Government safeguarding advisers set out a series of recommendations for improving care, social work practice, commissioning and regulation in residential services for disabled children and those with complex needs, in a report last week.
The study, from the Child Safeguarding Practice Review Panel, came in response to “very serious abuse and neglect” of children – mainly autistic or with learning disabilities – at three residential special schools registered as children’s homes in Doncaster, from 2018-21.
In a predecessor report published in October, the panel, while heavily critical of provider the Hesley Group for allowing a “culture of abuse and harm” to prevail at the schools, also found significant failings among the institutions responsible for oversight.
Failures of oversight
These included Ofsted, who had rated the settings as good as of 2021, despite receiving complaints dating back to at least 2015. But the panel also applied this critique to the 55 councils that placed 108 children at Fullerton House, Wilsic Hall and Wheatley House during the time studied, and Doncaster, as the ‘host’ authority.
In relation to the latter, the panel found major failings by Doncaster’s local authority designated officer (LADO) service, which received 232 referrals in relation to staff at the schools from January 2018 to March 2021.
The panel found that the Doncaster LADO function did not effectively collate information from different sources to analyse patterns of concerns about staff, and there was a lack of communication about staff conduct between it and LADOs at placing authorities.
In relation to those authorities, the panel found that quality assurance was inconsistent, with insufficient challenge of reports provided by Hesley or collation of evidence from different sources. This meant that practitioners did not have “a full picture of the children’s progress, welfare and safety”.
Some children ‘known only through written records’
The children were placed, on average, 95 miles from home, and, the review found, some were “known only through written records”, with limited capacity for practitioners to visit children placed so far away.
This was exacerbated by Covid and, potentially, high turnover of social workers, team managers and commissioning staff, though the panel highlighted good practice from some practitioners who travelled up to 200 miles so they could visit children regularly.
The panel’s work for the first report triggered a number of actions designed to address these issues.
Education secretary Gillian Keegan announced a review of the LADO role, with a view to consulting on “developing a LADO handbook that includes improving handling whistleblowing concerns and complaints in circumstances such as these”.
And, before the phase one report’s publication, the panel wrote to directors of children’s services, calling on them to ensure:
- LADOs urgently reviewed all referrals, complaints or concerns regarding residential special schools registered as children’s homes over the previous three years to ensure they had been appropriately dealt with.
- Reviews were carried out by placing authorities of children in these settings to ensure they were in safe placements, with any concerns being shared with the local LADO if the threshold for referral were met.
Several requirements were set for the latter, known as quality and safety reviews. These included ensuring the child was seen at home and school, talking directly to their families and checking if any safeguarding issues had been raised and that these had been followed up appropriately.
Fortunately, these reviews found that the vast majority of children were having their needs met, none was living in an unsafe setting and councils were taking appropriate assurance action when concerns had been raised about a placement, said the panel in its report last week.
Need for greater professional curiosity
However, the panel did find areas for improvement, including “the need for greater curiosity and challenge from social workers and independent reviewing officers in visit and review processes” to recognise the “inherent safeguarding risks” children faced in these settings.
“Practitioners in these roles also need the requisite skills to communicate with children with disabilities, complex needs and behaviour that challenges,” the panel added.
The panel also found the reviews had revealed an “urgent training requirement to ensure that practitioners understand the requirements for legally compliant practice” in cases where children were being deprived of their liberty.
Council and children’s home practitioners had not sought authorisation to deprive children of their liberty in cases where children were being subject to restrictive interventions, due to a lack of understanding.
Children in residential special schools registered as children’s homes are generally subject to multiple statutory review processes, being both looked after and having education health and care plans (EHCPs) for their special educational needs.
A positive outcome of the reviews, said the panel was that councils, along with health commissioners, were using them as a model for assuring themselves of placement quality, with come bringing together looked-after children and EHCP reviews for the children concerned.
Panel’s recommendations regarding placing authorities
- Councils and ICBs should be required in statutory guidance, developed by the DfE and NHS England, to “jointly commission safe, sufficient and appropriate provision” for disabled children and those with complex health needs.
- The government and NHS England should co-ordinate support for local authority and ICB commissioners to help improve, forecasting and market shaping.
- Councils, health services and residential settings should review their current systems, procedures and practice to determine their readiness for meeting deprivation of liberty requirements.
- Care, education and treatment reviews (CETRs) should be carried out for any disabled child on a pathway to a residential placement lasting longer than 38 weeks per year. CETRs are multi-agency meetings, involving the person, their family, professionals and independent experts, currently carried out for young autistic people or those with learning disabilities who have been, or may be, admitted to a mental health hospital.
The panel’s first report exposed the failure of monitoring bodies – Ofsted, placing authorities, to piece together the bits of the picture they each held about what was going on at the Hesley Group’s homes.
Proposed oversight role for host authorities
Consequently, a key priority set out in the second report was improving “systems for triangulation of intelligence, information sharing and
identification of risk in residential settings”.
The panel said that it saw host authorities and ICBs as key to bringing this intelligence together, and that they should have an enhanced role in doing so. One reason for this was that children at residential special schools, whether on term-time, 38-week placements or 52-week arrangements, were registered local ICB population.
It suggested a possible model for this role. This included:
- Having named officers in the local authority and ICB with responsibility, oversight and accountability for ensuring high quality care and health provision for children placed in the area.
- For those named officers to receive and review reports on settings by regulation 44 visitors – appointed by children’s homes to inspect them monthly – and six-monthly regulation 45 reviews of the quality of care by the provider.
- Ofsted and DfE regional improvement and support leads notifying host authorities and ICBs about whistleblowing reports and parental complaints.
- Having a maintained register of children living away from home in children’s homes, residential special schools, residential special schools registered as children’s homes, and children’s homes registered with both Ofsted and the Care Quality Commission.
- LADOs to monitor and analyse allegations and share information with placing authorities.
Ongoing LADO review
Meanwhile, the government’s review of the LADO role is ongoing.
In a statement on the panel’s phase 2 report last week, children’s minister Claire Coutinho said the DfE had been working on it with the LADO Network, which represents officers, Association of Directors of Children’s Services (ADCS), Home Office and Ofsted, among others.
The panel, in its second report, said it welcomed the DfE’s plan to develop a handbook on the key requirements of the role. It said these should include:
- an understanding of the inherent safeguarding risk factors associated with residential settings;
- a grasp of risks associated with ‘closed cultures’;
- the importance of multi-agency advice to the LADO to support decision making about whether thresholds for intervention have been met.
Though the panel concluded that most of its recommendations could be delivered by more effective use of existing resources, its plans to strengthen the oversight role of host authorities was one that needed additional resource.
Whether this will materialise will have to await the DfE’s full response to the report, due within the next six months.
In a statement last week, the lead reviewer for the report, Christine Lenehan, director of the Council for Disabled Children, spelt out her view of the consequences of the panel’s recommendations not being implemented.
“These recommendations set out a roadmap to more humane treatment of these children,” she said. “But without the wholehearted commitment to implement these measures fully, these failings will come back to haunt us when the next group of disabled children fall foul of services that cost the taxpayer dearly but rob vulnerable children of their basic humanity.”