Coordination of Services for Vulnerable Children Sub-Panel Review - Report - 27 July 2009

Health, Social Security and Housing

Scrutiny Panel

Coordination of Services for Vulnerable Children Sub-Panel Review

Presented to the States on 27th July 2009

S.R.6/2009

CONTENTS

CONTENTS........................................................................................................................ 3 CHAIRMAN'S FOREWORD............................................................................................... 5

1. TERMS OF REFERENCE...................................................................................... 10
2. SUB-PANEL MEMBERSHIP .................................................................................. 11

Main Panel Membership................................................................................................ 11 Expert Advisers............................................................................................................. 11

2. KEY FINDINGS ...................................................................................................... 12
3. RECOMMENDATIONS .......................................................................................... 14
4. INTRODUCTION.................................................................................................... 19

The local picture............................................................................................................ 19 The wider context.......................................................................................................... 19

5. STATES SERVICES: GOVERNANCE AND ACCOUNTABILITY........................... 21

Political accountability................................................................................................... 21 Governance and accountability..................................................................................... 22 Management and staffing.............................................................................................. 27 Serious complaints and advocacy................................................................................. 34

6. FOSTERING, ADOPTION AND RESIDENTIAL CARE.......................................... 36

The shape of the Jersey care system............................................................................ 36 Leaving care.................................................................................................................. 41 Obstacles to good service............................................................................................. 43

7. SERVICE DELIVERY AND ACCESS..................................................................... 47

When to intervene......................................................................................................... 49 Inter-agency coordination.............................................................................................. 56 Access........................................................................................................................... 64

8. CHILDREN AND THE LAW.................................................................................... 72 Children in court............................................................................................................ 72

Children who offend ...................................................................................................... 78 9.  THE WILLIAMSON REPORT................................................................................. 86

APPENDIX I: .................................................................................................................... 90

Evidence gathering........................................................................................................ 90 APPENDIX II: ................................................................................................................... 93 A Review of the Williamson Report............................................................................... 93 APPENDIX II: ................................................................................................................. 100 Should Jersey become Laming Compliant'? .............................................................. 100 APPENDIX II: ................................................................................................................. 103 Comments on the Shape of the Jersey Care System.................................................. 103 APPENDIX II: ................................................................................................................. 113

How can family support services contribute to the delivery of high quality services for vulnerable children?.................................................................................................... 113

APPENDIX III: ................................................................................................................ 121 Levels of intervention .................................................................................................. 121 APPENDIX IV:................................................................................................................ 123

Submission on the work of the Leaving Care Team, from Steve Mcvay, Team Manager of the Child Care Team............................................................................................... 123

APPENDIX V:................................................................................................................. 125 Strong Foundations..................................................................................................... 125 APPENDIX VI:................................................................................................................ 126

Background and context to the work of the National Society for the Prevention of Cruelty to Children (NSPCC)................................................................................................... 126

APPENDIX VII:............................................................................................................... 128

Submission from Milli's Child Contact Centre.............................................................. 128 Background and Overview of Jersey Mencap............................................................. 132

APPENDIX IX:................................................................................................................ 135 Background and Overview of Brook............................................................................ 135 APPENDIX X:................................................................................................................. 137

Background and Overview of the Children (Jersey) Law 2002, Submitted by the Jersey Family Law Association (JFLA)................................................................................... 137

CHAIRMAN'S FOREWORD

I would like to thank, most sincerely, all those individuals, organisations, establishments and States Departments who have willingly given their time and effort to contribute to making this Scrutiny Review possible, in such a short period of time.

In writing a short summary of what I have heard, seen and read, I find that I cannot effectively condense it into a few paragraphs, however, I believe that the Sub-Panel has conducted an open, fair and rigorous review that has focussed on the facts.

I estimate that I have met or had direct contact with over 100 people, which I believe, has given weight, depth and variety to the Report albeit in a very short period of time.

I also recognise that because of time constraints, it has not been possible to visit or hear from everyone involved on a regular basis for the health, welfare and safety of the Island's young people: to those whom we have not contacted or been made aware of their work, I offer my apologies.

I wish to put on the record the care, compassion and professionalism I have witnessed, which has demonstrated to me that much good work is going on supporting families and children within a variety of sometimes very difficult and emotive situations.

While there may have been some assumption by States Members and others that this Scrutiny Review was just about the review, report, recommendations and possible implementation plan of the work of Mr Andrew Williamson, I always believed that the issues effecting the lives and well- being of children and their family life and values were far wider than the content of the Williamson work and this has proved to be the case, indeed, Williamson is silent on some of the areas that we have looked at. For example, the work done by Family Nursing & Home Care with their network of Health Visitors who play a pivotal role in services and support provided to vulnerable children and their families.

The range of people who have made time and effort to see the Sub-Panel or make submissions ranges from those working in a voluntary capacity to some highly paid professionals, however, I can say that all contributions were treated with equal weight and were greatly appreciated in assisting the Sub-Panel with its work.

Whilst it is not possible to summarise all of the issues in a few short paragraphs by way of introduction to this Review, I can say with some certainty the many people and organisations working with families and young people are under some serious pressure because of increasing demands for their services. Those demands exceed the number of staff in those areas who lack adequate facilities, premises and guaranteed or secure funding. I do not believe it is appropriate for some organisations to rely on charitable or individual donations or on their own fund raising efforts, such as car boot sales, sponsored walks, dressing up days etc, to support the supply of very essential services.

My reason for saying this is that I have heard from those working at the sharp end' of caring for our young people and families where, on too many occasions, interventions' (i.e. support) are at a critical level, when, if resources had been more readily available, effective work could have be done earlier to provide support and assistance at a lower level or tier. That is a view I fully support and I believe that although it has a cost, it also has a long-term benefit, which should now be recognised.

There is evidence now emerging, which I have seen, that the work of the Royal Court and Family Division is increasing because of the consequences and effects of the Children (Jersey) Law 2002 and its interpretation. This is causing some tension in the system when professionals and those advising the Court have to wear two hats; as support to the child and family; then as adviser to the Court. These situations are not right and proper and a clear division is required, supported by a professional and adequately resourced mediation service.

During the course of this Review, the States of Jersey considered and approved some of the funding for the "Williamson Implementation Plan", due to pressure caused when the circumstances of the children of Family X became publicly known. This agreed funding mechanism is at odds with what the money was actually identified for – the Plan requested money for on-Island provision – when the money was to be used to provide the appropriate level of specialised care off-Island. The circumstances surrounding the children of this family and other cases before the Royal Court, in particular cases known as "Re KG" and "Re V", suggest to me that there have been some serious failures in the child protection "system" that go beyond the scope of this Review, but which need to be investigated.

Whilst it may have been convenient for "buck passing" between Officers and Departments, politicians and the Courts, I believe what Lord Laming said (when he was Chairman of the Inquiry into the death of Victoria Climbié) in his Summary & Recommendations, after listening to witnesses and receiving submissions:

"Some used the defence no one ever told me.'. Elected councillors and senior officers must ensure that they are kept fully informed about the delivery of services to the populations they serve, and they must not accept at face value what they are told"

Laming's summary also says the following:

"Time and again it was dispiriting to listen to the buck passing' from those who attempted to justify their positions. For the proper safeguarding of children this must end. If ever such a tragedy happens again, I hope those in leadership posts will examine their responsibilities before looking more widely."

I believe that there is a requirement to establish some facts regarding the above child protection issues.

In addition, the Jersey Child Protection Committee has a vital part to play here; by establishing a higher profile and engaging the public by publicising its role and responsibilities. A change of name to include "Safeguarding Children" seems eminently sensible. This body' also needs to give transparency and comfort to the general public, children and families, as well as to those involved in working with and supporting children and families.

The key findings and recommendations are carefully drawn together after the gathering of a considerable amount of evidence from witnesses before hearings and other written submissions or authorities and reports from elsewhere, however, the main issue is the action that is taken from these in order to promote better levels of non-stigmatised support to those families who need or seek it.

We are now seeing high levels and costs for specialised care requirements being identified for abused children. Also, court and case costs are escalating and are running into hundreds of thousands of pounds because of the workings of the Children (Jersey) Law 2002, which was enacted in August 2005. The medium- to longer-term solution must be to invest in good quality non-stigmatised childcare and support from a variety of agencies for a range of ages, which CAN make a difference. The cost of one should offset the other in the medium to longer term. The failures to make the investment now will, I believe, see the later outcomes worsen, both in terms of service provision and escalating costs, so the question then is: Do we put the fence at the top of the cliff or the ambulance at the bottom?

The Sub-Panel was therefore very surprised to read of the proposed closure of the Grands Vaux Family Centre. This organisation plays a vital role in its surrounding community and is an excellent example of the very bodies that are crucial in preventative and pro-active work with children and families.

I have witnessed different levels of residential care and custody for young people and met many dedicated people entrusted with their care.

La Preference was a positive setting with the young people at home' and engaging positively with staff and each other in what appears to be a caring environment.

Heathfield was more energised and coping with a range of young people, each presenting their own problems and challenges. Staff and young people were interacting well, however, the place does need some serious modernisation and remodelling and I have no doubt that it would benefit from catering for less young people but on a supported self-catering basis.

A meeting with the Committee and Senior Management at Brig-Y-Don demonstrated a homely environment with particular focus on the under-11s. However, there are issues, such as the tremendous facility of a well- equipped and well-sited children's nursery that lies dormant or the fact that the Trust is eating into its own funds at an unsustainable rate to provide an ongoing service. I believe Brig-Y-Don's targeted future should lie with catering for those younger persons in need of care and in encouraging fostering and adoption. Also, the nursery provision needs to be re-activated with wider community access, perhaps with other agencies like the NSPCC or looking at the Bridge model.

 HM Prison La Moye and Young Offender Institution: as well as discussions with the Prison Governor, Mr. Bill Millar , and Members of the Senior Management Team. I was involved in stand- alone' open talks with three young residents. I am convinced by what I heard and saw here and from visits to Greenfields that we need more flexibility around secure welfare and other remand and custodial options for young people.

In situations I have witnessed and after having spoken to young people themselves, there are some very real issues around secure placement, sentencing options and remanding of young people. Greater flexibility is required to reflect what happens to the mature 14 year olds or the immature 17 year olds – drawing a line at a certain age is inappropriate.

Where young people are living, who they mix with, and the effect this has on their future life as well as shorter term attitude and behaviour all need to be considered as part of wider, more flexible and comprehensive care options and plans.

I visited Greenfields on 20th April, on which date the centre had a full complement of eight residents. I made another check on 27th May when the centre was full plus one. This is the opposite  of  the  Williamson  visits,  when  Greenfields  was  seriously  under  utilised.  This demonstrates the difficulty of the Island's situation of providing catch-all facilities for young people.

Common sense suggests to me that young people leaving care should have more targeted and continued support up to the age of 25, especially with regard to housing, education and training and finding employment. Parents would not, and indeed their children do not, find their own way in the world at 16, 18 or even 21 – then I believe it is unrealistic for us to be placing age-related demands on young people when they may also have had some difficult early years problems and are without family support.

With all of the aforementioned there needs to be a positive way forward. Indeed, the States Strategic Plan 2009-2014 (P52/2009) recently approved by the States of Jersey has, at section 9, the following:

9. Enhance Support Services to Vulnerable Children, Families and Others at Risk whilst the majority of Islanders take pride in their independence and self determination, we recognise that some sections of our community need support to improve their life-chances and access the same opportunities available to others.

Understanding  child  and  family  characteristics,  parenting  practices,  family  structures  and influences in the wider community and social environment is vital for the development of policy and the provisions of services to families. Our Aim is to work with local families to reduce the number of young people leaving school with poor skills, qualifications and low expectations and to reduce personal  and  social  problems  in  later  life.  One  priority  will  be  immediately  implement  the recommendations of the Williamson review of children's services.

I would suggest that this is NOT enough, we need to do more than Williamson. The Report goes on: Why We Must Do This

Children fare badly when their families face multiple disadvantages – poor parenting, poor physical or mental health, substance and alcohol misuse, domestic violence, learning disabilities, crime and financial stress. If we are to tackle the challenges faced by disadvantaged families, we need to address the root causes and consequences.

I would agree with this on the evidence I have seen, however, it really does need to translate into effective action now.

The Report continues:

Early investment in and support for, vulnerable children and families not only improves the outlook for the individuals concerned, it also benefits society in the longer term by ending the cycle of dysfunction and reducing ill-health, irresponsible or anti-social behaviour and crime.

Again, this needs to translate into effective early intervention and non-stigmatised support.

In conclusion, I would like to thank the other Members of the Sub-Panel, Deputies Trevor Pitman, Roy Le Hérissier and Geoff Southern for their hard work, time and effort for combining the work on this Review, with other Reviews and duties they have been undertaking. Also thanks to those working within the Scrutiny Office, especially Mr. Sam Le Quesne for being highly supportive, as well as being a well-balanced organiser and generally collating people and facts and handling all who contacted us with tact and diplomacy.

I hope the content of this report will play a vital part in determining the future role and development of policies, services and support for families and children. It is, however, part of an ongoing process and not the end of it.

I commend the Report to you and hope all who read it will give its content due thought and consideration but, more importantly, that the recommendations are acted upon.

Senator Alan Breckon

Chairman

Health, Social Security and Housing Scrutiny Panel

1. TERMS OF REFERENCE

REVIEW OF THE COORDINATION OF SERVICES FOR VULNERABLE CHILDREN  

1. To review the structures of governance and accountability within Jersey's proposed child protection services.
2. To assess the role of the voluntary agencies in the provision of services for vulnerable children.
3. To assess whether the recommendations of Andrew Williamson's An Inquiry into Child Protection in Jersey  reflect the best of modern practice and are suitable for a small jurisdiction.
4. To review the phasing and finance of the implementation of Andrew Williamson's recommendations.
5. To assess the importance of compliance with Lord Laming's recommendations to the delivery of services for vulnerable children.
6. To consider any lessons learnt from Review of the Principles, Practices and Provision for Children and Young People with Emotional and Behavioural Difficulties and Disorders in the Island of Jersey (K Bull) and its implementation, and the relevance of Jersey Review (Howard League for Penal Reform).
7. To consider any other relevant matters that may arise during the course of the review.

2. SUB-PANEL MEMBERSHIP

For the purposes of this review, the Health, Social Security and Housing Scrutiny Panel established the following Sub-Panel:

Senator A Breckon, Chairman Deputy T M Pitman, Vice-Chairman Deputy R G Le Hérissier

Deputy G P Southern

Main Panel Membership

The Health, Social Security & Housing Panel itself comprised the following members: Senator A Breckon, Chairman

Connétable S A Yates

Deputy G P Southern

Deputy D J De Sousa

Expert Advisers

The Coordination of Services for Vulnerable Children Sub-Panel appointed the following expert advisers:

Professor Ian Sinclair

Professor Emeritus, Social Policy Unit, University of York Professor Jane Tunstill

Visiting Professor & Children's Services Consultant, Social Care Workforce Research Unit, Kings College, London

2.  KEY FINDINGS

1. That the lack of one Minister being directly responsible in the role of Corporate Parent' has not afforded the function the attention and drive that it required.
2. There is an immediate need for a clear line of accountability, running to a single Minister, in order for the Island's services for vulnerable children to operate effectively.
3. The creation of a pan-Departmental Children's Plan is essential to the delivery of children's services, particularly those of a non-stigmatising nature.
4. Difficulties in retaining frontline child protection staff are seriously impairing the Island's services for vulnerable children.
5. The internal management structure and operation of the Children's Service and the Children's Executive must be reviewed as a matter of urgency.
6. The need for an external audit of Jersey's Child Protection Services has not been adequately met.
7. Robust whistleblowing and advocacy procedures are vital to the safe and efficient operation of the Children's Service.
8. There is an immediate need for a thorough and impartial investigation of alleged unprofessional behaviour among the senior management of Social Services and other Departments, which impact upon its work.
9. Brig-Y-Don, has a history of providing a positive setting and care for younger children.
10. There is a need in Jersey for varied residential care for children. The restructuring of the Island's care system to include only therapeutic residential units would overlook the needs of some looked-after children.
11. Young people leaving care or custody are not receiving adequate support from the States.
12. Providing foster care is prohibitively expensive for many couples who may otherwise be interested in this valuable area of support. Further investigation and investment is required to ensure that the role of the foster carer is a financially viable one.
13. Further thought and investment are required to produce the kinds of flexible, innovative and responsive fostering schemes that will meet the needs of our looked-after children.
14. The Youth Enquiry Service is successful, as is outreach youth work, but there is a need for more resources to fund these projects.
15. There is a need to increase the current level of universal, non-stigmatising services for children in order to ensure early intervention and the aversion of crises in the lives of vulnerable children.
16. The current shortage of school nurses is preventing problems with vulnerable children and their families from being identified at an early stage.
17. There is a need to establish more family centres and recruit more health visitors if the Island's vulnerable children are to benefit from multi-agency intervention at an early, preventative stage.

18. Jersey's Child and Adolescent Mental Health Services (CAMHS) are critically understaffed and are unable to adequately treat what, anecdotally, appear to be large numbers of children and young people in need of help.
19. The Jersey Child Protection Committee needs to raise its profile with the public as a transparent, independent body with which people are encouraged to engage in a positive, proactive manner.
20. The existence and powers of the Jersey Child Protection Committee need to be recognised in Statute in order for it to effectively discharge its duties.
21. There is a need for a children's voluntary sector forum to share information, best practice and procedure, and to enable the third sector' to have a common voice. A representative of the voluntary sector forum should sit on the Jersey Child Protection Committee.
22. Existing family support centres and the voluntary sector are in need of more direct funding from the States in order to meet demand for high-value, community based services.
23. A vocational qualification in family support work would be of benefit to all providers of services for vulnerable children.
24. Staff shortages and retention will need to be addressed before any meaningful change can be made to the Emergency Duty system
25. In-school social workers play an important role in the services that Jersey provides for its vulnerable children. The four States-run secondary schools require full-time social workers to take on the substantial workload involved in case referrals.
26. Effective communication with the public concerning the child welfare and protection work undertaken by the States and the many other agencies involved would help to increase knowledge of and access to services.
27. The establishment of a Jersey Court Advisory Service (JCAS) would improve the representation of vulnerable children in Jersey's courts and would alleviate the strain of court-related casework under which the Children's and Probation Services currently find themselves.
28. The implications of the United Nations Convention on the Rights of the Child need to be analysed by those with direct knowledge and experience, and then be ratified by the States of Jersey.
29. More States funding is necessary if the Jersey Family Mediation Service is to expand in response to growing demand.
30. Jersey needs more secure accommodation for children and young people, as well as a greater degree of flexibility in the ways in which this provision can be used.
31. The Youth Action Team (YAT) have done some excellent intervention and support work with young people in and outside the criminal justice system.
32. While the document  Williamson Report: Implementation Plan provides a baseline for improvements to the Island's services for vulnerable children, it does not address all the salient issues because Andrew Williamson's An Inquiry into Child Protection in Jersey, on which the Implementation Plan is based, does not constitute an exhaustive investigation of Jersey's child protection services.

3.  RECOMMENDATIONS

Please note: Each recommendation is accompanied by a reference to that part of the report where further explanation and justification may be found.

The Sub-Panel recommendations are presented in four sections, Committee of Inquiry, Staffing, Financial Support and General. They have been grouped for ease of reading but are not presented in any order of priority.

COMMITTEE OF INQUIRY

1. The Health, Social Services and Housing Panel will bring a proposition to the States within the next three months to set up a Committee of Inquiry to investigate the allegations of misconduct and incompetence within Management at Health and Social Services and other relevant services.

The States will be asked to decide if they are of the opinion to -

1. agree that a Committee of Inquiry be established in accordance with Standing Order 146 to inquire into a definite matter of public importance, namely the actions and effectiveness of the Management at Health and Social Services and other services available to vulnerable children. [Sections 5.39-5.40]
2. request the HSSH Panel -

i)  to identify an appropriately qualified individual or organisation to be invited to undertake the investigation and to bring forward for approval by the States the names of a proposed Chairman and members; [Sections 5.39- 5.40]

iii)  to bring forward for approval by the States detailed terms of reference of the Committee of Inquiry. [Sections 5.39-5.40]

STAFFING

The Minister for Health and Social Services should ensure the following -

2. That Jersey's Child & Adolescent Mental Health Services (CAMHS) are allocated the following staff increases [Sections 7.39-7.42];

1. 1 Psychiatrist
2. 2 Clinical Psychologists
3. 2 Family Therapists
4. 2 Cognitive Behavioural Therapists

3. That Family Nursing & Home Care receive specific funding to provide an additional two School Nurses. [Section 7.10-7.27]
4. That the management structure in Social Services be rationalised by the removal of one tier of management. [Section 5.19-5.26]
5. All management posts are revised in a Social Services structure which must be subject to job re-evaluation. The new posts must be advertised and applied for in accordance with human resource policies. [Section 5.32-5.35]

6. In the context of the shortage of professional staff generally and the difficulties in recruiting and retaining staff, individual incentive packages must be developed to ensure success in a very competitive market. [Sections 5.32-5.35]
7. That Management structures and training are put in place so that managers are enabled to provide effective supervision and support to front-line staff. [Sections 5.18-5.36]

The Minister for Health and Social Services with the Minister for Education Sport and Culture should ensure the following -

8. That Social Workers are allocated to all four States Secondary Schools to work with Multi Agency Support Teams (MASTs) and thereby reduce pressure on central services and community agencies. [Sections 7.69-7.72]

The Minister for Health and Social Services, together with the Bailiff , should ensure the following -

9. That a Jersey Court Advisory Service is set up and equipped with four appropriately qualified staff and establishes links and working relationships with the Jersey Family Law Association and the Jersey Family Mediation Service. [Sections 8.3-8.18]

FINANCIAL SUPPORT

The Minister for Health and Social Services, together with the Minister for Treasury and Resources, should ensure the following -

10. That direct States funding should be guaranteed over the next five years (but reviewed after two years) for the following Charitable and Voluntary organisations to receive funding for child and family support work. [Sections 7.17-7.20; 7.31-7.38; 8.3-8.15]

11. That Organisations receiving funding should operate to a Service Level Agreement and be subject to Annual Financial and Reporting structure. [Section 7]
12. That annual training grants of £10,000 each are made available for specialist training for children and family related matters to the following agencies [Sections 7.63-7.64];

1. Family Nursing & Home Care for Health Visitor training
2. Jersey Child Protection Committee
3. Jersey Childcare Trust
4. The Bridge

GENERAL RECOMMENDATIONS

The Minister for Health and Social Services and the Minister for Education, Sport and Culture should ensure the following -

13. That a review of the Children (Jersey) Law 2002 is undertaken to ensure that it provides adequately for all aspects of child protection, safety and care with any changes required included within the Law Drafting programme for 2010. [Section 8]
14. That a more proactive approach be taken in supporting families and children with efforts being targeted towards providing non-stigmatising services and early interventions using a coordinated approach which includes all agencies. [Sections 7.31-7.74]
15. That the existing Fostering and Adoption Services are reviewed and a five-year plan produced in line with current best practice in other jurisdictions, and that an assessment is made of likely future requirements for Jersey, including funding, and the need for varied fostering provision. [Section 6]
16. That two more centres such as the Bridge and NSPCC Pathways (that provide a non- stigmatised family focussed approach, accommodating a number of agencies) are replicated to support families in the urban Parishes. [Sections 7.54-7.64]

The Minister Council of Ministers should ensure -

17. That a robust, independent and non-threatening whistleblowing process is put in place for both staff and clients. [Sections 5.37-5.40]
18. That financial provision is made to ensure the availability of adequately resourced Advocacy services to assist children and families as required or requested. [Sections 5.37- 5.38]
19. That the necessary consultation process is undertaken so that the UN Convention on the Rights of the Child can be ratified. [Sections 8.22-8.23]

The Minister for Health and Social Services should ensure -

20. That a "Children's Plan" for Jersey is developed to achieve coordinated, inclusive and effective delivery of services to support vulnerable children and families. [Sections 5.11- 5.14]
21. That a transparent and independent interview and reporting process is put in place for for looked-after children exiting the care system and that follow-up procedures are in place to ensure that any findings and recommendations are acted upon. [Sections 6.18- 6.23]
22. That the capacity in Children's Homes is maintained at an appropriate level and modernised to meet the needs of the young residents and comply with standards and best practice in other jurisdictions. [Sections 6.12-6.17]
23. That as a matter of urgency CAMHS is provided with a therapeutic unit for the delivery of specialised care. [Sections 7.39-7.42]
24. That a local Independent Reviewing Officer is appointed to monitor and review the effectiveness of children's services and their compliance with local policies, procedures and best practice. [Section 5]

25. That annual external inspections should investigate and report on the practices, policies and procedures of safeguarding of children and other matters such as specific "case reviews". [Section 5]
26. The establishment of a "Voluntary Sector Forum" (to coordinate and publicise the work of the voluntary agency sector) is recognised and facilitated and that a representative from that group is allocated a place on the Jersey Child Protection Committee.

[Sections 7.51-7.52]

27. That the Jersey Child Protection Committee is renamed the "Safeguarding of Children Committee", which would more clearly represent its role and function to the wider community. [Sections 7.47-7.48]
28. That the Jersey Child Protection Committee is established in Law to ensure that it has the necessary authority to ensure its recommendations are acted upon. [Sections 7.49-7.50]
29. That the Jersey Child Protection Committee's independence is clearly established and that work is undertaken to raise its public profile and the public's awareness of its role and responsibilities. [Sections 7.47-7.48]
30. That an urgent review of staff recruitment and retention policies is undertaken and that exit interviews are provided to those leaving the service with reasons being recorded and acted upon. [Sections 5.15-5.36]
31. That a Service Level Agreement is reached with the Brig-Y-Don Trustees and Management that draws upon its areas of expertise. [Sections 6.10-6.11]
32. That the Minister for Health and Social Services must be the Minister responsible for the role of Corporate Parent but should liaise with the Ministers for Education, Sport and Culture and Home Affairs. [Sections 5.1-5.10]
33. That a review of the role, overlap and function of the Children's Service Department, Children's Executive Service, its Board and the relationships with other children's services is undertaken to ensure clear accountability, responsibility and management structures to deliver effective services. [Sections 5.10-5.14; Footnote 22]

The Minister for Health and Social Services together with the Ministers for Housing, Education, Sport and Culture; and Social Security should ensure -

34. That care leavers' support is continued up to 25 years of age and that provision is made to ensure that those individuals are supported to find: adequate housing, work, relevant training, advice and access to health or welfare services. [Sections 6.18-6.23]

The Minister for Health and Social Services, together with the Ministers for Home Affairs, Housing and Social Security, should ensure that -

35. Young people leaving custody are provided with adequate housing, work, relevant training, advice and access to health or welfare services so that they are less likely to re-offend and find themselves back in the Criminal Justice System. [Sections 8.19-8.36]
36. That some six-bedded units are provided for young people who need specialised support to provide semi-independent living prior to leaving the care or custody systems. [Sections 6.18-6.23; 8.19-8.36]

The Minister for Health and Social Services together with the Minister for Home Affairs should ensure the following -

37. That video link facilities are established between all courts and custodial centres so that attendance at court is not always required and the costs and difficulties associated with the transport and holding of prisoners can be avoided. [Section 8]
38. That an urgent review is undertaken on the suitability of accommodation and the policies relating to those under 21 years of age who are on; a care remand, sentenced, held on remand or awaiting sentence. [Section 8]

4. INTRODUCTION

The local picture

1. Jersey has, in recent years, had the benefit of its own crop of reports that have examined in some depth the provisions for the safety and wellbeing of the Island's vulnerable children. The first of these reports, commonly referred to as the Bull Report[1], resulted in a raft of recommendations, many of which caused far-reaching changes to be made to the Island's child protection services. Two reports in the years that followed, one by Andrew Williamson[2], another by the Howard League for Penal Reform[3], further enriched the store of expert analysis on which Jersey is able to draw.
2. It has not been the intention of this Sub-Panel to peer review or second-guess these reports but rather to continue the scrutiny of this crucially important subject and discover whether there is a satisfactory level of coordination between the services that Jersey provides for its vulnerable children. And if not, what more can be done to assist the smooth and effective functioning of those services.

The wider context

3. When the details surrounding the death of Victoria Climbié[4] first became public, a process of reform began in England that would have a transformative effect on the country's services for vulnerable children. The catalyst for this reform was a wide-ranging report published in January 2003 by Lord Laming[5], who made a series of recommendations as to how the State might improve its duty of care towards vulnerable children. Subsequent events, notably the scandal surrounding the death of Baby P'[6], as well as a number of recent reports by Lord Laming[7], the House of Commons Children, Schools and Families Select Committee[8], the Irish Government[9] and other jurisdictions10, have ensured that the welfare of society's vulnerable children remains a live and prominent issue.

4. Opinion varies on just how effective Lord Laming's recommendations have been, so it is perhaps unwise to take the template of Laming Compliance' as a universally applicable formula for success[10]. What can, however, be seen as universally applicable are the core values and priorities that underwrite Laming's work. These are:

• "Please keep me safe. This simple but profoundly important hope is the very minimum  upon which  every  child  and  young  person  should  be  able  to depend."[11]
• "Keeping children safe and promoting their wellbeing is a responsibility of us all."[12]
• "The single most important change in the future must be the drawing of a clear line of accountability, from top to bottom, without doubt or ambiguity about who is responsible at every level for the wellbeing of vulnerable children."[13]

5. Given that these fundamental tenets have also been at the heart of the evidence gathered by this Sub-Panel, we are confident in asserting them as signpost values' that should determine the future direction of any proposed or existing services for vulnerable children in Jersey. Every child in Jersey must be assured of his/her right to safety and wellbeing, and it is the signal duty of the States to ensure that all Departments and agencies charged with this task are properly funded and staffed, and are fully supported and coordinated.

5. STATES SERVICES: GOVERNANCE AND ACCOUNTABILITY

Political accountability

1. One of the most pertinent questions that can be asked of the States of Jersey's services for vulnerable children is really a very simple one: who is in charge at the top? It is a question that has taken centre stage since the publication of the Bull Report nearly seven years ago, and yet it has never been properly dealt with. What we have seen instead is a protracted period of rudderless leadership due to the political failure of the Corporate Parent. The Children's Executive, has appeared to operate under the direction of the Children's Service. However, its initial remit was, in the words of Kathie Bull's original recommendation, to have -

 "responsibility for, and oversight of, all matters relating to children in need The group would be directly responsible to Ministers and would prepare the way for Ministries to adopt, both in principle and practice, the Concept of Corporate Parenting."[14]

2. That responsibility has quite categorically not been met. If it had been adequately met, Andrew Williamson would not have included the following observations on the Children's Executive in his own report:

"I remain unclear as to its function and more importantly the line of accountability to Ministers I remain concerned at the Executive's lack of clear accountability in such an important area of care for children."[15]

3. Nor is he alone in his concern. Dismay at the dysfunction of the Children's Executive is widespread. Submissions that were made to us, both in writing and at Public Hearings, frequently focussed on this problem. Take, for example, the conclusion drawn by Professor June Thoburn, erstwhile Chair of the Jersey Child Protection Committee:

"I think the Children's Executive was a mistake – it was too low a level – and the concept of the Corporate Parent as being a sort of barrier because nobody quite understood it."[16]

Governance and accountability

4. The Corporate Parent proposed in the Bull Report was to include Committee Presidents/Ministers for Health and Social Services, Education, Sport and Culture and Home Affairs and their respective Chief Officers. In practice, this never happened and was a miserable failure with no apparent political leadership or direction.

The Minutes received by the Sub-Panel indicate that the above Chief Officers and other officers met on 2nd March 2005 to discuss the mechanics of a "Corporate Parents' and Children's Executive Board." The first meeting with the Corporate Parent took place on the 10th November 2006, with Senators S. Syvret, M. Vibert and W. Kinnard in attendance. The next meeting was on the 20th December 2007 with Senators J. Perchard, M. Vibert and W. Kinnard in attendance, that attendance was repeated at the meetings of 29th March and 4th July 2008. Senator M. Vibert chaired all five meetings.

The Sub-Panel finds that the Corporate Parent did not function because there was not cohesive political leadership based on the active and continuing involvement of all three Presidents/Ministers. That was the main reason why it failed.

Under arrangements put in place following the Bull Report, the Corporate Parent was to be responsible and accountable for the strategic planning and direction of the Children's Executive Board. The lack of meetings demonstrates a failure to take an active interest and indicates that no political leadership or direction existed, resulting in an ineffective Corporate Parent. The Children's Executive Board was established and included senior managers from the Probation Service, the Education Department, CAMHS, the Children's Service, the Prison and Social Services, charged with co-ordinating and directing operations and implementing the recommendations from the Bull Report across the relevant services, under the supervision of the Corporate Parent. However, the reality was that the Corporate Parent lacked the requisite political or Chief Officer drive, interest or active involvement and appears not to have been an appropriate motivator for service enhancement, delivery or improving the public profile. The Children's Executive: Progress Report R.89/2008 was presented to the States on 20th August 2008 by the Minister for Health and Social Services, and it indicated some progress with regard to the 50 recommendations  in  the  Bull  Report;  however,  more  work  and  improved  cohesion  is required.

5. The most damning evidence against the Corporate Parent and with it a knock on effect to the Children's Executive, is not so much that its function is unclear or that its remit is confused, it is the more perturbing fact that no one has taken a firm grasp of the reins, no Minister has accepted ultimate responsibility for the child protection work that is being undertaken in Jersey. As Phil Dennett, Children's Executive Coordinator puts it:

"There was not one person ultimately responsible to be able to say this is where the buck stops' in a sense and I think over the last couple of years when we know there have been issues in lots of different areas I think that issue has come to the fore and, indeed, Williamson very particularly addressed that and said what was needed. We still needed the concept of corporate parenting about everybody being involved and recognising their agenda, however, you need lines of accountability to be very clear and we need to report to one Minister."[17]

6. This lack of leadership has had a deleterious effect on the Island's services for vulnerable children, not only because the hoped-for levels of interagency coordination and joined-up working have failed to materialise, but also because, as Chief Probation Officer Brian Heath pointed out to us,

"there are a number of issues which require decisions at ministerial level which have not yet been made".19

7. All of which leads to the very specific, and increasingly urgent, question of who exactly is going to assume this mantle of ultimate accountability? Williamson's answer was to create a new position, that of Minister or Commissioner for Children and Young People, with the parallel  remodelling  of  the  Children's  Executive  into  a  Children's  Services  Executive Committee, which would be responsible for developing and delivering a Children's Services Plan. But would that really be the best way? We think not. Surely the most expedient solution would be for the direct accountability to rest within an existing Department, on the shoulders of an existing Minister?

8. Our view is that the most suitable candidate for the job would be the Minister for Health and Social Services. Professor Thoburn makes a similar assessment:

"I think you have to have clear accountability. If we are talking about vulnerable children then the main role is with Children's Social Care; social workers plus all the other people involved in that. So it does make sense for the key accountability to be with the Minister for Health and Social Services and then to build bridges across to the other key Ministries."20

9. This is a powerful statement, coming as it does from someone whose knowledge of the coordination (or lack thereof) in Jersey's child protection services is extensive. Yet it is important to note that support for this idea does not only exist at operational level; Senator Ian Le Marquand, Minister for Home Affairs, is of the same mind:

"Williamson is right; one Minister must take the lead and obviously that needs to be Health and Social Services. It cannot be us. But we obviously have a particular slant, as we see on this, because of the crime prevention aspect of it. The old system is too cumbersome. One Minister must take responsibility."21

10. It  is  our  finding,  then,  that  the  Corporate  Parent22  and  by  implication  the  Children's Executive is dysfunctional and has not therefore contributed effectively to the Island's child

19 Transcript of Public Hearing with Mr B Heath (Chief Probation Officer)

20 Transcript of Public Hearing with Professor June Thoburn

21 Transcript of Public Hearing with the Minister for Home Affairs, the Deputy Minister for Home Affairs, the Acting Deputy Chief of Police and DS C Davison (SoJ Police Force Public Protection Unit)

22 i.Under the arrangements put in place following the Kathie Bull Report a body called the Corporate Parent' was created. This was made up of the Ministers and Chief Officers of H&SS, ESC, HA plus the Chief Probation Officer. The Corporate Parent was to be responsible and accountable for strategic planning and direction of the Children's Executive

Board. In the event few meetings of the Corporate parent took place, thus resulting in the rudderless ship' effect alluded to by the Panel as illustrated by Brian Heath's comment (P 9, second paragraph) there are a number of issues which require decisions at Ministerial level which have not yet been made'.

ii)The  Children's  Executive  Board,   made  up  of  senior  managers  of  Probation,  Education  (including  Educational Psychology and Youth Service), CAMHS, Children's Service, Prison, Social Services, Children's Executive Service, was charged with responsibility for overseeing, co-ordinating and directing operations across the relevant services, under the leadership of the Corporate Parent.

iii)To add further to the confusion of titles, the term Children's Executive Service' refers to the conglomeration of services (residential & secure services, YAT and MAST) which came into being as a unique structure, separate from the

[18]protection services. Until this happens and the roles are suitably realigned it will not be possible for Jersey to say that it is doing its utmost to ensure the best possible outcomes for its vulnerable children. It is therefore imperative that the Minister for Health and Social Services should immediately assume full responsibility for these services.

11. In his Victoria Climbié Inquiry, Lord Laming reminds us that it is the duty of those who have been placed in positions of responsibility within child protection services to actively involve themselves in the delivery of those services and to ensure that the required levels of accountability and communication exist. He writes:

"Some used the defence no one ever told me'. The chief executive of Brent council, Gareth Daniel, chose to describe his role as strategic' and to distance himself from the  day-to-day  realities.  Gina  Adamou,  a  Haringey  councillor,  said,  If  I  ask questions  she  [Mary  Richardson,  the  director  of  social  services]  would  say "everything is okay, do not worry, if there is a problem I will let you know".' I find this an unacceptable state of affairs. Elected councillors and senior officers must ensure that they are kept fully informed about the delivery of services to the populations they serve, and they must not accept at face value what they are told. There was also a reluctance among senior officers to accept there was anything they could have done for Victoria. The former chief executive of Haringey council, Gurbux Singh, said, There is the issue of resources ... but beyond that I cannot honestly think of what else I could have actually done to ensure that the tragedy which happened did not happen.' This is not a view I share."[19]

12. The absence of political accountability was not the only concern to be raised in evidence to the Sub-Panel. Of equal importance to witnesses was the need for, and current lack of, a coherent Children's Plan in the Island. Peter Liver, the NSPCC[20] Divisional Director of Children's Services for Midlands and West, had this to say on the subject:

"I struggle to see a strategic children's plan for Jersey and I have had lots of documents given to me that say some really positive things about Jersey and why  Jersey is a good place but what I do not see is very clear strategic planning and I think unless you put in place a very clear plan with some achievable outcomes – and they are some fine words – then I think however much resource one tends to throw at children the evidence would suggest it does not make a huge difference. I think priorities are going to be really, really important for you moving forward. I think that at the heart of that, which Williamson did flag up, was about planning."[21]

13. In our view, though, the scope of a Children's Plan should be a great deal wider than the specific needs of those who are vulnerable or at risk in the community. A Children's Plan should include every single child in the Island, so as to allow a significant increase in preventative work, which is of inestimable value to the future life chances of children. Simply put, the more early intervention that health visitors, social workers and family support teams are able to do, the less critical and acute work the Children's Service will be required to undertake at a later stage. Also, the consequential long-term financial savings to the States of such early interventions cannot be overstated.
14. This issue of when to intervene is formally addressed elsewhere in this report (see Service Delivery), but for the purposes of the Children's Plan, all that is required is to take note of this basic advice provided to us by the Jersey Child Care Trust:

"Joined up multi-agency working with the whole family and input that starts at an ante-natal stage will produce the best outcomes for children."[22]

15. This is a simple goal requiring a straightforward plan. Further delay could result in the continuation of the current planning vacuum. What is required now is affirmative, joined-up action in the form of a universal Children's Plan for Jersey, which all can contribute and sign up to.

Management and staffing

16. It will by now be well known to all States Members and others that there is a shortage of what are commonly termed frontline staff' within the Department of Health and Social Services. This problem was addressed by Williamson in his report and has subsequently become a feature of the Williamson Report: Implementation Plan, which recommends the recruitment of more fully qualified full-time social workers [23], as well as compliance with Lord Laming's recommendations that social workers' caseloads be monitored and capped at certain, manageable thresholds. However, none of these measures will, in our view, address the root cause of this issue, namely the management failings that have allowed this crisis situation to develop.
17. What, then, are these management failings? A professional source outlined for us the gulf that exists between the way in which things should be working and the reality of how day- to-day duties are actually being supervised:

"The top tier are the vulnerable families and children, the frontline workers support them, the management is there to support the worker, not the other way around. You know, sometimes I think we have these huge structures that exist, you know, to support themselves rather than those they are meant to serve What worried me in Williamson recommendations was if we spent a lot of time and a lot of money on organising the various departments and what have you and we missed out on the coalface workers because that is where the difference to children and families is made really."[24]

18. The same source went on to explain the grievous repercussions of an unsupportive management combined with a diminishing workforce:

"Social workers were leaving, social workers were going off sick with stress and we were getting a high level of cases held in duty unallocated. At one point there were 80 cases held in duty. That is not safe In fact, at that time a letter went around from the Children's Service to the key agencies saying that due to shortage of staff they would be prioritising referrals and taking the more serious first. Now, from my

point of view that is like the Fire Brigade saying: We are only going to go to big fires'. But, as you know, a small fire can become a big fire."[25]

19. The Chief Probation Officer, Brian Heath, was able to provide a similarly well-informed perspective on what has been going wrong with the Children's Service. He had this to say:

"It is well known that currently Children's Service are under-resourced, understaffed, people do not want to come and work here. I think morale has taken a real battering over the past 18 months. I would be very surprised if they were working at 100 per cent, given the history of the last couple of years. We see very good practice, I have to say; sometimes we see examples of excellent practice. Other times we are really quite frustrated at seeing some poor practice."[26]

20. However, rather than attributing these shortcomings to individual performances, which he acknowledged are necessarily variable, Mr Heath also highlighted the issue of management:

"I think, you know, they are understaffed; I think people are doing their best and it is difficult to unpick what is due to lack of resource and whether any of it is due to, you know, individuals being idle or whatever. So I think it is perhaps unfair that we criticise them for that but, certainly, there is a level of unhappiness among my officers from time to time when they are dealing with problems

"I think my officers, if you asked them, would have a league table; they would say: If it is so-and-so, no problem; if so-and-so is the officer, there is more of a problem.' I was going to say, what we do about that is that, through our own line management structures, you know, the team leader will have a conversation with their team leader. We do not let it pass and I think that is important."[27]

21. The implication of this last sentence is pivotal: it is important not to let these things pass. Vigilance, communication and, above all, supervision are the keys to successful management in this difficult, often highly charged area of work.
22. Peter Liver of the NSPCC acknowledged that "whatever structure you have will only be as good as the managers that you employ"[28] but went on to make the following comments when pressed on Jersey's specific management problems:

"Your question about management and management structures, I mean I am not going to duck it but I have to say I am not familiar with the detail of all your management. Having said that, when I have been involved in some dialogues more recently with more senior management in the States, I have found it terribly difficult to know who has responsibility for decision making. I think that presents a challenge."[29]

23. Again, the issue of supervision cropped up in some of Mr Liver's later remarks:

"Now, I think we tend to focus on systems rather than looking at have we got good leadership, have we got enough and well qualified staff that can do the work and have we got good management. Now, when I talk about management I mean supervision which is the key."[30]

24. It seems that there is a tendency within the children's services to allocate resources to the management structure when they could far more usefully be diverted to the operational, frontline' workforce. This trend will need to be reversed if we are to curb what appears to be an inexorable decline in both staff morale and the standard of service delivery.
25. The most obvious measure that could be taken to effect this change would be a simplification of the management structure of the children's services. This could be achieved by pruning the top-heavy shape of the Service, which seems over-staffed with senior managers. Lines of communication, not to mention accountability, are necessarily stronger when a simple structure is in operation.
26. Professor Thoburn makes the following suggestion:

"I have problems about the structure and I would not have a Directorate Manager followed by a children's services. I would get rid of a tier. I would get rid of the tier of directorate manager and have 2 directorate managers: directorate manager of children's health services, directorate manager of children's social care. Those 2 will be directly accountable to the Chief Executive. Underneath the directorate manager of children's social care would be a series of team managers. Until you have appointed that person, you are not going to be able to know how to run the

service cost-effectively. When you have run the service cost-effectively you can see how many more social workers you need."[31]

27. Simplify the management structure first, in other words, and then worry about staffing. In order to operate successfully, the Service needs a transfusion of fresh blood. It needs managers with the skills and experience to run an effective, motivated team of child protection officers and social workers, complemented by a seasoned workforce with the desire and ability to bring about real and lasting change. Peter Liver spoke to us about the idea of staff secondment and how schemes of this kind are conspicuously absent in Jersey:

"I mean clearly, and it is logic, if you do not have the staff to do the work then the work will not get done and Jersey faces the same challenges about workforce issues as we do in the UK. At the moment why would you want to become a social worker is the question really, and I do understand and am very aware of the difficulties that the islands face in recruiting social workers. Flagging up the issue is obvious, what the answer is I am not sure Williamson answered that and I think one is going to have to think out of the box if you are going to attract a good quality workforce of social workers to the island. I think one might have to think rather differently about that. Interestingly the NSPCC has had discussions with colleagues around the whole idea of secondments about staff being able to come and work on the island but not necessarily live on the island. I am an advocate of that and I have to say I have not seen a great deal of that happening."[32]

28. This problem of staff recruitment and, especially, retention is in our view the single most important challenge that the Children's Service currently faces, and the solutions put forward in the  Williamson Report: Implementation Plan do not go far enough towards remedying it. What is required is wholesale change, at cultural and operational levels. And, according at least to Mr Liver, the will for that change is there:

"I have had a couple of meetings with officers, with Mike Pollard and Mario Lundy, and there has been some discussion about whether the NSPCC might be able to assist with children's planning. That has not moved on any further, but we have had a couple of meetings about that and that was something that we have already said we would be keen to do if we were asked. I do think that genuinely from what I have

experienced and the discussions I have had with your staff and colleagues who work in Jersey there does seem to be a momentum for change."[33]

29. So if the will is there, what have been the obstacles to effective change in Jersey's services for vulnerable children? Service Manager for the Children's Service, Tony Le Sueur , put it in the following terms:

"Those services need to evolve on the Island but are currently struggling on the back of staffing vacancies, historic abuse inquiries and everything else that has been going on around children's services. So there is a whole raft of developments, some of which is contained in Williamson, which need to move forward but are being hampered by the current climate and the current circumstances."[34]

30. An added difficulty is the unpredictable nature of the work. Staffing in this area, where levels of demand are inconsistent, can be a moveable feast. Julie Gafoor of Family Nursing and Home Care told us:

"I think what happens is child protection, you cannot plan for the year the resources because demands vary so much, so if there is a rise in demand and there is no staff, the thresholds go down. That is the problem, you cannot respond because you do not have the staff. So I think at times we do it really well and at times we do not and I think what is disheartening is when you are seeing the children of people you have health visited and the same issues are coming again with that family."[35]

31. The key word to pick out here is thresholds'. In this concept of thresholds lies the answer to why service delivery begins to unravel and why, ultimately, the services that the Island delivers to its vulnerable children can become severely compromised. Peter Liver was emphatic on this point:

"Yes, I think probably, again, you will have heard I am sure, the whole concept of thresholds and again clearly when you have a limited workforce you have a lack of social workers that the whole idea is to raise the threshold and as a consequence that seemed to be a natural response. I think it is the wrong one, absolutely the wrong one."40

32. This comment recalls previously quoted evidence concerning the number of cases that are held in duty' because of staff shortages among field social workers; what it also raises in our minds is the more pervasive concern that problems encountered in a certain area of social work will have an inevitable knock-on effect in a different, but related area. Take for example the triumvirate of Departments that deals with almost all of the work relating to vulnerable children in Jersey (Health and Social Services; Education, Sport and Culture; Home Affairs): surely, failings in one Department will have wider consequences in the workings of another. We have already seen how the Probation and After Care Service is affected by some bad practice in the Children's Service, but the tendrils extend further than that,  as  evidenced  by  this  statement  made  to  us  by  Mario  Lundy,  Director  of  the Department of Education, Sport and Culture:

"Now, if you have, for example, let us say a Children's Service that is resourced to intervene at this high level of need and is struggling to recruit and perhaps does not have the resources to recruit the numbers of staff they would need, then quite clearly that department will have to respond at that level of need in order to make sure  that  the  highest risk  cases  and  the most  vulnerable  people  are  properly supported. If, from an educational perspective, you want some intervention down here,  a  lower  tier,  the  resources  are  not  going  to  be  there  to  make  that intervention."[36]

33. What, then, is being done to improve the situation? In terms of recruitment, the Children's Service is working steadily to fill the vacancies among its field social workers. In October 2008, the Service had 12 vacant social worker positions; at the time of writing, that number had been reduced to four, of which two positions had been filled pending successful police checks, one had been offered to a candidate and the other was being advertised.[37]
34. The problem of staff retention, however is not so easily remedied. The Williamson Report: Implementation Plan recommends that the concept of Laming Compliance' be applied to the work of Social Services. In our view, however, this would be little more than a sticking plaster on an open wound. In his assessment of the usefulness of the Laming Compliance model to Jersey's existing child protection services, Professor Sinclair remarked that Lord Laming's report "is far from a blueprint"[38]. Uniformly capping a social worker's caseload to a prescribed number is not the panacea it might appear to be: cases differ in complexity,  especially in the area of child protection work, and making the judgement on what is or is not a manageable caseload is a great deal more sophisticated than simply counting out files. It is a matter for high-level, intelligent management. It is imperative, therefore, to have in place managers who are able to make those judgements and deliver the necessary support to their frontline workers.

35. The question, then, that we need to be asking ourselves above all others is Do we have those managers in place?' and If not, how can that problem be addressed quickly and efficiently?'
36. As Andrew Williamson told us,

"I think you have got some opportunities to redesign some process You have got to avoid this thing of just adding more and more and more to it; redefine, take a step back."[39]

37. One  of  the  most  effective  ways  of  ensuring  optimum  management  and  operational efficiency within the Island's child protection services would be to introduce an independent reviewing mechanism to audit these services. We endorse the plans that have been put forward to implement a full inspection and audit of Jersey's children's services[40], but it is vital to acknowledge that this inspection has yet to be conducted and that neither the Williamson Report nor any other report can be viewed as a substitute measure for rigorous external audit. Professor Thoburn made this point during her Public Hearing with the Sub- Panel:

"You were lacking independent audit, if you like, of your children's social care services.  You  have,  I  think,  commissioned  the   Scott ish  Inspectorate,  which  is absolutely necessary because neither Williamson, nor I, nor the League have really done a thorough audit/inspection. We have not been asked to do that. I think if you are really going to understand how adequate your services are, that process has got to happen and that has been agreed. So I think at the point in which the Scott ish Inspectorate have done their first inspection, you would have a better idea of just what are the strengths and weaknesses of your services."[41]

Serious complaints and advocacy

38. One of the most important recourses in the field of child protection, for professionals and service users alike, is the freedom to voice an honest opinion or complaint without fear of reprisal. Among professionals, the perceived risk of making a serious complaint (more commonly known as whistleblowing') would be negative career repercussions, which might range from subtle forms of intimidation or discrimination through to overt suspension or dismissal. For the service users (meaning, the children themselves and their families), the worry of making a complaint is either that it could result in further deterioration in what might already be a poor relationship with a social worker or child protection officer, or else the sense that rocking the boat' might lead to unforeseen, dire consequences, such as children being taken into care.
39. Outlined above are the generic concerns that underpin the need for a robust whistleblowing procedure and a well-supported system of advocacy for children; it is not the function of this Sub-Panel to inquire into individual cases but it is our aim to highlight the importance of these issues and to ensure that adequate provision exists for the voices of the workers and the clients of Jersey's services for vulnerable children to be fairly heard. The degree of importance with which these matters should be treated cannot be underestimated.
40. The Williamson Report, along with contributions from other parties such as the Jersey Child Protection Committee, has ensured that the Williamson Report: Implementation Plan specifically addresses whistleblowing procedures and service user advocacy[42]. These are steps in the right direction; however, we have become aware of certain allegations during the course of this review that suggest further steps may need to be taken.

41. It has been alleged to us that serious, long-standing unprofessional behaviour among the senior management of Social Services has blighted the performance of the Department of Health and Social Services over a protracted period of time. This alleged unprofessional behaviour may have had far-reaching consequences on children and families to whom the Department has had a specific duty of care. We are in no position to judge whether these allegations are, in fact founded, nor would we seek to make such a judgement within the Terms of Reference of this review. However, it is our finding that such allegations exist and it is therefore of immediate and critical relevance that they be investigated thoroughly, impartially and professionally by an outside body with no political or judicial connection to the States of Jersey.

6. FOSTERING, ADOPTION AND RESIDENTIAL CARE

1. A large number of academic studies have been undertaken into the comparative advantages and disadvantages of foster care and residential care. It is not our intention to summarise these arguments in this report (that job has been done for us by Professor Sinclair[43]); what we do intend to examine are the provisions that Jersey currently makes for its looked-after children, and how those services could be most usefully expanded and adapted to ensure the best possible outcomes.

The shape of the Jersey care system

2. The Children's Service has certain key strategic aims for its looked-after children that can be broadly summarised as follows: the number of children in residential care should be reduced; the number of residential homes should be similarly reduced, leaving only therapeutic facilities that would cater to the specific needs of a handful of individuals; the number of foster carers should be increased to take up the resulting slack' in the care system. In the words of the Service Manager for the Children's Service, Tony Le Sueur :

"We have been in a process of developing on the Island fostering and adoption services and that received significant investment in 2006 to 2008. The clear aim of that investment was to reduce the numbers of the young people in residential care on the Island so that we could reconfigure that residential care; because if you go all the way back to the Kathy Bull Report it was recognised that these big residential units were not fit for purpose, needed to be reduced in size and needed to be reduced in terms of the numbers of the young people in there."[44]

3. It should be said first of all that we endorse the general principle of increasing the provision of foster care in Jersey, which could in our view be of enormous benefit to many of the Island's looked-after children. However, it is equally important to note that such reforms must also take into account the fact that some children may not be suitable candidates for fostering or adoption, and that a degree of creativity and insightful management will be necessary to ensure that those children do not become victims of a revised care system that excludes their needs.

4. During the course of this review we visited Brig-Y-Don, La Preference and Heathfield children's homes. We also visited Fostering & Adoption Jersey at La Chasse Centre, St Mark's Adolescent Centre, Jeune House[45], Greenfields Centre and the Young Offenders Institute at HMP La Moye. These visits provided us with opportunities to speak to a number of children and young people, as well as staff.
5. These visits, together with evidence that we will present in this report, have led us to the conclusion that there is an age group (in general terms, the over-tens) who may in fact be better suited to the lifestyle of a children's home than to the more stereotypically familial environment of foster care. This is a misgiving that is shared by the Jersey Care Leavers Association (JCLA), whose representative Candia Cooper told us:

"The one thing, though, is that (and I know quite a few care leavers are of the same opinion) there seems to be a move towards children going into foster care and closing all the children's homes. That is not necessarily a good thing because some children only thrive in a care home environment, but a smaller care home, nothing like Haut de la Garenne was. I know there are a lot of members that do not think that children's homes should be totally closed down."[46]

6. And yet States policy in recent years has been to plough money into Fostering & Adoption Jersey; only Brig-Y-Don children's home has recently received any States investment, as a result of certain exceptional developments. In the words of Fostering & Adoption Jersey's Team Manager Sean Pontin, "huge growth and investment"[47] has been channelled into the fostering service: but is it covering all the bases? Mr Pontin does not think so:

"Whilst the needs of primary school age children are being broadly met in placement it has to be accepted that the team are struggling to recruit carers for children and young people older than 10 years of age. An unprecedented amount of court proceedings has also placed pressure on services as we search for long term carers for these same older children."[48]

7. It is here that we are able to identify the vulnerable children who are slipping through the net and who may, if not properly catered for in the future plans of the Children's Service, end up with services and facilities that are inadequate. The former Minister for Health and Social Services, Senator Perchard, referred to this problem when he spoke to us towards the end of his term of office:

"The little orphan in ladybird pyjamas is easily fostered or adopted. It is the awkward squad, the 14-year-old who wants to fight and swear and throw food and punch and drink, they are the ones that are not so easy to set to fostering and adoption and that is why our residential homes have to change and become more therapeutic and more relevant to the customer or the client. As I say, the pretty little orphan with pigtails, no problem. The fostering and adoption works easily for those and that is why, in our residential environments, we need to reflect this."[49]

8. In general terms, we accept that this is a true representation of the current state of the Island's care system; however, we are not convinced that the provision of residential care needs to be modified so that only therapeutic homes remain as an alternative to foster and family-based care.
9. In his paper on the shape of Jersey's care system, Professor Sinclair takes a similarly sceptical view of the proposal to whittle the Island's residential care down to a niche, therapeutic model. Among his concerns are: that Jersey may not have a sufficient number of children with the specific needs that are envisaged for these therapeutic homes; research does not suggest that a high staffing ratio leads of itself to better outcomes; that there is better evidence in favour of therapeutic foster care. In summary, he writes:

"For these reasons, I would regard investment in a therapeutic model of residential care as risky. It would be less risky, as I see it, to invest in therapeutic foster care in Jersey and use therapeutic residential facilities in the UK when necessary. There are also enough of these units in the UK to try to select ones which are working well. If experience suggests that a model of this kind is needed in Jersey, it would then be possible to try to replicate one. On the other hand, if there are one or more therapeutic units on Jersey, there will be pressure to use them even if they are not working well."[50]

10. Surely, there will still be a need in future years for homely, informal and inclusive children's home environments such as those, we witnessed during our visits to La Preference and Brig-Y-Don. This latter, with its history of dealing with children of a younger age and its excellent (albeit disused) nursery facility, has a place in the lives of many Islanders. Surely,

there is some value in capitalising on this facility and making the most of Brig-Y-Don's proven  track  record  of  caring  for  younger  children,  especially  those  presenting  more challenging  behaviour.  Recent  statistics[51]  submitted  to  us  by  Brig-Y-Don  show,  for example, that a five year-old child with severe attachment disorder left its care in 2007 to be placed with foster carers and has now been placed back into residential care after a breakdown in two separate foster placements. Also, according to the same statistics, a total of six children aged between three and 12 years of age were referred to Brig-Y-Don during 2008 and the first half of 2009 but had to be turned away due to a lack of available beds.

11. This evidence shows that Jersey has known cases of younger children who are either not suitable for foster placements or are being referred to residential care due to a lack of available foster carers, and yet Brig-Y-Don, the most suitable facility to accommodate them, is unable to do so due to lack of space and resources. It seems to us that while, to use Professor Sinclair's words, "long-term residential care for young children should now be avoided"[52], Brig-Y-Don would nonetheless be a suitable placement for such children as an interim, preparatory step to successful fostering.

12. Professor Sinclair has also put forward the view that there will always be children of a certain age (more commonly teenagers) and background who are more likely to thrive in the  traditional  setting  of  a  children's  home  than  in  the  more  stereotypically  familial environment that characterises foster and family-based placements. In his paper on the Jersey care system, he writes:

"Some teenagers prefer residential care to foster care, feeling that they have had enough of families, that they will always be an outsider in them or that they already have their own family and that it would be disloyal to commit to another."[53]

13. Naturally, this will not be true of all children. It will not even be true of the majority of children. But it is often the minority, the aforementioned "awkward squad", who are likely to be the ones who lose out when the system changes. And it is for that reason that we strongly feel that their case should be considered in its fullest terms. What exactly would be

the right kind of residential care for these children, and indeed how many of them do the States currently have responsibility for?

14. Taking the last question first, these were the numbers provided to us by Sean Pontin:

"Currently, Jersey looks after approx 80 children, 32 of whom are primary school age. Of these, 17 are living with foster carers, 6 with Kinship Foster Carers, 1 is home on trial with parents and 8 are in residential care. Due to the progression of care plans etc of the 8 children in residential care a further 3 are in the process of being introduced to foster carers and will move in within the coming month. In overall terms this means that 78% of primary age children are looked after in family placements, which is a new high for Jersey and would indicate that the team are on target to meet their performance target of 85% by 2010."[54]

15. These are certainly encouraging statistics, in so far as children of primary school age are concerned. What worries us, however, is that less than half of the looked-after children in Jersey are of primary school age. What of the remaining 60 per cent? If they are not being placed with foster carers and if the Children's Service continues to move forward on the premise that Jersey's children's homes are "not fit for purpose", what exactly will be the right kind of residential care for them? Is it really the case that every one of the remaining looked-after children, some 48 in total, all require some form of therapeutic residential care?
16. Tony Le Sueur acknowledged that there is an immediate problem in this area:

"What has happened is that we have hit a lull where we have not been able to move forward and in that lull the numbers of young people in residential care have started to increase again. That is going to be difficult for us now. Even once new investment becomes available that is going to be difficult because we have now got full homes again."[55]

17. It is clear to us from the evidence we have received that this is, as yet, an unresolved matter and that further thought and planning will be required before a complete solution is reached.

Leaving care

18. In the light of the aforementioned evidence that the Children's Service now has "full homes again",  it  can  be  assumed  that,  for  the  foreseeable  future  at  least,  Jersey  will  be accommodating a significant proportion of its looked-after children in traditional residential care. That being the case, it is our view that more attention needs to be given to the question of what happens to children and young people when they come to leave the residential facility where they have been living. We feel that this is of particular importance since Jersey has no legislative equivalent of the UK's Leaving Care Act, nor does it have the same levels of accommodation available to care leavers as can be found in the UK or in  Guernsey[56].  Eireann  Le  Poidevin  of  the  JCLA  explained  the  difficulties  that  the association has in trying to find appropriate accommodation for local care leavers:

"A lot of things have been closed down over here. There used to be Camelot, I went into Camelot in St. Saviour 's Road, and that was a girls' hostel and it was sort of moving from children's home it was like a stopgap preparing you for moving on into society. You had to pay your rent on time; you had to be working, have some sort of job; once a week you had to stay in and do your washing. You had to you know,  it taught  you the  things that  parents  usually  teach  you: managing  your money, taking care of your personal hygiene. That is lacking over here now. There are some children in Greenfields that might be better off in somewhere like that."[57]

19. The kind of set-up described in Ms Le Poidevin's evidence is very similar to what we saw at Jeune House, the housing initiative run by the Jersey Association of Youth and Friendship. This charitable organisation provides accommodation to young people who are in full-time work or education and who do not have any kind of behavioural disorders or drug- and alcohol-related problems. Operating within this, albeit rather limited, section of the care- leaving community, Jeune House is able to provide the kind of support service of which we feel is generally lacking in the Island. In terms of the provision of this kind of support to a wider community of care leavers, we are aware of (and fully support) work that is currently under development at the Department of Health and Social Services to convert the old Les Chênes site into semi-independent residential units for young care leavers.

20. Some of this argument hinges, of course, on the issue of the age at which a child becomes an adult. Clearly, in certain areas (notably the criminal justice system) this is a hotly debated issue and one whose consequences often have far-reaching, statutory implications. But in the area of leaving care, it is a somewhat softer issue; it is, in fact, largely a matter of opinion (just as the age at which children leave home in the traditional family setting is a variable and entirely personal matter). Some of the opinions we have taken into account are, in our view, well founded and based on first-hand experience or the kind of exhaustive investigation into the subject that we have not had time to undertake. The first of these opinions is to be found in the House of Commons Select Committee Report Looked-after Children:

"We recommend that the Government explore ways of ensuring that care leavers have full and proper access to health, social care and education services, commensurate with their needs, until they are 25 years old."[58]

21. Closer to home, Candia Cooper of the Jersey Care Leavers Association told us:

"The Association feel quite strongly about this fact that from 16 to 18 or, in some cases, 25 if you are trying to get housing benefit, that it is just woefully lacking. There is nothing there."[59]

22. Nor is housing the only area of support in which care leavers are lacking. Eireann Le Poidevin made the simple point that

"there has to be some sort of support because a lot of them in children's homes, you are in a children's home, you are not allowed in the kitchen. So 9 times out of 10 you do not even learn how to use a toaster. Now, that would not happen if you were living with your parents."[60]

This may be a simple point but it is one of devastating relevance to those who are leaving care for the first time only to be overwhelmed by the litany of daily responsibilities for which they have had no adequate preparation.

23. While there are some services already in place (which are overseen by the Department of Health and Social Services Leaving Care Team[61]), we are convinced that more needs to be done to provide care leavers to stand on their own two feet'.

Obstacles to good service

24. The provision of foster care is an expensive, often difficult and always demanding task, and it is our view that further investment is required to support and promote foster care in Jersey. Currently, Fostering & Adoption Jersey needs to recruit more carers if it is to be able to start to meet demand:

"Currently Jersey has approx 30 active foster carers. This is a slight decrease on previous years however it should be noted that the creative utilisation, training and support of current carers to provide permanence for some children and young people have made actual' statistics inaccurate in the short term. It should be noted that during 2008/09 only 4 carers ceased to be registered as foster carers. Of these 3 retired and 1 adopted."[62]

25. It is interesting to compare these numbers with other statistics that have been gathered during recent recruitment drives led by Fostering & Adoption Jersey. For example, in 2007 the Fostering and Adoption Team received 107 initial enquiries, of which 65 progressed to more detailed discussions, with a final total of just 14 new sets of carers coming on stream that year.[63]
26. So what is the reason for such a low take-up rate? The basic fact that it is just too expensive for most ordinary couples to actually take on the responsibility of fostering a child. It is one of the single most serious problems that was evident in submissions made to this Sub-Panel. There are many who simply cannot afford to provide the service, and yet these are often the same people who tick all the boxes set out in recruitment campaigns such as this:

"Foster carers must be able to offer the time, commitment, space and skills to care for children separated from their own families. Children in care can benefit enormously from the chance to experience a stable family life. If you think you are a good listener, resilient, flexible, optimistic and a great role model we would love to hear from you."[64]

27. What can be done to put this right? The idea of professional foster care is one that is often mooted and, while there has been some move towards promoting that concept in Jersey, Tony Le Sueur told us that it is still far from being a financially viable option for most couples:

"They will say Oh, yes, professional foster carers' but when you say Can you tell me what that is?' most people struggle because are you talking about an employee of the States? If you are, they have to conform to the employment law and should not be working 24/7 and should not be this and should not be that. So we hit a whole set of problems with recruiting them. If they are a voluntary foster carer who operates under the same system, how do we pay them then? Because as soon as you give them more money than an allowance for looking after the child (as soon as you give them a grant, a bursary, a honorarium, dare I say a salary), you then move into the employment law. What they will say, their big issue – and it is true in England – is where is their pension entitlement and how do they support that? Where is their social security payments? Because if one partner becomes a foster carer on a full-time basis they are technically self-employed, so they have to make social security contributions. So we give them a fostering allowance for looking after the child. They then have to spend that allowance to pay social security, to pay additional rent, to pay So one of the very difficult pinch-points, as you described it, is resolving some of those issues to the satisfaction of the people who would want to do it."[65]

28. Professor Sinclair has a suggestion as to how these issues could be resolved:

"Even with the current recession, I am not convinced that it could not do more to attract stranger and kin carers and support them properly so that they stay. England has a good understanding of how to do this, even if it often lacks the political will to put this understanding into effect. If there is any doubt in the Island over what is

necessary, I would have thought that they could ask the UK Fostering Network[66] to look at their support arrangements for foster carers and see if there is anything more that can be done. Fostering Network should certainly know about practice on insurance and similar issues that are problematic in the UK as in Jersey."[67]

29. It is also worth bearing in mind that it is not only the straightforward recruitment of foster carers  that  requires  investment.  It  is  our  view  that  Jersey  needs  to  spend  more  on developing  new  and  innovative  types  of  fostering  if  we  are  really  going  to  create  a satisfactory alternative to the current shape of the Island's care system.
30. There are a number of ways in which the fostering and family-based models can be adapted  to  meet  the  needs  of  cases  that  may  not  fall  into  the  conventional  mould. Professor Thoburn outlined some of them:

"There are some what I call fostering careers where people take a turnover of children – short term, respite, give parents a break. You could do with a respite care scheme whereby you twin foster carers with families and the child always goes to that same family. You need that scheme which is a bit like daily minding. It is an extension of that. Then you need people who want children long term as part of their family. You need quite a few of those. But they are not looking for pensions and reward. They will go on having their careers, as it were. Then you have got a much smaller group of therapeutic foster carers, shall we say. Those you have to pay. You have to think about pensions and holiday pay. Again, they have more children for shorter periods of time. So you do not have to have the same response to every foster carer."73

31. Professor Sinclair posits another interesting idea in this area of creative fostering':

"A second form of residential care that Jersey might consider would be a kind of extended foster care'. The aim of this would be to cater for those young people who need to be in care but do not want to be fostered. The longer these young people are likely to be looked after, the stronger is the case for trying to meet their

wishes.  One  possibility  is  to  provide  a  large  ordinary'  house  which  can accommodate a married or similar couple. The aim would be to build up a group of young  people  in  the  house  who  were  compatible  and  wanted  this  kind  of accommodation. It is important that the young people feel happy with these quasi- siblings'. As more young people join the household, it becomes important to provide practical  support  (e.g.  with  cooking  and  housekeeping).  However,  it  is  also important to keep costs down. If this is not done, there is increased pressure to move the young people on, something which works against the security that this provision is supposed to give."[68]

32. It has become clear to us even in the very short timescale within which we have had to produce this report that further thought and investment need to be applied to the provision of foster care in Jersey. We have been impressed by the enthusiasm and the breadth of knowledge that has been evident in our contact with Fostering & Adoption Jersey, and if they are to be the mainstay of Jersey's revised care system then they will require the financial muscle to ensure that the right number and quality of carers can be recruited and that flexible, responsive fostering schemes can be created as required.

7. SERVICE DELIVERY AND ACCESS

1. The successful delivery of services to vulnerable children and their families is contingent on two pivotal requirements: firstly, that there are sufficient funds and staff to allow early and timely intervention, and not just firefighting intervention at a point where a situation has already become critical; and secondly, that the many agencies involved in this area of work communicate with each other and coordinate their services effectively, with the child's best possible outcome in mind.
2. During the course of this review, however, the Sub-Panel has become aware of a number of child welfare cases that have been brought before the Royal Court in which multi-agency failures have been cited. In the high-profile case of Family X', the children in question were the subject of a Report and Proposition P.62/2009 Family X: placement in the United Kingdom. The Proposition was as follows:

"(a) to request the Minister for Health and Social Services to take the necessary steps to ensure that the X children are moved as soon as possible to the United Kingdom placements that have been identified as suitable for them; and

"(b) to request the Minister for Treasury and Resources to assess whether the funding required for these placements can be identified through the reprioritisation of existing heads of expenditure and, if not, to further request the Minister to bring forward for approval a request under Article 11(8) of the Public Finances (Jersey) Law 2005 for the necessary additional funding to meet the cost of these payments in 2009 in view of their urgency and to then make appropriate provision in future Annual Business Plans to meet the on-going annual cost."[69]

3. The issue before the Royal Court had centred around the children, who are in the care of the Minister for Health and Social Services. And yet the Minister, despite professional opinion in favour of doing so, had not placed these children in UK establishments capable of providing specialised wrap-around care. Contrary to this, part of the funding identified for the Williamson Report: Implementation Plan was to establish an on-island unit to provide specialised care for this family and others.
4. However, the part of the Report most relevant to this review stated that: "Children in the care of the Minister

"The children who are the subject of this proposition are currently in the care of the Minister. All the professionals involved in their care in Jersey, and experts from England who have assessed them, have expressed the view that their needs will best be met by specialist therapeutic residential placements in England. This is also the view expressed by the Royal Court on 27th April 2009. Care proceedings were first instituted in 1999 in respect of these children because there were real concerns that their parents could not care for them. The system failed the children in the essential period 1999–2000 and thereafter. It then took some 9 years for the children to be taken into care, by which time the children had suffered years of abuse and neglect. A Serious Case Review has now been instituted in response to allegations of multi-agency failures by the States of Jersey. They now rank as the most damaged children in Jersey and also in the top tier of all such children in England. Dr. Silver (an expert engaged by the States and practicing as a consultant psychologist in Northamptonshire) states that the children would be in the top 5, possibly top 3, of 650 damaged children that she deals with, and that they would have been placed in the specialist therapeutic placements that are now sought. (Northamptonshire spends £16 million on its 42 children that are in residential care.)

"Therapeutic placements for the children

"The children are very damaged and vulnerable and are in dire need of residential therapeutic placements to help them recover from serious and sustained abuse over many years. The children have been neglected to a significant degree over the whole of their lives, their birth family not being able to care for them properly, largely due to problems in their parents' own backgrounds. In addition to chronic neglect over many years the children have suffered sexual abuse to a quite horrific extent. This abuse is likely to have been committed by different adults at different times. The children have displayed highly sexualised behaviour from a very young age, such that one of the children has been described by the consultant clinical psychologist as the most disturbed child she has ever worked with. The children all have very serious problems."[70]

5. The Sub-Panel are very concerned by the following statement in particular:

"The system failed the children in the essential periods 1999-2000 and thereafter. It then took 9 years for the children to be taken into care by which time the children had suffered years of abuse and neglect. A serious case

review has now been implemented in response to allegations of multi agency failures by the States of Jersey."[71]

6. There are a number of things that concern the Sub-Panel if this statement is true. It suggests serious failures with Jersey's child protection system over a considerable period of time, which requires further investigation beyond the scope of this review. It also questions the role and responsibility not just of the multi-agency' failures but of the transparency and accountability of the Corporate Parent.
7. The problem of access, also dealt with in this chapter, is discrete from but, in many ways, bound up with the idea of service delivery. Access covers a wide range of topics, including the physical and geographical location of services, the ways in which people are able to obtain information and services, and whether those services are in fact tailored to suit their actual needs. But irrespective of which type of access is in question, there is, as we have been told on many occasions by witnesses and service users, one golden rule for success: it should be non-stigmatising. In our minds, it is beyond question that the most effective and beneficial services for vulnerable children are those that are delivered in a way that is non-stigmatising and non-judgemental.

When to intervene

8. The most important question of all, we were told by many witnesses, is this: at what stage should the States intervene in order to assure the best possible outcomes for vulnerable children? To which the resounding answer, throughout this review, has been: as early as possible'. We have heard enthusiastic endorsements of early intervention from every quarter of the Island's child protection services, as well as from the children themselves during our various site visits.
9. Known to practitioners as universal' or primary' prevention, early intervention represents the first of three tiers of intervention in the standardised model of social work good practice. This tiered model is often expressed pictorially[72] but can also be summarised as follows:

• Primary prevention services are directed at the whole population and have the aim of supporting positive developmental outcomes for every child;

• Secondary prevention interventions are those which are offered to populations that may have one or more risk factors associated with poor child outcomes, such as poverty, parental substance abuse, young parental age, parental mental health concerns, and parental or child disabilities;
• Tertiary prevention interventions focus on families where maltreatment has already occurred and seek to reduce the negative consequences of the maltreatment and to prevent its recurrence.

10. As mentioned previously, we found no shortage of informed, experienced professionals eager to emphasise the need for a significant increase in the Island's primary prevention services. This does not mean that there is not already a great deal of excellent work taking place – there is – but we are convinced that more investment is needed to progress the high-quality services that are currently on offer. These services include family centres such as The Bridge, NSPCC Pathways and Brighter Futures, as well as the universal home- visits conducted by Family Nursing and Home Care (FNHC).
11. In practical terms, much of the primary prevention work that goes on in Jersey will often target children in a pre-school age group (the under-fives), and their parents, but its effects are far from confined. Barbara Bell, Divisional Manager of Governance at FNHC, outlined the enormous potential gains in this kind of work:

"So there are quite a lot of incidents, I think, with the older child but it is the younger child, the 0 to 5, that cannot speak for itself that needs a great deal of support, and we need to be very vigilant with those. I am not saying that we should not be vigilant with the others, because they have major issues that need to be dealt with, huge issues that if they are not dealt with when they are babies become major problems when they are older. But the vulnerability, in terms of physical vulnerability of a baby that cannot speak for itself is much higher. You may have less of them but you have... you could have bigger problems."[73]

12. Mr Williamson also touched on exactly this area when he spoke to us, highlighting the importance of a new strategic approach to primary prevention:

"You are doing some good stuff at the lower level not lower but the first tier, you know. There is some good work going on at Pathways, I remember, NSPCC, The Bridge. You have got a number of places where there is some good work going on with the families to try and develop parenting skills to keep families together. Maybe we need to sharpen up the strategy; what is the plan? Is the plan to have more of the Pathways? If it is working do we want three more in other parts of the Island? I do not know. I was really saying I think you at least need to think about these things and develop a strategy."[74]

13. In fact, the need for strategic planning and investment in this area extends even further than Williamson has suggested. It is of course true that the family centres are doing invaluable preventative work but it is also true that the health visitors and family support staff affiliated to FNHC are delivering similar services, except in their case it is across a universal platform. The advantage of this particular agency is that their work reaches all families in Jersey, without exception: every child below the age of five is visited by a health worker from FNHC, and they remain within the purview throughout their school careers until they reach the age of 18. This is in marked contrast to the work of the Children's Service (to whom children must be referred) and to the work of centres like The Bridge and NSPCC Pathways (which rely on parents having the will or capacity to seek out family groups). This means that workers from FNHC are able to come into contact with children when they are at their most vulnerable age, before schools and, in many cases, the community at large are aware of them. Most crucially, though, FNHC (like the family centres) is able to fold a child protection element into what is ostensibly an entirely non- stigmatising service:

"We visit every family. Everybody knows that when they have a baby they have a health visitor and our remit, obviously when we identify a child in need, it is child protection, but it is not just that at all. So it is supporting people not to reach that level."[75]

14. It is for this reason that FNHC is "one of the key referrers to children's services for the under fives"[76] and it is also the reason why they are uniquely positioned to access the Island's most vulnerable children. Child and Family Services Team Leader Julie Gafoor explained:

"Because the most vulnerable people with children do not go to groups, they will not come into centres, so the health visitors are doing that work in the home, and that is hidden, that is often hidden, but yes, we do offer that."[77]

15. It seems to us that this hidden' work very often slips off the page when the workload and funding for primary prevention services are being considered. It is vital to remember that intervention at this stage takes a number of forms and that, the less stigmatising and intrusive that it is seen to be, the more positive the outcomes are likely to be. What is, in our view, beyond question is that the proper coordination and funding of all of these primary services should be given serious consideration. This has not yet been done; nor will it happen as a result of the Williamson Report, which did not include FNHC in its remit:

"We looked at the terms of reference of the Williamson Report too and realised that Family Nursing really were not incorporated into the terms of reference and thought there was a huge gap, because there were services that we provide that no other service on Jersey provides."[78]

16. We believe that every agency that affects outcomes for vulnerable children should be taken into account, particularly those offering the kind of universal coverage that FNHC provides. It is a matter of taking a holistic view of what can be done to improve children's wellbeing and life chances, and not simply looking at Social Services from a managerial viewpoint. As the NSPCC's Peter Liver put it:

"So, I mean there is a lot of evidence of that and I just think, again, it would be early intervention but it would be something that is non-stigmatising; there are ways of doing things and perhaps coming from social work/social services is not always the right area and that is where, if there was a proper working together of coordinated services I would like to think the support was there. There is a limit, isn't there? When does somebody reach that point that they have the capacity to parent effectively? It goes on and on and on and we have seen that."[79]

17. Similarly, the fallout from those parents who have surpassed the limit' described above can also be caught at an early stage through the work of the Youth Service. This is a phrase that may conjure in some people's minds images of youth clubs with a few youngsters hanging around a hall perhaps having a game of table tennis, but the modern reality of today's Youth Service is a million miles from that cliché. Jersey's current Service extends beyond clubs and premises in partnership with parishes, to drop-in centres and cafés, as well as street-based, detached and outreach work.

18. A team of dedicated youth workers across the island are working with 11 to 25 year-olds (focussing  mainly  on  12  to  18  year-olds),  targeting  those  young  people  who  are disadvantaged, vulnerable or at risk of social exclusion. This includes young people who: are not in education, training or work; whose first language is not English; have a disability or learning difficulty; are in or leaving care; are young parents or carers; have been involved in criminal activity; are leading high risk lifestyles.
19. The Service is actively and positively engaging with a range of young people, and the recently established Youth Enquiry Service (YES) is proving to be very successful in providing a range of real life' information for young people as well as free confidential advice and counselling.
20. The YES project, set up in partnership with the charity Jersey Youth Trust, is a recipient of funding from the Bosdet Foundation, without whose support the YES project may never have been developed. This is another example of an excellent grass-roots initiative that is reliant on charitable donations. YES is making a very real difference to young people, especially those who have dropped out of school or who are living on the streets, sofa surfing' or seeking advice about work, income support or accommodation. In the period from May 2008 to February 2009, YES had 328 drop in' visits from young people – 209 males and 119 females86 – which led to follow up services being recommended including counselling.

21. Given that there is general agreement on the importance of primary prevention and that there seems also to be a willingness to develop this kind of lower-tier child protection work, the sharpening up of the strategy, to borrow Williamson's term, should be a matter of the highest priority. Why, then, has this not already been addressed?
22. There are two significant problems that have been holding back the Island's primary prevention services. The first is that there has never been enough money or manpower to resource them, the second is that the outcomes of primary prevention are difficult to quantify because they involve the number of children who are not appearing on the radar of the Children's Service, as opposed to a measurable decline in the number of those who currently are known to the Service. This second point was summarised by Ms Bell:

outcomes and it is extremely difficult and that is not an excuse, it just is, because it takes years to have an outcome. I think we would be really happy if we were seeing the children of the families that we are visiting now not getting into difficulties when they have got children. That is what our outcome submission would be."87

23. This is a difficult area for the Service for the simple reason that, while those on the ground' are convinced of the positive effects of primary prevention, it has traditionally been difficult to put forward a strong submission for funding (especially in the recent climate of an under- staffed, fire fighting workforce). Ms Bell told us that the discernible benefit of primary prevention -

"takes many years and people do not have time to wait. When we are planning resources and all the rest of it you do not have time to wait 15 years down the line to see whether that service worked."88

24. This was an emergent theme in much of the evidence that was submitted to us. Take, for instance, the following comment made by Principal Educational Psychologist Jo Forrest:

"You can look back and say: We could have done this, this or this, at these points that might have been a different outcome for that person.' There are children who are dealing with really adverse circumstances that it has not been possible to intervene with because of lack of resources."89

25. Similarly, the Director of the Department of Education, Sport and Culture, Mario Lundy, explained why it is especially important for school-age children to be effectively monitored in a universal sense:

"If the school is rightly trying to bring to the attention of the Children's Service where a child may be at risk, if not immediate risk but may be at risk in the longer term if resources do not go into it and the Children's Service are faced with that and a serious child protection issue at the same time, well it is quite clear where they have

86 Statistics submitted by Youth enquiry Service

87 Transcript of Public Hearing with Ms. B. Bell, Ms. J. Gafoor, Ms. J. Querns

88 Transcript of Public Hearing with Ms. B. Bell, Ms. J. Gafoor, Ms. J. Querns

89 Transcript of Public Hearing with the Minister for Education, Sport and Culture, Mr M Lundy, Ms J Forrest, Ms P Tumelty and Ms B Cochrane

to put their resource. So, the effect is that we need to consider how we invest in early intervention."[80]

26. All  of  which  gives  rise  to  the  question:  how,  specifically,  can  we  "invest  in  early intervention" in the area to which Mr Lundy was alluding, namely school nursing? Following the same model of FNHC's universal service, the role of the school nurse is crucial to the safeguarding of our children as it allows key areas of need to be identified at an early stage in a non-stigmatising way. In the words of Ms Gafoor:

"It is a gap that we have very few school nurses and obviously a large school age population, 13,000 children, and we only have one qualified school nurse and another two and two-thirds full-time staff [Registered Nursing, Staff Nurses]. So we are really short, so we cannot offer – as much as we would like to – the same service as we can for the under-fives."[81]

27. There is, therefore, a clear need to recruit more qualified school nurses. This would enable schools to identify any nascent problems, both with families and children, during a stage at which early intervention would be both possible and highly effective.

28. The last point to consider here would be the method of intervention employed by agencies such as FNHC. This follows a strict set of guidelines, which allow for intervention in the case of -

"all  families  with  children,  health  and  developmental  needs  who  may  be compromised unless multi-agency services are provided. Any intervention in the life of a child should be purposeful and the effect of the intervention must be judged as more beneficial than not intervening."[82]

29. Ms Gafoor elaborated on this policy by highlighting the inclusion in the decision of when to intervene

"mental health as well as physical health, and that is of the child and then of the parents as well, so their capacity as well. So any of the addiction problems where parents are struggling."[83]

30. The key factor in all of this is the phrase "unless multi-agency services are provided". It is evident from the many submissions that have been quoted in this chapter that a number of factors influence the decision of when to intervene. It therefore stands to reason that the intervention itself, if it is to be truly successful, cannot be unilateral, on behalf of just one agency or service. The solution is almost always a multi-faceted one, requiring the positive cooperation of all parties and, most significantly, the requisite degree of inter-agency coordination.

Inter-agency coordination

31. Professor Ian Sinclair has said that -

"the need for joined-up working is the leitmotiv for reports on child protection"[84];

this report is no exception. The majority of the people who have submitted evidence during the course of this review have at some point referred to the importance of creating and maintaining a properly coordinated approach to child protection.

32. In many cases we have found laudable efforts being made to coordinate services among professionals in States Departments, their counterparts in the private sector and the workforce operating in and around the voluntary sector. And yet, despite these efforts, there is rarely enough genuine coordination to produce first-rate service delivery. The absence of coordination exists at the very top of the Island's services for vulnerable children (see Political Accountability) and, save for notable pockets of joined-up working, tends to percolate down through the ranks.
33. This is, in part, a result of ingrained ways of working that thread back through many years of service provision – what Kathie Bull encapsulated with the watchword "that's Jersey for you".[85] However, the main reason for the current lack of coordination is related to the following statement made in a Public Hearing by Dr Bryn Williams, Consultant Clinical Psychologist at the Child and Adolescent Mental Health Service (CAMHS). Dr Williams had

been asked for his views on how best to tackle the kinds of problems that vulnerable children are susceptible to; this is what he told us:

"I think the model that seems to work best, if you think about the work that goes on in the Island, is the idea of taking a child who has a problem and putting the team around the child, rather than having the child and finding the right team to put them in."[86]

34. Here Dr Williams is simply telling us that the best outcomes for vulnerable children will be achieved when services work flexibly and pull together to meet the needs of the child, rather than shoehorning that child into one rigidly defined service or another. Experience shows us that the one size fits all' approach to service provision rarely produces the optimum outcome for a child. Individual cases are exactly that: individual. When resources are pooled and professional views and services are shared, the package of care and treatment that is available for vulnerable children and their families is broad enough to be tailored to individual needs. This is a common theory, and one that has become prevalent in child protection work in the UK under the aegis of the Every Child Matters programme:

"The Every Child Matters programme aims to ensure that services are organised around the needs of children and families and not around the convenience and traditions of service providers. Through common assessment, shared information systems and integrated organisational structures Every Child Matters aims to reverse the fragmentation of services, which confuses families, wastes limited public resources and is at root of most of the recent failures in safeguarding children. Instead the vision of services is child centred, with the voice of the user central to individual interventions and service design, and the effective an efficient deployment of public resources dedicated to improving actual outcomes for children and families."97

35. As Dr Williams said, Jersey already has some service providers who work in this joined-up way, and we have seen for ourselves the resounding success of this approach at The Bridge, Brighter Futures and NSPCC Pathways (see Access). Yet, while these are all steps in the right direction, a lot more work is needed. A culture of working together must be promoted throughout the Island's child protection services, and that will require a significant change in the general attitude to how we do things here'. As FNHC's Ms Gafoor remarked to us:

"I think allocating certain budgets makes everyone quite protectionist about their area, so it does not make for such a sharing, joined-up working, is my feeling because people think, Oh no, that is my area so I do all that'. Well, it is a lot of people's areas and we all try and do it together well."[87]

36. This is an example of the silo mentality that permeates Jersey's child protection services. All too often, efforts to provide an all-round package' for vulnerable children are stymied by an apparent unwillingness to allocate resources or to work outside of set parameters. It seems to us that the root cause of this unwillingness is, more often than not, the pressure that is brought to bear on Departments and other service providers by a lack of core funding. Consider, for instance, the following statement by Nola Hopkins of the NSPCC Pathways Project:

"We cannot meet demand at all. I can't accept this. The more we work, and word gets out, they come along and ask us to do it. But we are a very small team and we cannot expand."[88]

37. When we inquired further into what might be the cause of this inability to expand the service, Ms Hopkins' UK-based colleague, Peter Liver, told us:

"I mean we spend something round about £300,000 a year in Jersey. We will raise, from Jersey, in the order of £200,000 to £225,000. So, in essence you might say nationally we will subsidise some of what we do on Jersey through what we call generic donor giving, in other words people will give to the NSPCC, not with any particular target in mind but they will say we want to support the organisation and that generic fund is used to, if you like, top up, subsidise locally where we are not able to raise enough money to support the services. In Jersey we, historically, have had no formal funding partnership with the States ever."[89]

38. Why is it that one of the best family centres in the Island is being majority funded by national institutions such as the NSPCC or the Lloyds TSB Foundation[90]? Why is it that this centre, which is so over-used by the public and yet so undervalued by the States, is not able to expand to meet the demand of vital, primary prevention work with vulnerable

families and children? These are difficult questions for the States, and they are by no means confined to Pathways Project.

39. The CAMHS team is the most important mental health resource for the Island's children and young people and yet it is limping along at half capacity, barely able to meet the demands of critical cases, let alone indulge in the luxury of extensive joined-up working with other agencies. Dr Williams told us that statistically Jersey's population would see an annual incidence of around 1,600 children and young people experiencing some form of serious psychological disturbance, and yet only a quarter of them can be looked after by CAMHS:

"We can look after 400 children a year, which means that 1,200 children at some degree are not getting access to the kind of help they need. Which is why... and I do not think we will ever have enough because nobody is going to buy enough, but the Royal College of Psychiatry, Young Minds, Kathie Bull, say for example, said there should be two psychiatrists working in Jersey, we have got one; it says there should be four clinical psychologists, we have got two. It says we should have family therapists; we should have specialist cognitive therapists. We have got John, but he is on his own."[91]

40. It is evident that the Island treats the mental wellbeing of its children with scant regard, but this same lack of support is also undermining the work of other child protection services. Ms Bell of FNHC told us:

"I can tell you that we had a significant increase in the amount of time that health visitors have spent, and school nurses, dealing with vulnerable children in families So in 2006 they spent about 1,981 hours. Now that is not visiting, that is attending case conferences, core group meetings, making referrals, liaising with other services, writing court reports, case conference reports and dealing with issues maybe to do with domestic violence, and that is a huge amount of time out of those 11 staff's hours. In 2008, we spent 2,621 hours. So that is an increase of 640 hours' work specifically related to the mechanics of protecting and safeguarding children, not the going out there and visiting them which is an additional thing, but that is the mechanics of the logistics of the work that has to be done."[92]

41. These are by no means new problems. As far back as June 2006, the specialist consultancy and training service YoungMinds[93] was commissioned by the Department of Health and Social Services to undertake a service review of CAMHS in Jersey. Many of the problems that were identified at that time by Young Minds are those that continue to dog CAMHS three years later. For example, the recommendation was made to increase -

 "the capacity and expertise of the specialist CAMHS team by recruiting a second consultant psychiatrist to focus on the 16 and 17 year olds, the secure unit and intensive packages of care"[94].

This has not been done.

42. The staffing of the Service was also compared in the report to Guernsey's CAMHS which, despite its smaller population, has the following variance in senior FTEs: 2.5 psychiatrists (Jersey has one); 4 psychologists (Jersey has one).[95] The report also recommends the employment of -

"Primary Mental Health Workers, with a focus on minority communities, and partly located in different venues, for example large GP surgeries and the voluntary sector"[96].

 Again, these are continuing areas of need.

43. In making reference to the findings of a separate report and to its own conclusions, YoungMinds was also able to highlight certain weaknesses within the Children's Service, which it considered to be impacting on CAMHS:

"Another important concurrent development is taking place in community child health services. The external review commissioned from the Royal College of Paediatrics and Child Health found that children's services in Jersey are fragmented with multiple and incompatible information systems and weaknesses in clinical audit (issues also identified in this report)."[97]

44. The authors of the YoungMinds report added their own weight to this finding of a fragmented Children's Service by saying, "In common with other reviewers of children's

services on the island, we have identified fragmentation as a key issue to tackle."[98] Then, with a view to how this fragmentation can hinder the effective operation of CAMHS, the report found that:

"There  is  an  absence  of  systems  to  identify  and  lever  up  low  standards. Governance arrangements caused us some concern in a service more than usually faced with risks associated with isolation."[99]

45. Increased funding would certainly facilitate a more flexible, joined-up approach but it would still not address what we perceive to be the cultural' element of this problem. As cited earlier in this chapter, the Bull Report made much of the entrenched culture of Jersey's services ("that's Jersey for you"), and the submissions that have been put to us during the course of this review suggest that there is still a resistance to attitudinal and cultural change in the Island's child protection services. However, we have been very encouraged to see that some highly significant improvements in this area have been effected through the recent work of the Jersey Child Protection Committee (JCPC)[100].
46. The appointment, in June 2009, of a new Chair of the JCPC[101] is the second phase in a process of reinvigoration that was begun in October 2007 when Professor June Thoburn was appointed on a short-term contract as the first independent Chair of the Committee. The arrival of Professor Thoburn was widely regarded as a breath of fresh air and the changes  that  she  subsequently  instigated  have  done  much  to  renew  the  spirit  of cooperation  and  joined-up  working  between  services  at  an  operational  level.  These changes have largely revolved around the creation of proper levels of independence in the work carried out by the JCPC. Professor Thoburn summarised these efforts for us in the following terms:

"I saw it as my role to differentiate between Children's Social Services and the role of  the  Jersey  Child  Protection  Committee.  I  found  that  people  did  not  see  a distinction between the two; politicians and especially members of the public. That is not surprising and indeed it is not a critical comment because the same would have applied to most places in England too. So that is what I have mainly been trying to do over the last two years. We now have a separate office and a separate professional officer and administrator so good progress has been made in that respect. "[102]

47. As Professor Thoburn says, good progress has been made, but there is still a way to go. Politicians may have become more aware of the work of the JCPC but what has been done to increase the public's awareness of the Committee's work? To our knowledge, the answer is very little', and this is a situation that needs to be remedied. For example, there was  a  suggestion  in  the  Committee's  2008  Mid-Contract  Report  that  the  Council  of Ministers changes the name of the JCPC to something more recognisable to the public: