Vanessa George Case Review - Lessons to be learned

Any discussion of the Serious Case Review into the Vanessa George child abuse case by the Plymouth Safeguarding Children Board has to first acknowledge the thoroughness of the report. It represents an excellent analysis of events and a welcome list of recommendations.

The review aimed to analyse what happened, why it happened and how such an event might be prevented in the future. It took an analytical and critical overview on individual, organisational and inter-agency practice. From this I draw some important conclusions:

• - What settings need to take from the review is that a culture of professional, reflective practice is vital and that children, their welfare and well-being are our central focus. Essential to achieving this is a manager who models high standards, recognises that managing a nursery is a learning journey for the whole team, is prepared to take the lead and is confident enough to request and accept advice and support from other agencies.
• - A whole-team approach and ownership of a vision for the nursery is key, including 'mindfulness' as to what constitutes high standards of childcare, which should ideally be reflected in a Professional Code of Conduct. Taking ownership of this shared 'Code' should be accompanied by agreed methods for challenging poor standards or destructive dynamics.
• - The review demonstrates that systemic flaws within the early years sector have resulted in a case with parallels to the 'Baby P' review: a vulnerable woman, a 'unit' (in this case a nursery rather than a family) resisting efforts to communicate with it, and no (or poor) channels of communication between the various public agencies.

The nursery operated from a local primary school and a neighbouring church hall (referred to as Z1 and Z2 in the report), while Vanessa George is referred to as K.

SYSTEMIC FAILINGS

The review makes a thorough analysis of systemic failure in communication throughout. Coupled with a common theme of 'assumption', it is easy to follow exactly how K was provided with a fertile environment in which to abuse children in her care, a point that has been made ably by the mainstream press.

The nursery operated as a relatively 'closed system' in many ways, selective in the persons or agencies with which it communicated. Assumptions were made by Children's Social Care that the nursery manager was competent in her safeguarding role as the Designated Person (or lead) for Safeguarding and was therefore suitable to be registered as a foster carer. In fact, K often babysat for the manager and nursery staff took the foster children to see their biological parents, for supervised contact sessions (an inappropriate deployment of staff).

The review noted a general reluctance on the part of agencies or services connected to the nursery to challenge. These included the primary school appearing quite passive in dealing with concerns about the nursery, in part because the manager was a school governor. A local secondary school that arranged student work experience placements within the nursery also avoided acting on expressed concerns by a student with regards to standards of childcare, saying 'you have not got long left to go'.

This dynamic is consistent with the behavioural and communication patterns between families and professional safeguarding services, often referred to in Serious Case Reviews, including in the case of 'Baby P'. These patterns are recognised as being 'avoidant, ambivalent, confrontational, threatening or actively violent'.

LEADERSHIP ISSUES

A competent and confident manager is central to providing clear leadership and high standards within an early years setting. The review is a timely reminder of the importance of the following:

Clear lines of responsibility and accountability

Nursery Z was an unincorporated not-for-profit association, 'owned' by a committee of trustees. However, the trustees interviewed were unaware of their responsibilities. The manager disputed Ofsted's claim that she was a trustee, while another trustee was found to be dead.

No trustee meetings took place, nor was there a proper constitution or any supervision of the manager's practice. Parents believed that the manager owned the nursery and, like many of the staff, were unaware of the trustees and unclear about who to approach with concerns or complaints.

The nursery frequently operated outside of staff:child ratios and there was no keyworker system in place. Staff were deployed in a loose way within the nursery, moving between Z1 and Z2, as needed. Although the review noted that children were generally 'happy', several staff disputed this. Since the closure of the nursery and parents enrolling their children with different providers, they have commented on the qualities of high standard childcare.

This lack of transparency in provision of an accountable service contributed to an environment where K could operate without challenge.

Policies and procedures

As a registered provider, the trustees had a responsibility to ensure that staff were inducted and trained in the nursery's policies and procedures. Although some procedures did exist, they were 'lifted' from a range of sources and had not been adapted to use in this nursery. They had also not been formally adopted by the team.

There was no clear staff recruitment and selection policy and the manager had not attended Safer Recruitment training. K had been recruited via 'word of mouth' through the primary school, where the manager knew her in her school governor capacity. There are no records of an advertisement, formal interview or references for K's post, though there was a cleared CRB check.

The child protection policies and procedures were inadequate and rarely followed, as the manager feared reprisals from parents or feared that they would move their children to other settings.

There was no code of conduct to guide the staff on what might be considered as appropriate or inappropriate behaviour, including on the use of mobile phones or participation in social networking sites. Similarly, there was no whistleblowing policy to support the reporting of K's escalating sexual behaviour within the workplace. Equally, there was no policy on allegations against staff, a requirement under the statutory framework.

While a nappy-changing policy may not have prevented the abuse, it would have alerted staff to breaches in their expectations of each other. In fact, in the months preceding her arrest, K had started to change children in a different toilet cubicle to that used by other staff.

Training

Staff had attended no safeguarding training or had attended courses a long time ago. There was no evidence to suggest that this training had been integrated into practice in a meaningful way. For example, staff did not seem to recognise that professional practitioners, including women (and in their case, K), could pose a risk to children. K's conduct and sexualised behaviour in the nursery was not noted as a clear 'sign' that they may have a sexual predator in their midst.

The review recommends specific requirements for child protection training under the EYFS, including the recognition of 'risky' staff within the workplace. While I support this recommendation, I would add that it is imperative that such training is tailored specifically to the needs of early years staff and focuses on building confidence in the child protection role. I would urge this in light of experience of relatively inexperienced early years practitioners being silenced alongside professionals from other disciplines within multi-agency LSCB training events.

Investing in this training, however, will only be successful if it is integrated into daily practice and embedded fully within a staff team. Robust mechanisms will need to be put in place to 'test' understanding, to be reassured of enhanced professional competence.

Supervision

There was no supervisory framework implemented at the Z nursery and as already demonstrated, the weak manager modelled blurred, professional boundaries and selective resistance to contact with outside agencies and did 'just enough' to stave off too much scrutiny by Ofsted.

Although the manager did detect that K had 'changed' from around December 2008 and from that time seemed 'to be on the internet, and chasing men', she did not act on it. Nursery staff also appeared to be 'paralysed' - deterred, the report suggests, by K's age, personality and length of service, which gave her an illusion of power within the nursery. The dynamic of this dangerous environment thus went unchecked. I therefore applaud the report recommendations that:

1. EYFS safeguarding requirements should be reviewed and strengthened in order to identify the characteristics of unsafe organisations.

2. A regular 1:1 staff supervision structure should be put in place.

I support these recommendations in particular, as in my experience, the early years sector continues to attract some staff who are challenged by their own neglectful or abusive childhoods. Although robust and value-based recruitment and selection procedures should not seek to exclude such staff from entering the workforce, I do believe they can be vulnerable to grooming within the nursery environment. An effective supervision structure can be used to reduce this likelihood.

Communications

The lack of professional boundaries between nursery staff and parents allowed cliques to form and socialise with each other outside of nursery hours. The report describes a system where some parents seemed to be favoured and a part of the inner sanctum, while others were kept at a distance. The culture was one of no pro-active communication with the parent body.

A similar ambivalence seemed to apply to the nursery's contact with outside agencies, which was described in the report as 'generally isolated' and 'resistant to change'. Ofsted's requests for reports were not completed within timescales, and there was often a poor response to the local early years service's repeated efforts to improve the setting's environment and planning, in partnership with the nursery. In fact, the early years team seemed to be received in the spirit of reluctant tolerance and little or no improvement was made in the nursery.

The review exposed a significant disparity between Ofsted's view of the nursery and that of the Early Years Advisory Service. This raises important questions about the capacity of an Ofsted inspector to appraise standards during a one-off visit, every three years. A welcome recommendation is made for 'a communication pathway to be established between Early Years Advisory Services within each local authority and Ofsted in order to ensure that local intelligence informs the inspection process'. In my opinion, such 'scratching well beneath the surface' of an organisation is vital for strengthening safeguarding requirements.

GOVERNMENT STANCE

It is essential to place the findings of this Serious Case Review within the wider context of the coalition Government's measures for children's service reform. Both Professor Eileen Munro's review into child protection and Dame Clare Tickell's review of the EYFS form a significant part of this movement, and I feel confident they will have already considered the weight of the Plymouth SCR findings.

I believe a key to making policy change sustainable, however, will lie in local Safeguarding Children Boards actively including Early Years Advisory Services as key partners in their work, in recognition that it is children under five years old who represent over 50 per cent of deaths or serious injuries in this country. The coalition Government seems resolute in its commitment to safeguarding vulnerable children. The question that will remain, however, is how the wave of massive cuts will meet this commitment.

Catherine Rushforth is a former early years practitioner and manager, a qualified social worker, systemic psychotherapist and managing director of Catherine Rushforth & Associates, training and consultancy agency with expertise in safeguarding

MORE INFORMATION

'Serious Case Review Overview Report: Executive Summary in respect of Nursery Z' by the Plymouth Safeguarding Children Board, www.plymouth.gov.uk/serious_case_review_nursery_z.pdf

Nursery World will be running a seminar on safeguarding at our London show on 11-12 February. For details and to register, visit www.nurseryworldshow.com