Some of the most interesting comments in the Ofsted report on children’s services in Gloucestershire are to be found in the section on leadership, management and governance, an area in which the inspectorate found the authority ‘inadequate’.
The first worrying statement in this section of the report is:
“Inspectors discovered significant discrepancies in some information provided to them by the senior leadership team, bringing into question the integrity of the leadership of children’s services.” (p. 29)
This is an extraordinary statement, which in the absence of further clarification, suggests that inspectors were deliberately misled. A natural first reaction to reading it might be to jump up and down with moral outrage and blame those who may have done any misleading.
But my reaction, while not condoning egregious behaviour, is to ask if the current inspection regime generally predisposes towards lack of candour. The stakes in Ofsted inspections are very high. For those at the top of a local authority, a good Ofsted can result in personal approbation and career success. A poor Ofsted is equally likely to end promising careers or, at the very least, to tarnish indelibly professional histories. It is difficult to be open and honest if the personal consequences of doing so are likely to be disastrous. An inspection regime which makes people afraid to tell the truth will always be one which encourages some level of dishonesty.
Fear, and the evasion and dissembling that go with it, are the inevitable consequences of having inspections which judge rather than enlighten and inform and support. There are alternatives to the ‘take-names-and-kick-arse’ philosophy currently adopted by Ofsted. One approach would be to help local authorities develop better systems of quality management. Another would be to provide analysis of the genesis of problems like staff shortages and high turnover and provide helpful suggestions about how to rectify them or mitigate their impact. A third would be to act as a catalyst for continuous improvement and greater understanding of the needs of children and young people.
The next worrying statement from the report is:
“Senior managers do not provide an environment in which healthy challenge is evident and social work practice is allowed to flourish, and a high number of staff reported that they feel vulnerable, unsupported by senior managers and fearful of challenging or exposing poor practice.” (p.29)
I’m sure the inspector is right to disparage a management culture in which staff feel afraid to speak out about things that they think are wrong, but I baulked at the concluding words of this paragraph – “… challenging or exposing poor practice”. Those words leave me with an uncomfortable image of encouraging practitioners to speak out about their perceptions of their colleagues’ failings; an image of an organisation in which everybody is challenging, confronting and criticising everybody else.
It suggests to me that the inspector has what I believe is a wrong-headed view about how to improve services for children and young people and make them safer. It is what Professor James Reason calls “the person approach” which he says focuses on the errors and failings of individuals, blaming them for “forgetfulness, inattention, or moral weakness”. He goes on to observe that “… (b)laming individuals is emotionally more satisfying than targeting institutions” but he concludes that it “… has serious shortcomings” because “…(e)ffective risk management depends crucially on establishing a reporting culture”. 
In contrast Reason believes that what he calls “the system approach” is the correct path to organisational safety. That focuses on the systems and conditions under which individuals work and attempts to construct defences which prevent errors or mitigate their impact. The system approach is about openness and transparency, but it is not about blame. It recognises that we all make mistakes and that we all perform below expectations from time to time. However, the vast majority of mistakes and failings occur not because somebody has acted egregiously. Most mistakes and failings are committed by people acting in good faith.
The key to better services – greater safety, greater quality –is to focus not on blame and accountability, but on learning and improvement. If people feel free to report and discuss errors and service failings without fear of reproach or sanction, they are also free to analyse the things that go wrong and to understand their causes. They are free to put things right. That is the route to constructing better defences and more resilient systems and processes. It is the route to safer organisations delivering higher quality services.
A third worrying remark caught my eye. The inspector writes:
“Instability in the workforce is having a significant impact on the quality of practice. The turnover of social workers and managers is high. The majority of social workers have less than two years’ post-qualifying experience and, for too many, the caseloads are too high and include complex cases that require a good depth of knowledge and experience.” (p. 29)
To be sure, the inspector is right to draw our attention to this fact. But it is baldly stated and there is no analysis. How has this situation arisen, what are its causes and what can be done to reverse the trend? I suspect, although I do not know, that there has been high turnover, not least because “…a high number of staff reported that they feel vulnerable, unsupported by senior managers”. But again, that raises the question why? How has a such an unconducive working environment arisen and what needs to be done to change the culture? I don’t know, I suspect the inspector doesn’t know and I doubt that those charged with putting right the mess will be very open about what they believe. Just holding folk accountable for creating a bad culture, without trying to understand why it happened, is not going to put things right.
Once again, it seems to me, an Ofsted report is part of a cycle of fear and recrimination. It’s almost as if somebody had said: “We are going to punish all those responsible for sustaining the blame culture”. That’s what philosophers like Bertrand Russell  used to call a ‘semantic paradox’. Paradoxes may be interesting to logicians, but they aren’t a very good basis for building better organisations.
Just blaming the blamers will get us nowhere.
 Reason J. “Human error: models and management” British Medical Journal 2000; 320:768–70
 Russell, B. The Problems of Philosophy (London : Oxford University Press, 1912).