Ms George was jailed last year for a minimum of seven years after admitting abusing children at Little Ted's, the Plymouth nursery where she worked, and photographing the abuse.
The serious case review by Plymouth Safeguarding Children Board found the nursery to be an 'ideal' place for George to abuse, with safeguarding frameworks that were not fit for purpose, unclear lines of accountability and governance and an environment where outside challenge and support was not always welcomed.
Little Ted's nursery, a not-for-profit setting owned by a committee of trustees, was closed in June 2009 when George was arrested.
The review found that George, (pictured), was considered to be in a position of power within the staff group at the nursery, meaning that staff who had become concerned about her behaviour, which included showing indecent images of adults on her phone and using crude language, felt they were unable to challenge her.
The review found that there is no formal mechanism for Early Years Advisory teams to report their concerns to Ofsted, if they do not reach the threshold of a breach of regulations. In 2008, just months before George began abusing children, the nursery was inspected by Ofsted and awarded a 'good' rating for protecting children from harm or neglect.
However, by the end of March 2009, the nursery was rated red on the council's RAG system, because of concerns over management, quality, inclusion and sustainability.
The review highlights the limitations of the EYFS in providing a framework for inspecting the safeguarding capabilities of the nursery. It says that Ofsted does not inspect the culture of a setting, but that unsafe cultures are known to be places where abuse is more likely.
The review questions whether the inspection framework is fit for purpose with regard to safeguarding, as there are no requirements specified in relation to staff supervision, safeguarding training, the nature of staff interviews and the lack of attention to the overall culture of an organisation.
A statement from Ofsted said, 'Ofsted has already implemented a number of changes in the way we work as a result of this review and to address the recommendations made. It said it had improved its complaints process and the way it shared information with local authorities.
Purnima Tanuku, National Day Nurseries Association chief executive, said, 'This report reinforces why nurseries must ensure that they have robust procedures in place for protecting children and ensuring that staff can report any concerns. This case has demonstrated that settings need to ensure their policies must work whether there are concerns about children internally in the nursery or externally at home.'
Neil Leitch, chief executive of the Pre-school Learning Alliance, said, 'We would ask all settings to review their recruitment procedures and management structure. All staff should be properly supervised and have robust whistleblowing procedures in place. A practitioner should be supported to report any concerns about a child's safety'.
The Serious Case Review Executive Summary is available at www.plymouth.gov.uk/serious_case_review_nursery_z.pdf