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IICSA Independent Inquiry into Child Sexual Abuse

Children in the care of the Nottinghamshire Councils Investigation Report

C.7: Continuing problems under the control of the City: 1998–2006

90. The recently created City Council assumed the ownership and management of Beechwood in April 1998. Andrew Bosworth, who continued as manager during this change, felt that for a considerable period, senior staff were preoccupied with their own concerns for their future, and did not have any understanding of the unsettling effect on frontline staff.[1]

91. Around this time, the majority of placements at Beechwood, for 13 children aged 14 to 17 who had been bailed or remanded to care, were still “unplanned” and at short notice. Staff “felt that young people were safe while in the unit … but felt that young people were at risk when out of the unit”.[2] However, for Margaret Mackechnie, the City’s Assistant Director for Children’s Services, with senior line management responsibility for the home, Beechwood reflected a “youth justice approach … less caring … male dominated … there was a harshness about it”.[3] In spite of being aware of this at the time, Ms Mackechnie did not do enough to improve conditions at Beechwood.

92. Inspections and reviews of Beechwood were largely negative, making adverse comments about the lack of policies, procedures and training for staff and the physical conditions of Beechwood.[4] The number of children sharing rooms was “unacceptable”, and the standard of accommodation was “very poor”, which had been “well documented in previous reports”.[5]

93. In the early 2000s, Beechwood faced the same problems that it had over the past 20 years. Alison Michalska, the City’s Corporate Director for Children and Adults, told us that Beechwood should have been closed when the City took over ownership in 1998.[6] It continued to be over capacity and the mix of “aggressive and loud to vulnerable and subdued” residents was considered difficult to manage.[7]

94. In 2001, the City’s Registration and Inspection Unit identified 29 issues requiring attention at Beechwood, including addressing overcrowding, urgently reviewing placements to ensure they were appropriate and that children could be protected from bullying and other forms of abuse, and providing child protection training (which had also been identified in a previous review).[8]

95. Michelle Foster, a residential care worker at Beechwood between 2000 and 2002, told us that it was not “an optimistic place” for children to be.[9] Despite concerns raised in inspection reports about the lack of child protection training, she said that no training was provided on working with children who had been sexually abused or on dealing with sexualised behaviour.[10]

96. Although sharing bedrooms had been identified as a “risk” in 1997[11] and “unacceptable” in 1999,[12] it was still happening in 2002. Joanne Walker (who had been seconded to manage Beechwood) identified this as a “grave concern”: 

I am aware of a previous incident of rape being perpetrated in another home with just such a situation, indeed, within the last week a young man who was placed in a shared room was urinated on whilst in bed! The horror of this happening is unspeakable. How can we give care to anyone who has been so abused by a system which allowed this to happen? … Sharing bedrooms is a source of constant friction between the young people resulting in unnecessary dangers. It is a disaster in the making and only a matter of time before a tragedy happens. I would go so far as to say this practise constitutes institutional abuse.[13]

Margaret Mackechnie disagreed that the sharing of rooms was “institutional abuse”, but accepted that it was “not good practice in a children’s home”.[14]

Bronwen Cooper report: 2001

97. Bronwen Cooper, an Investigation Officer with the City, was asked to investigate allegations and counter-allegations concerning NO-F1, a former staff member of Beechwood now working in another home, relating to the period from the mid-1990s to 2001.[15] Ms Cooper said her remit was to consider “the whole operation of the unit, the culture and practice … and whether children felt safe”.[16]

98. Her 2001 report revealed serious concerns of a staff culture of “sexual banter” and harassment at Beechwood.[17] She listed 10 specific allegations against staff, including an “inappropriate relationship” between NO-F1 and “a young person in the Unit”. The report described a “‘macho’ environment”, sexual and racial harassment and inappropriate behaviour between staff. 

99. Ms Cooper “was extremely concerned that the care of the children in this situation was being neglected” and that the behaviour of staff, particularly the sexualised behaviour, “would have an impact on children that we knew had previously suffered physical/sexual abuse/neglect and were looking to this staff group to care for them, keep them safe and also show them appropriate boundaries”.[18] She felt that “the whole atmosphere of the home was unsafe sexually” making it “very hard” for children to be able to disclose any abuse they were suffering.[19] For Ms Cooper:

there was a high level of risk of sexual abuse of residents within the home at the time of my investigation, by staff and other residents, because of the environment and culture generated by the staff group”.[20]

100. An initial draft of the report,[21] provided to Margaret Mackechnie, recommended that Beechwood be closed.[22] Closure was envisaged as temporary – while certain staff were supported and trained, and necessary disciplinary action taken against other staff[23] – but was seen by Ms Mackechnie and other managers as “contentious” and “practically and politically impossible” at the time.[24] Closure also raised “the challenge of finding placements for children”, which was “huge”, as well as problems with re-deploying or making staff redundant. She recognised that the behaviour of the staff was “very concerning” but said she had to “balance the needs of the service and the needs of the children”.[25] Ms Cooper removed the closure recommendation from her final report, feeling “a little pressure” to do so. She was “reassured” that alternative measures would be put in place to improve the situation for residents.[26]

101. Ms Mackechnie recalled that, in response to the report, the City reduced the number of children at Beechwood and did “the usual things you would do when there was a children’s home in difficulty”.[27] Ms Michalska accepted on behalf of the City that steps taken to address problems in the home “were wholly inadequate”.[28] Ms Cooper thought that there was a sexualised culture which created an “unsafe environment” for children, in which they would “find it very hard to talk about sexual abuse”.[29] These concerns required urgent action. The response of Margaret Mackechnie and her colleagues left children in the City’s care exposed to continuing risk of harm. 

Events leading to closure: 2002–2006

102. In April 2002, following disclosure by a resident that she had been raped by a 21-year-old male from outside the home, National Care Standards Commission (NCSC) inspectors were notified and visited Beechwood. They recommended that Beechwood be closed “because it was failing to safeguard and promote the welfare of the children resident there”, but within 48 hours agreed that the home could remain open provided that the number of residents was reduced from 10 to eight.[30] The City disputed that any recommendation to close was ever made at this time.[31] The proposed reduction in numbers does not appear to have taken place. Michelle Foster told us that in practice the number never went below nine,[32] and the NCSC subsequently reported that the City had continued admitting young people to Beechwood over capacity, resulting “in some young people having to sleep on couches or share bedrooms against their wishes”.[33]

103. In September 2002, the same resident who disclosed in April that she had been raped, killed herself in her room at Beechwood. The NCSC formally notified the City that it had “reasonable cause to suspect that young people are likely to suffer significant harm. We think it incumbent upon the Local Authority to carry out immediate child protection risk assessments, as the basis for providing an informed judgement about whether young people in this children’s home are safe.[34] The City proposed relocating children to other homes, but the NCSC was not satisfied that the City had demonstrated “adequate and due regard to ensuring the safety and welfare” of those children, having inspected conditions and occupancy levels at the other homes.[35] 

104. The NCSC’s report on the resident’s death[36] was critical of the City’s care for her and of its running of Beechwood. It concluded that:

104.1. the City failed to respond to concerns relating to risks to the resident’s welfare and to notify the NCSC of “significant events” including allegations of sexual abuse; 

104.2. children’s social care management had been advised that the resident should not remain in residential care amidst concerns that she was sexually active with a number of boys in the home and was being sexually exploited outside the home; and

104.3. while it might “transpire that this was a tragedy that could not have been averted”, her life in care “was characterised by unacceptable levels of risk, neglect and vulnerability. She was being ‘looked after’ by Nottingham City Council because she was considered to be in need of its care and protection. In the opinion of this Review the Local Authority failed to meet her needs in respect of the care it provided to her … young people have not been cared for … in a manner likely to safeguard and promote their welfare.[37] 

It recommended closure of Beechwood with “immediate effect”. 

105. This was the third closure recommendation in around a year. The NCSC stated that Beechwood was only to be reopened once the City could demonstrate it was “capable of meeting the requirements of the Children’s Homes regulations and National Minimum Standards”. The City was told to undertake “a comprehensive review of all of its children’s homes”, to urgently review its procedures on notification of significant events, and to formulate a plan on the suitability and relevance of its existing residential child care provision.[38] It agreed to temporary closure, declaring “There are firm plans in place to refresh all aspects of operations at [Beechwood] with a view to it being reopened.[39]

106. Michelle Foster told us that, the day before she was due to give evidence at the inquest into the resident’s death, Margaret Mackechnie made it clear that she should not do so as “it wouldn’t be good for the children if the public found out that they were taking drugs and having sex”. She was told that if she went ahead she would lose her job.[40] Ms Mackechnie did not remember specifically meeting Michelle Foster before the inquest, but did recall “a group meeting for the staff who were going to give evidence to the inquest”. She firmly denied that she told Michelle Foster that she “would lose her job if she said anything to the inquest”.[41]

107. Beechwood re-opened in June 2003. The City’s Area Child Protection Committee (ACPC) published a 44-page overview report into the resident’s death around the same time.[42] It concluded that “no single action by a person or agency … could have prevented [the resident’s] death” but questioned whether “more could have been done” at Beechwood “to create an environment where vulnerable young women, and men, were not liable to be sexually exploited by each other”.[43] Ms Mackechnie accepted that a similar issue had been identified in Bronwen Cooper’s report two years earlier and that more could have been done.[44] There were several recommendations, including that the City develop “Residential Care Standards, with appropriate staff development programmes, to ensure that children’s homes provide a safe environment where sexual and violent behaviours … are appropriately managed” and that the ACPC develop “Practice Guidance and training for all agencies on assessing and working with children who have been sexually abused”.[45] Similar recommendations on the need for such guidance and training had been made as far back as 1988 and 1990.[46]

108. On receipt of the ACPC report, the Social Services Inspectorate (SSI) wrote to the City’s Chief Executive highlighting the report’s criticism of the lack of strategic response to incidents at Beechwood and commenting that it was very clear the child was in need of protection.[47] 

109. The picture of Beechwood over the following three years, from monthly visits and external inspections, is mixed. Residents were said to present “a high level of aggressive and challenging behaviour[48] and to be “fed up with the complaints process”.[49] Some young people placed at Beechwood had “to live with young people who are persistent offenders”, leading to attempts to coerce others into “drug use and prostitution”.[50] On the other hand, staff were seen to be making “concerted efforts” to maintain positive relationships with residents, and were trained on and aware of the processes to safeguard young people.[51]

110. By 2006, there was little evidence of positive relationships between staff and young people, and the home was still in a poor physical state.[52] The Commission for Social Care Inspection (CSCI) wrote in February 2006 to Margaret Mackechnie identifying concerns that residents were exposed to “a variety of risks in terms of self harm and harm to each other. The City was required “to take immediate action to address these issues and to ensure the safety of all persons in the service”.[53]

111. Subsequent inspections record an improved picture – in September 2006, the overall rating was ‘good’.[54] By the end of the year Beechwood had no residents, with a “proposal currently being made to close the Unit”.[55] It appears to have been finally closed in late 2006 or early 2007.

Reporting of and responses to allegations of sexual abuse

112. Approximately 10 allegations of sexual abuse have been made relating to the period from 1998 to 2006 at Beechwood,[56] including from:

112.1. L43, who told staff in 2002 that he had been sexually assaulted by an older boy and the police were involved. He was told by a member of staff that if he went along with a prosecution he would be moved further away from his mother’s home. He told us that he felt both very let down and unsafe, not least because for a period his abuser stayed in the home.[57]

112.2. L29, who said that he tried to tell a social worker about his abuse by a staff member in 2005, but felt like she was ignoring him as she changed the subject.[58]

113. There is evidence of only one allegation against a staff member being made at the time in relation to this period. NO-F47 was suspended in October 1998, following an allegation of an “inappropriate relationship” with a male resident, and resigned before the disciplinary hearing.[59] There were no documents on her file to suggest that a disciplinary investigation was concluded, despite guidance on the need to continue investigations following a resignation.[60]

114. Andrew Bosworth’s understanding of the low number of allegations made at the time can be seen from a complaint he made in January 1999 about two inspectors from the City’s Registration and Inspection Unit:

There seemed to be a continued pursuit of trying to find some form of abuse of young people, then a denial of being allowed to make a complaint. This preoccupation had been recognised by several staff members including myself. There was simply nothing to find because we do not abuse young people or deny them the opportunity to complain about issues at any time.[61] 

Andrew Bosworth said that this showed he was “prepared to challenge issues in an open and professional manner”.[62] 

115. Beechwood was allowed to carry on operating dysfunctionally. Supervision of staff was negligible. The physical environment was overcrowded and unsuitable. Children were subject to bullying and harmful sexual behaviour. Margaret Mackechnie, the City’s senior manager with responsibility for Beechwood, failed to address these problems. When the City took over the management of Beechwood in 1998, it should have been closed.


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