Friday, 31 October 2014

Open season on Ofsted

It seems like the knives are coming out for Ofsted. 

I read in Children and Young People Now that Alan Wood, President of the Association of Directors of Children’s Services (ADCS), has said that in some cases Ofsted's inspectors lack experience of children's services. Having read a lot of Ofsted reports of inspections of child protection arrangements, I have often wondered about the experience of the author, and now it seems that ADCS is thinking along the same lines.

Wood said that the inspectorate needed to change its recruitment policy to attract people who had substantial recent experience of children’s services.

The other question that occurs to me is what experience and knowledge of management do Ofsted inspectors have? I think the very na├»ve and formulaic tone of some Ofsted reports could only come from people who don’t really understand management issues well. Perhaps ADCS would like to reflect on that as well.

Wood also said that inspections resulted in significant financial costs for the inspected authorities and that they are disruptive. Those are well known negative side effects of inspection, but it’s good to see that ADCS is bringing them to public attention.

Speaking at the same conference, Ofsted’s head of social care inspection, Debbie Jones, defended her organisation. Children and Young People Now reports that she called for a debate about how together Ofsted and local authorities could build together a system that could ‘help families’ and that is responsive to the current difficult financial situation.

I’m sorry Debbie, but I can’t think why anybody would want to come to Ofsted for ideas about how to build better organisations, when the most common sort of recommendation found in Ofsted reports is of the this-is-wrong-put-it-right variety.

Take some of the big issues such as recruitment and retention: I’ve never heard Ofsted suggest how that could be done better. Or what about cost control? You never see any analysis of costs or spending in Ofsted reports. Nor have I ever seen anything about waste reduction, value-adding, continuous improvement, lean synchronisation,  organisational learning, team building, job design, motivation … I could go on and on!

Perhaps she is talking about more ‘robust’ management?

Who regulates the regulator?

I see that the Local Government Association (LGA) is calling for an urgent review of Ofsted.

The association’s main concern appears to be with school inspections. It says: “… public confidence in Ofsted has been undermined by the inspectorate’s habit of re-inspecting schools when they hit the headlines, only to downgrade them from ‘good' or ‘outstanding' to ‘inadequate'…. Councils believe this raises questions as to the validity of the inspectorate's judgments, as it is quick to re-inspect – and often downgrade – schools which are embroiled in a scandal, even if it is an historic report.”

Exactly the same thing appears to occur with Ofsted’s inspections of child protection arrangements. It was only this week that the BBC TV documentary, Baby P: the Untold Story, revealed further unanswered questions about the Ofsted reports conducted just before and just after the Baby Peter scandal broke; and why they were so radically different in their conclusions. The documentary revealed that files associated with these inspections had been mysteriously deleted and quoted an anonymous Ofsted inspector as saying it was a cover-up.

The idea that an inspection report could be prepared by moving from conclusion to analysis to evidence, instead of the other way round, is deeply disturbing, but there now seems to be more than just a prima facie case for Ofsted to answer. It is not clear who regulates the regulator, but I believe that some independent audit of Ofsted practice is urgently required.

Child Protection Social Work – the Skills Crisis

The Local Government Association (LGA) in England is calling for an urgent review of the social work skills crisis. The LGA argues that acute problems have resulted following the 'Baby Peter' scandal. Research undertaken by the organisation has found that social workers say they have been "run through the mill" and criticised unduly. This is causing many to consider leaving the profession.

Cllr David Simmonds, Chairman of the LGA's Children and Young People Board, is reported as saying:

 "With tens of millions of pounds currently spent on grants for social work trainees with no assurance that they will find their way into any of the many vacancies around the country, we need to get smarter and ensure that these resources are available to councils who can act more flexibly to respond to local need.

"In many areas career development for existing social workers and recruiting experienced managers are higher priorities than getting more people through social work courses. With 60 per cent of children's services departments reporting rising recruitment challenges and a 50 per cent rise in the number of referrals to children's social services, we need to use all available resources in the most effective manner so that we have a workforce fit for the challenges our society faces in keeping children safe and giving them a fresh start when things go wrong at home."

I agree with a lot of that. My long held view is that there is no point in subsidising qualifying training and designing schemes to fast-track new recruits, if they are not going to stay in the job, not just for a couple of years but for most of their careers.

High and ever rising caseloads, high levels of bureaucracy, poor administrative support, aggression and violence from members of the public, low professional esteem, the prevalent blame culture and the way in which they are treated by some sections of the press, has proved too much for many experienced social workers who have moved on. These are exactly the people who should be retained, because what is required at the front-line is experience.

Work needs to be done on how to design jobs and working conditions to minimise the negative aspects of the job. An easy target would be using new technology and smart thinking to reduce the administrative burden. But instead the last twenty years has seen a decline in traditional administrative support combined with the introduction of IT systems which seem to have been designed to frustrate and stress their users, not to mention making simple tasks difficult. And a plethora of initiatives, largely from central government (but with local elaborations), has resulted in various kinds of frameworks and systems being imposed which just make the work even harder, with no proven benefits.

The only sure way to redesign jobs to improve job satisfaction is to work closely with the people who are actually doing the work. Find out what their needs are. Find out what they find difficult. Find out what frustrates and stresses them. Then work with them to remove the worst features and to introduce new and better ways of working.

Up, up, up – England’s child protection statistics, October 2014

They have improved the presentation of the Characteristics of children in need in England statistics. They now have helpful graphs that show the trends. They are nearly all upward trends.

The highlights of increases from the previous year are:

The number of referrals to children’s social care in 2013-14 – an increase of 11%

The number of children in need (of whom 47% of whom are identified as abused or neglected) – an increase of 5%

The number of section 47 enquiries (into alleged abuse or neglect) carried out - an increase of 12%

The number of children who were the subject of a child protection plan at 31 March 2014 - an increase of 12% (this figure has increased 23.5% since 31 March 2010)

The graphs show that generally these increases are part of a sustained year on year upward trend in all child protection work since 2010. But the statistics DO NOT show anything at all about trends in resourcing.

In terms of the impact on the work of children’s social workers – of whom there is a national shortage – the figures  translate more or less directly into more than a 10% annual increase in work. If anybody knows how that sort of swingeing increase is being absorbed I’d be very interested to know -

Thursday, 30 October 2014

Baby P: the Untold Story BBC 1 TV Monday 27th October 2014.

Patrick Butler’s review of the BBC TV programme Baby P: the Untold Story is a must read, especially if you didn’t see the programme.

The documentary clearly established a number of important conclusions.

Firstly the failures that resulted in Peter Connelly’s death were widespread across agencies and professions. There were no examples of individual professionals committing gross errors or negligence. On the contrary the combination of lots of small failings together added up to cause the tragedy.

Secondly there were important structural problems. There were high workloads in Haringey Children’s Services and more or less a meltdown of paediatric assessment services at the St. Ann’s children’s hospital, with two out of four consultant posts unfilled.

Thirdly the culture of blame was pervasive. The unedifying scramble to finger scapegoats when the story broke in 2008 is perhaps the most sickening example of this, but the programme left no doubt that there were long established problems, such as the way in which staff who tried to signal concerns about safety at St Ann’s were dealt with. The author of the Serious Case Review report observed that agencies were defensive and were trying to point the finger of blame at others. She felt people were scared about their jobs.

The programme revealed the extent of the truly shocking behaviour of some members of the public who threatened and intimidated individuals involved in the case. It is hard to imagine that conduct of this sort could have occurred in a civilised society. The role of the tabloid press, especially the Sun, in stoking up an irrational and emotive public mood was clearly outlined. The craven response of some politicians to the public clamour was utterly dispiriting.

Then there was the issue of cover-up. Important information about the struggling services at St. Ann’s hospital appears to have been withheld from the Serious Case Review. There is no point at all in having a SCR if crucial information is withheld. The resulting report becomes part of the problem, not part of the solution.

The programme also explored the issue of why the Ofsted report, that was prepared after the scandal broke, differed so radically from the one that was prepared just before. This remains a bewildering puzzle that may never be resolved, not least because crucial Ofsted files appear to have been deleted. The programme quoted as anonymous Ofsted inspector as saying that they didn't know who had made the decision to delete the files, and that it was a cover-up. The inspector pointed out that removing that information resulted in removing accountability. I find it hard not to lapse into talking of ‘Ofstedgate’ at this point, because the whiff of obfuscation and conspiracy hangs heavily over the whole affair. And Ofsted’s senior management remains strangely silent on the issue, suggesting that it has little to say.

An interview with Edi Carmi, the author of the first Serious Case Review overview report, revealed two things that were very interesting to me. Firstly she described the way in which thinking about Peter’s bruising moved slowly from ‘non-accidental injury’ to ‘bruising as a consequence of neglect’ to the possibility of the child harming himself as a result of over-activity. There could be no clearer example of what Prof. Eileen Munro has called a ‘garden path error’. I like to use Prof. Charles Handy’s parable of the boiled frog in this context. In his 1989 book The Age of Unreason Handy tells us that if a frog is put in water that is slowly heated, the frog will eventually let itself be boiled to death. He uses this as an illustration of what happens to businesses that don’t respond to the way in which the world is changing around them. I think it is also a very good metaphor for what happens when professionals become too close to a family in which abuse and neglect is occurring. Cumulative small changes pass unnoticed so that thresholds are never crossed.

The other thing that Edi said, which seemed to me to be spot on, was her description of lots and lots of small mistakes made by every agency involved in Peter’s care. There wasn’t one big mistake, she said, but that it was just that lots of little mistakes happened at the same time. There could be no clearer example of Prof. Jim Reason’s Swiss Cheese model of organisational error – see Lots of small weaknesses in process and organisational design and working practices (holes in the cheese) line-up and allow the trajectory of the fatal error to pass unimpeded. That implies the need for a human factors approach to improving safety in child protection. Professionals with high workloads working in difficult conditions and dealing with complex problems need to be equipped with techniques to recognise, analyse and reduce or mitigate the errors they will inevitably make. That, to me, is the abiding message of the Baby Peter tragedy.

Sunday, 26 October 2014

Calling the Chief Social Worker

I was never impressed by the idea of a “chief social worker”. I’m sure such a person could speak to meetings and brief journalists, but to be honest I can’t see what else they are supposed to do. Perhaps somebody knows.

One thing I would expect the chief social worker to be interested in is innovation - new ideas, new approaches, new ways of working.

I searched the Internet for the contact details of the Chief Social Worker for Children, Isabelle Trowler. I found lots about her role and her experience but nothing about how to contact her. 

Isabelle – I think I have an idea (as Michael Caine said at the end of the Italian Job ). How can I tell you about it? You have no email address, no form to fill in, no point of contact.

Speak to me!! Better still, listen to me. Maybe you’ll read this – probably not but it’s worth a try?

My idea is quite simple. Child protection social workers should seek to understand and adopt approaches developed in other safety critical industries, like aviation, anaesthesia and surgery. Human Factors training (HF) emerged in civil aviation during the late 1970s and 1980s but did not gain widespread acceptance until the 1990s. It has now become mandatory for all US and European airlines. In recent years HF thinking has been found to be transferable to medical contexts such as surgery and anaesthesia. It has been found that it can also be used very successfully with child protection professionals. A short basic course of one or two days duration equips someone with sufficient knowledge to begin to practice HF thinking at work, using it to help reduce and mitigate workplace error.  Knowledge of human-factors complements important child-protection skills and helps professionals to filter complex information and identify patterns that indicate harm or risk. This sceptical, professionally curious approach is what saves lives and reduces the risk of future harm.  

Come on Isabelle. I could tell you more, a lot more. But I do need to know how to contact you. My email address is What’s yours?

Friday, 24 October 2014

Rebranding the NSPCC?

It is interesting to read that the NSPCC has just spent £150,000 on ‘rebranding’.

I suppose that in the world of rebranding  £150,000 is not a lot of money.

I can’t help feeling that I would have preferred to read that the NSPCC had just spent an extra £150,000 directly on services to abused and neglected children.