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Introduction

 31.01  The Tribunal's terms of reference do not refer specifically to this topic but the evidence that we have heard from complainants and others has demonstrated that, for many children in care in Clwyd during the period under review, the quality of care provided fell far below an acceptable standard. The cumulative effect of the Social Services Department's various failings in this respect amounted, in our judgment, to abuse of those children; and the lamentable result was that many of them emerged from care unfitted to meet the demands of adult life, without adequate continuing support and filled with resentment about their treatment in care.

31.02  It has not been the purpose of this Tribunal to carry out an audit of Clwyd Social Services Department's practice and procedures generally and the procedure of a Tribunal of Inquiry is not appropriate for such an investigation. Nevertheless, the evidence before us has pointed so clearly to basic failings in the quality of care provided by Clwyd that our report would be incomplete without reference to them.

  31.03  The major failings that we have identified were:

(a)  The lack of adequate planning of each child's period in care.

(b)  The absence of any strategic framework for the placement of children in residential care.

(c)  Ineffective reviewing processes and lack of consultation with the child.

(d)  Intermittent and inadequate surveillance by field social workers.

(e)  Failure to establish any co-ordinated system for preparing residents for their discharge from care.

The lack of adequate planning for each child in care

  31.04  The need for individual child care plans was recognised generally as good social work practice throughout the period under review but we found little evidence of them in Clwyd and the practice in respect of them was at best patchy. On a different, but analogous, subject, Gordon Ramsay said that a social history proforma to be used for all children coming into care was drawn up in 1974 but was rarely completed properly; and available information was rarely put into reports or transfer summaries. Moreover, Janet Handley, the Area Officer for Wrexham Maelor, told us that the standard of maintaining case notes of a child in residential care, including admission documentation, "lapsed in practice" by some staff between 1971 and her retirement in 1985.

  31.05  Elaine Baxter, who carried out a review of files and of interviews with social workers on behalf of the Tribunal, confirmed the lack of structured assessment and planning: the social workers interviewed commented that there was no structural proforma for individual care planning in the 1980s and that the only planning mechanism was the review, the form for which provided a space for future plans. None of the social workers interviewed could recall any specific training or guidance in care planning prior to the Children Act 1989. Furthermore, despite the statutory requirements that the local authority should, so far as was practicable, ascertain the wishes and feelings of a child regarding any decision and give due consideration to them having regard to the child's age and understanding[432], the social workers could not recall any training or guidance on that subject in the same period. The reality, as one quite senior officer put it, was that obtaining the views of the child did not happen in Clwyd in the 1980s in any formal sense before the Children Act 1989.

  31.06  The result of all this was that many of the children in residential care had no coherent picture of their likely future in care and were not given any clear conception of how they might progress positively.

The absence of any strategic framework for placements

  31.07  One of the reasons for the lack of individual care plans may have been the absence of any clear framework for the placement of children after their reception into care. Gordon Ramsay's role as Placement Officer was formalised in 1975 and he retained this responsibility until his retirement in 1987 but he seems to have had very limited effective discretion in the matter. The practice was to hold a case conference at a community home shortly after a child had been admitted there initially, except in the case of Bryn Estyn and the two assessment centres at Bersham Hall and Little Acton. Ramsay would preside at case conferences at the assessment centres, which would be multi-disciplinary, and the appropriateness of each placement would be reviewed together with future plans for the child. The latter would not be present at the discussion but might be invited in at the conclusion of it to be told the outcome. At Bryn Estyn a similar type of case conference would take place and would be chaired by Arnold.

  31.08  This procedure was apparently designed initially for children who had been the subject of emergency placements but it became the practice in respect of all placements. The reality was that the number of available places in residential care in Clwyd was limited throughout and that, in many cases, admissions were treated as emergency cases when they need not have been. Thus, many (perhaps most) placements were decided on the basis of availability rather than suitability. Concern about unplanned admissions figured in management discussions in 1980 and 1981 and again in 1983. According to John Coley, the Deputy Director of Social Services from 1980 to 1984, unplanned admissions escaped the scrutiny and endorsement of supervising officers; they could involve the inappropriate reception of children into residential care as an easy short term solution but with the attendant danger that they might become institutionalised.

  31.09  The other form of review in which Gordon Ramsay played a leading part was a six monthly review, called a placement review, at each community home, other than the three Wrexham homes mentioned in paragraph 31.07, of all the children in the home. The object was to consider the suitability of the placement of each child there and Ramsay went to the home on his own for that purpose. At Bryn Estyn, Arnold would chair reviews but they were not strictly parallel to Ramsay's placement reviews: a review there would take place as the need arose for a particular child or, for example, if there was a need to reduce numbers. Ramsay would attend, if he was available, and the review at Bryn Estyn might be multi-disciplinary. At the assessment centres also reviews would be held if there was a special reason, such as non-availability of a placement for a child, and the head of home would preside but Ramsay would attend.

  31.10  Despite these procedures there was no underlying strategic planning. From the point of view of the child in care he/she was liable to be moved for reasons unconnected with his/her welfare or behaviour and might be placed far away from his/her home of origin and friends. Moreover, financial constraints became a factor in the reviews from 1980 onwards, particularly in relation to the impending closure of Bryn Estyn. Thus, it was difficult for many children in care to hold on to any coherent vision of their future or to retain any realistic immediate aims.

Ineffective reviewing processes and lack of consultation with the child

  31.11  We have referred in the preceding section of this chapter to what were called placement reviews but there were statutory requirements governing a different type of review, known as a "statutory review", throughout the period. Section 27(4) of the Children and Young Persons Act 1969 required a local authority to review the case of every child in its care every six months and to consider upon the review whether to apply to discharge the care order. A parallel duty in respect of boarded out children under successive Boarding-Out Regulations was to review the child's welfare, health, conduct and progress, in the light of written reports about the child, at six monthly intervals, following an initial review within three months of the placement. In practice Clwyd, like many other authorities, integrated these two forms of review into a single system covering both requirements; but Clwyd went a step further by including in the system children in day care and children subject to supervision orders, neither category of whom were covered by a statutory requirement.

  31.12  We received evidence of divergent practice in carrying out these reviews. Gordon Ramsay told us that they took place in the Area Office until he retired in 1987; they usually involved just the field social worker (who was expected to represent the views of the residential care workers involved with the child) and his/her line manager, although a health visitor or school welfare officer might attend. Neither Ramsay himself nor any representative of the residential sector would attend. Janet Handley, on the other hand, said that in the Wrexham Maelor area reviews of children in residential care were held in the community home so that the field social worker and residential care workers could review the case with an independent person. Another Area Officer said, however, that the only people involved in the early days were the social worker and the Area Officer (later the Deputy). Whichever procedure was followed, however, the direct contribution of the child was very limited in the 1970s and 1980s. It was not normal for the child to be consulted or directly involved in reviews.

  31.13  It is difficult to see how a system of reviews without direct input from the residential care workers or the child could be effective, particularly when relations between field social workers and residential care workers were poor and there were criticisms of the visiting records of the former. Furthermore, parallel systems of separate placements and statutory reviews conducted by different personnel were most unsatisfactory and unlikely to result in coherent, positive planning for each child in the light of full information and understanding.

  31.14  A further serious problem was the delay in carrying out the statutory reviews in some areas, which was all the more serious because these reviews were regarded as the main instrument of care planning. In November 1977 the Director of Social Services (Emlyn Evans) instructed Area Officers to certify to their Area Sub-Committee that statutory reviews had been completed but we heard evidence of subsequent long delays in completing reviews in both the Wrexham Maelor and Delyn areas. In 1980 Emlyn Evans and Ramsay visited the Wrexham office and found that there were serious delays; and in 1982 Janet Handley reported that 209 (including 80 supervision order cases) out of 267 reviews were overdue in that area. As for the Delyn area, a detailed report by Ramsay on 16 June 1981 showed that there had been many breaches of detailed requirements: 42 reviews had been missed, some reviews were 12 months late, and two of the teams had each been late in completing 35 reviews. In consequence, according to Ramsay, three persons in the Delyn area were disciplined: it appears that the Area Manager received a formal written warning and a Team Leader was given a final written warning.

  31.15  We must emphasise finally on this subject that, in any event, the review process is not a substitute for a clear and recorded initial child care plan. Reviews should provide independent monitoring and evaluation of the assessment and planning processes but they should not be used as a substitute for those processes.

Intermittent and inadequate surveillance by field social workers

  31.16  Field social workers provide the primary point of contact with families in difficulty and their work is crucial in determining whether children enter the care system or remain at home. Once a child is admitted into care, the field social worker carries the main responsibility for planning the future, including working with the child's family towards rehabilitation, where this is a possibility. In this context the development of a close and confiding relationship between social worker and child is of paramount importance and this, in turn, can only be established by regular visiting of both children in residential care and boarded out children.

  31.17  Elaine Baxter's review of social work practice in Clwyd on the Tribunal's behalf confirmed the oral evidence that we heard to the effect that visiting patterns were extremely varied, with long gaps in reported visits to both community homes and foster homes. The account that we have given of this in paragraphs 29.60 to 29.64 of this report emphasises both the inadequacy of the contact between field social workers in Clwyd and children in residential care and the fact that this was known to senior management in the early 1980s. This serious breach of approved practices did not, however, provoke any effective managerial response.

  31.18  Whilst we heard some evidence of good practice in visiting and of the general availability of social workers at, for example, Park House and South Meadow and early on at Bersham Hall, we have no doubt that for most children contact with social workers was insufficient to establish or maintain a level of confidence that would enable them to make complaints or indeed to preserve a significant relationship. Once children were placed in residential care, they became a low priority and field social workers tended to concentrate their efforts on work with their families; some saw children mainly when they were on home leave, thus missing the opportunity of observing and talking to them in their residential care situations. Moreover, even if the minimum frequency of visiting taken from the Boarding Out Regulations was complied with, this was insufficient to foster a confiding relationship with a child.

  31.19  One of the consequences of (or reasons for) the infrequent contact between field social workers and some of the community homes was that there was considerable disaffection between them and residential care staff. Janet Handley described the relationships between them as "abysmal", although this varied from home to home. At Bryn Estyn, for example, social workers felt unwelcome. On the other hand, some senior residential care officers attributed delays in rehabilitating some children, after they had ceased to benefit from residential care, to inefficiency or indifference on the part of the field social workers after the initial placements had been made.

  31.20  It would be wrong to infer that all the blame for the failure to establish appropriate relationships with the children rested upon fieldwork staff. Quite apart from the failure of senior management to monitor the performance of field social workers in this respect, there were other contributory factors. Some children did not have any social worker allocated to them. Some other children were placed far from their own homes, making visiting by social workers, who were limited at one stage to a monthly mileage allowance of 250 miles, difficult. In general also, case loads were high.

  31.21  According to the Area Officers, inadequate staffing levels and the loss of qualified and experienced staff were major factors in the lack of support and supervision by fieldworkers from the beginning. In February 1976, the agreed field social work establishment was 58 (against a policy ideal of 76), but only 49 were in post, of whom 25 were qualified. Since 1974, 63 field staff had left, of whom 44 were qualified, and only 14 qualified social workers had been recruited. Thereafter, the lack of experience of the unqualified staff was a constant worry, according to Janet Handley, and professional training needs further reduced the number of staff available at any particular time. However, substantial progress was made in the following ten years. Whereas in 1975 only 48% of fieldworkers were qualified, the percentage of them who were qualified by 1985 was 89 (93% in 1994).

Failure to prepare residents for their discharge from care

  31.22  A recurring criticism made by complainants who had been in care for substantial periods was that they were unprepared for their discharge from care when it occurred. They had not been given any adequate training specifically directed to the problems that they would face on discharge and received little support from social workers once they ceased to be in care.

 31.23  From the evidence presented to us it would appear that greater sustained efforts to prepare young persons in care for discharge were made in the earlier part of the period under review than later, when the boarding out of children predominated. At Bryn Estyn, for example, Cedar House was used until about April 1977 as a working boys' unit[433]; and several other community homes, such as Bersham Hall, Park House and South Meadow, had a cottage in the grounds that was intended in the early years to be used as accommodation for small numbers of older residents, who would be taught some of the basic skills necessary for independent living. As unemployment increased, however, work training for residents seems to have faded from the picture and we heard very little of any positive training once residents had passed the compulsory school age limit.

  31.24  In November 1984 the Director of Social Services (Gledwyn Jones) was invited to address a conference organised by the National Association for the Care and Rehabilitation of Offenders at Llandrindod Wells on the subject of housing homeless young people at risk. In preparing his own contribution to that conference, dealing with the responsibilities of Social Services Departments, the Director arranged for a survey to be carried out of young people in Clwyd who had left care during the period of 18 months between 1 April 1983 and 30 September 1984. The information was supplied by the social workers responsible for supervising the young persons and the aim was to achieve a "down to earth" evaluation of the results of the service provided for children in care with a view to improvement where necessary.

  31.25  In the event 62 (37 boys, 25 girls) out of a total of 79 young persons who had been discharged in the prescribed period were covered by the answers to the questionnaire that was distributed; and 44 of them had been discharged from a community home against 18 from a foster home. On discharge only about 50% of them (32) went to accommodation in which they might expect to receive continuous support: 21 went to live with a parent or parents, four to relatives and seven remained in their foster homes. The other 27 (excluding two serving custodial sentences and one absconder) had to survive independently in various types of accommodation (almost wholly temporary) as indicated by the following list:

Friends: 2 

Approved lodgings: 7

Private house/flat/bed sit: 1 (inherited) 

Landlady/boarding house: 1 

Hostel: 2

  31.26  The report on the survey, written by John Llewellyn Thomas (Principal Officer (Children)) and David Davies (Child Abuse Co-ordinator) was prefaced with the following bleak quotation from Mia Kellmer Pringle on "The Needs of Children", "Not only does the child in long-term care have no reliable past; equally devastating, he has no predictable future except that he will come out of care at the age of eighteen". Amongst the report's findings were that only ten of those in temporary accommodation were receiving any planned follow up and 37 of the total of 62 were unemployed (11 others were on Youth Training Schemes). The authors commented:

"Even by Clwyd's serious unemployment figures the 60 per cent of young people being without work when they leave care presents a very grim picture. In a general discussion with the Principal Careers Officer he suggested they often do not have the skills to compete in the jobs market and partly for this reason are placed on 'sheltered' Youth Training Schemes (eg cleaning railway lines, cemeteries etc). They are, therefore, not attached to potential employers (eg Boots,British Aerospace) where they could obtain a permanent post at the end of the scheme."

  31.27  The report concluded also that, on the basis of the answers to the questionnaire, most children in care were offered few opportunities to learn basic 'survival' skills. The authors added:

"We fully appreciate the difficulties, such as Health and Safety Regulations, the management of group-living and some adolescents might even reject adult standards. However, we would suggest that if offered a tangible task related programme, agreed with the teenager, (and parents where appropriate) most would respond rather than face an insecure future and self-doubts about surviving alone."

  31.28  Follow up action was confined to distribution of this report to the Area Officers and other middle management staff involved with child care, including the heads of community homes, in June 1985 but it does not appear to have resulted in the formulation of any programme to prepare children for their discharge from care before the Children Act 1989.

  31.29  That Act imposed a wide range of duties on local authorities in relation to young people leaving care and led to comparatively swift developments in Clwyd when it came into force in October 1991. These included presentation of a report on "Leaving Care", which was placed before the Children and Families Sub-Committee on 12 February 1992; the subsequent attendanceof staff from the Social Services Department at a Welsh Office two day workshop on the same subject; and the formation in Clwyd of a steering group and working parties to examine issues relating to preparation for independence, housing and accommodation, support (emotional, financial and practical) and after care. The result was the formulation of a leaving care strategy embodying 11 policy statements, which was approved by committee on 3 May 1995.

  31.30  Whilst these developments were taking place, the Welsh Office carried out an inspection in November and December 1992 of outcomes for children leaving care in three Welsh counties, one of which was Clwyd. The report extended to 64 pages, with annexes, and the overall picture presented was dismal, although Clwyd did not compare unfavourably with the other two counties. Nevertheless, the situation in Clwyd was still much as it had been eight years earlier, during the period surveyed by Thomas and Davies. Of eight young persons seen (in the South Division), who had all left care in the preceding 14 months, only one was undergoing training and the other seven were unemployed; and all were dependent on state benefits and top-up payments made by the Social Services Department. In the view of the inspectors, some of the young people had been well prepared for leaving care but there was no consistency of approach. Most had found reasonable accommodation, though choice was limited, and social workers had been very active in assisting them to find accommodation: all were continuing to receive support and advice from social workers and others. The inspectors stressed the need for Clwyd to produce a statement on leaving care policy and the high priority that should be given to education, training and employment in all reviews of children looked after. They urged the authority also to explore further ways of diversifying accommodation available to young people leaving care, in order to enhance choice.