Alleged sexual abuse of an adolescent boy by foster carers in two separate placements between 2013 and 2015; a criminal investigation was initiated but neither foster carer was charged with criminal offences. Child PB became looked after aged 12 due to behavioural problems. His first long-term foster carer (FC1) requested that the placement be ended, citing ill health. PB was placed in a residential educational setting, living with a second foster carer (FC2) during weekends and holidays. His behaviour deteriorated and he was moved to a permanent residential placement. PB went missing several times, returning to FC2 although this was not always reported. On one occasion FC2 told police he hadn't seen PB, but PB was found hiding undressed at FC2's home. Despite FC2 being suspended as a foster carer, PB was persistently found at FC2's home. Weeks later, following therapeutic support, PB disclosed sexual abuse by both FC1 and FC2. Key findings include: although the disclosures have not led to prosecutions, the actions and behaviours of both foster carers should have led professionals to consider at a much earlier stage whether they could keep children in their care safe and whether they posed a risk to children placed with them. Recommendations include: ensure foster carer assessments and reviews are robust, thorough and appropriately challenging; ensure supervision files have carefully maintained chronologies to support supervision and review so that any emerging concerns or issues can be addressed; ensure all practitioners have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children.
      
 Title:  Serious case review: the placements of Child PB. LSCB: Trafford Safeguarding Children Board Author: Trafford Safeguarding Children Board Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                    Serious Case Review    The placements of Child PB               March 2017  SCR Trafford/ Fostering/December 2016 - amended March 2017 2  Contents  1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews   2. The circumstances which led to this SCR   3. The approach used   4. Scope and terms of reference    5.  Cross Boundary Issues  6. Significant Events   7. Appraisal of Practice and Processes  8. The Recruitment and Selection of foster carers.  9. The Fostering Panel and the Agency Decision Maker  10. PB’s placements  with FC1 and FC2  11. Supervision of Foster Carers  12. Annual Foster Carer Reviews  13. Communication and collaboration between agencies  14. Managerial Oversight  15. The  views of PB  and family  16. Summary   Appendix 1: Recommendations for Trafford Safeguarding Children Board and the Local Authority      Key: (names have been anonymised)  Mother:   MPB Stepfather:   SFPB Subject:    PB First Foster Carer   FC1 Second Foster Carer  FC2 Supervising Social workers SSW1 and SSW2 Social Worker    SW  SCR Trafford/ Fostering/December 2016 - amended March 2017 3 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)1 are to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance2, which accompanies legislation and underpins the work of LSCBs, is very clear in its expectation that LSCBs should maintain a local learning and improvement framework so good practice can be identified and shared.  1.2. In situations where abuse or neglect of the child is known or suspected, and children die or are harmed, LSCBs are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce the risk of future harm to children. There is an expectation that these processes, known as Serious Case Reviews (SCRs) should be transparent with the findings shared publicly.  2. The circumstances which led to this Serious Case Review (SCR) 2.1. In the summer of 2012, the mother (MPB) and stepfather (SFPB) of child PB requested help from Children’s Social Care (CSC) because they were unable to manage his behaviour. The family were offered support through the Child in Need process, but in February 2013, PB aged 12 years old, became a looked after child under section 20 of the Children Act 1989 and was placed with foster carers. Later, at different times, PB was placed with Foster Carer FC1 and Foster Carer FC2.  2.2. PB was placed with FC1, a newly approved single foster carer, in May 2013 and he remained there until January 2014, when FC1 advised the authority that due to his ill health he was unable to continue caring for PB. PB was moved a short time later and placed with other foster carers.   2.3. FC2 had been approved in February 2013 as a single foster carer. PB was placed with FC2 in March 2014, where he remained for several weeks until moved to a residential school as a weekly boarder and returned to FC2 only at weekends. In November 2014, CSC made a decision to place PB in a 52-week residential placement, which also offered education. PB persistently absconded from this placement and frequently returned to the home of FC2.   2.4. Residential staff and social workers had growing concerns about the possibility that FC2 was colluding with PB during the times he was missing, and these were confirmed when, in February 2015, despite his presence being denied by FC2, police found PB hiding, partially clothed, in an upstairs bedroom in FC2’s home. FC2 was subsequently served with an abduction notice and was later de-registered as a foster carer.  2.5. Further placement breakdowns occurred for PB before he was placed in secure accommodation amid concerns about his safety, and his aggressive and sexualised behaviour. PB made progress in this secure placement with the help of a therapeutic support worker from Barnardo’s and, after several sessions, he told this worker that FC2 had on several occasions made sexual overtures and tried to encourage him to engage in sexual activity. The Police were informed and a criminal investigation was initiated.                                                   1  Children Act 2004, s14  2 Working Together to Safeguard Children 2015. HMSO  SCR Trafford/ Fostering/December 2016 - amended March 2017 4 2.6. In December 2015, PB told his key worker that when living with FC1, he had watched a scary movie and slept in the bed of FC1 and had woken the following morning to find the foster carer touching his genitals and told him to stop. PB later found FC1 collapsed on the floor and contacted a friend’s mother for help. PB said he had forgotten about the incident until he had read court documents [relating to charges against FC2] and a reference to ‘grooming’ and this had triggered the earlier memory. This information was passed to the Police and FC1’s foster care registration was suspended pending further enquiries.    2.7. Neither foster carer was charged with a criminal offence, but following internal inquiries which examined the actions and behaviours of FC1 and FC2, the Chair of Trafford Safeguarding Children took a decision in February 2016 to commission a Serious Case Review so that a thorough and objective analysis of actions and decisions taken by professionals in respect of both foster carers could be undertaken.  2.8. The Lead Reviewer sought further clarification of the rationale for commissioning a Serious Case Review. Statutory guidance states that Serious Case Reviews should be undertaken when abuse or neglect of a child is known or suspected and there is cause for concern about the way in which the authority, their Board partners and other relevant persons have worked together to safeguard children.3  At the point at which the decision was taken to undertake a SCR, the LSCB had information which raised significant concerns about the safety and wellbeing of a looked after child whilst in the care of FC1 and FC2. Several professionals were involved with PB, mainly from different areas within the Local Authority - the children in care team, the fostering and adoption team and children’s homes – each of which had quite different perspectives. Police were also involved with PB as were education and health albeit to a much lesser degree.  2.9. What was not clear prior to beginning the SCR was how agencies and specifically the professionals within those agencies, had worked together to safeguard this young person. The guidance clearly states that ‘where a case is being considered under regulation 5 (2) (b) (ii), unless there is definitive evidence that there are no concerns about inter-agency working, the LSCB must commission an SCR’. This is the threshold, which was applied in this case and together with the fact that PB was a looked after child, provided the rationale for the decision to commission an SCR. In effect however, the lessons emerging from this review impact predominantly on Fostering Services within Trafford. 3. The approach used    3.1. A small Review Team of Senior Managers was established and their role was to provide strategic information about the involvement of their service/agency and to identify learning for their agency through the submission of an Agency Learning Report.   Independent Chair     Linda Richardson Safeguarding Development Manager    Trafford Safeguarding Children Board Acting Joint Director Children’s Social Care  Trafford Council Designated Nurse (Safeguarding Children and LAC) Trafford CCG  Head of Service (Children in Care)   Trafford Council Detective Inspector Public Protection   Oldham Police                                                  3 Regulation 5 of the Local Safeguarding Boards (LSCBs) Regulations 2006  SCR Trafford/ Fostering/December 2016 - amended March 2017 5 Interim Head of Service (MARAS)   Trafford Council  3.2. Members of the Review Team also identified frontline practitioners and first line managers who were known to PB and both foster carers. These practitioners formed the ‘Practitioner’s Group’ and they met on two occasions and offered valuable insights through group discussions and individual conversations with members of the Review Team.  Manager Residential Placements (RP1)      Trafford Council Supervising social worker – MDFC programme   Trafford Council Supervising social worker 2    Trafford Council Independent Reviewing Officer    Trafford Council LAC Nurse      Pennine Care Foundation Trust Social Worker (3)     Trafford Council Manager      Trafford Council Practitioner      CAMHS (did not attend) Police       GMP  3.3. In August 2016, Trafford commissioned an independent review to consider FC1’s continued suitability as a foster carer. This was concluded in November 2016. The Review Team agreed that the outcome of that internal investigation should be considered before the SCR was finalised.  3.4. Both FC1 and FC2 were offered the opportunity to contribute to this report. FC2 did not respond to overtures by TSCB but FC1 met with the Lead Reviewer and the Interim Lead for Looked After Children in late February 2017, on a date selected to accommodate FC1’s working commitments. The comments of FC1 are included on page 29 of this report.   4. Scope and Terms of Reference 4.1. The Review Team began the process with an open enquiry rather than a detailed pre-determined set of questions from terms of reference. However, key lines of inquiry for this review quickly emerged around the recruitment and supervision of the foster carers, placement matching and the challenges for professionals in being curious and maintaining an open mind when supervising foster carers.  4.2. The Review Team were mindful of the need to keep the scope of this review clearly focused; this was not about PB’s journey through the care system or the decisions which were taken in regard to his welfare and safety, although inevitably some pertinent questions needed to be asked in relation to some placement decisions.   4.3. Both FC1 and FC2 denied the allegations made by PB, which he has not retracted, and although the allegations can be neither proven nor dismissed with absolute certainty, it is incumbent upon the local authority to consider whether the allegations could have any basis whatsoever. The Review Team thought it essential that any reader of this report understands the context in which it was commissioned and the statutory duty placed upon local authorities to take all reasonable steps to safeguard and promote the welfare of children and young people in their care. The CPS, the Police and the judicial system all operate from the principle of what can be proved in a court of law; i.e. the standard of proof being   ‘beyond all reasonable doubt’. In civil cases, such as those initiated in social work and care settings, a lower standard of  SCR Trafford/ Fostering/December 2016 - amended March 2017 6 evidence is required and this works on the principle of  ‘the balance of probabilities’ i.e.: is what is alleged more likely to have happened than not?  4.4. Internal reviews of both FC1 and FC2 as foster carers led Trafford Council to the conclusion that both FC1 and FC2, notwithstanding the allegations made by PB, were dishonest in their dealings with the local authority, behaved in ways which were not in keeping with safe practice and caused, or may have caused, harm to a child or children in their care. The Serious Case Review was therefore commissioned in order to provide a rigorous analysis of the actions and decisions of professionals and the systems which informed those actions, to determine if the selection, recruitment and supervision of the foster carers, together with the decisions to place PB in their care, was in line with good practice and fostering standards.   4.5. The review period for the SCR was from 2013 when both foster carers were approved, to   December 2015 when FC1 was suspended from his fostering role.  5. Cross boundary Issues 5.1. FC2 was well known in a professional capacity in another local authority. Although several meetings took place between the two authorities, there was no representation from the other authority on the Review Panel despite a high profile role held by FC2 in that area. Only at the end of the review process did it become apparent that no formal invitation had been extended to the LSCB in that area, thereby missing a useful opportunity to share learning across the two authorities. However, a subsequent meeting took place between senior managers and a decision taken that the report would be shared with that authority prior to publication.  6. Significant Events    May 2012  Talks began with FC2 about becoming a foster carer.  June 2012 FC2 began  ‘Skills To Foster’ training Feb 2013 FC1 observed in a professional setting in response to application to become foster carer Feb   2013 PB became a Looked after Child on a s20, CA 1989 (12 years old)  Feb   2013 FC2   approved as foster carer. May 2013 FC1 approved as foster carer and placement commenced with PB.  June 2013 Complaints from MPB concerned that PB was posting messages and images on You Tube. Discussions with FC1 about importance of restricting and monitoring access to Internet June 2013 PB confirmed he was happy in placement June 2013 Complaint by MPB that FC1 allowed PB to shave off eyebrows. FC1 admits to SSW that he gave PB his electric shaver as it was ‘safer’ July 2013 FC1 advised SSW that PB is scared of dark July 2013 Complaints from MPB that PB was again accessing Internet. MPB and SFPB requested change of placement. FC1 informed and shared this information with PB. SSW again discussed access to Internet and importance of boundaries for PB. July 2013 PB was in altercation with local youths. PB slightly hurt. FC1 did not report until following day.  July 2013 FC1 left PB alone upstairs with friend. PB accessed Internet. FC1 said he was unaware of this.  SCR Trafford/ Fostering/December 2016 - amended March 2017 7 Aug 2013 FC1 told  PB that he would like to care for him on long term basis Aug 2013 FC1 advised SSW that was emotionally exhausted caring for PB who did not appreciate all the things that he did for him. Aug 2013 FC1 recorded hearing PB snoring and talking in his sleep saying ‘Get off me, leave me alone”. Few days later FC1 recorded ‘no more snoring, but PB kicked covers off, so I covered him up again.’  Sept 2013 School report PB: theft of food and fighting. Behaviour deteriorated during term. Oct 2013 PB refused to go to school and damaged furniture in FC1’s home. He later apologised. FC1 said he needed time out to support sick relative. PB moved to respite carers who advised that PB had money and cigarettes and did not know where he got these. FC1 later reported that he noticed £40 missing from his wallet but did not report this at the time.  Sept/Oct Two periods where both PB and FC1 were poorly so did not attend work/school. Later in the month PB refused to attend school.  October  FC1 attended for blood tests re his weight loss. PB stayed with respite carer so FC1 could support ‘Aunt’ who later died.  Nov 2013 Fostering Panel agreed an exemption so two children could be placed in the care of FC1. Concerns about his ill health noted.  Nov 2013 FC1 informed Supervising Social Worker that PB was in his bedroom again this morning claiming that he wanted to be near FC1. Nov 2013 FC1 reported that his test results were negative. PB reported to again be using Facebook. Images seen by family members of PB drunk. FC1 insisted someone else was using PB’s account.  Nov 2013 MPB complained after contact visit, that PB has too much information about FC1’s ‘cancer’   and the ‘dry skin hanging off his back’. FC1 said he had never discussed his concern that he could have cancer with PB, but that PB may have seen a lump on his back when they went swimming.  Dec 2013 FC1 reported he was finding it difficult to manage PB’s behaviour. Alleged that PB struck him in the face when he refused to buy cigarettes and intimated that he had stolen money before from FC1 but he had not reported these as he did not want to get PB into trouble.  Jan 2014 Meeting with SSW - FC1 reported poor health and requested end of placement. PB later contacted SSW saying he found FC1 collapsed on floor. SSW spoke with FC1 who claimed he was fine, had taken two tablets belonging to the ‘Aunt’ (who had died) and they had affected him. Refused to seek medical attention.  Feb 2014 PB was moved to different placement  FC1 later advised he was well after resting. YP2 was placed with FC1 for short break. FC1 advised SSW that he had been diagnosed with a specific medical condition. Mar 2014 PB was placed with FC2. Decision was made early in placement that PB’s needs would be best met by educational setting and returning to live with FC2 only at weekends and holidays. June 2014 FC2 advised that PB refused to return to school. FC2 requested additional support. PB later absconded from school and turned up at the home of FC1 who did not report until the following day.  July 2014 An allegation was made against FC2 that he allowed two young people previously in his care, to access and drink alcohol in his home. PB was moved to respite placement whilst further inquiries were underway. Investigation concluded that allegations could not be substantiated.  July 2014 PB’s placement with FC2 resumed.   SCR Trafford/ Fostering/December 2016 - amended March 2017 8 Oct 2014 FC2 reported that PB had threatened him with violence and was abusive Oct 2014 PB telephoned SSW very distressed saying FC2 had told him ‘no-one wanted him’. PB rang off and went missing; he was thought to have returned to the home of FC1. He later returned to FC2. Nov 2014  Placement with FC2 ended following a decision that PB needed a 52-week residential placement.  Nov 2014 FC2 made requests to SW, that he be supported to seek Special Guardianship Order for PB. This was refused.  Nov – Feb 2015 PB went missing several times. Records indicated PB turned up at home of FC2 ‘most days’. FC2 was advised that he must immediately contact the residential placement if PB turned up at his house.  SSW very concerned about FC2’s mental state and advised him to see his GP.  Jan 2015 CSC records refer to being concerned at PB mixing with older men   and querying whether PB should have ongoing contact with FC2.  Feb 2015 Concerns began to emerge that FC2 did not always report that PB was at his home. PB frequently reported missing.  Feb 2015 FC2 met PB and bought clothing which PB told staff was a ‘Valentine’s gift’.  Feb 2015 PB again was reported missing and Police call at home of FC2. FC2 denied he had seen PB. Police find PB hiding undressed in wardrobe. FC2 is served with an abduction notice and advised he must not have contact of any sort with PB, or any of the young people who had been placed in his care, or any young person under the age of 18.  FC2 intimated that the police officer had misunderstood his response when asked if he had seen PB.  Feb 2015 FC2 was suspended as a Trafford Foster Carer.  Feb 2015 (Various dates) FC2 called Police to inform them that PB was again at his home.  FC2 advised Police that he had a specific medical condition brought on by stress. FC2 called Police to advise that PB was again outside his home. Mar 2015 (Various) PB was reported missing. Neighbour reported FC2 leaving house with a young male.  FC2 called Police to say that PB was outside with house with another male.  April 2015 Envelope with £30 inside arrived for PB at placement from someone with reversed initials to that of FC2. PB later told his mother that the money was from FC2.  May 2015 FC2 advised there would be no further action in respect of the abduction charge. He was given notice that under no circumstances was he to have any contact with PB. FC2 signs the notice.  June 2015 FC2 was de-registered as a Foster Carer for Trafford Council.  July 2015 PB made an allegation of sexual abuse against FC2 Dec 2015  PB made an allegation against FC1 who was suspended as foster carer. June 2016 Crown Prosecution Service PS took a decision not to prosecute either FC2 or FC1. August 2016 Trafford commissioned an independent investigation into FC1  7. Appraisal of practice and processes 7.1. The Review Team were mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions in relation to the foster carers and PB’s placements may  have made sense at the time and importantly, what systemic factors in place then could still be  SCR Trafford/ Fostering/December 2016 - amended March 2017 9 impacting upon practice in 2016. In this respect, the findings from this review should be seen as a ‘window’ on existing processes and practice rather than a review of what happened in only in this case. The Review Team also considered the ways in which agencies worked together and the extent to which they shared their concerns and collaborated, although much of this review was linked to the recruitment, selection and supervision of two foster carers who, at different times, cared for PB.  7.2. From studying key documents and listening to the views and experiences of practitioners, the Review Team identified several key areas to be explored in greater detail to better understand the actions and decisions of professionals working with both foster carers and with PB and whether there was sufficient consideration given to any risks which these carer may have posed to any child placed in their care.  7.3. This report relates to a review of the systems and processes in place at the time, the review was not required to offer comment upon Trafford’s decision to de-register either FC1 or FC2 as foster carers.  8. The recruitment and selection of the foster carers.  8.1. The last detailed independent regulatory inspection of Trafford’s fostering service took place in June 2011. Although there was reference to some assessment reports of foster carers needing to be more evaluative, the overall quality rating was good. In 2015, the Ofsted inspection also rated the fostering service as ‘good.’ This review has however highlighted a number of areas where practice in the existing arrangements for recruitment and supervision of foster carers could be improved. It should be stressed, that although this report links the two single male foster carers, there is no evidence that they were personally acquainted prior to their registration as individual foster carers. 8.2. Fostering regulations contain checks and balances designed to make the recruitment and selection of foster care as safe as possible and it is the way in which these were interpreted and implemented in Trafford that is an aspect of this review. Abuse by foster carers is rare, but there are additional and much more generally applicable reasons why professionals need to remember how vulnerable children in public care are and why service provision needs to actively promote measures to keep them safe. 8.3. Both adults individually expressed an interest in fostering children in 2012 and had relevant and recent experience of working with children and vulnerable young people. After some preliminary contacts, the fostering service commenced its formal approval process for both individuals in line with fostering regulations.4 The personal references obtained for both carers were very positive and commended each applicant in term of their skills, knowledge, and expertise. A comment of a referee in relation to FC1 highlighted his lack of a support network in undertaking such a demanding role but otherwise no concerns were raised by those providing references for either applicant. FC2 had worked in a semi-professional capacity in another authority for several years in another authority. An independent social worker who had chaired meetings attended by FC2 and who had worked alongside him remembers a                                                  4 The Care Planning, Placement and Case Review and Fostering Services (Miscellaneous Amendments) Regulations 2013 amended the Fostering Services (England) Regulations 2011  SCR Trafford/ Fostering/December 2016 - amended March 2017 10 conversation when she was asked about FC2 as part of his recruitment process. She does not however recall being asked specifically to provide a verbal reference in terms of his suitability to foster and has not had sight of, nor signed any record, which relates to that conversation.  8.4. Requesting verbal references is in line with regulations, but these should always be written up and copied to the referee so there is agreement as to what information has been shared. There are considerable benefits in receiving all references in writing and especially so, when prospective carers are professionals already working with or for the benefit of children and young people.   8.5. Whilst it is unlikely that a written reference from social work colleague in the other authority would have highlighted the discrepancies which later came to light in terms of what FC2 was telling different colleagues about his lifestyle and relationships, there are significant benefits in always requiring written references as this offers greater scope for more considered and carefully thought through comments by referees.  Recommendation 1:  Where a prospective foster parent works directly with or on behalf of children and young people, formal references should always be requested from a senior professional in their agency in addition to any other references and these references should always be submitted in writing.    8.6. From the assessment records for both foster carers, it is clear that the information gathered as part of the assessment process was extremely positive for both applicants and indicated both adults were effective and thoughtful communicators, with many skills and much to offer children who might be placed in their care. The assessment reports for both applicants are however largely descriptive and rely heavily on self-reported information but without any meaningful critical analysis of their qualities, skills and resilience, which are needed by foster carers. Given that neither the fostering panel, nor any line managers challenged these assessments, the lead reviewer concluded that these were considered to be of an acceptable standard to the fostering service and would therefore suggest there is value in the service considering future assessments in the light of comments made in this report.  8.7. FC1 advised SSW1 during the assessment process that he had been estranged from his family for over 30 years, directly because of telling his family he was gay. The Review Team was told there was no attempt to seek out any family member as according to FC1, there had been no contact for such a long time and he did not know where they were living. Clearly, this was a difficult issue and one which required sensitive handling but if a prospective foster carer has no references from family members due to family conflicts, there should at least be some consideration as to how and if the ‘other’ side of the story can be explored.  8.8. Whilst it will not always be possible to seek references in these circumstances or indeed make contact with estranged family members, the Review Team considered that much more could have been done to explore this issue with FC1. Although he lived for many years with a close family friend and her husband, there is no evidence that FC1’s estrangement with his family was discussed with this person who may have been able to offer a view and perspective about what happened in the family. The Skills to Foster assessment format used by Trafford and other councils, is designed to highlight the applicant’s skills, abilities, qualities and previous experiences that are relevant to the fostering task. It also allows for the identification of areas  SCR Trafford/ Fostering/December 2016 - amended March 2017 11 that require further training, acknowledging that at this stage, applicants will not be fully versed in all aspects of the role. Applicants need to demonstrate an understanding of how their own upbringing and personal past experiences influence their attitudes and their behaviour in respect of bringing up children. Exploring an applicant’s experiences of previous relationships, whether positive or negative, is a useful way of identifying their values and attitudes to family life and relationships.  8.9. Assessments are not just a method by which information is collected about someone's life it is in the telling of this story that social workers move beyond the content to explore the gaps and themes that emerge. As well as helping applicants 'tell their story', the assessing social worker is exploring how applicants have dealt with and experienced attachment, loss and transition; their experience and management of adversity; identifying factors of resilience and the quality of the important relationships in their life. There is a clear sense from records that FC1 did not want to explore the issue of his past and said clearly that he ‘did not need to go back there’. This was not however pursued as would be expected given the relevance of these experiences to the fostering role. The fact that FC1 had experienced ‘rejection’ from his family was seen as strength and evidence of a resilient nature, which was thought, would enhance his capacity to relate to children with similar experiences. This - and it would be the same for any prospective carer-   was a flawed assumption, which was neither challenged nor tested.  8.10. Holistic assessment links strengths to negative life experiences and measures the resolution of hardship, disadvantage and pain rather than the event itself. Most importantly, the applicant and the worker must be able to reflect on how this experience may impact on caring for a child in care. Sometimes the factors that motivate and empower carers are the same ones, which present challenges or appear to undermine their suitability to care for others. It would have been helpful if the assessment had encouraged FC1 to talk more about his family to explore how his own experience of having a secure base in childhood made it more or less difficult to cope with the issues of loss and separation which came later in his life; whether and how these had been resolved and what potential difficulties FC1 could foresee occurring as a result of those experiences.   8.11. Records attest that these issues were not explored and so an opportunity was lost amid a view that FC1’s experience could only enhance his role as a foster carer. Later evidence emerged that despite all he said, FC1 found it difficult to deal with conflict and struggled to apply boundaries or assertively challenge unacceptable behaviours. It is possible that these traits stemmed from past experiences and may have usefully been explored had there been more in depth discussions about experiences of rejection and the impact of handling conflict and challenging situations. 8.12. There is a plethora of research and guidance which outlines how   the subjects of gender, sex, and sexuality need to be firmly and permanently placed within the assessment process for all applicants to foster. The assessments for both prospective carers did not completely ignore issues around sexuality; they simply referred to it, but almost in passing. The assessments should have explored the experiences of each applicant; their own response when ‘discovering’ they were gay, how they felt about relating to birth parents of children in their care and how would they deal with schools, playgroups, childminders and other professionals. The assessment could also have addressed how homophobia and heterosexism had impinged  SCR Trafford/ Fostering/December 2016 - amended March 2017 12 on their lives; how they dealt with this, what coping devices they used and what impact this could have on their roles as foster carers.  This was a weak area in the assessment of both carers and particularly so for FC2, whose description of his sexuality raised a number of issues that suggested a sexual immaturity yet to be developed. This is a particularly pertinent point of an assessment for an adult being assessed to specifically care for adolescent children. 8.13. The debate about whether or not the assessment of LGBT5 prospective carers should be the same or different from that undertaken with heterosexual carers has been evident in the literature for some time. The consensus from the publications reviewed is that all assessments need to be enabling, rigorous, and analytic, covering all subjects considered with all foster carers; but in addition social work assessments of LGBT applicants should think through the areas pertinent to a person’s gender and sexuality relevant to them becoming foster carers. 8.14. Research6 shows that historically social work has negatively discriminated against gay foster carers and as a result social workers today can experience anxiety about appearing homophobic which can then lead to practice that is insufficiently discerning and discriminating. This is, however, just as worrying as someone who is overtly prejudiced and was clearly evidenced in the Wakefield Inquiry7 (2007) where growing concerns about the behaviours of a gay foster couple were not addressed by social workers, who were fearful of being accused of being homophobic.  8.15. The challenge of ensuring that assessments do not ignore nor over-focus on sexuality was explored in detail as part of this SCR. Whilst most practitioners, and also the Chair of the Fostering panel when she reflected, thought that so much more could have and should have been explored with both males as prospective carers, the views were expressed that any risks that the applicants posed or may have posed to children placed in their care, would have been unlikely to emerge at the early stage of the assessment process. The Review Team concurred with this view but felt that the learning from these discussions had implications for future assessments of LGBT adults as prospective foster carers.   Recommendation 2: The fostering service in Trafford should: a) ensure that all assessments of foster carers are thorough, robust, and appropriately challenging with information being sought from a wide range of sources.  b) ensure there is adequate guidance for assessing LGBT applicants8 - there would also be merit is using this guidance as an opportunity to train panel members.  c) undertake a review of panel membership to ensure it represents and reflects the diverse community it serves.                                                    5 Lesbian, Gay, Bisexual, Transgender 6 Sexual Identities and Sexuality in Social Work: Research and Reflections from Women in the Field  Priscilla Dunk-West  (2016)     7 Independent inquiry report into the circumstances of child sexual abuse by two foster carers in Wakefield Parrott Brian, McIver Annie, Thoburn June (2007) 8 British Association of Fostering and Adoption   (BAAF) offer excellent resources in this area.  SCR Trafford/ Fostering/December 2016 - amended March 2017 13 8.16. Both foster carers were approved by the Fostering Panel: FC2 in February 2013 and FC1 in May 2013. Each applicant had independently attended ‘skills to foster’ training, received excellent references and sound medical reports with no contra-indications to fostering. 9. The Fostering Panel and the Agency Decision Maker 9 9.1. The functions of the fostering panel in respect of cases referred to it by the fostering service are to consider each fostering application for suitability and to recommend whether or not a person is suitable to be a foster parent. The Panel plays an important quality assurance role in assessing the continued suitability of foster carers at the first annual review and for any further reviews which are complex or involve allegations, otherwise the Panel assesses the suitability of foster carers every 3 years. The Panel also considers exemptions to normal fostering limits, and any specific issues identified during the assessment and review process.  9.2. Trafford’s Fostering Panel has a central list membership of 9 members. It has an independent chair and two independent vice chairs both of whom have social work backgrounds. The role of Panel adviser is shared between two team managers from Children’s Services who advise on protocol, procedure, legislation and policy; they quality assure the reports prior to be tabled for the Panel meeting. There is not a legal representative on the Panel but there is access to legal advice as and when required.  Panels also need to have access to a medical advisor who has a clinical role and is expected to offer advice and guidance on any matter relating to health and well-being of foster carers. In Trafford, this role has traditionally been perceived by the panel and managers within the authority to be held by the LAC Nurse, an issue addressed later in this report. The Agency Decision Maker is the person within a fostering service who makes decisions on the basis of recommendations made by the Fostering Panel. They hold a senior management position within the authority and take into account the Panel's recommendation before proceeding to make a decision. 9.3. FC2 was approved at Panel in February 2013. He gave a reassurance that he would fit his busy professional life around children and confirmed he had a large family from who he received support. He was noted to be very quiet at panel, almost shy, but he was thought to have many skills and experiences to offer children. He was unanimously recommended for approval   by the Panel and subsequently by the Agency Decision Maker, as a specialist foster carer for one child of either gender 9 – 17 years. FC1 was also unanimously recommended for approval by the panel in May 2013 and, although there were some questions about the lack of a support network, FC1 gave assurances that he had in fact lots of support from colleagues and friends, although no further details were provided or requested. It was suggested that that FC1 should be linked with a ‘buddy’, but this does not appear to have been progressed. FC1 was approved by the Agency Decision Maker for one child aged 10-18 years.  9.4. The Review Team concluded that although some queries were raised and tentatively explored, the Fostering Panel could usefully have adopted a far more challenging and questioning approach to the assessments of both foster carers, specifically in relation to the level of                                                  9 The Agency Decision Maker is the person within a fostering service and an adoption agency who makes decisions on the basis of recommendations made by the Fostering Panel (in relation to a fostering service) and the Adoption Panel (in relation to an adoption agency). The Agency Decision Maker will take account of the Panel's recommendation before proceeding to make a decision. The Agency Decision Maker can choose to make a different decision.  SCR Trafford/ Fostering/December 2016 - amended March 2017 14 reliance on self-reported information, the particular issues related to diversity, and the fact that both applicants would be learning parenting skills for the first time as untested carers. Again, whilst there is no evidence that such challenges would have influenced the decision to recommend approval for the applicants as foster carers, there may well have been a more realistic understanding about their immediate support needs and therefore greater oversight of their developing role as foster carers.  9.5. Fostering Panels for FC1 and FC2 took   place about 3 months apart, and it was noticeable that comments were made which suggested that Trafford were fortunate to be able to attract such skilled and knowledgeable individuals to the foster care role. The comment that both individuals  ‘almost seemed too good to be true’ is in no way an indictment on the quality of foster carers either locally or nationally, but such views should perhaps always be tempered with a degree of respectful caution.  9.6. Recruiting and retaining sufficient foster carers remains an ongoing challenge for all fostering services across the UK10. The number of children coming into the care system is increasing and many fostering services struggle to find enough foster carers and especially those who are interested in caring for adolescents. Fostering services need to ensure that systems are in place to ensure that critical appraisals of prospective applicants suitability are not unduly influenced by the need to recruit more carers or by the perceived status or experience of the applicants however ‘good’ they appear.  9.7. The Chair of the Fostering Panel has worked for Trafford previously, as have many others who sit on the Panel. Care needs to be taken to ensure that that the work of the Fostering Panel is subject to a regular audit of its membership processes and decision-making to ensure that it retains its independency and ability to challenge the local authority.   10.  PB’s placements with FC1 and then later with FC2 10.1. Research 11 highlights that matching a child with a foster carer is one of the ‘turning points’ in a child’s life. Successful matching depends on good assessments, clear support plans, careful decision-making, and a high level of information sharing between professionals. Although there is little research that links specific elements of matching practice to successful outcomes, there are studies that identify the factors involved in disruption and these include behavioural problems and mismatching of child to foster carer. There is also general agreement about the parenting characteristics that help to support children and young people in foster care: these include sensitivity, consistent boundary setting, tolerance, and resilience. 10.2. PB told the Lead Reviewer that when he was told he was being moved to the different placements with FC1 and FC2, all he knew was the name of the foster carer and that each carer was single and lived alone. He said he thought that if he really didn’t want to go somewhere he wouldn’t really make a difference ‘as they made all the plans and what I want doesn’t matter’. He did agree he had wanted to be moved from his first foster placement, because they were too strict and that he was moved. PB said he never however wanted to go to the educational placement as ‘it was too far’. With foster placements, PB said he often                                                  10 Fostering Network report 2015 11 Schofield et al (2011) Randall, (2013).Quinton, (2012)    SCR Trafford/ Fostering/December 2016 - amended March 2017 15 ‘didn’t know what it would be like until he got there’. PB said he couldn’t remember if he knew that FC1 and FC2 were gay and shrugged his shoulders when asked if it would have made a difference to him accepting the placement. He said that his Independent Reviewing Officer (IRO) would always ask him about his placements before his review but he never had any complaints except for his very first placement. When asked by the Lead Reviewer which placement he would return to if given the chance, he immediately said ‘FC2’…  and then added ‘because  he let me do whatever I wanted’  10.3. PB was the first child placed with FC1 and appropriate details were shared by the SSW and PB’s social worker at the time about the PB’s needs and the challenges FC1 would be likely to face. Clearly, given his employment history and experience in a professional role with vulnerable young people, FC1 was thought to be well placed to offer care to PB and provide well defined boundaries, and be sensitive to his needs he had however no parenting experience or contact with young people outside his work setting and as the placement progressed it became evident that FC1 struggled to cope with PB’s behaviour and failed to report concerning behaviours to his social worker. Despite the breakdown of PB’s placement with FC1, PB was placed again with a single male foster carer with very limited experience of parenting and without as far as the Review Team could ascertain, the benefit of any end of placement review or learning from the placement with FC1. The Review Team was not confident that the matching for FC2 was well considered.   10.4. Questions were asked of the practitioners about how risk assessments and safe care issues around sexuality are promoted for all fostering placements. A specific question was asked about the issues involved in placing a single male adolescent in the care of a single male gay foster carer. Some practitioners found this question uncomfortable but it actually led to some helpful discussions around the difficulties in talking about sex and sexuality in fostering situations. The discomfort for some stemmed from an assumption that implicit in such a question was a suggestion that male children may not be safe if placed with single gay males. The discussion was helped by changing the question and asking what risk factors would naturally be explored if a teenage girl was   placed with a single male carer. What emerged from the discussions were three issues which may well be worthy of further exploration amongst practitioners and managers in Trafford: • The fear of being accused of homophobia can seriously impinge on professionals’ confidence to explore issues around sexual behaviour and attitudes when placing children with LGBT foster carers. (FC2 had been known to accuse others of this) • There is a lack of confidence for some professionals in approaching issues of sex and sexuality frankly with all foster carers, regardless of their sexuality  • Safe Care policies do not encourage discussion around these topics in sufficient depth but the policy and references to it, can give the impression that these sensitive issues have been explored and addressed.  SCR Trafford/ Fostering/December 2016 - amended March 2017 16 10.5. Different studies12 have highlighted the importance of children and young people being prepared before being placed with LGBT foster carers. Experience of foster carers suggested that individual children and young people responded differently to being placed within a LGBT household, but even though many children had no discriminatory preconceptions, preparation was still considered extremely important. There was no evidence in the records provided to the Review Team that this issue had been discussed with PB before the commencement of either placement and the views expressed in the practitioners group suggested that perhaps social workers did not always recognise the value and relevance of such conversations.    Recommendation 3:  Social workers should be reminded that they are responsible for talking with children about proposed placements and in general the lives and lifestyles of the carers with whom they will be living. The responses of the children should be noted and monitored, the Review Team could find no evidence that this is routinely done in Trafford and there would be benefits in further discussions around this issue.   10.6. PB experienced at least 14 placements between 2013 and 2015, an exceptionally high number of moves and transitions. PB’s first placement when he came into the care system was a planned short-term placement, but his later placement with FC1 was expected to continue whilst possibilities for re-integration into his family were explored. Records refer to several occasions when FC1 told PB that he wanted the placement to be a permanent one. After 8 months, PB was told by his social worker that he could no longer live with FC1 due to his poor health, yet PB became aware that FC1 continued to foster other children. It is not difficult to imagine how he must felt upon learning that other young people were being placed in the care of FC1 whilst he had been required to move on. According to his LAC reviews, PB was very clear in discussions with his IRO that he wanted to continue to live with FC1, but was advised that this was not possible.  10.7. Despite Trafford’s LAC procedures and national guidelines, there was no ‘end of placement’ review when PB’s placement with FC1 ended in February 2014. If this happened the Review Team could find no evidence that such a meeting had taken place and although FC1 said he thought he could remember a meeting, he could not recall who attended. End of placement or disruption meetings as they are sometimes called offer important opportunities to examine the extent and nature of a child’s challenging behaviour and this can help with decisions about future matching. Placements can break down for a variety of reason; the term ‘disruption is used to describe an event otherwise referred to as a ‘placement breakdown’ or a placement ending that was not part of the Child’s Care Plan, either in the ending itself or in the timing of the termination. The objective of ‘disruption’ or ‘end of placement’ meetings is to look at the sequence of events and to learn from the experiences in order that a child’s future needs can be met and the carers can be appropriately supported to recover and learn from the experience. The Review Team could find no evidence that these meetings had occurred when                                                  12 (1) The recruitment, assessment, support, and supervision of lesbian, gay, bisexual and transgender foster carers Helen Cosis Brown, Judy Sebba and Nikki Luke (2015) Hill, N. (2013). (2)Proud parents: Gay men and lesbians share their experiences of adopting and long-term fostering, London: BAAF.     SCR Trafford/ Fostering/December 2016 - amended March 2017 17 PB’s placements with FC1 and FC2 ended despite them being a crucial part of a child’s journey through the care system and are key to future stability and permanence.  10.8. Records state it was not only FC1’s health which contributed to the move it was also the difficulties the foster carer was experiencing with PB’s challenging behaviour. The following month PB was however, placed with FC2, again a single carer and  growing concerns about his ability to manage PB’s behaviour began to surface which  contributed to the decision, in November 2014 to end the placement. In conversation, PB asked the Lead Reviewer why he had been moved so many times. This appeared to be a genuine question borne more out of curiosity than resentment; PB said he did not know why certain placements had ended or why he had not been allowed to ‘properly’ live with FC2.  10.9. Ten LAC reviews13 took place in respect of PB between March 2013 and December 2015, each was chaired by the same Independent Reviewing Officer (IRO) who met with PB on 12 different occasions, usually just before or soon after the LAC review. Records refer to the attempts made by the IRO to ensure that PB was listened to and his voice heard.  10.10. It emerged that the IRO had raised a number of concerns in relation to PB, which he considered were not being addressed and a decision was therefore taken  by himself and the IRO manager to instigate the Dispute Resolution process. In line with agreed procedures, a meeting was arranged with key parties but the Team Manager failed to attend the meeting and the IRO manager escalated the issue to the (Acting) Director of Children’s Services.  The response of the Acting Director was to advise that some of these issues were being addressed and another meeting was not the best use of time. This was not in accordance with procedures. Whilst it appears the IRO contacted the Director (Acting) of Children’s services directly rather than routing his concerns through the Head of the Fostering Service, the Review Team was concerned to note that the agreed process was not followed and this raises important concerns not only about the Dispute Resolution process itself but also raises questions about how well the local authority and senior managers supports and values the roles of IROs.  10.11. If the system for escalating concerns is not followed then this significantly impacts upon the ability of the IROs to quality assure practice and act as driving force in identifying systemic weaknesses in the authority. The Review Team was of the view that if senior leaders within Children Services do not utilise the expertise and knowledge of IROs and do not respond to their concerns about practice and decision-making, then this leaves looked after children even more vulnerable. The Review Team was concerned to note that had due process being followed in response to the IRO’s concerns, the issues relating to FC2 and possibly FC1 may have been addressed much earlier.  Recommendation 4: As a corporate parent, the local authority should ensure that the IRO role and function is better understood by key professionals and managers and explore ways to ensure and support more effective challenge about care planning and decision-making.   10.12. The notes from the LAC meetings do not directly comment upon the quality of care offered or seen to be offered by FC1 or FC2 and although there are references questioning whether FC2                                                  13 A looked-after child (LAC) review is a regular meeting that brings together those people who are closely concerned with the care of the child who is being looked after.   SCR Trafford/ Fostering/December 2016 - amended March 2017 18 was able to apply appropriate boundaries, this was not explored in any depth in the review meetings.  10.13. Throughout the period under review, the IRO received only one request from the Fostering Service to contribute to the Annual Review of one of the carers with whom PB was placed (FC2). This is not good practice as IRO’s are well placed to offer invaluable and independent insights into care aspects of a child’s plan. This is an issue which the IRO service should address. The IRO for PB was clear that he was not given any information or had identified any concerns, which may have indicated that either foster carer posed or was posing a risk to PB.  Recommendation 5: Trafford’s Independent Reviewing Unit should ensure regular scrutiny of annual reviews of foster carers and ensure these are robust, thorough, and challenging.   11. Supervision of the Foster Carers  11.1. The Review Team accessed information about the foster carers and their working relationships with their supervising social workers between 2013 and 2015 when both carers were deregistered.   11.2. Records relating to PB’s placement with FC1 show that during the 8 months that PB lived with FC1, some concerns emerged about the lack of supervision of PB and failure to appropriately apply boundaries and manage PB’s behaviour. Specifically, concerns emerged about PB having access to Facebook and posting images and messages whilst living with FC1. FC1 suggested that PB’s Facebook had been hacked but confirmed there had been times when PB was not supervised and may have had access to the Internet and social media.  11.3. FC1 reported health difficulties in November 2013 and informed his SSW that he had been diagnosed with a specific medical condition and was undertaking further medical tests. FC1 attributed his deteriorating health to possibly being due to stress caused in trying to manage PB’s behaviour. PB’s placement with FC1 ended in January 2014, several days after PB found him collapsed on the floor. FC1 gave notice that he was unable to continue with the placement due to ill-health. He was not however asked by his SSW to undergo a medical examination to confirm his fitness to foster and a short time later, he advised he was feeling much better and agreed to a respite placement for another young person. Further placements followed and then a young person was placed in his care in May 2014 where he remained until FC1’s suspension in December 2015. During this time, fostering records indicate several occasions where FC1 was challenged about not reporting significant events, not following procedures and disagreeing with safe practice requests from SSW. These were each dealt with as individual incidents and did not lead, as they should have done, to a review of FC1’s role as a carer.  11.4. During the time PB was placed with FC2, fostering records also indicate concerns about FC2’s ability to manage PB’s behaviour and his disregard to follow agreed sleeping arrangements for children placed in his care. An allegation that he had provided alcohol to two YP who had been placed in his care led to a brief suspension prior to PB’s placement. This matter was addressed through appropriate procedures involving the LADO but it was not proven and FC2’s suspension was lifted. When PB’s placement with FC2 ended in November 2014. PB continued to abscond from his residential placement and turn up at FC2’s home, Despite being informed  SCR Trafford/ Fostering/December 2016 - amended March 2017 19 that he was to report every occasion when PB arrived at his house, residential workers and the social worker began to worry that FC2 was colluding with PB and allowing him to stay overnight at his house. These concerns were verified when police found PB hiding in a bedroom in FC2’s who had told police he had not seen PB.  11.5. As mentioned earlier in this report, many things become clear with hindsight, but the Review Team nevertheless wanted to understand why patterns and concerns highlighted in this   review were not identified or actioned at the time. It is acknowledged that foster carers will not always do the ‘right’ thing; they will make errors of judgment and find themselves responding to situations in ways, which they later come to regret, but the key question for social workers is whether lessons are learnt so mistakes are not repeated. There is evidence in records, which suggests that both foster carers misled workers whilst appearing to work in partnership and stressing how much they were doing for the young people in their care - arguably, a form of disguised compliance, which can be used to keep professionals at a distance. It seemed to the Review Team that at times there was less emphasis on the needs of PB and a greater emphasis on meeting the needs of the carers.  11.6. The various incidents, recorded in Section 5 14, which prompted intervention, by social workers/supervising social workers, were clearly dealt with on an incident-by-incident basis and consequently a holistic picture for either foster carer did not emerge. The recording systems on Liquid Logic were not used effectively to produce tight and succinct chronologies from which clear patterns of behaviour and related incidents could be seen, and purposefully addressed. Yet from the simple and relatively brief chronology of significant dates outlined in Section 5, patterns of behaviour can clearly be discerned.  11.7. Both foster carers at different times, failed to report significant incidents, changes in sleeping  arrangements and threatening behaviours towards themselves and each appeared to have agreed a ‘pact’ on occasions with PB, ‘not to say anything’ [to the SSW/SW]. These are behaviours which do not support healthy relationships and which cannot be condoned under any circumstances. Without easily accessible and succinct chronologies in foster care files, social workers did not recognise emerging patterns of concerning behaviour. When concerns are dealt with on an incident-by-incident basis, children in placements can be highly vulnerable.  11.8. The Review Team were not confident that the 'daily records' pertaining to PB whilst on placement with FC1 and FC2 were regularly scrutinised in ways which may have alerted professionals to the need for further conversations with the foster carers about their care of PB.  Significant efforts were needed   to track down these records, which were eventually located. They were not however held or copied onto PB’s file despite the fact they contained significant information about PB during his placements.  The Review Team were told that social workers would be expected to transfer significant details to children’s case records but these were more often identified though conversations and feedback about issues rather than as a result of social workers reading foster carer’s daily recordings. Neither do these records appear to be routinely scrutinized by foster carers, although the Review Team was told they were sometimes used in supervision processes.  The Review Team acknowledged that such records would not be read on a daily or even a weekly basis but were assured there was a process                                                  14 There were other reported incidents/concerns, which relate to young people not subject to this SCR.   SCR Trafford/ Fostering/December 2016 - amended March 2017 20 whereby significant information was passed to and discussed with the child’s social worker.  There were however, a number of comments in FC1’s daily recordings, which, with hindsight, would have been worthy of further discussion. FC1 said however that his notes were rarely seen or asked for. The Review Team was of the view that the purpose of keeping these ‘daily records’ and the processes for reviewing and sharing their contents could usefully be reviewed in Trafford.   Recommendation 6:  Trafford Fostering service should ensure that all supervision files for foster carers contain easily accessible, purposefully prepared, and carefully maintained chronologies to support supervision and reviews of foster carers. There should be evidence of, and reference to foster carer’s daily records so any emerging concerns or issues can be addressed.   11.9. Without a doubt, the issue of   FC1’s health needs should have been properly addressed. Much of the information shared with the SSW was self-reported by FC1; his refusal to seek medical treatment when he had had fainted and been found by PB was accepted too readily and led to no further action by SSW. The frequency with which FC1 was reporting health concerns should have led to a health review being commissioned by his GP to ensure he was fit to foster. In effect, when such a health report was requested in September 2016 it transpired that according to his GP records, FC1 had not had any significant health issues since he began fostering in 2013.  11.10. Whilst FC2 was a foster carer with Trafford, he was well supported by his Supervising Social Worker and there is evidence of this on the electronic recoding system (Liquid Logic). There is also evidence that both foster carers made full use of the support offered to them as foster carers. Reports, emails, and case notes seen by the Review Team evidence that both foster carers were polite and accommodating to the needs of the department, and highly appreciative and complimentary of the support they were receiving. Neither foster carer regularly attended the foster care support group despite being encouraged to do so.  11.11. At different times both foster carers were keen to demonstrate their understanding of the needs of children placed in their care, but also on occasions disregarded directions or procedures and when challenged, argued that their decisions had been made solely in the interests of the young person. FC1 could not, for example, accept the need for different changing rooms for himself and an adolescent boy when they went swimming; FC2 made decisions, despite being told otherwise, that it was ‘safer’ for PB to sleep in his house than for him to  ‘run’ if FC2 reported him missing. Whilst it is entirely appropriate for foster carers to query why certain decisions make sense, the continued and ongoing disregard for plans and procedures by both foster carers should have raised concerns. It is of course, with the benefit of hindsight that the behaviours of both foster carers, examined in a different light, are now viewed as manipulative and dishonest; the question is why were they not seen as such at the time?  11.12. Munro (2010)15  argues that professionals should always take time to step back and question the assumptions, which underpin their actions and decision-making, a form of reflection she                                                  15 Munro, Eileen (2010) Learning to reduce risk in child protection. British Journal of Social Work  SCR Trafford/ Fostering/December 2016 - amended March 2017 21 describes as ‘double loop’ learning. The Review Team questioned some of the assumptions made by professionals in relation to both FC1 and FC2 in that until PB began to go missing and later made allegations in respect of both carers, there were no significant concerns identified although there was a recognition that both foster carers struggled to manage difficult behaviours and did not always follow agreed procedures. The recognition that fosters carers may not be all they appear to be, or that a child may be at risk in a foster placement is entirely dependent on the professionals’ inherent willingness to entertain the possibility that such things do happen.  11.13. Munro’s research suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with plans without question or challenge. Fish (2009)16 writes ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgments and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’  11.14. There is a sense that when the foster care assessments were undertaken, professionals were delighted to have attracted such skilled, insightful and reflective applicants to the fostering service in Trafford and they remained intensely supportive to both carers despite some behaviours which should have led to a reappraisal of their roles as foster carers. It is not the intention to replicate comments already made earlier in this report in relation to the assessments but the Review Team wanted to stress the importance of professionals keeping an open mind and a degree of healthy scepticism in any work involving the need to make judgment calls. Confirmation bias can, without access to quality and reflective supervision, too easily occur when professionals rely more on evidence that is consistent with existing views or preconceptions and place less emphasis on evidence, which contradicts this view.   11.15. PB made direct disclosures about both foster carers, which have not led to prosecutions. However, the Review Panel recognised that this does not mean that PB’s account of what happened to him is not true. The panel certainly found evidence to support the view that the actions and behaviours of both individual carers should have led professionals to consider at a much earlier stage whether FC1 and FC2 could keep children in their care safe and whether they themselves posed a risk to children placed with them.   11.16. Erooga17 reports on research into a range of what are termed ‘manipulation styles’. He describes the ways in which perpetrators who were working in a professional role with children seek to create a positive impression among some co- workers, in order to draw them closer, or to undermine the credibility of those who might have suspicions or might be able to act in a protective role. These behaviours included:  • Being overtly altruistic and thoughtful about the needs of children  • Stressing their own ‘integrity’ and expertise                                                   16 Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews, London: Social Care Institute for Excellence.  17 Towards safer organisations:  Using the perspectives of convicted sex offenders to inform organisational safeguarding of children Marcus Erooga (2012)   SCR Trafford/ Fostering/December 2016 - amended March 2017 22 • A pretence of being ‘put upon’ suffering either in their own past or in their present role by taking on extra work or duties  • Presenting themselves as ‘broad minded’ or liberal in attitude  • Obstructing or blocking approaches and withdrawing from contact with colleague’s altogether (for example by avoiding training and supervision). 11.17. Behaviour fitting these categories has been described at various points in the preceding paragraphs. New evidence that challenges an established viewpoint is known to have far less impact than it should because people are unwilling to let go of established beliefs. Munro argues that the single most pervasive bias in human ‘avoidance is ‘forgetting the evidence’, ‘rejecting the evidence’ and ‘reinterpreting’ as reasons why it happens. It is perhaps not insignificant that professionals who knew both FC1 and FC2, acknowledged the difficulty they were experiencing in accepting the possibility that the actions of both foster carers were intended to deliberately cultivate a favourable impression in order to deflect or dampen any criticism about their behaviours. Professionals acknowledged feelings of discomfort when they accepted the possibility that they, as adults, could also be ‘groomed’ by perpetrators intent on throwing them ‘off guard’. 11.18. Without ongoing learning and development opportunities, professionals may overlook or be unaware of how perpetrators can condition professional networks so they can more easily operate without impunity in a professional context. This leaves children vulnerable.  Recommendation 7: Trafford Safeguarding Children Board should ensure that all practitioners and especially those within the fostering service have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children and have opportunities to discuss these challenges within multi-agency settings.   12. Annual Foster Carer Reviews  ‘Foster carer reviews are the central building blocks to monitoring and improving the quality of foster care and in doing so the quality of experience for foster children’ 18  12.1. The relationship between the foster carers’ original assessment and subsequent reviews is of fundamental importance as the first foster carer review offers an opportunity for a formal re-consideration and is the time when the assessment of a carer’s potential is ‘tested out’ against the reality of practice. Foster carer reviews are subject to statutory regulation under the Fostering Service Regulations 2011, Regulation 28. This Regulation states ‘Reviews must take place not more than a year after approval, and thereafter whenever the Fostering Service consider it necessary, but at intervals of not more than a year”.  12.2. Annual review meetings are expected to be given high priority and planned well in advance and should only be cancelled, delayed or re-organised in exceptional circumstances. The first Annual Reviews for both foster carers were however out of timescale; FC1’s first review was 4 months overdue and FC2’swas 3 months overdue; later reviews were also not on time and were deferred as a result of incomplete or missing papers. The Review Team was informed that at the time there were capacity issues. The Chair of the Fostering Panel who has retained this post for several years agreed that practice at that time tended to rely on fitting reviews                                                  18 British Association of Adoption and Fostering  SCR Trafford/ Fostering/December 2016 - amended March 2017 23 into existing timetables which caused inevitable delays, but that practice has now changed and additional panel meetings are arranged as and when needed, in order to meet demand.  The issue of incomplete or missing paperwork was raised with the Chair, who advised that when this happened, which was not often, the issue was taken forward by the Panel Adviser. However she agreed there would be benefit in the Chair escalating concerns on a more formal and independent basis, if an issue led to a Panel meeting needing to be deferred or being unable to make a decision.  12.3. The Review Team had access to reports and panel minutes for the reviews for both FC1 and FC2. The very positive perceptions of the carers formed during both fostering assessments clearly influenced social workers and members of the fostering team to conclude that both individuals would bring much to the fostering role and had the potential to enhance the lives of children placed in their care.  12.4. The first review provided an opportunity for reflection on the issues raised at the point of approval. For FC1 there were clear references to the fact that without a support network, the demands on him would be considerable. FC1 gave an assurance that he had support, but the language he used at approval and at review was revealing; he spoke of receiving support not from ‘friends’ but from ‘colleagues’; he did not attend fostering support groups, despite the suggestion that he do so and he was not in contact with any member of his family, insisting he was unaware of where they lived or what happened to them. This  would seem to describe a person who did not have  access to any support networks. Whilst not suggesting that such individuals do not have the potential to make good foster carers, this issue should have been explored in detail during the assessment process, challenged by the fostering panel when it was not and then most certainly picked up at his review which took place almost 16 months later. To expand on the training, FC1 undertook 4 online courses. He also attended 4 half day training courses and a 20 week program alongside other foster carers. 12.5. The Panel did not challenge or question the reoccurring issue of FC1’s health concerns, which seem to fluctuate amid various hospital and GP appointments, medical tests and scans. Such were his health needs that PB’s placement came to a relatively abrupt end after FC1’s alleged fainting episode and after 8 months, PB was moved to a different placement. This did not lead the fostering service to seek a medical report to ensure that FC1 was fit to foster and nor were they challenged by the fostering panel (or indeed by the IRO) when this had not happened. Reading the minutes from the foster panel meetings, there is almost a sense of admiration that FC1 was so ‘selfless’ that he placed the needs of the department above concerns for his own health. At no time, however, did the panel seek assurance about FS1’s health and his fitness to continue in his role as a foster carer. This was an omission on their part. Once PB had left his care, FC1 seemed to make a swift recovery which led to the department placing another young person in his care only weeks later and without any medical assurance that he was now   well enough to continue in a fostering role.     SCR Trafford/ Fostering/December 2016 - amended March 2017 24 12.6. Both foster carers referred to stress, fatigue, and general ill –health at various times to explain why they acted as they did or why they did not act at all. The Fostering Panel were well placed to ask for medical reports from their respective GPs, but there is no record of them doing so. Medical advice, when required is provided to the Panel by the LAC nurse, and this is not appropriate. The Review Team would recommend that the Fostering Panel ensures it is supported by a Medical Adviser with a much wider knowledge base than that which can confidently be provided by a nursing practitioner with responsibility for meeting the health needs of looked after children. The Medical Advisor is a clinical role that should provide brief written reports to the panel on the health of prospective carers. This should include interpretation of health and lifestyle information provided by the applicant and their GP.  From time to time, it may be necessary to liaise with specialists about health issues identified; these actions would have been particularly relevant in relation to FC1’s health concerns.  Recommendation 8: When a placement ends unexpectedly due to health concerns of a foster carer, or there are ongoing health issues of a foster carer or noted by the supervising social worker, a medical report should always be sought from the foster carer’s GP.  Recommendation 9: The local authority should, together with Fostering Service and Fostering Panel  a) ensure that an experienced Medical Advisor is identified to support the work of the Panel in addressing and confirming the health needs of prospective and current foster carers.  b) Cease, with immediate effect, to refer to the LAC Health nurse as the Medical Advisor  12.7. Foster panels are required to place the needs of children at the centre of their work and there was evidence in this review that in relation to PB this did not happen. There is for example no feedback report from PB in FC1’s annual review, which captures his perceptions as to why the placement ended and the manner in which it happened. There is no reference in any of the minutes from review meetings to the voice of the child and this is a significant omission. The Review Team could find no evidence of any disruption or end of placement meetings. 12.8. In a review such as this the ‘why’ questions are crucial to understanding why certain decisions would have made sense at the time. It appeared to the Review Team from talking with individuals who knew the carers and from reading reports and minutes of meetings that the need for professional curiosity and healthy challenge from panel members was overshadowed by the professional persona of both individuals, their clearly articulated confidence and their employment history. The very positive perceptions identified at the assessment stage appear to have been strengthened because of the success of the initial placements and it is possible that this led to a degree of complacency, which was promoted through the very positive reports from social workers and supervising social workers.     SCR Trafford/ Fostering/December 2016 - amended March 2017 25 13. Communication and collaboration between agencies.  13.1. Prior to entering the care system, PB and his family were offered support through Child In Need arrangements, but SFPB described the support offered as ‘pointless’ and that it ‘didn’t change anything’. MPB said PB’s behaviour ‘only seemed to get worse’ and consequently PB became a looked after child in February 2013 after his mother and stepfather said they could no longer manage his behaviour. There is no indication that any multi –agency work with the family occurred once PB entered the care system, despite there being frequent references in his Care Plans indicating the goal of him returning to live with his family at some future point. Whilst the focus of this review was not PB’s journey through the care system, there are nevertheless issues, which are worthy of comment.  13.2. Parents experiencing difficulties in managing the behavior of their children frequently seek a solution from Children’s Services. This can include a request that the child be accommodated elsewhere for a period of respite, or sometimes for a more permanent solution. For the majority of children who become looked after, return home will be the preferred pathway to permanence. The Review Team were told that this was what PB wanted but he was realistic enough to understand that without the agreement of his stepfather, it was unlikely to happen. In order for PB’s return to his family to happen, it would have been necessary to develop child- and family-centred approaches to his placements so that the issues that led to his coming in to the care system could be addressed. The Review Team could find no evidence of this work being undertaken or considered necessary and yet it appeared that neither was there any plans made to establish permanency for PB.  13.3. In one care plan, it was stated that that at the age of 13, PB needed a stable and nurturing environment   and the likely duration of any placement would be until he was 18. The risks associated with entering the care system at a time of significant emotional and psychological development, together with his experience of loss and rejection   does not appear to have led to any specific or focused therapeutic intervention.  13.4. The Review Team had access to numerous LAC review minutes and various Care Plans, which the Lead Reviewer found confusing, unhelpful, and certainly not child-friendly. These were largely task focused with very little consideration about what PB might be feeling and what life was like for him moving from placement to placement. There was little to evidence, until the work with the Barnardo’s worker began that any professional had managed to establish a working relationship with him. There is a wealth of research, which indicates that the best chance of adolescents responding to relationship-based practice is when it is consistent, holistic, and available over a long period on their own terms if possible. The Review Team considered that when young people enter the care system, they could often thought to be in a safe and secure place and therefore become less of a priority for their social workers. Yet, the risks that LAC adolescents face are particularly complex and wide-ranging and there is no reason to believe they are any less harmful, on the whole, than those experienced by young children not in the care system.  13.5. Despite PB’s numerous placements there was very little analysis in LAC meetings about PB’s placement breakdowns and whilst the precipitating incident was often clear, there was little evidence of PB’s view as to what had happened, despite the contacts made by the IRO.  SCR Trafford/ Fostering/December 2016 - amended March 2017 26 Questions must be asked as to whether the existing systems for LAC reviews actually work or whether they may alienate young people and may inadvertently lead to them feeling stigmatised and alienated by the process.  13.6. PB was reported missing to police on 36 occasions between December 2012 and March 2015 and was arrested numerous times for assault, criminal damage, and possession of cannabis. There is evidence of some joined up practice in the response to PB going missing from care; the police, social workers and education staff collaborated on developing and implementing a Missing from Care (MfC) strategy and multi-agency meetings were held on 10.12.14 and 11.2015.  13.7. There was however clearly scope for better communication between the key agencies. When PB turned up at the home of FC2, after being reported missing, police officers were initially unclear as to whether, given this was a registered foster carer, he could be allowed to stay there. On two occasions, 2nd and 4th December, police advised residential staff that they considered PB safe in the care of FC2 as he was a foster carer with the authority and therefore would not collect him reasoning there was a greater risk of him absconding if they returned him to his residential placement. The MfC action plan created later in December 2014 still listed FC2 as a friend who could be contacted, but also stated that PB was not allowed stay at his address. It does not however, offer any rationale for this and police records suggest that although CSC had some concerns about FC2 they could not ‘articulate these to officers’. This was not helpful and better communication by CSC about their growing concerns may well have alerted police much earlier to the risks FC2 posed to PB.   13.8. On 13.2.15, PB was subject to a CSE risk assessment, which indicated medium risk. There was however no reference to FC2, despite the fact that he would persistently turn up at the foster carer’s home and there were by then significant concerns   that FC2 was colluding with PB and allowing him to stay overnight.  13.9. PB’s health needs were regularly assessed by the LAC nurse who met PB on several occasions and discussed with him smoking, his occasional use of cannabis, his girlfriend and sexual health all part of a regular health assessment. On her first meeting with PB at the home of FC2, the LAC Nurse recalled she was surprised to be left alone with PB for his health assessment when FC2 left to attend a meeting. She thought this highly unusual but did not think to share this as she noted that PB seemed very settled with FC2. The health records indicate no concerns were raised.  13.10.  The first allegation against FC2 was made to a specialist foster programme team manager by a parent who alleged that FC2 had supplied alcohol to her child and another child whilst on placement. The allegation was inappropriately dealt with as a complaint and as there appeared to be no evidence to support the allegation, no further action was taken. When evidence later emerged through ‘Facebook’ the allegation was only then referred to the Local Authority Designated Officer (LADO) in the other local authority and FC2 was suspended from his fostering role in Trafford. Following further enquiries, FC2’s role in providing or allowing the alcohol to be consumed could not be substantiated so this to led to no further action on the part of the fostering service and FC2 suspension was lifted. The Review Team could find no trace of any case recordings in Trafford and despite the outcome, it would have been appropriate to monitor the extent to which FC2 was supervising young people in his care, the  SCR Trafford/ Fostering/December 2016 - amended March 2017 27 Review Team was informed that as the allegation was ‘unfounded’, no further action was deemed necessary.  13.11. The allegation made against FC2 in July 2015 against FC1 in December 2015 was each referred to the LADO and appropriate strategy meetings took place at which both authorities were represented.   13.12. Questions were asked during the review process why PB was not able or willing to talk about the experiences he later described to his key workers. Research suggests that for many young people a consistent long –term relationship with a professional is the most important factor in talking about worrying or abusive experiences19, whilst an occasional one off conversation is unlikely to elicit an accurate picture of what might be happening. This possibly explains why PB was so willingly to talk with the Barnardo’s worker and his key worker both of whom he appeared to know and trust. Building relationships of trust is at the core of all successful interventions and this is perhaps more pertinent for adolescents for whom volatile developmental changes are coupled with their movement out of the family and into wider social networks. 14. Managerial Oversight 14.1. High quality, reflective supervision is central to providing good support for professionals working to improve outcomes for children and young people. There is a wealth of research and literature to assist managers to develop high quality supervision across agencies20.The best supervision offers both managerial oversight and constructive challenge to practitioners, using evidence based research to help the practitioner decide what sort of support is required for individual children and their families.   14.2. The supervision notes seen by the Review Team suggest that more could be offered to social workers in the fostering service by way of opportunities for reflective practice. Effective professional supervision plays a critical role in ensuring a clear focus on a child’s welfare. Supervision should support professionals to reflect critically on their views, assumptions, and judgements and the review team considered that improved practice in the delivery and the recording of supervisory practice would be of benefit.     14.3. Several of the practitioners recalled feeling uneasy and a little uncomfortable when meeting FC2, for example, ‘he used my name at every opportunity…it just felt odd’. Another practitioner said ‘I just didn’t warm to him…there was just something’. These comments however were shared with the benefit of hindsight, the dangers of which have already been mentioned in this report. None of the practitioners, although claiming to have experienced some of these feelings at the time, raised concerns with colleagues or their managers. One practitioner told the reviewers. “What would I have said? There was nothing to actually say? Another practitioner upon being told of PB’s allegations was recorded as saying ‘Yes, I knew it!’                                                  19 Rees G, Gorin S, (2010)  Safeguarding Young People ; aged 11.- 17 years The Children’s Society 20 Staff Supervision in Social care,” Tony Morrison, 3rd edition and  “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003.Jane Wonnacot; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012  SCR Trafford/ Fostering/December 2016 - amended March 2017 28 14.4. Personal perception of issues, “warning signs” and gut feelings about applicants are sometimes a starting point for looking deeper into specific areas, but there was little to evidence in any records that practitioners working alongside FC1 and FC2 considered or suspected at any point that they were not acting in the best interests of PB or other children in their care. Even accepting the above comments were how practitioners actually felt at the time rather than using hindsight to express what they think they should have felt, the questions in the practitioners group were centred around the difficulty in sharing  ‘gut feelings’ when so much practice needs to be evidence based.  14.5. It is here that quality supervision plays its part and supports good practice by encouraging a process of examining, the thoughts, feelings, actions, and reactions evoked in the course of working closely with foster carers, young people, families and even colleagues. Respectful uncertainty, intuitive reasoning, and critical reflection are practice skills that practitioners need to use and apply in all aspects of their work but these will be of little benefit if opportunities to discuss and test them are not available.   15. The views of PB and his family   The perspective of PB  15.1. PB agreed to speak with the Lead Reviewer in the presence of his therapeutic worker from Barnardo’s (B1). It was agreed beforehand that the purpose of the conversation was to listen to PB’s views about his placements but that the detail pertaining to his allegations would not be part of any discussion.  15.2. PB clearly had a warm and respectful relationship with B1 and made several references throughout the conversation to the work they were undertaking together. PB offered a clear and coherent account of his various placements and the pros and cons of each place he had lived. He could not recall being given specific information about FC1 or FC2 other than they ‘lived on their own’ and couldn’t recall whether he knew they were gay or not. He shrugged when asked if it would have made a difference to him staying there. PB expressed mixed feelings about living in secure accommodation and said ideally he would like to go back to the North to be near his family. He said he had not liked the specialist foster programme as there were ‘too many rules’ and he wasn’t allowed a phone or use of the Internet. PB said that he had been upset and angry when the   placements ended with FC1 and FC2 as it was ‘easy’ and he liked living with those carers. Reflecting on this, PB acknowledged that this was because there weren’t any rules and he could do, as he wanted. He said other foster carers were too strict. Although he had met his Independent Reviewing Officer (IRO) a few times, he said he hadn’t told him much about [those] foster placements. He said he hadn’t wanted to move so far away from where his family were living.  15.3. PB asked the Lead Reviewer why he had been moved so many times. He said he thought it was probably to do with his behaviour but then sometimes he had to move because his foster carers had gone on holiday and that didn’t seem fair. With the help of his therapeutic worker, PB shared his struggle with managing his emotions and said he knew that ‘flying off the handle’ usually got him into trouble. He talked a little about his family background. The conversation ended after almost an hour, by this time although PB had been willing to talk, he was clearly beginning to tire of the conversation. He asked why FC1 and FC2 had not been charged after  SCR Trafford/ Fostering/December 2016 - amended March 2017 29 what he had told social workers and we spoke for a brief time about the justice system. B1 suggested that he could pick up some of the issues with her and if he wanted she would pass on any additional comments to the reviewer.  Perspectives of Mother (MPB) and Stepfather  (SFPB)  15.4. The Lead Reviewer met with the mother and stepfather of PB so their views could be incorporated into this report. They were open about the difficulties they had in managing PB’s behaviour over a number of years and explained they had requested that he be accommodated by the local authority when he had physically assaulted his younger step-brother.   15.5. The couple said they did not receive any effective help during the years when they were trying to cope with PB’s behaviour; they acknowledged they had been offered parenting sessions but considered that this was a waste of time as it was PB’s behaviour that needed to change. They were kept informed about PB and his fostering placements but considered that the authority took no notice of their views when they explicitly said that PB should remain with his [first] foster carers as they provided the boundaries that their son needed. They said they had complained several times about PB being on Facebook although he was on a SPECIALIST FOSTER PROGRAMME and should only have limited and supervised access to the Internet. They said FC1 allowed PB to shave his eyebrows and even gave him the shaver with which to do it. The reason, they said why PB liked living with both foster carers was that he could do as he pleased and had them ‘wrapped around his finger’. They said they had shared their concern about whether a single carer would be able to effectively manage PB’s behaviour.  15.6. MPB said that when they first met FC2, she felt uneasy and did not ‘take to him’. Both adults recalled that on their first visit to the home of FC2, he told them that their son was gay and indicated that he was in ‘a relationship’ with the other child who present.21 They didn’t believe this and thought it an odd thing to be told by a foster carer and although they discussed this with the social worker nothing came of this. They were not surprised when they learnt of the allegations made by PB against FC2. 15.7. Both MPB and SFPB believed that PB needed firm boundaries and these had clearly not been provided by FC1 or FC2. They offered examples of when foster carers, FC1 and FC2 had colluded with PB and said their concerns were not addressed by social workers, even when PB was ‘supposedly’ on the SPECIALIST FOSTER PROGRAMME. They recalled that the IRO had indicated that PB needed a safe place, which offered clear boundaries, and they had supported the idea of a full time residential/education placement but social workers disregarded their views and PB was allowed to go home at weekends to FC2.  15.8. Asked what they thought may have helped, the parents said earlier assistance with PB’s behaviour, and some sort of help which would have helped them understand his behaviour would have been of immense benefit. They pointed out that they had three other children and there were no concerns about their behaviour. Perspectives of FC1                                                  21 This issue was followed up by social workers but no additional information could be found and the young person to whom this was thought to refer denied any sexual relationship with PB.   SCR Trafford/ Fostering/December 2016 - amended March 2017 30 15.9. FC1 met with the Lead Reviewer and the Interim Lead for Looked After Children in late February 2017. The Lead Reviewer explained that the purpose of the meeting was only to discuss the SCR process and offer FC1 the opportunity to comment on the findings and related recommendations and there would be no discussion of PB, the allegations he had made or any subsequent procedures in relation to those allegations. FC1 said he was in contact with FC2 and was aware of all that had happened. 15.10. FC1 said he accepted the findings and recommendations in the report and as he had provided some written comments these were used to structure the conversation. Some of these points were related to an ongoing process related to FC1’s de-registration as a foster carer but these were not discussed.  15.11. FC1 said that despite his delight at being accepted as a foster carer, he was surprised that the vetting process had not been more challenging and indicated that he had said as much to his supervising social worker. He said he had expected far more discussion around the fact that he was a single male carer and in particular more probing about his sexuality and the extent to which this could have impacted on his role as a foster carer. He gave an example of the sort of things he asked when interviewing staff in the work place. FC1 explained that he had been very concerned at being asked, on what was his very first placement, to be a specialist carer for PB and believed this had directly contributed to the deterioration of his health. He said he found PB’s behaviour very challenging and his failing health during the placement meant he was unable to care for PB. He pointed out that his health quickly improved once PB had left his care and said he was surprised that he had not been sent for a medical before his next placement, as this would have been appropriate. FC1 also expressed surprise that his daily records were not routinely read by either PB’s social worker or his supervising social worker as this would have testified to the difficulties he was experiencing. FC1 said he had expected more support than had been offered but thought he was just expected to ‘get on with it’. He expressed thanks for the opportunity to discuss his views.   16. Summary 16.1. Whilst evidence shows that the overwhelming majority of foster carers offer safe care, it is important for professionals to acknowledge the risk, albeit a small one, that abuse may occur in any form of substitute care. Looked after children are vulnerable whatever their persona or presenting behaviour and robust care plans are essential to not only safeguard the child from further abuse and harm but also to help build resilience and help young people to  learn coping strategies. Actions in care plans must be implemented, closely monitored, and regularly updated.  16.2. An awareness of patterns of manipulative behaviour should inform the recruitment, approval and continuing monitoring and supervision of all those working with children, especially foster carers who have the day to day care of some of society’s most vulnerable children, and of necessity with little direct supervision of their work. LR/End December 2016  SCR Trafford/ Fostering/December 2016 - amended March 2017 31 Appendix 1 Recommendations for Trafford and the Local Authority Recommendation 1: Where a prospective foster parent works directly with or on behalf of children and young people, formal references should always be requested from a senior professional in their agency in addition to any other references and these references should always be submitted in writing  Recommendation 2: The fostering service in Trafford should: a) ensure that all assessments of foster carers are thorough, robust, and appropriately challenging with information being sought from a wide range of sources.  b) ensure there is adequate guidance for assessing LGBT applicants22 - there would also be merit is using this guidance as an opportunity to train panel members.  c) undertake a review of panel membership to ensure it represents and reflects the diverse community it serves.  Recommendation 3:  Social workers should be reminded that they are responsible for talking with children about proposed placements and the [general] lives and lifestyles of the carers with whom they will be living. The responses of the children should be noted and monitored, the Review Team could find no evidence that this is routinely done in Trafford and there would be benefits in further discussions around this issue.   Recommendation 4: As a corporate parent, the local authority and its senior managers should ensure that the IRO role and function is utilised effectively so that challenges about care planning and decision-making are acknowledged and addressed.   Recommendation 5: Trafford’s Independent Reviewing Unit should ensure regular scrutiny of annual reviews of foster carers and ensure these are robust, thorough, and challenging.   Recommendation 6:  Trafford Fostering service should ensure that all supervision files for foster carers contain easily accessible, purposefully prepared, and carefully maintained chronologies to support supervision and reviews of foster carers. There should be evidence of, and reference to foster carer’s daily records so any emerging concerns or issues can be addressed.  Recommendation 7: Trafford Safeguarding Children Board should ensure that all practitioners and especially those within the fostering service have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children and have opportunities to discuss these challenges within multi-agency settings.    Recommendation 8: When a placement ends unexpectedly due to health concerns of a foster carer, or there are ongoing health issues of a foster carer or noted by the supervising social worker, a medical report should always be sought from the foster carer’s GP.  Recommendation 9: The local authority should, together with Fostering Service and Panel,  a) ensure that an experienced Medical Advisor is identified to support the work of the Panel in addressing and confirming the health needs of prospective and current foster carers.  b) Cease, with immediate effect, to refer to the LAC Health nurse as the Medical Advisor                                                  22 British Association of Fostering and Adoption and Adoption (BAAF) offer excellent resources in this area. 