social services and education authorities (as appropriate) and the local community.

Accounts etc

(43) The accounts and other relevant financial information relating
to private children's homes and private residential schools approved generally for SEN children or receiving SEN children with the consent of the Secretary of State should be disclosed to the relevant regulatory authorities.

Regulation of schools

(44) There should be an urgent review of the legislation governing the regulation of private residential schools to include particularly:

(a) approvals and consents under section 347 of the Education Act 1996[921] and for provisional registration of schools,

(b) the Notice of Complaints provisions and the procedures for the withdrawal of approvals generally, and

(c) the interaction with the provisions for registration of private children's homes, with a view to establishing a stricter and more readily enforceable regulatory regime.

Assessment

(45) Any placement of a child by a local education department or by a social services department in a residential school should be preceded by:

(a) consultation between the departments as to whether an assessment by an appropriate social worker of the child's needs and family situation is needed as well as an educational assessment; and

(b) in the light of (a) and any subsequent assessment, a decision about the need for (and extent of) any further involvement of the social services department with the child to ensure continuity of planning for the child's long term welfare and protection of the child's rights.

Emergency admissions

(46) Emergency admissions should not be made to private residential schools.

Inspection

Inspection agency

(47) Without prejudice to the continuing role generally of the Social Services Inspectorate for Wales, an independent regulatory agency for children's services in Wales should be established, with a local base or local bases in North Wales, and charged with the responsibility of inspecting.

(a) all local authority, voluntary and private children's homes;

(b) the welfare provision in residential schools;

(c) fostering services; and

(d) the other components of children's services.

(48) When inspections are made by the agency of homes, schools or services mentioned in recommendation (47) at least one of the inspectors should have substantial experience of child care.

Joint inspection of SEN schools

(49) The agencies responsible for educational and welfare inspections of private residential schools accommodating children with SEN pursuant to section 347 of the Education Act 1996 should be required to agree joint programmes of inspection and reporting.

Common standards

(50) A common set of standards should be applied to the local authority, voluntary and private sectors in relation to residential provision and other services for looked after children.

Reports

(51) Copies of the reports of inspections of local authorities' children's homes and services should be sent to the Chief Executives as well as the Directors of Social Services.

(52) Copies of reports of inspections of private and voluntary children's homes and of private residential schools should be sent to the Director of Social Services of any placing authority with a child at the school and of the authority in whose area the establishment is located.

(53) The agency referred to in recommendation (47) should present an annual report on all aspects of its work, including any constraints upon that work and any shortfall in fulfilling its obligations.

Senior management

Structure

(54) There should be at least one full member of a local authority's social services department management team with child care expertise and experience.

(55) The responsibility for policy and service development and for oversight of the delivery of a local authority's children's services should be assigned to one member of the social services department management team of at least Assistant Director status.

(56) Staffing resources at intermediate management level for a local authority's children's services should be sufficient in number and quality to enable positive and close supervision and support to be given to residential establishments and the fostering service.

Training

(57) Local authorities in Wales should review their current arrangements for management training and development for senior managers, including social services managers, giving particular attention to the development of skills in strategic planning, policy implementation and performance appraisal.

Elected members

Responsibilities

(58) Elected members should from time to time be advised about and reminded of their responsibilities to develop policy and to oversee and monitor the discharge by the local authority of its parental obligations towards looked after children.

Reports by Director of Social Services

(59) It should be the explicit duty of the Director of Social Services to assist and support elected members in discharging those responsibilities and, in particular.

(a) to inform elected members of all matters of concern touching upon children's services, including reports upon them, whether adverse or favourable;

(b) to provide information on comparative spending on children's services by local authorities in Wales and an analysis of that information;

(c) to submit an annual report to the Social Services Committee on the department's performance in relation to children's services including its record of compliance with required safeguards for looked after children.

Guidance about visits

(60) The purpose and scope of visits to children's homes, whether by councillors or by senior and intermediate managers, should be clearly defined and made known to all such visitors.

Rota visits

(61) The willingness of councillors to visit children's homes should be a pre-condition of appointment to the committee responsible for the homes and the importance of fulfilling the duty to visit and to report on visits conscientiously should be emphasised to them. Elected members should be provided with appropriate guidance, including reference to the need to be vigilant in protecting the interests of the child residents as well as to be supportive of the staff.

Strategic issues

Advisory Council

(62) An Advisory Council for Children's Services in Wales comprised of members covering a wide range of expertise in children's services, including practice, research, management and training, should be established in order to strengthen the provision of children's services in Wales and to ensure that they are accorded the priority that they deserve.

(63) The functions of the Advisory Council should include:

(a) advising on government policy and legislation with regard to their likely impact on children and young people;

(b) commissioning research;

(c) disseminating information and making recommendations.

Nationwide review of children's services

(64) There should be a nationwide review of the needs and costs of children's services based on local authorities' development plans and leading to a comprehensive and costed strategy for those services, including any necessary education and health elements.

Local authority plans

(65) Local authorities, in collaboration with voluntary and other relevant organisations and acting together with other local authorities where appropriate, should prepare costed development plans for children's services as a prelude to the proposed nationwide review, such plans to ensure (amongst other things) that:

(a) there is an adequate range of residential care provision of appropriate quality, including secure provision, within reasonable reach of a child
's family or other relevant roots;

(b) such residential provision includes safe places where children can recover when relationships break down;

(c) as in (a), there is an adequate range of fostering facilities available of similar quality and accessibility;

(d) all residential placements are designed to be developmental and therapeutic rather than merely custodial;

(e) full educational opportunities are available for looked after children, including remedial education.

Use of residential schools

(66) Central government should examine the extent to which residential schools are being used as a substitute for social services care and support, and identify the implications for children's long term welfare.

Availability of placements

(67) Provision should be made for repeated monitoring at appropriate intervals of the availability and quality of residential placements and fostering services on a nationwide basis.

Management training

(68) Consideration should be given at national level to the need for, and provision of, training and management development for senior managers in local authorities in Wales, including the availability of such facilities for social services managers.

Resources at national level

(69) Adequate resources should be provided to ensure that the departments in Wales responsible at national level for children's services are sufficiently and appropriately staffed to support and monitor the provision of these services in Wales.

Statistics

(70) The national statistics services in Wales should be strengthened to provide a comprehensive management information system.

Supplementary matters

Law Commission

(71) The Law Commission should be invited to consider the legal issues that arose in relation to the publication of the Jillings report and the associated problems, as explained in Chapter 32 of this report.

Guidance on inquiries

(72) Subject to the preceding recommendation, guidance to local authorities on the setting up and conduct of inquiries and the dissemination of reports thereon should be up-dated and re-issued[923].44