Plymouth Safeguarding Children Board
Plymouth City Council
Plymouth PL1 2AA
Serious Case Review into abuse at Little Ted’s Nursery
A detailed summary of a serious case review into abuse by a worker at Little Ted's Nursery has been published by the Plymouth Safeguarding Children Board.
The review was commissioned in June 2009, immediately after the arrest of Vanessa George, a worker in the privately-run nursery in Laira, Plymouth.
It aims to look critically at individual and organisational practices to establish whether there are lessons to be learned about the way professionals, agencies and independent sectors worked to safeguard children in the nursery setting.
Serious case reviews are normally carried out by local safeguarding children boards when a serious incident or death of a child occurs, but given the extremely unusual circumstances, the focus of this review is on the nursery as a whole, rather than individual children.
The review set out to get an understanding of what exactly happened, why it happened and how such an event might be prevented in the future.
It includes a series of recommendations which agencies in Plymouth are already implementing. There are also a number of national recommendations.
Serious case review summaries are usually between four and six pages long. The executive summary of this review is 39 pages long and is detailed to enable the public, including the families affected, to understand as fully as possible its findings.
This summary is a redacted version of the full report, with details removed that would identify members of the community, as well as explicit content that would be inappropriate for publication.
The review looks at a range of factors around how the nursery was run, family involvement, accountability and safeguarding of children as well as the role of George within the nursery.
It concludes that there was no indication 'that any professional could have reasonably predicted that George might be a risk to children'. The evidence points to her having no sexual interest in children until she made contact with Blanchard via the internet.
The report found that the nursery had some strengths in that it was firmly based in the community, was seen as friendly and the children were happy.
However, the report sets out a wide range of issues with the nursery management, culture and physical environment that meant safeguarding risks were not minimised.
There was a weak governance framework at the private nursery with no clear lines of accountability, which the report says is likely to be a feature of other similar early years settings that have developed within local communities.
Factors that meant safeguarding risks were not minimised included the absence of safer recruitment procedures, an informal recruitment process and a lack of formal staff supervision within the nursery. Policies and procedures in relation to child protection had been lifted without adaptation to the setting from other documentation.
The report says that from staff interviews and discussions with parents, as well as a review of the records, it was apparent that Little Ted's did not provide a safe, positive environment for children in its care. It says: "This would indicate that either the individual inspections were not rigorous enough, or the framework for inspection is not adequate." (5.42)
The environment enabled a culture to develop in which staff did not feel able to challenge some inappropriate behaviour by George. Staff working at the nursery became increasingly uncomfortable and worried about George's behaviour but felt they had nowhere to go with these feelings. (5.62)
There appears to have been a complete lack of recognition of the seriousness of the boundary violation and a culture in which explicit sexual references about adults in conversation were the norm. (5.79)
The report concludes that Little Ted's "provided an ideal environment within which George could abuse." (5.76)
The report says that Plymouth's Early Years Advisory Service had regular contact with Little Ted's and had flagged concerns over a period of time, although these related to concerns about management and the nursery’s ability to adapt to the practices expected. None of the issues raised related to safeguarding.
The service is not a regulatory body and supports settings to improve by offering information, advice, support and challenge.
The report notes that the Early Years Service can only complain to Ofsted about a setting if there is evidence of a breach of compliance with the statutory regulations. But, Ofsted had always judged Little Ted's to be 'satisfactory' or 'good'.
The report says: "It has become clear from this review that whilst the Early Years Service had many concerns about the nursery there was no formal mechanism for informing Ofsted, since they did not reach the threshold of a breach of regulations. Similarly Ofsted had no means of discussing with Early Years the support need for the nursery." (5.44)
The serious case review report details a number of lessons learned, which include:
- The positive impact of an effective family support strategy in situations of potential multiple abuse. There is evidence that organisations across Plymouth worked extremely well together. (6.1)
- The important role the Early Years Service can play in identifying poor practice within nursery settings. The report says: "There is much good practice by the Early Years Service, who made strenuous efforts to work with Z [Little Ted's] to improve the experience of children attending the nursery." (6.3)
- The danger of mobile phones within day care settings. The report says: "Whilst stopping staff carrying mobile phones is an important preventative measure and will mean that images cannot easily be transmitted electronically; this alone will not prevent abuse taking place." (6.4)
- An urgent need to develop effective staff supervision within early years settings. (6.5)
- The separation of the regulator (Ofsted) from Early Years Services means the communications pathway is not flexible enough to allow sharing of information which could inform a judgement about good practice. (6.7)
- Staff did not recognise the escalation of George's sexualised behaviour as a warning sign and there is an urgent need for staff working in early years settings to receive training to help recognise potential signs of abuse and become confident in responding to a fellow staff member's behaviour. (6.9)
The final conclusion of the report is that while there were a number of factors that came together to support a culture where abuse was possible and a number of lessons to be learned, "ultimate responsibility for the abuse must rest with K [George]."
The review makes a series of key recommendations including national recommendations. They are:
- Clear communications mechanisms should be set up between Ofsted and early years advisory teams to ensure local intelligence informs the nursery inspection process.
- The Early Years Foundation Stage safeguarding requirements should be reviewed and strengthened in order to identify the characteristics of unsafe organisations. Further guidance should be issued to early years Ofsted inspectors to help them identify where these characteristics may exist. This should include safer recruitment procedures.
- The Early Years Foundation Stage should set out specific requirements for child protection training which considers sexual abuse and the recognition of abuse within the workplace.
- Government should review and consider changing the status of day care settings operating as unincorporated bodies to ensure that governance and accountability arrangements are fit for purpose and are sufficiently clear to enable parents and professionals to raise concerns and challenge poor practice.
Jim Gould, Chair of the Plymouth Safeguarding Children Board, said: "This has been a very thorough review of this very harrowing case. While responsibility for this shocking case of abuse cannot be taken away from Vanessa George, we are determined to learn from it and do everything we can to minimise the risk of this happening again. There are a range of lessons that can be learned for all the agencies involved, both locally and nationally.
"These recommendations are already being implemented locally and we hope that the report will be used to help protect children around the country. We would now like to see central government taking action to strengthen accountability frameworks for nurseries to ensure those managing nursery settings are held responsible for ensuring they provide a safe environment for children.
"We would also like to see Ofsted strengthen the inspection of nurseries to ensure there is a culture in all nursery settings that maximises the safeguarding of children."
The serious case review summary is available on our serious case reviews page.