Management of the nursery where paedophile Vanessa George sexually abused youngsters has been severely criticised in an official report.
The review of the scandal at Little Ted's in Plymouth concluded there was no indication "any professional could have reasonably predicted that George might be a risk to children" but that there appeared to have been a "complete lack of recognition" that her increasingly strange behaviour after the break-up of her marriage had crossed boundaries.
George, 40, who was jailed indefinitely last year after admitting seven sexual assaults and six counts of making and distributing indecent pictures of children, took photographs on her phone of herself abusing toddlers and shared them with fellow paedophile Colin Blanchard.
A summary of a Serious Case Review commissioned by Plymouth Safeguarding Children Board after the scandal pointed to what it said was weak management at Little Ted's, which closed immediately after George's arrest.
The review said Little Ted's "provided an ideal environment within which George could abuse" and it was critical that Ofsted inspections failed to spot shortcomings. The report said there was a lack of safe recruitment procedures, an informal recruitment process and lack of formal staff supervision. It concluded that the management culture allowed the abuse to happen and lessons needed to be learned but "ultimate responsibility for the abuse must rest with George".
Following interviews with George's colleagues and parents, it was apparent that Little Ted's did not provide a safe, positive environment for children in its care, the report stated. It said: "This would indicate that either the individual (Ofsted) inspections were not rigorous enough, or the framework for inspection is not adequate."
The report said it was not seen as significant that George began using a cubicle to change nappies rather than the general changing area. Staff did not report concerns about her openly discussing her sex life or showing them inappropriate images on her mobile.
"The escalation of George's behaviour should have prompted a response by the manager of the nursery, but it did not do so. There appears to have been a complete lack of recognition of the seriousness of the boundary violation and a culture within the nursery where explicit sexual references in conversation were the norm."
Ofsted said it took its role in the inspection and regulation of nurseries "extremely seriously". Patrick Leeson, the regulator's director of education and care, said: "It is important that lessons are learnt from this case. Ofsted has already implemented a number of changes in the way we work as a result of this review and to address the recommendations made."
The Department for Education said an ongoing review would consider whether standards for protecting young children need to be strengthened. "This was a shocking case of abuse of children. The Serious Case Review by Plymouth Safeguarding Children Board identifies important lessons that all early years settings need to learn from so that vulnerable children are better protected in future," a spokesman said.