Children with disabilities and complex needs suffered “very serious abuse and neglect” at three residential settings in Doncaster, according to a national review calling for “urgent action” to ensure children are safe.

The Child Safeguarding Practice Review Panel identified a “culture of abuse and harm” which saw some of society’s most vulnerable children experience “systematic and sustained” abuse and neglect over a period of more than three years.

There was also evidence of sexual harm, medication being misused and maladministered, an over-use of restraints and “unsafe and inappropriate” use of temporary confinement, it said.

The findings are so serious that the panel is demanding urgent action from councils across the country and Ofsted to ensure all children with complex needs and disabilities living in similar children’s homes are “safe and well”.

Phase one of the review, examined the experiences of 108 children and young adults living Fullerton House, Wilsic Hall and Wheatley House, three residential special schools registered as children’s homes and operated by the Hesley Group, between January 2018 to March 2021.

The safeguarding review was launched in January 2022, and found a number of complaints had been made to Ofsted dating back to 2015.

A complex abuse investigation, named Operation Lemur Alpha, is being carried out by the Doncaster Safeguarding Children Partnership, which was launched in March 2021 following whistleblowing report made the previous month.

This includes a criminal investigation by South Yorkshire Police.

The safeguarding review found abuse was “inflicted with no respite” and allowed to flourish, with children and young adults experiencing physical abuse from staff and other residents, excessive force, physical neglect and taunting.

It said they were subject to “significant and varied” emotional abuse by staff and there was evidence suggesting staff had “seriously breached sexual boundaries with each other and with children and young adults”.

Many of those impacted had difficulties in communicating and “would have found it difficult to report the abuse”, the review said.

Placements far from home increased children’s vulnerability, while some children were inappropriately placed at the settings, and high staff turnover and poor training affected their quality of care, it added.

A Hesley Group spokeswoman said the group is “deeply sorry for the hurt caused to young people and their families over this period” and will consider the issues raised in the review to ensure improvements “can continue to be made”.

Panel chairwoman Annie Hudson said it is “profoundly shocking” so many children who were in plain sight of public agencies “could be so systematically harmed by their care givers”.

She said: “This national review seeks to make sense of how and why a significant number of children with disabilities and complex needs came to suffer very serious abuse and neglect whilst living in three privately provided residential settings.

“Our evidence shows that the system of checks and balances which should have detected that things were going wrong simply did not work.

“While there are many skilled professionals who work with children with disabilities, we are concerned that these are not isolated incidents.

“That’s why we have asked all local authorities and Ofsted to take urgent action to ensure all children living in similar circumstances are safe and well.”

Alongside the urgent actions for councils, it said Ofsted must immediately analyse its evidence around workforce sufficiency, focusing on its suitability, training and support.

These actions are expected to be completed by the end of November 2022.

A second phase of the review seeking to identify necessary changes is expected to be published in spring 2023. 

A Hesley Group spokeswoman said: “We recognise that the panel has identified serious failings in the running of Fullerton House, Wheatley House and Wilsic Hall ahead of their closure which led to people receiving unacceptable levels of care, and we are deeply sorry for the hurt caused to young people and their families over this period.”

The group said it took “swift action” to address concerns at the time, including dismissing several staff, and deregistered the homes.

It added: “We will carefully consider the issues raised…to make sure improvements can continue to be made.”

South Yorkshire Police detective chief inspector Phil Etheridge said: “I understand members of the public will be concerned by this investigation and want to assure you that we are doing all we can, as part of the partnership, to address the issues that have been raised.

“Since Operation Lemur Alpha launched we have been working hard to identify whether any children, young people or adults suffered any experiences at these settings which would meet the threshold for criminal investigation.” 

He added that the force is working with specialist agencies to ensure individuals’ voices are heard during the investigation.

Anyone who wishes to contact the police with information regarding a family member who lived at one of the homes between January 2018 and October 2021, or who has information which may assist officers relating to that time period, is asked to submit details using the Major Incident Public Portal.

Riana Nelson, Doncaster Council’s director of children, young people and families said: “I understand that many families who have children with complex needs and are receiving residential care will be alarmed at the findings of this national review.

“Please be reassured that strong and concise action has taken place at a local level and procedures are in place to protect both children and adults living both locally and further afield.”

Ofsted said: “It is clear that the management and staff of these homes were not open and honest with authorities, including Ofsted.

“But it’s also clear there are lessons for all of us to learn.

“We will continue to support the police investigation into the abuse, and we are already taking steps to improve what we do through inspection and regulation.”