Report of the Independent Jersey Care Inquiry Panel 2019 (Two-Year Review)

2019  R.123

TABLE OF CONTENTS

Foreword  3 Two-Year Review: Findings and Recommendations  5 Appendix 1:  Addressing the Failings of the Past  27 Appendix 2:  Learning the Lessons of the Past  61 Appendix 3:  Post Inquiry Review July 2017   81 Appendix 4: Children's Legislation Programme (extract)   85

Foreword

The Independent Jersey Care Inquiry was a significant commitment for the people of the island, particularly those who had suffered abusive experiences while in care. The island had become the focus of international attention as a result of the investigations at Haut de La Garenne and all that Operation Rectangle had encompassed. It was clear that a public inquiry was necessary to get to the roots of what had happened and to identify what needed to be done in future to protect Jersey's children. During the Inquiry, harrowing accounts emerged of children's experiences in Jersey's care system from World War II onwards and of the enduring impact that had on their lives.

We were conscious throughout the Inquiry of the enormous responsibility we bore to ensure that the past was fully understood and that the future was different. We concluded that simply publishing the report would not, in itself, ensure that all necessary action would be taken to resolve the problems we had identified; we had heard of many reports which had not had their recommendations taken forward. We suggested that we should return to the island to review progress after a period of two years. This was readily agreed and we were pleased to undertake this review, which we believe to be the first of its kind following a public inquiry.

We returned to the island during the course of 2019 and met over 200 people, both in public and in private. We also had access to hundreds of documents. We received over 300 written contributions from people in Jersey. We have, therefore, had the opportunity to hear many perspectives on what has happened since the publication of the Inquiry Report. We are grateful to everyone who so willingly assisted us, whether by providing us with their insights, showing us their work or making arrangements to assist us.

This report sets out what progress we have found in terms of responding to our recommendations. In many areas there has been marked progress; where we consider significant deficits remain or where there is room for improvement, we have set that out along with recommendations. As before, it will be for Jersey to determine how it will respond to our recommendations for improving the safety and well-being of the island's children.

Jersey has the potential to provide world class services for its children. The long path to achieving that will involve fusing the best of the island's values with modern practice and relinquishing long-standing practices to allow new models to evolve.

With this report the Panel's work is concluded. We have, however, suggested a mechanism for ensuring that progress is reviewed by others in the future. We thank the people of Jersey, of all ages, for sharing their histories and insights with us.

We wish success to all who carry the responsibility for keeping Jersey's children safe and well.

Frances Oldham QC Sandy Cameron CBE Alyson Leslie

Independent Jersey Care Inquiry Panel Two-Year Review

Findings and Recommendations

Background

1  The Independent Jersey Care Inquiry Panel was appointed at the end of 2013 and began

hearing evidence in Spring 2014. The Panel's report was published in July 2017. During the Inquiry, we learned that Jersey had a history of commissioning inquiries and reviews into many aspects of island life, but often failed to take forward their recommendations. The Panel therefore proposed that we should return to Jersey after two years, to review what progress had been made in respect of the recommendations of our report. The then Chief Minister, Ian Gorst , accepted this proposal. We believe that we may be the first public inquiry to have been invited back by the commissioning agency to review progress.

2  In our 2017 report, we identified 10 significant failures by the States of Jersey between

1945 and 2017 and eight lessons to be learned from these failures. Progress on addressing the 10 failures is discussed in Appendix 1. Progress in relation to the eight lessons to be learned is discussed in Appendix 2.

3  The Panel made eight recommendations, having taken the view that it would be more

helpful to make a small number of high-level proposals, rather than many points in detail. We also considered that it was essential that the people of Jersey determine how to make the necessary changes, in ways that would work best for the current and future children of the island. In addition to our eight recommendations, we included, as an appendix to our 2017 report, a list of some 659 recommendations, which had been made to us by witnesses and other contributors to the Inquiry. We took the view that these were worthy of consideration, albeit we identified a small number which we did not feel able to support. Following the publication of our Report, Chief Minister Ian Gorst stated that it was his intention that all eight recommendations should be implemented. We were aware that a great deal of activity in relation to the recommendations had been going on in Jersey. We were also conscious that this activity might not necessarily translate into progress or a positive outcome.

4  It was in that context that we returned to the island in May 2019 to review progress.

We did not expect that it would have been possible to fully implement all of the recommendations by this stage, albeit we had an expectation that significant changes and improvements would be in place. At the end of the Inquiry we had set out, for our own reference, a series of indicators to help us determine what progress had been made in respect of our recommendations. That was not a public document but has informed our work in undertaking this two-year review (Appendix 3).

5  Ahead of our visit to the island, we met with a range of relevant people to help us

prepare for the work we would undertake in the island and also sought over 200 documents from the States of Jersey and other organisations.

6  Over a two-week period in May 2019 we met with more than 200 people, including a

number of young people, some of whom were care experienced. We also visited a number of establishments and services. We attended a training event involving over 100 frontline staff. Many of our meetings were held in private, but we also held four days of hearing from people in public, as we had done in Phase 3 of the Inquiry. We received over 200 contributions through an online survey, by e-mail and through the website which we had set up for the review[1] and by post.

7  In undertaking the review, we operated under the same independent principles of

working without fear or favour as we had done during the Inquiry. We made arrangements to receive contributions in private sessions. Where we have drawn on that material in this report, we have done so in a way that protects the privacy and identity of the participants. At the conclusion of this review, all confidential information will be held alongside the confidential archive of the Inquiry off-island. All public domain material, including the transcripts of our public hearings, will be transferred to the Jersey Archive.

8  We now set out below our findings and responses in respect of each of the

recommendations from the Inquiry Report.

Recommendation 1

9  We recommended that the post of Commissioner for Children be established and

enshrined in Jersey legislation, in a manner consistent with the United Nations Paris Principles.[2] This was promptly taken forward and the first Commissioner, Deborah McMillan, was appointed before the end of 2017, in a recruitment process which commendably included young people on the selection panel. Subsequently, she was closely involved in drafting the legislation which underpins her position and that legislation has now been passed by the States Assembly and approved by the Privy Council and is therefore now part of Jersey Law.  We consider this to be a very important step forward for the Island in protecting and meeting the needs of its children and young people now and in the future.

10  We said that, "It will be important to seek candidates of the highest calibre who have a sound track record of commitment to serving the best interests of children and young people and who will be seen as fully independent of government." The appointment of Deborah McMillan, in our view, fulfils that recommendation. It is clear

to us that she brings a wide range of relevant experience and a personal passion for the rights of children. Since her appointment she has made strenuous efforts to ensure that the way in which her office operates is consistent with best practice for equivalent Commissioners in other jurisdictions. She has also sought to ensure that the rights of children are fully reflected in all future policy and legislative developments.

11  The logistical arrangements for the operation of the Office of the Children's

Commissioner's Office have reflected its independence. Being visibly independent of the Government of Jersey will be critically important in building trust among young people in the island and amongst those who have experienced trauma as a result of their childhood experiences rooted in the poor governance of the past. Given that the Commissioner is now resident in the island, it will be important that she and her advisory board are vigilant against the risk of being drawn into any situations or relationships which could be interpreted as compromising her independence. This is an ongoing challenge in a small jurisdiction the size of Jersey.

12  It was, and remains, our view that the appointment of the Commissioner should be

made on the basis of the appointee serving no longer than a 6-year term of office, consistent with the other UK Commissioners. Our opinion is based on the need to ensure that the Commissioner is able to sustain her independence and importantly the public perception of that independence. The decision reflected in the new Jersey legislation is, however, that the term of appointment should be for 8 years. There is, in our view, a potential problem which could influence the attraction of future high calibre candidates from off the island, in that the current residency rules mean that at the end of a 6 or 8 year appointment, the post holder would not be able to continue to reside in or own property in Jersey. We therefore recommend that further consideration should be given as to what might be done to ensure the future attractiveness of the post to candidates of the highest calibre.

13  We note that Jersey has agreed to incorporate the United Nations Convention on the

Rights of the Child (UNCRC) on a "due regard" basis. The UNCRC is a legally-binding international agreement setting out the civil, political, economic, social and cultural rights of every child in a nation or jurisdiction. As such, it will be incumbent on the States of Jersey to ensure that full and proper regard is paid to the UNCRC principles in all future legislation and policies and that the Commissioner has oversight to ensure compliance with this positive commitment. We are pleased to note that the States of Jersey have asked the Commissioner to review all existing Jersey legislation and to provide advice in relation to its compatibility with children's rights. Commendably, this work is already underway. This approach has the potential to ensure that Jersey is in line with best practice worldwide.

14  We said that, "It is essential that there is a clear means for looked after children to raise complaints and receive a response from those responsible for their care. The Commissioner should have oversight of such arrangements". The Commissioner has

been given power to assist children in raising complaints and has indeed already been involved in this. This is particularly important because we consistently heard from a range of people, including young people and their families, that they found it difficult to raise concerns and complaints about health and social services with the relevant authorities and that where they did succeed in accessing the system, they often did not receive a timely or meaningful response. As far as we could determine, the main mechanism for raising complaints about services, currently, is through the corporate feedback mechanism via the States website. One young person described this as being "difficult and clunky", and we also found it to be arcane and unnecessarily cumbersome. Ensuring that young people and their families can raise matters of concern, with confidence that they will receive a timely response, is essential to building confidence in services. It also allows services to have a continual eye to improvement.

15  Given the impact which Children's Services can have on lives and future wellbeing of

children and families, it is, in our view, essential that users of services know that they have a right to raise a complaint; easy access to a system that will provide a helpful response; and the possibility of escalating matters if they are not satisfied with a response. Responses should be provided in ways which are age appropriate and comprehensible to the person raising the complaint. In the great majority of cases this should involve a personal meeting in addition to a written response. We consider that a statutory right to raise a complaint about any aspect of a Children's Service should be introduced, laying out timescales for responses and a mechanism for further review. We understand that there are proposals to legislate for the introduction of a Public Services Ombudsman for the island. Such posts are, in our experience, usually concerned with matters of maladministration and exist alongside robust internal means of dealing with a complaint. Therefore, it is important for Children's Services to have such a mechanism in place to allow for both informal and formal resolution of complaints before referral to an ombudsman. We commend the idea of having a system which is not only about complaints, but also encompasses an opportunity for comments and, very importantly, complements. It will, in our view, be essential for the Children's Commissioner to monitor arrangements for children and to comment on their operation in her Annual Report.

16  The legislation has empowered the Commissioner, as per our recommendation, who has "an unfettered right to make public the findings of any inquiry undertaken by

her". It has also provided a requirement for her to present an Annual Report. The new legislation provides for that to be laid before the States Assembly, which is consistent with the intent of our recommendations. We did, however, propose that "a duty be placed on the Chief Minister to make a public response to the States Assembly, indicating what action is proposed to be taken". No requirement of this kind has been included in the legislation and this is, in our view, a serious deficit. Our concern in making our recommendation was to avoid the risk that the presentation of the Annual Report would become a ritualistic paper exercise. The current legislation leaves this as a possibility. It is essential that there is an evident, enduring commitment from the States of Jersey to demonstrate its commitment to the rights and best interests of children and young people. This is, in our view, one of the key building blocks to ensure that the failures of the past are never repeated. We therefore recommend that, at the first opportunity for review, the Children's Commissioner legislation should be amended to include a duty on the Chief Minister to make a formal public response to the Commissioner's Annual report.

17  We recommended that there should be exploration as to the possibility of making the

appointment of the Commissioner a joint one across other jurisdictions, such as other Crown Dependencies, but that such exploration should not delay the appointment of the first Commissioner. We understand that there are ongoing discussions between Jersey and other jurisdictions as to possible areas of cooperation and we would be keen that the opportunity to share the post of Commissioner with other jurisdictions should continue to be part of future discussions. It is our view that such an arrangement would bring increased opportunities to underline the independence of the office. We are pleased to note the interaction of the Commissioner with longer established Commissioners in other countries and that Jersey has now been included in the British and Irish Network of Child Commissioners (BINOCC). This has been important in assisting Jersey to ensure that international best practice is incorporated into its legislation and we congratulate the Commissioner and the States Assembly in that regard.

18  There are two aspects of the new Children's Commissioner legislation which cause us

concern. First, it is essential that the Commissioner should have access to all documentation she requires in pursuit of any inquiry. Amendments to the legislation allowed legal advice given by the Law Officers Department to be withheld from the Commissioner, albeit with a provision that the Attorney General could make such advice available if he believed it to be in the public interest, having first applied a public interest test. Whilst we fully understand the importance of the convention that legal advice is not disclosed, we consider that, in setting the arrangement as it now stands, there is a real likelihood of suspicion being generated that critical matters are being covered up and that the "Jersey Way" is being perpetuated. We will come back to the "Jersey Way" later, but suffice to say, arrangements which could be seen to perpetuate this undermining belief should be avoided. To that end, we recommend that the presumption by the Law Officers Department should be framed to indicate that relevant legal advice will be made available to the Commissioner and withheld only where a public interest test is met for non-disclosure. This would symbolise a willingness to be open and transparent in most circumstances, since we believe that there should be few circumstances where it would not be appropriate to let the Commissioner have sight of legal advice, given the very direct impact such advice can have on the long-term outcome for a child.

19  Second, the legislation has provided for the Commissioner to appoint Advisory Panels as part of the governance arrangements for the office. We do not consider it would be appropriate for appointments to these to be made by the Government of Jersey or the States Assembly, but nor do we consider it satisfactory that the Commissioner should

make the appointments at her own instance. To that end we recommend that consideration be given as to how an independent element can be introduced to the appointment process for members of the Advisory Panel. This could, for instance, be done through an appointment process overseen by the Public Appointments Commissioner to ensure that due process was followed and that appointments to the Panel are seen to be made impartially, on the basis of competence for the task.

20  Currently the Commissioner receives some legal advice from the Law Officers

Department. Whilst not doubting the integrity of that department, we are of the opinion that it is essential that the Commissioner should receive all her legal advice from a source which is seen to be completely independent of the Government of Jersey. Building confidence in the independence of the Commissioner requires that all aspects of her work are seen to be independent of government and this includes the source of her legal advice. Without a suitable arrangement for independent legal advice, including separate advice on the drafting of any amendments to the Commissioner's legislation, the potential for perception of a conflict of interest on the part of the Law Officers could undermine the perceived independence of the Commissioner's role.

21  Whilst we would hope that it never becomes necessary to remove a Children's

Commissioner from post, it is nonetheless vital that robust arrangements are in place should the need arise. This is important for the protection of the office but also for the protection of the Commissioner, so that she can undertake her duties without fear of repercussions. The current provision in legislation for ending the appointment of a commissioner is for the Chief Minister and the President of the Chairmen's Committee to bring forward a proposal to that effect, which would be presented to a sitting of the States Assembly held in-camera. Whilst the Commissioner would have a right to make written representations to the Assembly, we consider it essential that she should be entitled to make representations in person during the in-camera session. We accept that on matters of this nature, regard must be given to protecting the privacy of the Commissioner, hence the need for proceedings to take place in a private session. We consider the Commissioner should also have the right to waive that facility in favour of an open public consideration. Our concern here is to ensure that circumstances, similar to those which pertained at the time of the removal from office of the former Chief Officer of Police, are not replicated. Jersey must demonstrate that it will deal with such a matter in ways which will evidence fairness and as much transparency as possible. We therefore recommend that  in reviewing the law, consideration be given to achieving the objective of fully demonstrable fairness in any proceedings to remove a Children's Commissioner from office.

22  We consider that the appointment of a Children's Commissioner, and the passing of the

empowering legislation, is a robust demonstration of the island's commitment to ensuring that the failures of the past are never replicated. The appointment of the Commissioner has put Children's Rights firmly on the agenda for all agencies in Jersey and has demonstrated that the island is open to adopting best practice. The matters which we have raised above are intended to further strengthen that commitment.

Recommendation 2

23  We recommended that, in addition to the appointment of a Children's Commissioner,

a number of steps should be taken to ensure that children and young people were given a voice in matters which affected their lives.

24  We recommended that the complaints system for young people should be reviewed,

as we have described above, with the objective of ensuring it was easily accessed and that clear responses are always made to complainants within set timescales. It is important to recognise how difficult it can be for anyone to make a complaint and particularly for children and young people to complain about adults.

25  To further strengthen the complaints system and to ensure oversight of how services

were being delivered, we recommended that the outcomes of complaints investigations should be regularly reported to the relevant Ministers and that they should be required to present a report on an annual basis to the States Assembly. Given the appointment of a Children's Minister, it could be the case that this responsibility could lie with that office. It would be important that this should not result in Ministers with other responsibilities failing to take ownership of resolving complaints within the services for which they have responsibility.

26  In order to assist children and young people to raise complaints and concerns, we

recommended that a Children's Rights Officer should be appointed and this has now been done, albeit on an interim basis. Notwithstanding that the interim post holder has been very active in establishing the role and making positive connections with young people in the care system, we consider that it is important to move as speedily as possible to make a permanent appointment and, in time, to assess whether a single post will be sufficient to ensure that all children and young people in the care system have regular and easy access to her.

27  We recommended that the Children's Rights Officer should have direct access to the

relevant Managing Director and we are pleased to note that, under the new structure, she has direct access to the Director General.

28  Given the number of children placed off island, we consider it essential that they also

have regular access to the Children's Rights Officer and this may have some

implications for the resourcing of the post which will require future consideration. 29  It will be important that the role of the Children's Rights Officer is fully and properly

understood and that there is no confusion between it and the role of the Children's

Commissioner. The Children's Rights Officer is a post which is internal to Children's

Services and is intended to ensure that the service has its own mechanism for

overseeing that the rights of children in its care are protected and overseen and that

their voice is always heard. The Children's Rights Officer must be able to operate

independently within Children's Services, but is at the same time part of the structure

of that service. It is vital that the Children's Rights Officer reports, in management

terms, at a very senior level and has direct access to the most senior officer i.e. the

Director General and if necessary, to the Chief Executive. This is different from the

complete independence from government which the Children's Commissioner must

have. As we said in our Report, it is not the case that all complaints are upheld, but it is vitally important that where this is not the case, a full and comprehensible explanation for the decision is given in a timeous way. The Children's Rights Officer has a powerful position, in that she has direct access to the Director General with whom ultimate responsibility lies for the effective delivery of services.

30  In addition to the above matters, we further recommended that there should be

engagement with an external advocacy service. We note that there have been visits to Scotland and meetings with Who Cares Scotland' which appear to have been helpful in taking these matters forward. We also note that a fledgling advocacy service is being created in the form of Jersey Cares' and that care experienced people are involved. In visiting Scotland, those involved will have heard of the Care Review there and the direct involvement of the First Minister. We suggested that the Chief Minister may find meeting care experienced young people from time to time to be of assistance in taking forward the recommendations from the Inquiry. That continues to be our view and our experience of meeting with young people, in the course of this review, reaffirms that view.

31  A positive response is under way to our recommendation on giving children and young

people a voice. It will be important, not least given the size of Jersey, that there is a clear understanding of the different roles between the three pillars of Commissioner, Children's Rights Officer and Independent Advocacy, to ensure that there is no unnecessary duplication or confusion of roles. We recommend that those involved should agree a common statement and ensure that it is available in an easily accessible form to children, young people, staff, elected members and the public in general.

32  We have referred above to the role of a Public Services Ombudsman and would reemphasise that we consider it to be essential that proposals currently under discussion are taken forward without delay. This role is a key element for further strengthening the rights of children and others to have their voices heard and their concerns and complaints dealt with effectively. Properly constituted, the operation

of the role will go some way to resolve deficiencies in complaints processes and to dispel public perceptions of lack of transparency and of partiality in decision-making.

Recommendation 3

33  We recommended that an independent inspection regime should be introduced for

Children's Services. We considered that it was essential that services in Jersey should be willing to open themselves fully to external scrutiny, in the interests of ensuring continuous improvement and development.

34  We are pleased to note that the Jersey Care Commission is progressing these matters and that they commissioned an independent inspection of Children's Services by Ofsted

from England. We have considered that inspection report in the course of this review and note that there were a number of concerns raised by the inspectors which we have also identified during the course of our work (these matters are covered more fully in appendices 1 and 2).

35  The 2018 Ofsted inspection, commissioned by the Jersey Care Commission, was an

important start to the regime of inspection we had recommended. It is nonetheless important that a statutory inspection regime for Children's Services is established as soon as possible in order that inspections do not continue to happen simply by invitation. It seems unlikely that Jersey would be able to resource its own inspection service and therefore the model of bringing in the expertise of a large inspectorate such as Ofsted, working in tandem with Commission staff, is likely to be the most satisfactory way forward. It is crucial, in the light of Jersey's history, that there is a visibly independent element to inspections of children's services in the island, given the dual registration and inspection roles of the small staff group of the Commission. We continue to be of the view that it would be beneficial for relevant staff working in services in Jersey to have the opportunity to participate in inspections in other jurisdictions in order to enhance expertise in the Island. It is, however, important in our view, that inspection arrangements should not be simply lifted from another jurisdiction and applied to Jersey. Adapting experience and approaches from elsewhere to fit with Jersey law and context is in our view important. Jersey has the opportunity both to learn from elsewhere but also to improve on arrangements.

36  We noted that a registration and inspection requirement for residential establishments

is being introduced as part of the remit of the Jersey Care Commission. Services are applying for registration, albeit at the time of writing there seems to have been some delay in some establishments coming forward with their registration applications. The need for full compliance with the new requirements cannot be overstated and services should see this process as an opportunity to reflect on their operating practices and consider where there is scope for further improvement.

37  We are pleased to note that consideration is being given as to how care experienced

young people can be involved in inspections. We understand and agree, given the size of Jersey, that there would be difficulties for young people with experience of care in Jersey to be involved. The discussions with other jurisdictions seem likely to open up opportunities for care experienced young people who are already involved in inspections to be involved in Jersey inspections. It would be a positive development if care experienced young people from Jersey had a reciprocal opportunity in another jurisdiction. The value of viewing services through the eyes of people with direct experience cannot be overstated.

38  We recommended that once an inspection arrangement was in place then the Independent Visitors for Young People should be wound up. This has been done. We understand that as part of the new registration requirements, there is a need for individual residential services to appoint an independent visitor who would be expected

to visit the home at least monthly. This seems to be the application of a requirement from England which has not, in our opinion, taken into account the context in which Jersey homes operate. Residential units here are small, as is consistent with good practice. Care should be taken to ensure that there is no extensive intrusion by strangers into the homes and living environment of children and young people. Some young people expressed the view forcibly to us that such additional independent visits, though well-intentioned, would be unnecessarily intrusive, alongside the inspection process, visits from the Children's Rights Officer and contact from the Children's Commissioner. This is an example of where it would be more appropriate to consider the Jersey context and needs rather than to lift an arrangement from another jurisdiction. There is a real danger of moving from inadequate protective and regulatory arrangements to excessive and duplicate arrangements. We recommend that consideration be given as to whether the planned requirement to appoint independent visitors is appropriate or necessary. Above all else, it has to be borne in mind that good residential homes are just that – home for looked after young people where the need for respecting their privacy and the need for ensuring their safety are carefully balanced.

39  The work of the Inspectorate, Children's Commissioner and Children's Rights Officer,

along with the development of advocacy services such as, potentially, Jersey Cares', should give confidence that the failures and inadequacies of the past are avoided and that high-quality services are developed and sustained in Jersey.

40  We are of the view that there is a need to move as quickly as possible to extending

inspection of the provision of fostering services. This would not be the inspection of individual foster homes but an examination of all aspects of the management and supervision of the service set against standards devised for Jersey. During our review, we heard many criticisms from foster parents, of poor administration and partnership working from Children's Services, just as we had done during the Inquiry. This suggests to us that there is a need for routine independent inspection of the Fostering and Adoption Service, which would include gathering the views and feedback of foster carers. This is not an inspection of individual foster homes but of the service within which they operate.

41  We heard of the impact which the Jersey Family and Court Advisory Service (JAFCAS)

can have on children's lives and given its powers and influence, we consider that its operation should be open to the same scrutiny as other areas of social work practice with children.  We recommend JAFCAS operations should be included in future programmes of inspection.

Recommendation 4

42  We highlighted the urgency, in our Inquiry Report, of Jersey's need to build a

sustainable workforce. We are concerned that whilst positive steps are being taken, it remains the case that a large element of the Children's Service workforce are interim appointments, including at the most senior levels.

43  We heard from young people that they had had numerous social workers and indeed one young person told us that she no longer bothered to learn the name of her social worker since they changed so often. Almost all of the young people we met reported similar experiences and, as such, they did not feel that building a relationship with their

social worker had any point. We consider that this is a serious deficiency in the service, which was also highlighted in the 2018 Ofsted inspection. We also heard from many sources that interim social workers often had no understanding of Jersey law and as a result often applied inapplicable English legislation or procedures. This undermines confidence in the service particularly from families and external agencies. We do not doubt the good intentions of interim social workers but operating in a different jurisdiction brings with it a need to be very well briefed on the legal framework within which they are operating. We also heard from staff who felt their interim colleagues had preferential conditions and better remuneration. These perceived disparities do not assist in building cohesive teams to deliver services.

44  We recognise the very significant difficulties in recruiting suitable, permanent, qualified

staff to Jersey, not least of all because of the challenges of the housing regulations, the high cost of living and terms and conditions of service inferior to other European nations. We note that a recent recruitment campaign and attendances at job fairs in the UK has generated a substantial number of enquiries. Converting such enquiries into applications and appointments is, of course, another matter.  

45  A stable and reliable workforce is fundamental to delivering practice standards and

quality services. Let there be no mistake, however, that real progress in stabilising and improving the quality of Children's Services cannot be made until the vast majority of social worker posts are filled on a permanent basis by well qualified professionals who are committed to staying in Jersey, delivering strong and innovative services for the island's children and their families. It is, in our view, essential that progress on this is constantly reviewed and an understanding is reached as to why enquirers do not follow through to making applications and why staff do not remain in post for long. Securing a stable workforce will mean the Government of Jersey dealing with whatever underlying reasons are identified for failures to recruit and retain staff, even if this means changing long-standing practices in respect of housing and robustly addressing aspects of current terms and conditions of service which act as a disincentive for staff to stay in the service.

46  Interim managers have been brought in at senior levels, as has been the case in the

past. Whilst such external expertise and experience are valuable, it is our view that professional leadership, based on a long-term commitment to the island, is the only way that the service will be strengthened. Frontline staff need to feel confident that senior managers are alongside them for the long haul, to see through the improvement of services. It is not enough for interim managers to apply systems and practices which they have experience of in other jurisdictions, but rather they need to be using their experience to develop systems and practices which are fit for purpose in the context of a small, but fiercely independent, jurisdiction with its own strong traditions and identity. This cannot, with the best will in the world, be delivered by managers who fly in on a Monday and out again on a Friday and who cannot be seen to have a long-term commitment to sustaining service improvement. We recommend therefore that permanent appointments to senior management posts are made, without any undue delay, in order that a leadership team with a commitment to the future is seen to be in place.

47  We recommended that a dedicated specialist HR resource be put in place to support

the  work of  developing  a  long-term  stable workforce  and  to  ensure  that  Human Resource practice reflected the particular needs of the Children's Service. We are pleased to note that this step has been taken.

48  We looked carefully at the development of a Jersey-based BA Social Work course at

Highlands College developed in partnership with, and accredited by, the University of Sussex. We consider this to be a highly creative and positive development, which should help build a sustainable professional workforce for the future. It will, however, be several years before the first entrants graduate from the course. We are pleased to hear there has been a large number of applications for the first entry and that the selection panel for the first group of student social workers included care-experienced adults.

49  We recognise that for most students on the Jersey degree course, undertaking practice

placements off island would be very difficult. We do, however, have a concern that if students only have experience in Jersey then their broader understanding of professional practice will be limited. We therefore recommend that consideration be given as to how students in Jersey can be linked into experiences in successful local authorities with which the University of Sussex already has links. Short periods of shadowing workers in such an authority, for instance, could help build a broader awareness of good practice. This would be even more positive if longer term links with the settings were built and maintained. Regular opportunities for exchanges of students and qualified workers with other jurisdictions, including other Crown Dependencies, would be a positive development for Jersey based staff.

50  During the Inquiry we were impressed with the way in which the Probation Service had

built a stable workforce, but were concerned by how the Children's Service had not looked to learn from this because of the culture of silo working which was deeply embedded. We therefore emphasised the need to develop a culture of corporate working across all public services, led by politicians and the Chief Executive and his senior team.   We  are  pleased  to  note that  there  is  activity  underway  to  change structures and culture across services. The One Gov.' initiative, led by the new Chief Executive, is an important development. If true corporate working is to be embedded, then it is vital that it is led through an expectation of positive behaviours from the top. We do not doubt the Chief Executive's commitment to this, but it does need to be recognised that the concept was not, as yet, well understood by many of the frontline staff we met. The value of corporate working is that staff feel empowered and expected to solve problems and the public receive a seamless service irrespective of what their access point is. This is of particular importance to families in contact with Children's Services who have to deal with considerable complexity in their lives and who often report a feeling of helplessness in the face of what they perceive to be needless bureaucracy. Whilst change will take time it is reassuring that there is now in place a commitment to working together which was not evident in the history we examined during the Inquiry.

51  Our Inquiry recommendations dealt with the need to develop a model of social work

practice for Jersey similar to the way Hackney had developed a model to transform both practice and culture in their authority and build staff engagement and morale. We learned from Hackney that their model could not be transposed to Jersey but that a Jersey solution had to be developed for its particular challenges. We are concerned that although there are some indications of improved practice, much of what is being put in place is largely process driven and it is difficult to discern what the quality of social work practice is in terms of delivering positive outcomes for children and their families. The Children's Service operation seems to be disproportionately influenced by the activities of the Multi Agency Safeguarding Hub (MASH). The feedback we had from professionals and from families was disheartening. We heard all too often from parents that they had been "Mashed". The unfortunate acronym seems to actually reflect the experience of people who have been exposed to the process. Whilst the MASH model was developed in England to try to build effective information exchange and  decision making  across  relevant  agencies  in  large  metropolitan  areas, we  do question whether the hub, as currently constituted, is proportionate to the size of Jersey. We estimated its annual costs were in the region £700,000, while we could find no indication of what specific outcomes were anticipated in terms of keeping children safe, let alone what had been achieved. We question whether this is the best use of money and resource.

52  Parents told us that they had been "Mashed" on repeated occasions, that the process had not been understood by them nor had it effected any change in their circumstances. This was particularly the case for parents who were struggling to cope

with their children with special needs. In effect, people perceived MASH as a means of denying them service. Like parents and young people, we found it difficult to understand what the Early Help' response was meant to deliver. Many parents described receiving a phone call explaining they had been "Mashed" and were being categorised as in need of Early Help', and asked to identify their case "lead" without understanding what this person's role would entail. The MASH team then notified the chosen agency (e.g. school) that they were the family's Early Help', without, it seemed, any checks on the capacity or willingness of that agency to take on the role. Many staff who were acting as Early Help' leads, particularly in schools, found it to be a bureaucratic, time-consuming and uncertain process which took them away from the job they were trained and employed to do. Our impression was that Children's Services were using MASH to divert referrals and gatekeep access to services, rather than as a safeguarding hub. Having sound child protection practices which operate on a multiagency basis is vital but it is the case that many, indeed the majority, of families which could benefit from the intervention and support of a skilled social worker do not pose a risk to their children. The terminologies of child in need', edge of care' or early help' are not readily understood by families, far less by children, nor do they reflect, in our view, anything more than a process of categorisation of referrals in most instances, rather than effective assessment and service delivery models. We recommend that a model of social work practice is developed which is fit for the Jersey context and which offers effective help for families experiencing hardship and distress and is delivered by a well-trained and stable workforce.

53  A key element in a comprehensive provision for children is a strong fostering service.

We commented on the inadequacies of the service in Jersey in our Inquiry report, and whilst we were pleased to hear of some progress having been made in recruiting foster carers, we remain deeply concerned that foster carers continue to experience unnecessary difficulties in their relationship with Children's Services. It is the case that those whom we heard from still did not feel that they were treated as knowledgeable partners in a team working with the child, and some felt they were considered, in their words, "minions".

54  We heard from foster carers, and indeed from parents, of the difficulties they had with

supervised access arrangements for children in their care. These have been held in rooms which were described as wholly inadequate', in the building in which Children's Services are now housed. Foster Carers felt little consideration had been given to the experience of service users, and particularly children using the building, given that contact with families of origin can be a deeply stressful experience that a child faces, over and over. Rooms for contact were described as "cupboards". While we were pleased to learn that alternative arrangements are being developed, we felt many of the problems of recent months, and the poor experiences of children, could have been avoided if foster carers had been consulted in the planning of contact space. The Children's Service building is not simply an office space for staff but it is a working tool for meeting with people in distress or supervising access. It is disappointing, therefore, that consideration for the experience of children has not been at the heart of planning the environment. We worry that this is a further reflection of an approach to social work being about process rather than care.

Recommendation 5

55  In 2017 we found that legislation for children in Jersey was almost invariably lagging

behind developments in the UK and beyond, and we therefore recommended that consideration should be given as to how the island could have a more effective mechanism for developing legislation, policy and practice guidance in relation to children and young people.

56  We were pleased, therefore, to hear from the team working on policy of the Children's Legislation Transformation Programme (see Appendix 4). This aims to ensure Jersey enacts a wide range of new or updated legislation to modernise the basis on which services for children operate and to underpin effective policy and practice that will keep children safe and thriving in the island. The programme demonstrates a genuine commitment to compliance with the principles of the UNCRC. We consider this to be a positive development in Jersey and recognise the very substantial amount of work which is being progressed by a relatively small policy team with support from the Law Officers Department. The fact that there are now well-qualified people with specific responsibility for policy development in place, gives us some reassurance that Jersey

can keep pace with new research and thinking about meeting the needs of children and young people and improving their life opportunities. It will, however, be important that the current momentum is maintained and supported, otherwise there would be a danger that Jersey could once again find itself continuing with outmoded practices. It will be important that this essential work on policy and legislative development takes into account the views of young people at every stage and that it is supported by the legislature.

57  We made recommendations, in respect of youth justice, to the effect that a review

should be undertaken with a view to moving to a welfare-based model rather than the traditional punitive one. In a welfare-based model, the youth justice system treats young offenders as children first and offenders second. We are pleased to note, therefore, that a Youth Justice Review was commissioned and published its report in October 2018. We are broadly in agreement with its findings and recommendations, which we consider will continue progress toward the welfare-based model we recommended. We have two caveats wherein our view is not directly aligned with that of the Youth Justice Review (YJR).

58  The YJR took a positive view of the Parish Hall Enquiry system, which we recognise is

valued by many in the island as a very long-standing means of dealing with minor offending at a very local level. The fact that it is based on a centuries old model does not mean, however, that it should not be scrutinised against modern standards and expectations. Our remit did not involve detailed scrutiny of the system and our comments are therefore based on the many comments we have received over the course of our Inquiry and this review. We heard from young people of their dislike and distrust of the Honorary Police and that they did not hold them in any regard. Whilst there are often tensions between young people and the police, it seemed to us that there was a particular tension between young people and their Honorary Police officers because of the very closeness of the community. The Parish Hall Enquiry system is closely aligned with the Honorary Police, given that it is a Centenier from the Honorary Police who presides at Parish Hall Enquiries. Whilst the Parish Hall Enquiry is not a court as such, its operating model is that, in effect, the representatives of parish law enforcement are also "prosecutors" and also preside over cases. This may not be compliant with modern standards of judicial practice, including UNCRC principles.

59  We recognise that parishes value the familiarity and locality of the Parish Hall Enquiry system. We are of the opinion that there should be a review of how it operates, particularly in respect of dealing with young people. Consideration should be given to

the separation of functions of parish law enforcement, presentation of facts and the presiding role. The concept of delivering justice within a young person's community has much to commend it, as the YJR has recognised, and we do not demur from that. It is, however, important that those who are the decision makers in the system are seen to be independent of the prosecution or presentation of the facts of offences. They must also have appropriate skills and training and their performance must be routinely reviewed by independent assessors. We agree that models, such as the Children's Hearing system in Scotland or similar Scandinavian models, cannot be transposed easily into the Jersey context and we would not advocate that. Jersey does however have the opportunity to build on its historic model of dealing with issues at a local community level and to develop a model which combines the best of the current system with the best practices from elsewhere. In this, Jersey could have a world-leading restorative model for dealing with young people outwith the formal justice system.

60  The YJR also took a positive view of the Greenfields facility which we revisited as part

of this review. Whilst we found the manager and staff working hard to do a positive job, it was of serious concern to us that, when we visited, there was only one resident, who had been there alone for some time and who would be moved to HMP La Moye later in the year when he reached the age of 18. We consider that, even with good care providers, detaining a single individual in a closed environment is oppressive and unacceptable practice. Greenfields, by the very nature of its design is, in our view, an oppressive and outdated prison-like environment unsuitable for young people. We recommend that urgent consideration is given as to how Jersey can develop alternative models for dealing with young offenders which are less oppressive. It is a matter of serious concern for us that there are two residential units for children on the Greenfields site. Whilst these are now providing care for small groups of children in a homely interior environment, externally they are part of a secure unit campus. This undermines the philosophy of providing a homely, welcoming setting for children indistinguishable from other homes.

61  For some families there may be poor associations of the homes because of their history.

One of the units was previously Les Chenes, in respect of which a compensation scheme is now in place for former residents who experienced inappropriate treatment there. We recommend that plans are developed to move all residential child care from this site. It is our view that the Greenfields building is entirely unsuitable for the care and welfare of distressed children and young people and that it would not be capable of being transformed into a more appropriate facility. A population of the size of Jersey does not require this type or scale of secure facility. Although the building is relatively new, it should be demolished and replaced with small homely units within which close support can be provided when necessary.

62  We recommended that there should be a programme of regular training for all those

acting  in  a  judicial  capacity  in  respect  of  children and  young  people.   Whilst  we understand that some training has been provided, we continued to hear that there was at least a perception that the courts did not always have the welfare of the child as their paramount consideration. There was again at least a perception that the courts tended to a view that the best option for a child would be to be with its parents, with the result that movement towards permanence was often slower than the needs of the child deserved. We therefore reinforce the need for ongoing training for all involved in court decision making in respect of children.

Recommendation 6

63  During the Inquiry we heard many references to The Corporate Parent', but we considered that it was often unclear to those with such duties what this meant. There

was, in our view, little evidence of a full commitment to the duties of corporate parenting by the States of Jersey. We heard that, whilst there had been a briefing session for States members after the election in 2014, it had been attended by very few members. That was, in our view, unacceptable and we therefore recommended that attendance at future briefings following elections should be mandatory and that there should be annual refresher training to underline the principle of paramountcy of the welfare of children in the care of the States of Jersey.

64  It is disappointing to find that this recommendation has not been implemented. It was

suggested that there was insufficient time following the election to set up a training programme and new members had many activities and responsibilities. In our view, corporate parenting is a vital duty for all States members. Whilst we found there was a noticeably stronger expression of commitment to corporate parenting and a somewhat clearer understanding amongst some members of the responsibilities it involves, we are strongly of the view that it is essential for all States members to show leadership through acquiring understanding and acknowledging acceptance of their role as corporate parents. Similarly, it is essential that senior officials across all services have a clear understanding of how they can support the responsibilities of the States through the work of their services. We therefore stress that we continue to be of the view that there should be mandatory training for all States members and that this should be followed through with annual refresher training. Arrangements should be put in place without further delay.

65  To further emphasise the importance of corporate parenting, we recommended that

reference to this specific responsibility should be incorporated into the oath of office which members of the States Assembly are required to swear before taking their seats. This has not happened. We considered that this would be a powerful symbol of a demonstration of a commitment to move from the failures of the past. That continues to be our view and we urge that a decision and arrangements are made in this regard, without further delay, in order to ensure that the oath of office is amended in sufficient time for future elections.  We noted that a Children's Pledge had been prepared and signed by most States Members and senior officials. In our view that does not carry the same symbolic weight as a commitment to Corporate Parenting being part of the oath of office taken by all States Members. We noted that a number of States members had chosen not to sign the Children's Pledge for a variety of reasons. We would stress that corporate parenting is a duty, not an optional interest for each member of the States Assembly. The corporate parenting responsibility, therefore, needs to be emphasised as applying to all members. This was why we recommended that it be included in the Oath of Office since it is a paramount responsibility.

66  Whilst we heard varying views during the Inquiry as to whether there should be a Children's Minister, we did not form a view that this would be the best way forward

and accordingly we did not recommend such an appointment. We do, however, respect the fact that a contrary view was taken following our Report and that a Children's Minister is now in place who clearly has a strong personal commitment to serving the best interests of children and young people. Our main concern is that this appointment must not be allowed to shift all responsibility to this one minister thereby creating any expectation across other ministers and members that their personal responsibility as a corporate parent is diminished.

67  We recommended that a Children's Plan should be published which included SMART

objectives. We note that a Children's Plan has been published covering the period up until 2023. This is a brightly presented document which makes a number of important high-level commitments to the island's children and young people. It is not however a truly SMART document which delivers objectives which are Specific, Measurable, Assignable, Realistic and Time–related. It is not clear from the published document how the laudable objectives are to be delivered and within what timescale nor what resources are to be applied. We are unsure that any member of the public reading the Plan would know whether and when it had been implemented and what difference it had made. In reality, children and young people do not need a document as much as they need the outcome of the plan in terms of the improved resources, services and life experiences it delivers. Members, managers and frontline staff need to be sure of how they will know that the plan's objectives have been achieved. We commend the amount of planning and policy work to date but recommend that more specific objectives, outcomes and timescales should be published, alongside clarity as to where responsibility for delivery lies.

68  We looked in considerable detail at the work and operation of the Care of Children

Review Panel of the Scrutiny Committee who are charged with reviewing progress on the implementation of the Inquiry's recommendations. We were impressed with the understanding of child care issues, their commitment to their task and their passion for child welfare. We consider their role to be crucial in ensuring that the recommendations are implemented in ways that deliver real change and improvement for children and families and do not become subject to inappropriate obstruction. For States members to fulfil their responsibilities, they need to have adequate support available to them to ensure that they can access all the information they need to undertake their roles and that they are well-briefed on key issues. We believe it is particularly important, in the short-term, for the Children's Minister and for the Review Panel to have access to dedicated policy and research support in order to ensure they can identify priorities and carefully monitor progress, while being responsive to the people they represent.  We therefore recommend that this be investigated with a view to adequately supporting States members, with priority being given to those with roles in monitoring the resources, activity and outcomes relating to children.

Recommendation 7

69  During the Inquiry we heard many references to "The Jersey Way". This was a term which was sometimes used to describe positive features of the island's culture but in

the context we were considering it was much more frequently used as a shorthand to describe a lack of transparency and of fairness in decision-making, a reluctance to challenge the status quo and an absence of redress for those who suffered what were considered to be injustices. This perception was fuelled for many victims of abuse, as the abusive systems and practices to which they had been subjected appeared to have been tolerated by those in authority. We considered the implications of the concerns raised during the inquiry to have been sufficiently grave as to warrant our attention, even though some of constitutional matters fell outwith our remit. In our view, addressing this issue is fundamental to restoring an ethos of trust in all the island's institutions.

70  We were of a view that there were constitutional matters referred to in the earlier

Clothier and Carswell Reports which should be revisited as part of an open consideration as to how there could be movement away from the perception that there was a culture of cover up and decision-making behind closed doors.

71  In conducting this review, we heard many references by Jersey citizens and by

professionals, to the "Jersey Way", whose experiences suggested there was still a strongly perceived "Jersey Way" in the island. We do not consider that this is, by any manner, a simple issue to deal with since much is based on perception rather than tangible evidence.

72  We do, however, believe that every opportunity should be taken to counter the

perception by working to demonstrate accountability, transparency and impartiality in all aspects of public services. Decision-making processes should be clear, consistent and demonstrably impartial. Complaints processes should be readily accessible with elements of independent oversight and effective redress, such as would be gained by the appointment of a Public Services Ombudsman. Simple actions can do much to change the perception of the "Jersey Way." As we have said above concerning the presumption of making legal advice documents available to the Children's Commissioner, the default position, with public interest safeguards, could have been seen to be an indicator of a willingness to be open to scrutiny.

73  The separation of judicial and legislative powers, particularly in respect of the role of

the Bailiff , were key recommendations of the earlier Clothier and Carswell reports which saw this as a necessary element of modern constitutional governance. We are concerned that the decision to retain the current arrangements are a further indication of a failure to recognise the importance of these systems, having evident impartiality and full transparency at their heart. In our view, such reluctance to make progress on a matter which sits at the centre of the negative perception of the island only further strengthens that perception.

74  Moving forward from traditional forms of governance is never easy; but the failure to

do so will hold back progress for the island and keep alive the suspicion of inappropriate influence being brought to bear on decision-making.  We recommend that a mechanism be established whereby all new policy, procedure or legislation is checked as to whether it has the potential to create a further perception of there being a "Jersey Way" or whether it counters any such perception by being as open and transparent as possible.

Recommendation 8

75  We made four recommendations on what we termed legacy issues' arising from the

history revealed through the Inquiry.

1. The preservation and accessibility of the archive of the Inquiry documentation and other material. Public domain documents are being dealt with by the Jersey Archive, in order that the documents and all the accounts they hold of people's experiences in the Jersey's care system can be easily available to future generations. The Inquiry also held sensitive and confidential material and information provided by individuals, on the basis that they would not be identified. This sensitive material is held securely off-island. These unusual arrangements were considered necessary because of assurances provided to witnesses and contributors to the Inquiry that their privacy and identity would be protected.
2. Remembering and recognising Jersey's child care history. We heard from the Citizens Panel, which was set up following the publication of our report, and from the officers who have worked alongside the members of the Panel. Their work has been commendable and we understand that there is a commitment to taking their recommendations forward, with funding having been set aside. The creation of a memorial, of an emblem and the establishment of an annual Children's day, will be very visible features of remembrance. It will be important that the commitments made are seen through. We hope that there will be widespread respect amongst islanders for what is planned. In our view, the proposed Children's Day should have ongoing contemporary meaning for the island's children and be forward looking. Similarly, we would recommend that the memorial commissioned is a high-quality piece of public art, which attracts interaction with both islanders and the many visitors to the island, in a similar way to how the fountain and statue in Liberation Square are experienced.
3. Redeeming the Haut de la Garenne site. We understand that the public view was that the building should not be demolished. We recognise there is often a reluctance to demolish old buildings. It remains our view in our recommendations that the building should be demolished and the site not used for any public services for children or victims of abuse. We note that it is proposed that the building continues to be used as an activity centre for groups, including children.

We also note that it has been said that "it was not the building that abused the children". It was, nonetheless, aspects of the design of Haut de la Garenne which made some of the abuse possible to conceal. The building was designed as a Victorian institution without thought to the safety and protection of the young residents. Unless there is very substantial redesign of the current building, it is our view that it continues to be a site in which supervision and protection of children from harm is difficult. Should any future incident of alleged abuse arise in that setting, it would be devastating to the wellbeing and trust of past victims and damaging to the island. It continues to be the case that, unfortunately, the image of Jersey is still elsewhere associated with the building. While the Haut de la Garenne building, in which much abuse occurred over so many years remains in situ, it will, in our view, continue to fuel negative perceptions.

We consider that the future of the site be re-evaluated, with a particular view as to how the substantial funds that could be realised from its sale could be applied to the legacy issues and as a means of supporting the island's most vulnerable children in the long term. The building has a considerable amount of land surrounding it which could be converted into attractive open space which could be designed in ways which would be attractive to families. We are aware of the memorial sited at the entrance and see no reason why this could not be retained there or relocated to an alternative part of the site. While the building remains in situ, we believe that activities for children should not be operating on that site, unless robust and validated safeguarding and safety measures are in place.

4. Care for witnesses after the Inquiry. We heard from the Citizens Panel of the need for ongoing support for victims and survivors and of their ambition that this resource should be readily accessible. We consider that it is important that this is followed through and that the necessary financial resources are made available to allow those experiencing ongoing trauma to obtain help and support for as long as is required.  

Ensuring Progress

76  During the process of undertaking this review we were frequently asked if we would

come back in another two years. It was clear that many people across all sectors and interests believed that unless there was external scrutiny of progress, there was a possibility, indeed in their view, likelihood, that the momentum for change would be lost.

77  While we appreciate the confidence this shows in the Panel, we are of the view that the

island now needs to move on from the Inquiry process, while never losing sight of the histories it revealed or the findings it made. Much progress has been achieved in Jersey, and is being made, but as we have identified in this report there are also many things still to be done. (These matters are considered in more detail in appendices 1 and 2).

78  Broadly, however, all of our recommendations are being progressed and we consider

that there is a genuine commitment on the part of many people with responsibility to continue to make progress. The various checks and balances such as the Children's Commissioner and external inspection which we recommended, along with the work of the Care of Children Review Panel, should help ensure that improvement continues. We are, nonetheless, well aware of the history in Jersey of good intent slipping and there being a failure to take forward the recommendations of previous inquiries across a range of subjects. We therefore suggest that consideration should be given as to how some form of continuing external review is maintained. This could be in the form, for instance, of a quinquennial review, to be undertaken by an independent person coinciding with the reporting of compliance with the principles of the UNCRC. The report of the quinquennial review should be a public document and a response should be made by the Chief Minister to the States Assembly.

79  Finally, we commend the progress which has been made in respect of our Inquiry

recommendations to date and recognise that a huge amount of effort has been put into starting that change. As we have set out above, we recommend attention be paid to areas where work remains to be done and to other matters which, in our view, could be strengthened or improved, including those set out in the following appendices.

80  We believe Jersey has the potential to learn from its past in order to put in place truly

world class services for children. Some long-held approaches will need to be relinquished to allow new ones to develop to ensure a better future for the island's children. We are reminded that almost everyone who had suffered maltreatment in the island's care system told us that the purpose of sharing their experiences was to ensure that, in the future, children in Jersey had safer, more fulfilling and happier childhoods. Delivering that future honours their past. We wish well to all with that responsibility.

Appendix 1

Addressing the Failings of the Past

APPENDIX 1

Addressing the Failings of the Past

1. Introduction

1. In our 2017 report, we identified 10 significant failures that had contributed to inadequate and often abusive treatment of hundreds of children either in the care of the States of Jersey or placed in charitable institutions in Jersey. These failures were rooted in government policies, lack of investment in staff and systems, lack of vision, failures of leadership resulting in an unhealthy organisational culture and poor standards of service and practice.
2. Throughout this review, we looked for evidence of whether and how these failings were being addressed and to what effect. We focused on identifying progress in addressing the ten failings  in our document review exercise, where we studied nearly 300 documents provided to us by the States of Jersey, professional organisations, voluntary organisations and individuals. We also considered these failings  in our public discussions with politicians, staff, foster carers and Jersey citizens. Over 50 people participated in public discussions with the Panel held at St Paul's Centre 21-24 May 2019. Transcripts of these sessions are available at www.ijcipanel.org/transcripts .
3. The themes for our public discussions were also informed by our program ofvisits and our private meetings with over 200 people (including families, care experienced young people and adults and staff from several disciplines) and by  over 300 written contributions to this review that we received from people in Jersey. Fuller discussion of these meetings and contributions is in Appendix 2.
4. In this appendix we set out our conclusions and findings in respect of progress in addressing the ten systemic child care failures that we identified in our 2017 report:

• Failure to value children in the care system, listen to them, ensure they are nurtured and give them adequate opportunities to flourish in childhood and beyond.

• Failure to have in place an adequate legislative framework that prioritises the welfare of children in need or at risk (both in respect of child welfare and youth justice matters).

• Failure to keep pace with developments in social policy, childcare practice and social work standards in the developed world.

• Failure to plan and deliver services in an effective, targeted manner to achieve positive, measurable outcomes for children.

• Failure to establish a culture of openness and transparency leading to a perception, at least, of collusion and cover-up.

• Failure to mitigate negative effects of a small island culture and its challenges.

• Failure to make sufficient investment in staff development and training.

• Failure to adopt policies which would promote the recruitment and retention of staff with essential skills in child welfare and child protection.

• Failure of the States of Jersey to understand and fulfil corporate parenting responsibilities, including adequate aftercare of children who have been looked after by the state.

• Failure to tackle a silo mentality amongst public sector agencies.

5. Our discussion below considers the extent to which these failures are being addressed. It is by no means a reflection of the entirety of the inputs we received, nor does it fully cover all the activities and initiatives which have been undertaken in Jersey in response to the recommendations of the 2017 Report. We have focused on the main issues which emerged from our public discussions, on initiatives and actions which illustrate marked progress and on areas where significant further progress is required. Our conclusions in all these matters are reflected in our discussion of the eight original recommendations in the main part of this report.
6. Inthecourseofthisreview,wehavestudiedandheardabout a vastamountofdocumentationincludingplans,strategies,minutesofpolicyandofmanagementmeetings,andreviewsofservices.Whilewehavebeenimpressedbythevolumeof work which has taken place in Jersey, we know that policy intentions andaspirationaldocumentsdonotnecessarilytranslateintoimpactfulactions. Wehave considered carefully, therefore, the feedback we received from peopleexperiencing services or who have first-hand knowledge of how systems areworking.

2. Failure to value children in the care system, listen to them, ensure they are nurtured and give them adequate opportunities to flourish in childhood and beyond.

1. This was the area in which we received most contributions. It has been the focus of much of the work undertaken by the Government of Jersey, some of it pre-dating the publication of the Inquiry report.

"There's no child that goes through the care system that doesn't have an element of trauma. And then I wanted ... all I ever really wanted was not business success, or anything like that. I wanted a stable family home where I could have my own children. And have my own house." - Lauren Burnett

2. EXAMPLES OF PROGRESS:

1. From the outset, there has been acknowledgement and appreciation of contributions to the Inquiry from Jersey people who had suffered in the care system. On publication of the Inquiry report, a profound apology was made to them by the then Chief Minister, on behalf of the Jersey Community. "There was such an acceptance of the failings, and that real desire to face up to the truth, and to put that in our collective memory." – Tom Walker

2. Readiness to engage with and listen to care experienced adults on recognising and redeeming the past. "The significance of the setting up of the Citizens Panel cannot be understated. After decades of silence and being ignored and cover-ups, we, survivors are being listened to. We have a voice. We are sitting at the table. We are helping make decisions on the future and every single one of us is incredibly proud to be part of this process." - Mr D.
3. Transformationofresidentialfacilitiesforchildren.Thishasinvolvednotsimplyanupgradingoffacilities,butreplacementofstaff,investmentinstaff development, new leadership and an adoption of policies whichpromotesmall,homelysettings. Thereis a clearvisionbymanagersofhowcare should be delivered in these settings. The short-term facilities forrespite care for children with disabilities have been described as "gold standard"bysomeparents.
4. AppointmentofaninterimChildren'sRightsOfficer. A careexperiencedadultdescribedthisasoneofthemostimportantresponsestotheInquiryfindingsandpaidtributetothecurrentpostholder'sapproachabilityandrelationshipwithyoungpeople.
5. Responsiveness to the Jersey Cares' initiative: "The story of Jersey Cares' doesn't come from a planned document. It comes from a group of people from across our community who wanted to respond to some of the recommendations, learnings, failings that you outlined in your report."- Andrew Heaven. The Government of Jersey recognised and responded to this initiative by citizens of the island. Alongside voluntary organisations and the Children's Commissioner, the government is supporting the development of the group into an organisation providing advocacy and participation services, as well as opportunities for care-experienced young people.
6. Recognitionthatyoungpeopleinthecaresystemhavecontinuingcareneedsbeyondstatutoryleavingcare'dates.Weheardseveralexamplesofmore flexible and sensitive approaches being taken to young people'sneedsandpreferencesandprovisionofsupportduringtransitionperiods. YoungpeopleinJerseynowhave a personalassistant'allocatedtohelpthemwhentransitioningtomoreindependentliving. Somearrangementsareinplacetoprovideadditionalsupportforthosewithoutfamilysupporttonavigatemovingintoemployment,furthereducation,securinghousingandmanagingfinances.Children'sServicesarelookingtohave a pointofcontactandprovidelongertermsupport,ifrequired,toyoungadultswhohave left the care system. Corporate parenting responsibilities will beextendedtotheageof25.

7. Thehealthandwell-beingoflooked-afterchildrenhasbeengivenhigherpriority,throughtheappointmentof a dedicatednurseforchildreninstatecare,whohasbeen a strongadvocateforlookedafterchildren.
8. The appointment of a Children's Commissioner was agreed before thepublicationofthe2017Inquiryreport. Thepostwassetupwithextensivepowersandiswell-resourced.Significantly,youngpeoplewereinvolvedintheselectionofthesuccessfulcandidatetoensurethatchildrenwouldhaveconfidenceintheappointee.
9. Young people have been supported and funded to participate in events for care experienced children and young people, including in the UK where they have had access to a range of resources, new experiences and expectations. "The conversations that were being had about their next steps, their future, it was really good for me to see that because we never had anything remotely like that. So, I definitely feel that there are changes going in the right direction". – Lauren Burnett
10. A virtual head teacher' position has been created to co-ordinate and monitor education provision for looked after children, and to ensure early intervention where a child is encountering difficulties in education and to plan for addressing needs and managing transitions.
11. There has been considerable investment in training staff in trauma informed practice. This is reported to have been particularly successful in Education Services and has resulted in a large cohort of staff with a better understanding of the needs of care experienced children, of how to respond to them and how to plan for the best outcomes for them.
12. More safeguards have been devised to monitor the experience of children cared for outwith their immediate families. These have included the introduction of a regulatory framework covering the appointment of the Children's Commissioner and the establishment of the Jersey Care Commission which will register and inspect homes caring for children. The establishment of the Care of Children Review Panel of the Scrutiny Committee has also been a positive development in scrutinising the effectiveness of services for children and in holding to account those responsible for the quality of experiences children have.
13. The events that gave rise to the investigations of Operation Rectangle' and led to the Independent Jersey Care Inquiry, fostered the growth of social media commentators in Jersey who determinedly advocated for victims and for transparency in governmental and criminal justice operations and continue to do so vigorously. Print and broadcast media in Jersey have increasingly played a role in holding to account government services providing care for children (e.g. by investigating the quality of the institutions in which Jersey children were being cared for off-island). All media play a role in questioning whether official accounts of progress reflect the actual experience of individuals, particularly children:

"I think we have seen more control over information and media now that I have noticed, than I have had in 20 years of working." – Andy Sibcy

"You would think everything was wonderful by what they were saying and that is the PR approach of loving Jersey, all this stuff, punching above our weight Everything is wonderful. There is nothing to worry about." – Mike Dun

We believe an unfettered, questioning, professional media and a thriving online community of social activists, respectful of the privacy of individuals and families, have vital roles in keeping the public informed, advocating for the rights of disadvantaged communities and holding public sector agencies to account.

14. Jersey Youth Service has been involved in the development of a Youth Parliament, which has the potential to increase the engagement and participation of young adults in island politics, as well as providing another forum for promoting the interests and views of young people.
15. The Les Chenes redress scheme has been agreed and, significantly, will offer an individual written apology to each person as part of the programme, in recognition that acknowledgment is often more important than financial redress to victims.

3. WHERE MORE PROGRESS IS NEEDED:

1. Two institutions in Jersey still fall far short of acceptable standards. The secure facility at Greenfields is not fit for purpose and we were told that, as currently established, it would not meet standards for registration. Orchard House, the residential in-patient mental health facility where young people are housed, is also not fit for purpose. Deputy Kevin Pamplin spent 24 hours in that facility: "I walked round, and I saw people, from my humble opinion in a facility that was tired, was like an oven. I went to an outside area, which was about a square foot, it looked like I'd gone into an outside prison areait was so, for me, demoralising. But also, looking around at the patients in there, there was no therapeutic care going on, and I was thinking, This has been in place for a few years.'"

In our view, neither institution's facilities nor practices would be regarded as acceptable in terms of established best practice under United Nations Convention on the Rights of the Child (UNCRC) principles.

2. It is important to recognise the trauma young people in the care system live with and to provide a range of supports and treatment for them. Problems arising from trauma that is untreated, or inadequately treated, should be better acknowledged and recognised as health rather than behavioural issues, particularly within health services. Much more investment is needed to give young people tools, through therapy and support, to manage their mental health and to deal with their trauma, including destructive thought patterns.

3. While some steps have been taken to enhance the educational experience of young people in the care system, more help is needed to encourage young people to stay in education and realise their potential. This could include development of mentoring and tutoring schemes for looked after children. The Virtual Head Teacher scheme is an excellent idea but requires proper resourcing. The appointee, also, must have authority to cut through bureaucratic and other obstacles to children receiving necessary educational support. The post should also be resourced to support the educational needs of children currently placed off island.
4. The government has taken a bold and progressive step in supporting the development of Jersey Cares'. When fully operational, Jersey Cares' will not only provide advocacy for, and advice on, the needs and aspirations of young people but also will challenge and hold to account government departments in respect of support for looked after young people. It is important that this emerging organisation is enabled to act independently, but also that it is supported to have in place good systems of governance and access to expert advisors to nurture it as it develops. It is also important that unrealistic expectations are not placed on Jersey Cares' in its early stages.
5. The engagement of young people in devising standards for inspection of care homes has been a positive step and one that teenagers in Jersey's care system, even a few years ago, could not have envisaged. Continuing input is required to ensure inspection remains focused on improving outcomes and experiences for young people, lest registration and inspection becomes entrenched in descriptions of process and completion of forms.
6. Thestrategyforlongertermsupportofcareexperiencedchildrenshouldbeclearlyarticulatedandthesupportprovidedmadeeasilyaccessible.Thisincludesidentifyingtraining,educationandhousingprovisionthatcanbetailoredtoindividualneeds.
7. Thecomplaintsprocessesforallserviceusers,andinparticularforyoungpeople,isrecognisedasnotbeinguser-friendlynorareresponsesalwaystailored to the needs and understanding of the complainant. Greaterrecognitionisrequiredofhowdifficultitisfor a youngpersontoquestionadultsortoraise a concern,whilesystemsmustbesimplifiedandmademore sympathetic and responsive. The readiness of current seniormanagers in Children's Services to meet with young people and dealdirectlywithcomplaintsiscommendablebutthesystemshouldnotbedependent on the professionalism of some individuals. The fortnightlyreviewofallcomplaintsbythemanagementteamofChildren'sServicesis a welcomedevelopmentbut a cultureshiftisneededacrosstheserviceawayfromresistancetoanddefensivenessaboutcomplaints. Therightofallpublicserviceuserstomake a complaintshouldbeenshrinedinlaw.

3. Failure to have in place an adequate legislative framework that prioritises the welfare of children in need or at risk (both in respect of child welfare and youth justice matters).

1. SincethepublicationoftheInquiryreport,the Children's Legislation Transformation Programme (CLTP) has been developed (Appendix 3). This is an ambitious programme which aims to establish a robust legislative framework in Jersey for achieving better outcomes and safer lives for children, while improving governance of and accountability for children's services.
2. EXAMPLES OF PROGRESS:  

1. Additional resources have been provided, including a dedicated legal advisor to support policy officers in developing law drafting instructions and enhancing the Safeguarding Team within the Law Officers Department.
2. The process of informing and developing drafting instructions for legislation has been much more open and inclusive since 2017, involving consultation and inputs from a range of professionals and has been experienced as a more collaborative and much improved process.
3. Developmentofextensivelegislationproposalsinvolving39separatepolicyareasintroducingneworupdatedlegislationcoveringtopicsasdiverseassafeguarding,regulationandinspectionofservicesforchildren, criminal record disclosure, housing, domestic abuse, care proceedings and education.
4. Legislation for the establishment of the Office of the Children's Commissioner was developed through a process of extensive consultation and promptly drafted and enacted. The law gives the Commissioner extensive powers and is framed in broad terms in respect of who she can assist.
5. The Care Commission legislation has been enacted and there are plans to give the Commission further powers to regulate and inspect individuals and organisations providing services to children.
6. Legislation has been enacted to provide more effective protection against sexual abuse and exploitation.
7. Key areas of proposed new or amended legislation, which underpin the 2017 Inquiry recommendations, include the establishment in law of the States' duty to any child in need', including children with disabilities; establishment of the rights of care leavers and of a duty to provide assistance to young people transitioning from care and beyond; principles of corporate parenting to be enshrined in law and the 1961 Adoption Law to be overhauled. Young people in employment will be afforded greater protections under the law to safeguard against engagement in inappropriate work.
8. A YouthJusticeReviewhasbeencommissionedandhasreported.
9. WorkisunderwaytoincorporatedueregardtotheprovisionsoftheUnitedNations Convention on the Rights of the Child (UNCRC) into Jersey's legislation, which would put an obligation on government to have due regard to the rights of children when undertaking government business and when bringing forward policy and legislation.

10. The Government of Jersey has asked the Children's Commissioner to review all legislation using a child rights' lens and to report to them next year on what needs to change.

3. WHERE MORE PROGRESS IS NEEDED:

1. We believe the appointment of an independent Public Services Ombudsman is an essential component of the strategy for addressing a poor tradition of complaints handling and for dispelling perceptions of collusion and lack of transparency in public services. We consider this provision should be accorded the same priority in the drafting and enactment of legislation as was given to the establishment of the Office of the Children's Commissioner. The legislation should reflect the independence of the role and provide extensive and robust powers to investigate complaints.
2. The right of children and adults to complain about public services, including services provided on behalf of government, should be enshrined in law.
3. The forthcoming review of the Children's Commissioner legislation should consider a requirement for people, independent of the Commissioner, to be involved in the selection and appointment of the Advisory Panel. The review should also consider making access by the Commissioner to legal advice provided by the Law Officers Department the default position in law, except where, in the view of the Attorney General, the public interest is not served by disclosing privileged material. Consideration should also be given to ensuring the powers and process for removing a Commissioner from office are as transparent as practicable.
4. We consider that some priority should be given to increasing the power of the Care Commission to cover the regulation and inspection of youth clubs, voluntary organisations and other environments (e.g. outdoor services) where children are supervised by adults other than their parents or carers. We also consider it would make sense for the regulation and inspection of early years provision – childminders and nurseries - to be brought under the auspices of the Care Commission.
5. Considerationshouldbegiventobringingforwardlegislationestablishing a duty to promote the social welfareofchildren. This would provide a statutorybasisforaddressingthesocialinequalitieswhichcanimpactthehealthandwell-beingofchildren,suchasaccessingmedicalanddentalservices.
6. InrecognitionoftheexperienceinJerseythatitisoftenmanyyearsaftertheeventsofchildhoodthatpeoplecomeforwardto shareaccountsofabusiveexperiences,lawsonlimitationshouldberevisedtoincludemoreflexibility.

4. Failure to keeppacewith developments in social policy, child care practice and social work standards in the developed world.

1. Standards of child care in Jersey suffered for decades, in part because policy and practice became disconnected from research, developments and emerging practice models in other parts of the western world. Staff had few opportunities to participate in training and continuing professional development outwith Jersey, in order to keep their skills and knowledge current. There was little encouragement for staff to engage with external professional networks. Standards suffered, and ultimately children suffered, because of outdated models of practice and because professionals were poorly equipped to understand the needs of, or care of, traumatised children.
2. EXAMPLES OF PROGRESS:

1. Whilesomeserviceusershaveexpressedfrustrationwithsometemporarysocialworkers'lackoffamiliaritywithJerseyregulationsandchildcarelaw,thereisalsoampleevidenceofallpractitionersbenefittingfromexchangesofideasandexposuretodifferentperspectivesandsocialworkpractices.
2. Trainingintraumainformedpracticeandadversechildhoodexperiences(ACES),whichunderpinsmostmodernapproachestoworkingwithchildrenwhohaveexperiencedabuse,neglectorsignificantfamilydysfunction,hasbeenmadewidelyavailabletostaffinJersey.
3. TheOfficeoftheChildren'sCommissionertookadvicefromcommissionersandombudsmeninUK,Ireland,Scandinavia,FlandersandAustraliaonthedevelopmentoflegislationandonestablishingandempoweringtherole,and incorporated good practice in those jurisdictions into Jersey'sapproach. Jersey is now part of the network of commissioners andombudsmenfromtheUKandIreland(BINOC).
4. A partnershipbetweenHighlandsCollegeandtheUniversityofSussexhasledtothedevelopmentof a Jersey-basedBAdegreecourseinsocialwork,validated by the University. The course involves exposure to currentresearchandbestmodelsofpracticeinsocialworkinternationally,aswellasreferencingJerseyexperienceandincluding a moduleonJerseylaw.
5. ThroughtheinitiativeJerseyCares'andwithsupportfromtheChildren'sCommissioner,Children'sRightsOfficerandChildren'Services,linkshavebeen developed with Scott ish initiatives for care experienced children,including with the young people's advocacy service, the Scott ish WhoCares?'andwithunitsinScotlandspecialisinginbestpracticeinresidentialcare. CareexperiencedyoungpeopleinJerseyhavebeenencouragedandsupportedtoparticipateineventsforyoungpeopleincareintheUK'sfourjurisdictions.
6. The Care Commission is looking to include young people from outwithJerseyinitsinspectionofcarefacilitiesforchildrenandhopesthat,intime,care-experiencedyoungpeopleinJerseywillparticipateininspectionsinotherjurisdictions.

7. External expertise has been engaged to assist the development andoperationoftheEarlyYearsPartnershipandin thekeyroleofinterimdesignatednurseforsafeguarding. Bothpersonsbringexperienceof a rangeofgoodpracticemodelsintheirfields.
8. MirroringtheexistingarrangementsforindependentchairmanshipoftheJerseySafeguardingPartnershipBoard,theChairandmembersoftheCareCommission (apart from a carer member) are also all externalappointmentswhobringexperiencein a rangeofsafeguardingandcaresettings.
9. Workbeingundertakenonearly years registration is linked into the British and Irish Network in that field to provide additional perspectives, to ensure consistency with other jurisdictions and to keep officers' knowledge up to date.
10. The Care Commission commissioned Ofsted to undertake an inspection of Children's Services, with a follow-up review due in the autumn of 2019. The follow-up review will involve the Commission's inspector to ensure a balance of wide-ranging knowledge of good practice models and standards with local knowledge of the Jersey context.

3. WHERE MORE PROGRESS IS NEEDED:

1. Promotion of links with international organisations, research institutions and integration into international networks is not intended for the purpose of importing practice and models from elsewhere to supplant Jersey operations. Rather, the aim is to ensure that models and policies, implemented in Jersey, draw on the best research and practice from across the world and use these to enhance and refine models and policies that are tailored to the Jersey context. The value of staying connected to international institutions and networks and drawing on external expertise and the dangers of failing to do so, need to be clearly and continually articulated to dispel ill-founded arguments that this approach diminishes Jersey's identity.
2. The reality of island life is that staff and political participation in external activities comes at a cost in time and money. Such activities should be viewed as an essential part of the island's child care operations, rather than a peripheral activity or unnecessary benefit.
3. Funding for children and young people to participate in off-island events for care-experienced youngsters should be guaranteed as part of the States' commitment to fulfilling its corporate parental role.
4. OpportunitiesforfrontlineChildren'sServicesstafftogetexperienceofothersettings,aspartoftheirongoingprofessionaldevelopment,shouldbeencouraged.AssistanceshouldalsobegiventoencouragesocialworkstafftobecomemembersofinternationalprofessionalnetworkssuchasBASW and IFSW and participate in these organisations training andresearchevents.

5. Failure to plan and deliver services in an effective, targeted manner to achieve positive, measurable outcomes for children.

1. In recent times, no one can say there has been a failure of planning around services in Jersey. Since the 2017 Inquiry report, there has been a prodigious amount of strategic and operational planning activity, with the goal of improving the life chances for children. There have been Programme and Improvement Boards, a comprehensive and coherent Children's Plan has been developed and launched, and frameworks and pathways have been developed. Commendably, a Scrutiny Sub-Committee, the Care of Children Review Panel, has been established to monitor and hold government and departments to account for progressing the Inquiry's recommendations. In reviewing progress in this area, we have focused on the impact and outcomes of all the planning activity and sought to understand how all the actions set in motion have been experienced by children and families.