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 naïve 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.

Thursday, 23 October 2014

Poor practice. Don’t blame and shame; support and retrain.

Community Care reports that the Health and Care Professions Council (HCPC) has suspended a children’s social worker for failing to keep clear and accurate records.

I agree with Unison’s representative, who is quoted in the article as expressing reservations about employers referring this type of case to a public disciplinary panel.

Indeed I would go further and say that the HCPC should confine its deliberations to intentional wrongdoing, not under-performance. I think employers need to look at retraining and supporting people who have difficulties meeting expectations, not setting out to show them a hard time.

Some people might accuse me of being soft; of too easily tolerating poor practice. But my argument stems not from undue sympathy for the social worker, but from concern that this is precisely the wrong way to deal with poor practice.

You only need to ask yourself what the effect of the tribunal’s judgement will be on the small minority of social workers who are out there struggling at the margins of competence. Are they going to rush off to their managers and confess that there are files lurking in the back of filing cabinets that have some serious omissions? You can bet your bottom dollar they won’t because they will have read what happens to people who get found out – sacked, suspended, possibly ruined. They will keep quiet and hope they are not discovered.

I would like everybody who has some doubts about their own competence to readily ask their managers for help. Particularly with an issue like recording, the sooner the problem gets tackled the easier it is to deal with. It is far better to take action early, before the backlog becomes irremediable.

This case sends out all the wrong messages. Putting fear into the workplace doesn’t result in good practice. It is much more likely to result in people hiding bad practice, which is the worst of all possible worlds.

Tuesday, 21 October 2014

Child protection staff shortages in Birmingham

The Birmingham Mail reports that Birmingham Children’s Services has more than 150 vacancies and now has to pay premium rates to attract agency social workers.

It’s not surprising the Birmingham is having trouble. Not only is there a national shortage of suitably qualified and experienced people, but the very public bashing that the authority has taken from Ofsted and the Government is hardly the kind of advertising campaign that will result in skilled people hammering on the door.

The general approach to children’s services departments that are in difficulties is one of blame and shame. Inspectors, civil servants, politicians and the media wag their fingers and waive their big sticks. The unrealistic expectation is that the local people who are trying to run the service will be suitably chastened and will pull themselves up by their own bootstraps.

The reality is, of course, very different. Few people are motivated by a damning Ofsted report. Few people are encouraged by being told that they work for a failing authority. Few people want to shoulder unmanageable burdens or put themselves at risk of being blamed further. Inevitably some will want to move on.

And so a downward spiral begins as vacancies and workloads shoot up, and morale plummets.

I think that we should treat children’s services departments that get into trouble more like sick patients and less like wrongdoers. At the first sign of trouble someone should be getting drips into veins, making sure that there is a good flow of oxygen and standing by with life saving drugs. Fulminating and jumping up and down with indignation might make some people feel good, but it does nothing to improve services or to ensure that children are safe.

Saturday, 18 October 2014

A fair day's pay ... ?

I have to wonder what anybody could do to justify a annual salary of more than £340,000. But that is what Somerset County Council is reported to have been paying its Director of Children’s Services.

I say ‘have been’ because apparently they are letting him go.

I had a look at vacancies for some other jobs in Somerset. They offer a newly qualified social worker £27,323, a social worker who has completed one year’s employment since qualification £31,160 and an experienced social worker £34,894.

Somerset County Council are quoted as saying that it has been decided to let the Director go because "faster improvement” has not come about. Sounds like the council, which is rated as ‘inadequate’ by Ofsted and subject to an ‘improvement notice’
was putting a lot of eggs in the dynamic-leader-super-hero-turnaround-wiz-kid basket.

I read with interest that the post of Director of Children’s Services in Somerset will now be covered by the Chief Executive “for the time being”. I find that puzzling. If it is the sort of job that can only be done by someone who is paid £340,000 per annum (which is more than £1000 per day), how can it be ‘covered’ by someone who has another full-time, and presumably very demanding, job?

Maybe they should just have a permanent vacancy and use the whole salary package to employ 10 more experienced social workers! I bet that would have more positive impact on children’s lives.

Fears of a deliberate cover-up in Rotherham?

BBC News quotes the Chairman of the House of Commons Home Affairs Select Committee, Keith Vaz MP, as saying that revelations about files that can no longer be found gives rise to public suspicion of a deliberate cover-up of the child sex abuse scandal in Rotherham.

A Home Office funded researcher, based in Rotherham between 2000 and 2002 and who suspected that there were serious failings in responding to child sexual exploitation in the town, has given evidence to the Committee saying that someone had entered her office (apparently using a security code) and removed her files.

It is chilling to think that something like that may have happened. Nothing could be more damaging to the safe operation of services than deliberately obfuscating serious failings. Hiding weaknesses increases the probability of more things going wrong at a later date.

If there has been a cover-up, it is not just the safety of children in the past that has been compromised, but the safety of children and young people now and in the future.

Someone needs to get to the bottom of this quickly.

Friday, 17 October 2014

You couldn’t make it up…

If it were a novel about a large city struggling to deliver children’s services, people would say that it lacked credibility. But it has actually happened; Birmingham’s new director has quit .... before she’s even started.

That’s the kind of thing that seems to haunt organisations that are down on their luck. One bad event seems to lead to another: a vicious downward spiral, perhaps.

Part of the problem is that ‘leaders’ are probably looking outside the organisation for a quick fix; searching possibly for a magic bullet of a director, a turnaround wiz kid, an expert in ‘repositioning’ and ‘transformation’, 're-engineering' perhaps. The clichés could go on and on.

The truth is that changing a few posh bums on a few posh seats is unlikely to do more than make money for the people who paint signs on doors. I bet there are plenty of people who already work for Birmingham who could tell us a lot about what is wrong – if they were allowed to do so. I bet they could put a lot right, if they were allowed to.

But they won’t be allowed to, because their leaders see them as part of the problem, not part of the solution. I expect they know that and so they will be keeping their heads down, mired in learned helplessness waiting for something to happen…

In the meantime the well-paid occupants of the big plush offices come and go.

Thursday, 16 October 2014

‘Baby P: The Untold Story’ - a forthcoming TV documentary

There’s a new documentary about the death of Baby Peter Connelly, which promises to be very interesting. I understand that it will focus on the way in which individual practitioners were blamed for Peter’s death while powerful organisations and institutions escaped proper scrutiny.

If you can receive BBC1 TV then tune in at 8.30pm on Monday 27th October. The programme is called ‘Baby P: The Untold Story’. I’ll certainly be watching it and commenting subsequently in this blog.  

Tuesday, 14 October 2014

Birmingham – are the responses ‘inadequate’ as well?

Birmingham Children’s Services, and other agencies engaged in child protection and safeguarding across Britain’s second city, are much troubled. Inadequate, inadequate, inadequate is the verdict of Ofsted and others who have tried to evaluate services. It’s a sad tale.

But after all that has been written and said, I’m still not clear why multiple failures have occurred in Birmingham and not elsewhere. To my mind all the reports do is list things that have gone wrong. They do not analyse why things have gone wrong and look at the underlying causes.

The latest report is from the Birmingham Safeguarding Children Board, the co-ordinating body that has itself been rated as ‘inadequate’ by Ofsted.

The Board’s independent chair is reported in the Birmingham Mail as ‘listing’ (yes more listing) a variety of things that are wrong, and the Lead Member for Children’s Services (an elected local councillor) is quoted as saying that the report details issues that “… we are already aware of” and that “… we now know quite clearly what needs to be done”

To my mind this sort of mechanical approach to improvement – ‘x is wrong, don’t do x in future’ – is a denial. Obviously it can be painful, and it is certainly hard work, for people to look at the underlying causes, but unless that is done the problems will just re-emerge in another form on another day.

Saturday, 11 October 2014

Ofsted IS part of the problem?

Over the years I’ve been writing this blog I have never minced my words – often harsh ones - about Ofsted. Now it turns out I’m not the only one! Advisers at the Department for Education are apparently hanging their heads in despair about the organisation, as a leaked memo makes clear.

I can’t comment on how accurate Ofsted’s school inspections are. All I know is that it is hard not to have too low a view of most of Ofsted’s inspections of child protection and children’s services. And I was particularly struck by Dominic Cummings’ comment in his memo that Ofsted has “… missed massive child abuse scandals under their noses, which they are very lucky not to have been hammered for”.

But my main preoccupation is Ofsted’s inspection reports and what they reveal about the organisation and the inspections it conducts. The reports are frequently formulaic and naïve. Many of the recommendations they make are unrealistic. The reports invariably lack an analytic approach. On too many occasions they blame but do not explain. They frequently judge but do not identify routes to improvement.

And I would love to know what Ofsted’s methodology is based on. When I wrote to them asking some straightforward questions I was shocked to find out that there doesn’t seem to be much methodology – rather just a bit of arbitrary accepted practice.

There is no evidence at all that the whole expensive Ofsted shebang has had any positive effect in improving standards in children’s services or in making children and young people any safer.

Sunday, 5 October 2014

Child Sexual Exploitation - enforce the law, don't change it

In the wake of the child abuse scandal in Rotherham, the police in Scotland - or some of them - are calling for the threshold of evidence used to impose court orders on people who are suspected of committing sexual offences against children, but who have not been convicted of any crime, to be lowered

Surely the problem in Rotherham was that there was lots of evidence against lots of people that manifestly exceeded the threshold for criminal proceedings, but which was not acted on.

I do wish that agencies would not seize the opportunity, in the wake of scandals like Rotherham, to call for the introduction of all kinds of new laws, which are only too likely to result in injustice, when what is required is the consistent and sustained application of laws that already exist.

More on Mandatory Reporting - are the Lib Dems about to wade in?

I am sorry to see that the Liberal Democrats are rumoured to be about to support mandatory reporting of child abuse and neglect in England.

Although worrying, I am not so much apprehensive about the impact on the number of cases reported, if the law is changed. That is said to be the primary concern of the NSPCC and the Lucy Faithful Foundation, organisations that should be listened to.

I am more concerned about the impact on practitioners when, as seems inevitable, someone is convicted of failing to report. There is a real danger that people who make honest mistakes will end up in court. And that will stoke up the fires of the blame culture still further, resulting in fewer and fewer people being prepared to talk openly about what happens when things go wrong.

That’s a recipe for making services less safe.