21. External inspection and oversight provide a means for central government to be assured of the quality of services in local authority areas, including commissioned provision from the voluntary and private sectors. As identified by the Barratt final report, external monitoring could “never be a substitute for effective internal monitoring” – it should have acted to “supplement, confirm or deny criticisms being formed within the Council, and to provoke Councillors to inquire for themselves”.[1]
22. From its establishment in April 1985 until its replacement in 2004, the SSI, as part of the Department of Health, had the role of inspecting, monitoring and advising local authorities with social care responsibilities.[2] In addition to evaluating services, the SSI also had power to place a local authority in ‘special measures’, requiring it to set out an action plan to address identified problem areas, prior to re-inspection. This power was not used in relation to Lambeth Council until 1999.[3]
23. During its existence as the inspection body of local authority social services, the SSI undertook eight relevant inspections of Lambeth Council’s social care. In 1991, it reviewed Lambeth Council’s progress in implementing recommendations of both the 1987 Tyra Henry public inquiry report and the 1989 Doreen Aston inquiry report and, more generally, to examine the management of child protection services in Lambeth Council.[4] Its report stated that while “all recommendations had been reviewed and actioned … some issues had received insufficient follow-up”.[5] Its detailed examination of written files for children in the care of Lambeth Council revealed a more alarming picture:
“work appeared to be fraught with delay in investigating, conferencing and programming … Conferences sometimes failed to distinguish individual children’s needs or consider the risks in respect of all children … Current procedures could be improved by better coverage of in-care abuse investigation”.[6]
As a result, the SSI’s recommendations included annual consideration of child protection training priorities and improved management of records and information about children.
24. These would be recurrent themes. Indeed, they had already been identified but not adequately addressed. In 1988, in a report to the Children’s Home Sub-Committee, Robert Morton (principal manager of children’s homes) highlighted staff training, poor record-keeping and failure to plan for children as issues of real concern.[7]
25. Ostensibly, the recommendations of the SSI 1991 report were considered. In June 1992, the Social Services Committee was shown a table listing the recommendations and a management action plan with progress to date.[8] However, as Ms Annie Hudson, strategic director of children’s services, accepted:
“A distinction must be drawn between changes in policy and changes in practice. Although the Council took action in response to the recommendations, Lambeth has not been able to locate any material that demonstrates whether or not that action had a consequential impact on practice.”[9]
26. Subsequent critical reports were to demonstrate that any impact on practice, or improvement for children in Lambeth Council’s care, was negligible or non-existent. An SSI report in 1992 identified Lambeth Council as having one of the highest numbers of looked after children without an allocated social worker (known as ‘unallocated cases’) in the London region.[10] It stated of Lambeth Council (and others with high levels of unallocated cases), “this represents a serious long term failure to fulfil statutory responsibilities towards children requiring protection”.[11]
27. The pattern of a critical report, a detailed list of recommendations and an action plan in response from Lambeth Council became a familiar one. The similarity of the recommendations across the totality of the SSI reports, and the persistent failure of Lambeth Council to effect change, is evident. Lambeth Council did little more than perpetuate a cycle of action plans that nominally responded to recommendations whilst consistently ignoring the fact that children continued to suffer neglect and abuse in a system that was failing on every level. Reports that should have caused serious concern amongst the management of social care in Lambeth and provoked real change appear instead to have been accepted as routine.
28. There were, however, some individuals who were sufficiently concerned at the situation that they highlighted concerns at the most senior levels. The concerns of Councillor Whelan about the quality of Lambeth Council’s children’s services led her to write to Mrs (now Baroness) Virginia Bottomley MP (Minister of State for Health from October 1989 to April 1992, and Secretary of State for Health from April 1992 to July 1995) in January 1991, and subsequently to meet with her.[12] Councillor Whelan’s letter stated:
“Since my election to Lambeth Borough Council in May 1990 I have become more and more concerned about the quality of Lambeth’s children’s services.”[13]
29. She enclosed with her letter the 1990 report of Mr Morton, in which he stated:
“The problems are so wide ranging and numerous … To put right, what I personally consider to be an unacceptable state of affairs, is going to take not only considerable management time but a clear commitment by the department and council in not tolerating certain situations.”[14]
30. Baroness Bottomley told us that having received the letter and after meeting Councillor Whelan:
“Lambeth was well and truly flagged, from my point of view, as having a children’s Social Services that needed attention, and I was in dialogue with the SSI as to what the next step might be.”[15]
31. Councillor Whelan wrote again to Virginia Bottomley MP in October 1992, referring to “paedophile activity in Lambeth children’s homes”.[16] Tim Yeo MP (the Under Secretary of State for Health from April 1992 to May 1993) responded, stating that there would be both an independent inquiry into the employment of Carroll (which would become the Clough report) and an inspection of Lambeth Council’s residential child care services by the SSI.
“The SSI inspection will look at the overall management of Lambeth’s residential child care service and also the quality of service provided at individual children’s homes.”[17]
32. This coincided with Councillor Tapsell writing to Mr David Lambert at the SSI in September 1992, stating:
“In allowing John Carroll to continue working at Angell Road the department put him in a terribly vulnerable position. I happen to believe that they also put children at unnecessary risk.”[18]
33. A meeting was called in October 1992 between the SSI and Mr Pope (then director of social services) to address Councillor Tapsell’s concerns about Carroll at Angell Road (see Part D), the allegations of sexual abuse perpetrated by staff at South Vale over the previous five years (see Part C) and Councillor Whelan’s efforts to secure a Department of Health enquiry into the management of residential child care. The note of the meeting stated:
“DSS [Mr Pope] said he did not question Councillor Tapsell’s motives in seeking an enquiry but they did not agree on what form this should take. DSS’s view was that the only solid evidence against Carroll was of dishonesty and that did not justify an investigation into possible sexual abuse under local procedures … Eventually a compromise had been struck that the Department under cover of a research project into the experience of Lambeth children in care would issue a questionnaire about their time in care on the pretext of developing the Complaints Procedure. This work was to be undertaken by the PO Child Protection and a senior Admin Manager. About 3 dozen children had been identified and had been traced. However plans to undertake the work had been superseded by the Gibelli and South Vale investigations.”[19]
This exemplifies how senior staff dealt with external scrutiny. In the face of proper concern that children may have been at risk at Angell Road, the preparation of a questionnaire appears to have been no more than an effort to appease the Department of Health. It did not for a moment constitute a serious attempt to ascertain whether children had been abused. Neither does it appear that the SSI followed up on this issue or sought to ascertain whether complaints were received from children in the care of Lambeth Council.
34. In February 1993, Tim Yeo MP commissioned an independent inquiry about the employment of Carroll.[20]
“Following discussions with the SSI, I had agreed to ask Lambeth to arrange an independent person to carry out the review of Michael Carroll’s employment. Lambeth appointed Richard Clough to do that.”[21]
The terms of reference, set by the SSI, did not include investigation of the risk of sexual abuse that arose during Carroll’s management of the home.
35. In March 1993, Tim Yeo MP requested that the SSI conduct an inspection of children’s homes to consider the quality of care offered by Lambeth Council.[22] Initially referred to as an inspection to “look at the overall management of Lambeth’s residential child care service and also the quality of service provided at individual children’s homes”, it was limited to an inspection of just three children’s homes. In his evidence to us, Mr Yeo was unable to recall if he was involved in the decision to limit the scope of the SSI’s investigation to three children’s homes – Stockwell Park Road, Lorn Road and Angell Road – or the reason for that decision. Given the extent and nature of concerns, it is unclear why such a narrow approach was taken. Mr Yeo said that he had a close working relationship with the SSI and most important decisions were a matter of joint discussion.[23] In such circumstances, it seems likely that the decision would have been a matter of discussion and agreement between the minister and the SSI.
36. It is evident – to reiterate the words of Baroness Bottomley – that by this stage, within the SSI and at ministerial level, “Lambeth was well and truly flagged”[24] as a local authority where there were concerns of the utmost severity about both the risk of sexual abuse and deplorable standards of basic care for children within the Council’s care.
37. The SSI 1993 report about the Stockwell Park Road, Lorn Road and Angell Road children’s homes highlighted significant concerns, including a lack of clear management plans for the development of good practice in homes, a lack of staff training and an uncertainty surrounding plans for the children’s futures.[25] It also identified staff vetting as a specific area of concern.[26] The report recorded that “Senior managers in the department will need to begin remedial action at once to improve the quality of standard of residential child care”. It noted that “Lambeth have made some progress in improving the situation, but there is much to be done”.[27]
38. The detail of the report provided a sense of the state of the children’s homes and the neglect of those within them:
“The exterior to the front houses rubbish containers and was smelly and not clean. The rear garden contained a boarded-up wendy house and a large pile of broken, disused furniture and junk. It contained items of discarded, dirty clothing, waste paper, broken toys and a slide that had been waiting for erection for over two years.
The standard of decoration, furnishings and equipment for the young people resident at the unit was seriously inadequate. The building was characterised by dirty, broken and inappropriate furniture and equipment and clothing scattered throughout the building and its grounds.
Fridges, work surfaces, sinks and microwaves were dirty, and in one home, breakfast cereal four months past the stamped sell-by date was put out for children’s breakfast.”[28]
39. A management action plan (in response to both the Clough and the SSI report) was presented to the Social Services Committee by the director of social services, Mr Pope. The plan was said to be “a single clear coherent framework for monitoring the Council’s progress in implementing all the various items on which the Council has given commitments”, progress against which would be reported to the Social Services Committee.[29] Mr Pope provided the Committee with five updates to the action plan during 1993 and 1994.[30] However, the SSI 1994 report raised a number of issues, including that basic information about children was missing from their files, written care plans were not on file or known to staff and training on child protection had begun but progress was uneven.[31] It stated that:
“despite the activity proposed and described by senior managers in their reports, the impact upon practice fell short of their expectations and of the requirement of regulations.”[32]
It concluded that “the improvements were limited and patchy and some worrying essentials of practice (care plans and supervision) were still not adequate”.[33] It should have been apparent then, if not before, that Lambeth Council was incapable of change of its own accord.
40. Lord Laming, Chief Inspector of the SSI from 1991 to 1998, told the Inquiry that, for the SSI, “it was an unremitting slog to try and bring about change”.[34] He said:
“SSI could recommend, they could even humiliate, if that’s not too strong a word. But at the end of the day, they weren’t responsible for managing the services.”[35]
41. In 1993, a report was also published into the death of Mia Gibelli, who was killed by her mother when she was seven weeks old. Staff had known that her mother had previously injured a sibling by throwing the child from a third-storey window. The report into Mia’s death made a number of criticisms about Lambeth Council’s children’s social care. This prompted Tim Yeo MP to make a public statement that:
“Lambeth have been once again guilty of the grossest degree of incompetence, but it is, I’m afraid, part and parcel of their record generally in relation to childcare.”[36]
42. Mr Yeo left his position as Parliamentary Under-Secretary of State for the Department of Health in May 1993, prior to the Clough report and the SSI 1994 report. His evidence to the Inquiry was that he did not consider that the SSI 1993 report concerning the three Lambeth Council homes warranted ministerial action.[37] Baroness Bottomley, who remained as Secretary of State for Health from April 1992 to July 1995, told us that:
“I think the reports [of the SSI] were pretty clearly worded and hard hitting. So I don’t think at that time, I would have done anything other … It’s just the persistent refusal to learn the lessons which with hindsight, is so unforgivable … for them to fail to act, looking back on it, is extremely serious, but … at that time, they didn’t – they weren’t sufficient of an outlier. Worrying, serious, ominous, but not sufficiently at that moment to take further steps.”[38]
43. Baroness Bottomley’s evidence accorded with the view of Lord Laming, that Lambeth “wasn’t a particular outlier”.[39]
44. In 1997, the SSI inspected Lambeth Council as part of a programme of national inspections, and evaluated planning and decision-making for children looked after by the Council. It noted that there had been a:
“fundamental and sustained change over the last 3 years. There had been an almost complete change in the Social Services Department’s (SSD) senior management team during that period.”[40]
45. Ms Cleary was an SSI Inspector from 1990 to 1998 and Assistant Chief Inspector for the London region between 1998 to 2002. She told us that the role “was to manage business relating to Social Services across the whole of London, and there were 33 London boroughs”.[41] By comparison with other London local authorities, she said that Lambeth Council was “regarded at the time as the worst”.[42] Ms Cleary told the Inquiry that:
“the special monitoring of authorities came in, I think it was in 1999, but before that, particularly in relation to Lambeth, we were already intensifying our monitoring of their performance”;[43] and
“after 1998 there was more concerted effort to try and address the … endemic issues.”[44]
Dame Heather Rabbatts was viewed as giving a “high level of co-operation” to the SSI.
46. Subsequent critical reports by the SSI suggest that any improvements by Lambeth Council were superficial, temporary or limited in scope.
47. Operation Care, the Merseyside Police investigation into Carroll, commenced in 1998. This in turn prompted the setting up of Operation Middleton and the Children’s Homes in Lambeth Enquiry (CHILE). Mr Barratt was separately appointed to examine Lambeth Council’s response to allegations that Forrest had sexually abused a child in the Angell Road home. Mr Barratt produced an interim report in May 1999 and a Part 1 report in September 1999.
48. In November 1999, Lambeth Council was placed under special measures and formally monitored by the Department of Health, due to “increasing concerns about the quality of their performance and their ability to actually turn around the council”.[45]
49. In October 2000, the Barratt final report set out that:
50. Mr Barratt also said:
“It would be unfair not to recognise that the Council has tried repeatedly to bring its children’s services up to a proper standard, and that those reforms have been effective in some respects. However, if the first Conclusion is correct, the failure of those reforms to achieve a competent Department is self-evident.”[47]
The three major reorganisations – in 1991/92, 1993/94 and 1995/96 – had not prevented the failures. In 1993/94 and 1997, officers put forward detailed ‘action plans’. The formal acceptance of these plans “did not prove to be a means of re-creation and control” of an effective social services department within Lambeth Council.[48]
51. As a result of ongoing concerns from the Minister of State for Health, John Hutton MP, about Lambeth Council’s performance, the SSI undertook an inspection in May–June 2000. It was highly critical of childcare practice:
“We were particularly concerned about potentially large numbers of children who had not properly been regarded as looked after … Urgent action was needed to trace these children and secure their safety.”[49]
52. It made 22 recommendations and set out the following:
“The overall impression we formed during the inspection was of a children and families division struggling under considerable and relentless pressure. In many areas basic work systems were functioning poorly or had collapsed. This led to inefficient, fragmented and inconsistent work practices. There were difficulties in almost every operational and support area.
This inevitably led to considerable variation in the quality of service to high priority children. At best some children and young people received an acceptable level of care and protection. Many did not. We were not confident that practice was safe and that children always received the care and protection that they deserved and needed.”[50]
53. In November 2000, John Hutton MP (Minister of State for Health) issued 20 formal ministerial directions to compel Lambeth Council to rectify the situation identified in the May–June 2000 inspection.[51] The directions (which were to be complied with by 31 August 2001) included that all children in care should have an allocated social worker, and that children should be visited at the required frequency, whether they were in a residential home or with foster carers or parents. There was also a direction that all local authority foster carers should be subject to appropriate checks.[52] These ministerial directions were in addition to the imposition of ‘special measures’ in November 1999, which were formally monitored by the Department of Health.[53]
54. One consequence of being in special measures was that an SSI and Audit Commission Joint Review of Lambeth Council Social Services was instigated, to take place alongside the May–June 2000 SSI inspection, and reported in December 2000.[54] It made 28 recommendations and looked more widely at Lambeth Council social services, concluding that they were:
“not serving people well and that its prospects for improvement are worrying … The Authority needs to achieve comprehensive improvements in children’s services … Standards of professional practice are unacceptably low in some parts of the service, with particular concerns about the delivery of effective and safe services to children looked after and in need of protection.”[55]
55. In response to the SSI 2000 review report and the SSI 2000 inspection report, Lambeth Council prepared action plans to respond to the recommendations set, detailing the instances where targets had been met.
56. In September 2001, the SSI assessed Lambeth Council’s progress in complying with the ministerial directions.[56] It identified areas that still needed to be addressed, including such fundamental issues as a requirement that “all looked after children should have an allocated social worker” and that “all children on the child protection register should be reviewed at the required frequency”.[57] The SSI 2001 report made a further 19 recommendations, about which Lambeth Council developed another action plan, and concluded:
“The authority had put a great deal of effort into complying with the directions. The Chief Executive and councillors were working together with the Children and Families Division and were supportive of their efforts to bring about required changes. However because of the number and depth of issues needing action there was still much to do. Nevertheless we found that morale and motivation had improved and the direction of change was gradually upwards.”[58]
57. Dame Denise Platt told us about her discussion with John Hutton MP after that report, about whether the social services function should be removed from Lambeth Council and a commissioner put in place:
“We had to consider, if we did take even more drastic action, what would be the effect on the children? Were the children really seriously at risk at that point? Or was sufficient being done that we could be confident that their situation was safe but we could do much more and keep in place the enhanced monitoring and not put in anything further. Actually, it was a very finely balanced decision because you can either keep pulling up the roots and never giving anything a chance to settle, or think, is this the point at which actually, we think the signs are the most positive that they have been and we will support them.”[59]
58. The decision taken was “not to take further drastic action”.[60] As a result, the special measures ended in May 2002.[61] This meant that Lambeth Council was no longer being formally monitored by the Department of Health. The SSI continued to carry out inspections, including an inspection of children’s social care in 2003 that concluded that Lambeth Council was only serving some children well and had uncertain prospects for improvement. The report also recommended that the Council should develop a more coherent corporate parenting strategy.[62]
59. In 2004, the SSI was replaced by the Commission for Social Care Inspection (CSCI). In turn, in 2007, the CSCI was replaced by the Office for Standards in Education, Children’s Services and Skills (Ofsted),[63] led by Her Majesty’s Chief Inspector of Education, Children’s Services and Skills.
60. Ofsted undertook fostering and adoption inspections of Lambeth Council from 2007. In 2008, Ofsted undertook an inspection of the adoption service. This inspection resulted in an overall quality rating of ‘good’:
“Children benefit from a service which has a strong approach to matching them with suitable families. Recent recruitment activities to attract black adopters are being successful in addressing an identified and long-standing gap … The service is managed effectively both operationally and strategically. There have been some excellent initiatives to address long-standing issues and historical concerns.”[64]
61. In May 2009, Ofsted inspected Lambeth Council’s fostering service. It gave an overall quality rating of ‘good’ and reported in these terms:
“The authority strives to safeguard children, with a number of well thought out strategies. There is strong leadership, excellent partnerships and a clear focus on improving outcomes for children.”[65]
62. In 2012, Ofsted conducted an inspection of Lambeth Council’s safeguarding and children looked after services, and assessed them as ‘outstanding’.[66] This presented a remarkably positive view of Lambeth Council’s children’s services. In 2015, Lambeth Council’s children’s services were judged as ‘inadequate’.[67] This was a four-week inspection in 2015 encompassing child protection, looked after children, care leavers and local authority fostering and adoption services in one inspection. The report stated:
“some children continue to live in circumstances that are harmful and neglectful for unacceptable periods of time.”[68]
63. In respect of this dramatic change in Lambeth Council’s rating between 2012 and 2015, Councillor Edward Davie (Lambeth councillor since 2010, chair of Children’s Social Work Scrutiny Committee from 2016 to 2018 and lead member for children’s services in 2020) told us that the 2012 inspection:
“found us to be outstanding across five categories, was more based on what senior management were able to show the inspector rather than the inspectors delving in-depth into individual casework. Therefore, it was easier to get through the inspection with high marks if you were really good at impressing the inspectors is my understanding. To be honest, I think there was a deterioration of service, but it was also partly that the inspection requirement was toughened up and, in 2015, they looked at much more front-line casework and spent more time on the front line and looking at cases and I think to be honest, it was a more accurate reflection of the quality of the service than the 2012 rather glowing inspection report. I also think there was a lot of change between 2012 and 2015. A lot of senior managers left. There was a lot of disruption. There was a lot of change but to be honest with you I’m not sure that the 2012 glowing five ‘outstandings’ out of five was a fair reflection of the practice.”[69]
64. Lambeth Council volunteered for support and intervention from Ofsted between 2015 and 2018, resulting in eight monitoring visits. There was also active engagement from Ms Hudson as strategic director of children’s services from 2016. Despite the level of monitoring and the programme of visits over a three-year period, Lambeth Council was assessed by Ofsted in 2018 as ‘requires improvement’. In April 2019, after a focussed visit, Ofsted concluded that further improvements had been made observing:
“Senior leadership in Lambeth is robust and there is a determination to improve outcomes for children and young people in the care of the local authority. The quality of permanence planning is improving. Children are seen regularly, and some are benefiting from more timely intervention. However, senior managers recognise that there is still a considerable amount of work to do to ensure effective and timely planning for young people”.[70]
65. Lambeth Council now has a system of assistants to support care leavers aged 18 to 25.[71] However, inspection of some accommodation for 16 to 17-year-olds remains out of the reach of Ofsted. Ms Carolyn Adcock, Senior Her Majesty’s Inspector at Ofsted, told us that the Department for Education was consulting on this issue in 2020.[72]