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Introduction

48.01  In this chapter we deal with the work of two separate Inspectorates, namely:

(a)  the Social Work Service for Wales (SWSW), employing SWSOs until it became belatedly the Social Services Inspectorate Wales (SSIW), staffed by SSIWs, in or about 1989[655];

(b)  HMIs employed by the Welsh Office Education Department (WOED) until September 1992, when they became an independent body, OHMCI (Wales), under a Chief Inspector (HMCI)[656]

48.02  We heard oral evidence from David Evans, who became Chief SWSO in 1986 and then Chief SSIW on redesignation of the post. He provided also a voluminous statement about his Inspectorate's activities, extending to 325 pages (excluding annexes), which is so verbose that it has been difficult to extract relevant information from it. In that statement he said that a substantial shift of emphasis in the role of the Social Work Service occurred in the quarter of a century following its establishment on 1 January 1971. Evans said, in relation to its child care role, that it was established to provide professional advice on all aspects of child care policy and procedure. "The majority of its time was spent in dealing with queries about individual cases brought to the attention of the Welsh Office, studying reports on the role of local authorities and, in consultation with administrative colleagues, dealing with day to day work and longer term policy questions".

  48.03  Evans stressed that SWSOs had no executive responsibility for children's services, either for policy or for practice. In his words they were "the Welsh Office's eyes and ears on local authority matters and the friends and advisers of local authorities". In relation to inspections the legal position was that section 58 of the Children and Young Persons Act 1969 (later section 74 of the Child Care Act 1980) conferred power upon the Secretary of State to "cause to be inspected" any premises at which one or more children in the care of a local authority were being accommodated and maintained as well as any community or voluntary home and premises at which one or more children were being boarded out or fostered, except premises (such as independent schools) subject to inspection by or under the authority of another government department. An inspector authorised by the Secretary of State to inspect a home or other premises under the section might inspect the children therein and make such examination into the state and management of the premises and the treatment of the children as he thought fit.

  48.04  John Lloyd told us that in the earlier part of the period under review there was a heavier concentration in inspections on aspects such as the suitability of the fabric of the home rather than on case management issues. Later in his evidence he indicated that despite few references in inspection reports, it had become customary for inspectors to look at care plans and consult records in area offices.

  48.05  The purpose of the inspection, as interpreted by SWSW, was described in Evans' statement as follows:

"The emphasis and style of work involved building good networks and informal working relationships. As well as the supportive ethos which underpinned the relationship between central and local government, the small number of social services departments in Wales made it possible to develop a close working relationship between SWSW and the field authorities and frequent meetings were held at an all-Wales level between the Directors of Social Services and SWSW, which considered the development of services for children."[657]

  48.06  The woolly description of the functions of SWSW given, for example, in an issues paper at the time of the Barclay report in 1982[658], which need not be quoted here, became more sharply focussed after it had been re-designated as the SSIW. The latter's Inspection Guide published in 1995, for example, defined the SSIW's objectives as:

  "  To provide Ministers and the Welsh Office with information about social services in Wales.

    To provide advice to enable the Welsh Office to develop policies which will lead to improvements in the quality, effectiveness and efficiency of the services and to enable the Department to carry out its statutory and other responsibilities relating to social services.

    To evaluate the effectiveness of social services in Wales and how well they work with other services.

    To promote improvements in the quality, effectiveness and efficiency of services amongst the agencies who provide services."

  48.07  Part XI of the Children Act 1989 codified and extended a number of provisions governing the Secretary of State's supervisory functions and responsibilities, including financial support (amongst other things, for child care training), research and returns of information and default powers. Section 80 dealt with the inspection of children's homes: the powers of the Secretary of State to inspect premises where a child had been placed away from home were rationalised and extended, for example, to include placements for children under general health and welfare legislation and independent schools[659]; and powers to require information to be furnished and to inspect records were conferred.

  48.08  Local authorities were directed by the Secretary of State to establish their own inspection units by April 1991 on the exercise of powers conferred by section 50 of the National Health Service and Community Care Act 1990[660].

  48.09  The following table supplied by the Welsh Office indicates the relevant allocation of manpower resources within SWSW/SSIW during the last nine years of the period under review (the asterisk insertion is ours).

Allocation of Resources (SSI Equivalents)

Note: Staffing figures include Chief Inspector & Deputies

*all services

  48.10  We have given a brief account of the background and statutory basis of the work of HMIs in Wales in paragraphs 47.14 to 47.19 of this report. Prior to 1992 the statutory basis for inspections of educational establishments was contained in section 77 of the Education Act 1944, which required the Secretary of State to cause inspections to be made of primary, secondary, special and independent schools and certain other educational establishments. The inspections were to be at such intervals as appeared to the Minister to be appropriate and special inspections were to be made when the Minister considered them to be desirable. HMIs did not have any right to enter community homes, whether or not they provided education, because they were not within the definition of schools for the purposes of the Education Act 1944. However, very occasionally HMIs did join SWSOs/SSIWs at the latter's invitation in inspections of community homes such as Bryn Estyn in order to inspect the educational provision there. Similarly, SWSOs/SSIWs joined HMIs on some occasions in the inspection of residential schools.

  48.11  Up to 1992 HMCI had no statutory powers apart from the inspection of schools by HMIs. The Education (Schools) Act 1992 gave the HMCI power to advise the Secretary of State on any matters connected with schools in Wales and to cause any school inspection (by Registered Inspectors and their teams from 1993) to be monitored by HMIs. Section 6(1) of the Act required HMCI to keep the Secretary of State informed about such matters as the quality of education provided by the schools, the educational standards achieved, the adequacy of their financial resources and various aspects of the development of the pupils. The Act also imposed other specific additional duties upon HMCI, including a duty to ensure that every school in Wales within the wide range of schools defined in section 9(2) was inspected on a five year cycle.

  48.12  According to Susan Lewis, who has been HMCI in Wales since 1 June 1997, the purpose, aims and objectives of HMIs did not change significantly during the period under review, despite the legislative changes. Since September 1992 OHMCI (Wales) has defined its purpose as "to improve the quality of educational provision and the standards achieved by pupils and students". Its aims are:

  "  to provide the Secretary of State for Wales, his officials and others with sound and timely information and advice, derived from inspection and reporting, on educational provisions, policies, trends or issues;

    to manage and monitor an efficient, effective and high quality system for the regular inspection of schools and of funded nursery provision;

    to raise awareness of the factors contributing to effectiveness and efficiency in education and thereby promote improvement in standards and quality at all levels of the system."

  48.13  Lewis emphasised in her statement that HMIs were not, and are not, investigators; nor were they commissioned to enter schools in response to single-issue concerns such as an allegation of child abuse. In her view the responsibility and expertise for investigatory inspections rested with the local Social Services Department. HMIs would inquire into the arrangements made for pupils' welfare but much of this could only be done through indirect evidence such as policies, procedures and record-keeping.

  48.14  The types of inspection have remained largely the same since the Act of 1992, as (in many aspects) have the principles and procedures guiding them, which are set out in a Handbook that is publicly available. The purposes of the inspections are said to be to assess quality and standards, to identify and disseminate good practice, to identify unsatisfactory/poor practice and bring it to the attention of those with responsibility for addressing it, to improve overall quality and standards and to enable HMI to advise the Secretary of State and others on the educational system.

The record of SWSW/SSIW inspections

  48.15  The history of these inspections of local authority community homes conveniently divides into two because in or about 1985 there was a change of policy. In 1974 SWSW began to follow broadly, in relation to former approved schools, the earlier practice of Home Office Inspectors in making regular visits. Thus, Bryn Estyn was visited by SWSOs on no less than 18 occasions between May 1974 and July 1983; and 14 of these visits occurred prior to March 1979. In the same period of about nine years there were visits to two other community homes in the Wrexham area, namely, Little Acton Assessment Centre (seven, all but one before October 1976) and Bersham Hall (six, four of which were before March 1979). The only other inspections in Clwyd before 1985 were one of Cartrefle on 25 April 1977 and four of Tanllwyfan, an assisted community home with education, between September 1973 and April 1978.

  48.16  In Gwynedd, there were four inspections of Ty'r Felin between July 1975 and November 1978 and one inspection of Y Gwyngyll on 9 October 1979, shortly after it opened as a community home. Ty'r Felin was also included in the agenda of a tour by a Minister, accompanied by an SWSO, on 4 July 1980.

  48.17  The explanation for this unimpressive later record of inspections given by David Evans is that the "culture" of inspections inherited from the Home Office gradually changed. He said in his written statement[661]:

"It began to appear increasingly out of step with our relationship with all other social services that these establishments in particular" (former approved schools and remand homes) "should be so closely monitored. They were no different in principle from any other local authority service and no less accountable to their controlling authority. And this pattern of inspection seemed also out of step with the new post-Seebohm relationship."

  48.18  We have not been told who authorised the implementation of this change in inspectorial activity, but it appears that professionals working in the children's services in the early 1980s were dissatisfied with it. In an issues paper on the role of SWSW, drafted in 1984, Evans commented on the Barclay report in 1982[662] and the second report of the Select Committee on Social Services[663], both of which had favoured increased inspection to monitor practice in social work; but he was lukewarm and defensive about any extension of inspection, even though he recognised that it was likely to attract the strongest support from "those professionals working in the Children's Services". His account of the current position then was as follows:

"In Wales, as in England, SWS has continued to exercise its inspectorial function mainly in relation to CHEs, secure accommodation and voluntary children's homes and, until the severe staff reduction in the last year, to a higher level than DHSS. It has not, however, been in a position to review children's services provided as a whole by authorities, or those areas of services governed by regulations such as Boarding Out."

  48.19  What eventually emerged was described as an "enhanced" inspection programme. In an explanatory internal departmental memorandum dated 17 January 1989 Evans said:

"The main features of the revised arrangements are:

(i)  a detailed inspection programme together with related survey and development work is prepared annually for the forthcoming year and in outline for the subsequent two years. The draft programme is discussed with appropriate policy divisions in the light of their requirements for policy advice and with local authority social service departments in relation to the need to monitor the services they provide;

(ii)  submitted formally to Ministers for approval;

(iii)  submitted to the Welsh County Council's Committee (Social Services Sub-Committee) for consultation."

  48.20  Although this memorandum was dated January 1989, the enhanced programme appears to have been started in 1987 and the memorandum referred to an increase in the time devoted to inspection work from 12 per cent of the Service's time in 1987/1988 to 25 per cent in 1989/1990. We have been supplied with what is called "Inspection Programme 1987-96"[664], which gives contrary (lower) figures for the number of SWSOs/SSIWs in post each year to those given in para 48.09. The list refers to the following inspections of aspects of children's services in North Wales:

  In addition reports on the new county inspection units were published in 1992, 1994 and 1995. A table of inspections made between 1986 and 1996[667] suggests that there were three in Clwyd of, or related to, the client group "children" but the apparent discrepancy between it and Annex C is not explained.

  48.21  Two further points need to be made about these later inspections. The first is that in the early months of 1994, in response to the Citizens Charter and following similar steps by the Department of Health, SSIW was divided into separate inspection and policy groups and lay people, including users and carers, were introduced into the process of inspection. A Deputy Chief Inspector was made responsible for inspection with four SSIWs as lead managers of inspection work; and thenceforth half of SSIW's time as a whole was to be dedicated to the inspection programme.

  48.22  Secondly, from early in 1987 SSIW began to publish most of its reports. Before that there had been a division of opinion between those who regarded the reports as confidential, so that distribution of them should be limited to those "who needed to know", and others who thought that there should be greater openness, so that a wide range of persons with an interest might be informed and comment.

  48.23  As we have indicated in paragraph 48.03, SWSW/SSIW had the power to inspect (but not otherwise to regulate) private residential establishments where children in care were accommodated under the Acts of 1969 and 1980; and section 80 of the Children Act 1989 rationalised and extended the list of premises that might be inspected, referring expressly to independent schools[668]. In relation to private establishments in Clwyd these powers were exercised almost wholly in relation to the Bryn Alyn Community and in conjunction with HMIs. Between 1975 and 1989 it seems that SWSOs visited the Bryn Alyn Community at approximately three year intervals and that there were at least three other visits in between (not less than nine in all)[669]. There was one visit also to Ystrad Hall School on 26 February 1975[670].

  48.24  In Gwynedd the main focus of attention by SWSW/SSIW was upon Hengwrt Hall (later Aran Hall) School to which nine visits were paid between January 1986 and February 1996[671].

  48.25  We have read a large number of the inspection reports prepared by SWSOs/SSIWs throughout the period under review on local authority and other establishments and on specific aspects of children's services in the second half of the period, and we have been provided with summaries of others. In general, we have been impressed by both the thoroughness and the high standards of these reports. What has emerged from the evidence before us and the reports themselves, however, is that SWSW/SSIW did not at any stage of the period under review provide an effective monitoring or supervisory service for residential care establishments for children in North Wales. Moreover, it was unlikely to play any significant role in the detection or elimination of physical or sexual abuse.

  48.26  There were a number of reasons for this, some of which are quite obvious in the light of what we have already said. In the first place, although there has been some confusion about the number of officers/inspectors in post at any one time, it is clear that the establishment was insufficient to carry out regular inspections of the very many children's establishments requiring monitoring, quite apart from other social service establishments and services for children. Secondly, the small core of officers with Home Office experience of inspections of children's establishments dwindled rapidly. Thirdly, the view taken of the relationship between the Welsh Office and the county social services departments was such that the need for monitoring and inspection was not recognised by the Welsh Office until the second half of the 1980s; and the programme of inspection formulated then was directed, in general, to wider children's services issues than the standard of care in individual homes. Fourthly, awareness by central government and by social services professionals generally of the possibility of serious child abuse occurring in residential care establishments for children was a late development in the period under review.

  48.27  Although there were apparently "numerous internal inquiries into the maltreatment of children in residential homes and schools in the years between 1945 and 1973"[672], and the Home Office register of offenders was established as early as 1952, it was not until the late 1980s that abuse of children being cared for in institutions became the subject of attention as the result of a series of reports of inquiries beginning with Leeways in 1985[673] and Kincora in 1986[674]. In June 1990 the Welsh Office issued a circular[675], to supplement advice and guidance in Working Together 1988[676], asking local authorities to review their policies and procedures relating to cases of actual or suspected abuse of a child within a residential school or other establishment accommodating children.

  48.28  Even within the limited and vague purposes referred to in paragraph 48.05 above, however, there were deficiencies in the inspection system, particularly before the inspectors' reports began to be published in 1987. It was the practice of SWSOs to visit the Director of Social Services after inspecting a children's home to discuss their findings and any remedial action that they proposed to recommend. These were very informal meetings, however, and any follow up by SWSW to the recommendations was, at best, sporadic. Circulation of the reports was very limited and there were no guide lines for informing councillors, chief executives or even the relevant officers within the Social Services Department and the head of home. Thus, the dissemination of information about good practice was very uncertain and wider re-consideration of procedures was unlikely. It must be said also that SWSW/SSIW was rarely, if ever, informed of the results of other investigations commissioned by county social services departments, such as the Dyfed team inquiry into Y Gwyngyll[677], so that the two way exchange of information between central and local government envisaged by Seebohm was seriously flawed[678].

  48.29  In his report "Children in the Public Care"[679], Sir William Utting described two types of inspection: regulatory inspections to check adherence to statute, regulations and guidance; and developmental inspections to provide empirical evidence against which progress in policy and practice can be monitored (the method now largely employed by SSI). He expressed the view that regulatory inspection less frequently than one substantial and one follow-up inspection each year is likely to be only marginally effective. He added:

"Neither form of inspection is in any sense a substitute for the reasonable discharge of all the responsibilities of management. Both can assist management, applied separately or combined, by a dispassionate external scrutiny of the service (and, in the case of developmental work) by assisting in the preparation for future plans drawn up in accordance with national policies and standards. Neither can compensate for deficiencies of management: both provide additional safeguards for people living in residential homes; the best safeguard remains the commitment and competence of the body responsible for and the people running the home."