Allegations of abuse and neglect in care
National Care Standards (NCS) Regulation 69 sets out the chief executive’s duties when an allegation of abuse or neglect is made about
and in care. These duties include providing a prompt response to the allegation, recording information about the allegation, informing the tamariki or rangatahi of the outcome where appropriate and taking steps such as reviewing the caregiver’s support plan.
Oranga Tamariki compliance with Regulation 69 has improved in some areas and decreased in others.
We have mapped Regulation 69 to the aroha outcome in our Outcomes Framework because the way that allegations of abuse and neglect are handled relates to tamariki and rangatahi feeling loved, supported and safe. The importance of how allegations are handled has been emphasised through the work of the Royal Commission of Inquiry into Abuse in Care. In particular, tamariki and rangatahi need to feel that they are able to raise concerns and know that appropriate action will be taken to keep them safe.
We have been reporting on compliance with NCS Regulation 69 since December 2019. Oranga Tamariki has reported improvements in a number of areas when handling allegations, including record keeping and advising tamariki or rangatahi of the outcome of the investigation. However, in other areas, data shows that practice has deteriorated, in particular timeframes for completing investigations. This is despite Oranga Tamariki having introduced new assurance processes reporting that they were placing a greater focus on compliance with regulation 69, including timeliness. 
The graph below compares findings for 2019/2020, 2020/2021 and 2021/2022 on whether the initial response at the site office was prompt, if the standard of completing the assessment or investigation within 20 working days was met, whether findings were entered correctly and if all information relating to the allegation was entered correctly into the Oranga Tamariki database.
Graph: Regulation 69 Assessments/Investigations
Initial decisions and actions when an allegation of harm is received
Oranga Tamariki policy states that when an allegation is made that a tamariki or rangatahi in care “is being, or is likely to be, harmed”, the allegation must be recorded as a report of concern. Most allegations are recorded as a report of concern by the National Contact Centre, with some recorded by Oranga Tamariki sites.
At the time of writing Oranga Tamariki has not released its Safety of Children in Care Unit annual report for 2021/2022. However, Oranga Tamariki has told us that 1,894 reports of concern were recorded. Of these 1,367 were considered to be allegations of harm to tamariki while in care for this reporting period. The others were a variety of concerns including self-harm and/or suicidal ideation, behavioural issues and pre-care incidents.
After the report of concern has been recorded for children in care, Oranga Tamariki makes one of three decisions:
- Take no further action (NFA). This decision is taken when the report has no substance, the concerns do not indicate harm to a child, or concerns are being appropriately responded to by others.
- Carry out a child and family assessment. This decision is appropriate if the child is experiencing (or is likely to experience) serious harm, and/or the concerns are having a significant impact on their development, safety, health and/or wellbeing but do not indicate abuse which may constitute a criminal offence.
- Carry out an investigation. This decision is appropriate when the concern for the child meets the criteria in the Child Protection Protocol.
Oranga Tamariki data shows of the 1,367 reports of concern that they considered to be allegations of harm:
- an assessment or investigation was required in 1,230 cases
- no further action (NFA) would be taken in 137 cases.
Oranga Tamariki reviews all NFA decisions as part of its quality assurance checks, and this is done weekly. These reviews found that 62 of the 137 NFA decisions (45 percent) were incorrect. This is a significant increase in the proportion of incorrect NFA decisions, up from 22 percent last year. However, Oranga Tamariki has advised that this result requires context and that in 38 of the 62 NFA decisions other case work was underway, and the allegation was being considered within the context of that work. Oranga Tamariki accepts that these allegations should have been managed like any other allegation, and therefore categorised them as ‘incorrect’.
For the other 24 cases (20 percent of NFA decisions), Oranga Tamariki has engaged with staff to review the decisions for further assessment or an investigation.
Timeliness of investigations
The Safety of Children in Care Unit (SoCiC Unit) reviewed the findings of 1,155 assessments and investigations between 1 July 2021 and 30 June 2022. For 968 cases (84 percent), the SoCiC Unit found the initial response at the site office was prompt and within the expected timeframe for completing an initial safety screen. This is similar to last year, where Oranga Tamariki reported that 87 percent of initial responses were within expected timeframes.
Following an initial safety screen, the site is expected to complete an assessment or investigation within 20 working days. The SoCiC Unit found that 251 cases (22 percent) met the standard of being completed within 20 working days. The 20-working day standard is set by Oranga Tamariki, with the
only requiring that the response is “prompt” (regulation 69(2)(a)). Timeliness of investigations has continued to decline since we first looked at this in 2019/2020, with overall timeliness falling from 41 percent in 2019/2020.
The lack of timeliness in investigating allegations was reflected when we spoke to members of staff from Police, education and healthcare services who told us about what they perceived as a lack of action in response to reports of concern.
A member of Police staff told us “We have had some good experiences with Oranga Tamariki recently, but it took five or six reports of concern before we really got any traction. Once we all came together, Oranga Tamariki and family, we have got a really good outcome”.
While these comments relate to how Oranga Tamariki responds to all allegations of harm rather than specifically allegations of harm relating to children in care, we have included them here because they provide wider contextual information on how allegations of harm are responded to.
In relation to timeliness, Oranga Tamariki was unable to explain the continued decrease in timeliness but told us “We acknowledge that on occasion the 20-working day timeframe is not sufficient. Some of the complexities involved mean that social workers require a longer period of time to gather all relevant information needed for an assessment”. Oranga Tamariki also told us that it has introduced new policy requirements, which state “the assessment or investigation should be completed within 20 working days. However, if the matter is complex or further time is needed to engage with the caregivers, the assessment or investigation must be completed within 40 working days.”
Next year we will be asking Oranga Tamariki to provide the average time to complete investigations so we can accurately understand trends, irrespective of any policy change.
Advising tamariki and rangatahi of the outcome
In an earlier report on the handling of allegations of harm and abuse, we noted the importance of advising tamariki and rangatahi of the outcome of the allegation. We said that “informing tamariki and rangatahi of the outcome of an assessment or investigation is important so they feel that they have been heard and that the concerns were taken seriously”. Since 2019/2020 Oranga Tamariki data shows that in cases where it is appropriate to advise tamariki and rangatahi of the outcome, performance has improved from 28 percent in 2019/2020 to 42 percent in this reporting period.
Steps taken in response to allegation(s)
Once an allegation is made the NCS Regulation 69 requires Oranga Tamariki to take appropriate steps, including a review of both caregiver and tamariki plans.
The graph below compares findings for 2019/2020, 2020/2021 and 2021/2022 relating to whether tamariki plans were reviewed, whether supports were put in place to address harm, whether the caregiver support plan was reviewed and whether tamariki were informed of the outcome of the assessment/investigation, as appropriate.
Graph: Regulation 69 Actions
Oranga Tamariki practice requirements
Oranga Tamariki developed a set of 12 practice requirements that, if followed, would assure it is compliant with NCS Regulation 69.
Data shows that for the period 1 July 2021 to 30 June 2022, performance against the 12 practice measures, to support achieving NCS Regulation 69, has not been achieved for the majority of tamariki or rangatahi who have had outcomes for allegations of abuse or neglect.
Demonstrated full compliance with the 12 practice measures was found in five percent of cases. Oranga Tamariki acknowledges that there is a need to significantly improve its practice in this area.
Assessing the safety needs of tamariki
Assessing the safety needs of tamariki and rangatahi in care is part of an overall assessment of their needs as per regulation 14 of the NCS Regulations. It’s important that support plans address any safety issues for tamariki or rangatahi, including situations where they may pose a risk to themselves or others.
This is the first year that Oranga Tamariki has provided information on the specific safety elements of the process for assessing safety needs for all tamariki in care. The four aspects are:
- the nature of harm experienced by tamariki and the effect this may have on their ongoing safety and wellbeing
- the risk of harm to tamariki by other people they come into contact, or may come into contact, with
- the resilience and protective factors present for tamariki in their environment
- aspects of the behaviour of tamariki that may present a risk to their safety or the safety of others.
Data from analysis of the case files where tamariki had a current Tuituia or other assessments was used to establish how well these four aspects were addressed by Oranga Tamariki over the reporting period. This data shows that in:
- 86 percent of cases, the nature of the harm experienced by tamariki and the effect this may have on their ongoing safety and wellbeing was assessed
- 79 percent of cases, the risk of harm to tamariki by people they come into contact, or may come into contact, with was assessed.
- 89 percent of cases, the resilience and protective factors present for tamariki in their environment were assessed in
- 75 percent of applicable cases, aspects of the behaviour of tamariki may present a risk to their safety or to the safety of others were assessed in (in some cases, this question was not applicable as there were no behavioural concerns that might present a safety risk).
Oranga Tamariki policy requires that actions to address assessed safety needs must be recorded in the child’s plan (either the All About Me Plan, Court plan or FGC Plan) and where the child has an Oranga Tamariki caregiver, the caregiver support plan should also be updated to reflect the assessment.
In the cases reviewed through case file analysis, safety needs were addressed in ‘other’ plans more commonly than in the All About Me Plan. Other plans include court plans or family group conference plans.. They contained actions to address the safety needs of tamariki in 83 percent of cases, compared to 70 percent of cases with a current All About Me Plan.
Social worker visits with tamariki and rangatahi
Part of keeping tamariki safe in care requires regular visits from social workers to assess how things are going. Regular visits are more likely to create a trusting relationship, where tamariki and rangatahi are more likely to discuss their needs and any concerns.
In 2021/2022, the frequency at which tamariki should be visited by their social worker was set out in their All About Me Plan in 62 percent of reviewed cases. This is almost unchanged from 2020/2021. Social workers visited tamariki at the planned frequency, or at least every eight weeks, in 70 percent of reviewed cases (similar to 2020/2021 at 69 percent).
This year, Oranga Tamariki introduced a measure to understand how well its social workers were engaging with tamariki. Evidence was found of quality engagement with the child in 76 percent of the cases reviewed (576 of 756 cases). When assessing quality engagement, Oranga Tamariki looks for evidence that social workers are:
- meeting the child regularly
- engaging where appropriate with the child in private (so they can freely express their views)
- talking about what’s going well and what’s not going well for the child.
As outlined in Manaakitanga, the views of tamariki and rangatahi on the quality of their relationships with social workers is mixed. What we often hear from social workers is the impact their workload has on their ability to develop and maintain relationships.
This year, Oranga Tamariki also provided information on how well social workers were carrying out actions set out in children’s plans. It has advised that in 81 percent of cases with a current plan (577 of 710 cases), there was sufficient evidence in the casework that the social worker was carrying out the actions as set out in the plan.
Placing tamariki and rangatahi with
Oranga Tamariki social workers told us that, whenever possible, they aim to place tamariki and rangatahi who are entering care in whānau placements. This approach recognises that a child’s wellbeing is intrinsically linked to their position in, and relationship with, their family or whānau. For tamariki and rangatahi Māori, wellbeing is also linked with, and improved by, connections to their whenua, marae,
Oranga Tamariki social workers say that suitable whānau placements are not always immediately possible. The reasons for this included, known family members being unable to take on tamariki and rangatahi because of a lack of suitable accommodation. A social worker said “Since Covid, housing has become a serious problem, which has become a problem for placements for children. Our intake has gone up by 14 percent and transfers from other sites have been increasing.”
Oranga Tamariki social workers, and Kaupapa Māori organisation kaimahi, also told us that through using local knowledge and connections, searches to identify other members of the whānau usually identified whānau care placements. However, this can take time and in the meantime, they need to find other stable, safe and caring placement options.
Māori whānau told us they are happy when an iwi social service is involved in the care of their tamariki. They see this is good for maintaining cultural knowledge and creating a pathway for tamariki to return to the whānau.
Of whānau we spoke with, one told us: “When I heard they were coming under [name] I was quite glad. What’s happened so far has been really good. I have noticed a change in the girls’ attitudes - a lot happier now.… I was hoping that in the near future they would come back to whānau. They could be 18 and then they want to start their own life.”
Whānau also told us about the impact Covid-19 was having on services and placing tamariki with whānau. A whānau member told us “I had a nephew who was transitioning here from [place], but it wasn’t done properly by Oranga Tamariki in [Oranga Tamariki site] so it kind of just fell over. They were basically non-existent at the time. I am not talking about [other Oranga Tamariki site] but I am talking about [Oranga Tamariki site]. It was pretty hard, people working from home because of lockdown, hard over Covid to communicate.”
Assessing caregivers and their household
NCS Regulation 47 places an obligation on Oranga Tamariki to assess a prospective caregiver and their household before the tamariki or rangatahi is placed with the caregiver. NCS Regulation 51 also allows Oranga Tamariki to grant a prospective caregiver provisional (interim) approval to care for a child in urgent situations.
Last year, Oranga Tamariki QPT showed that in 57 percent of placements, a full assessment was completed before the child was placed. For the others, 55 percent of were provisionally approved. This means that tamariki were placed before full assessment or provisional approval in 20 percent of cases.
This year, Oranga Tamariki QPT showed that in 53 percent of cases reviewed, a full assessment was completed of the caregiver and the household before the child was placed. For the others, 31 percent were provisionally approved. This means tamariki were placed before an assessment was completed or provisional approval given, in 32 percent of cases.
Oranga Tamariki data shows that elements of the assessment of caregivers were completed:
- Police checks 99 percent
- Identity checks 98 percent.
- CYRAS checks 98 percent.
- Referee checks 95 percent.
When looking at household members aged 18 years or over, Oranga Tamariki data shows that:
- Police checks were completed for 98 percent of the sample.
- CYRAS checks were completed for 89 percent of the sample.
- Referee checks were only done in 67 percent of the sample
- A list of previous residential addresses was checked 56 percent of the time.
For provisional placements, a full assessment was completed within 25 working days of the placement in 31 percent of cases and in 88 percent of sampled cases there was evidence that support was offered to the caregiver until the full assessment was completed.
From a data perspective, Oranga Tamariki has told us that they expect to see an improvement in the quality owing to the introduction of the new Caregiver Information System (CGIS). This will mean Oranga Tamariki can see the performance for every aspect of the caregiver and household assessment, and not just rely on a sample. While this will be progress, it is also important to understand the number of tamariki placed in households prior to approval.
Reviewing caregiver approval
NCS Regulation 50 provides that once a person is approved as a caregiver, that approval must be reviewed every two years. There are also other times when an approval review is needed, which include:
- when there’s a significant change to the circumstances of the caregiver or their household
- when they wish to change their approval type or conditions
- following an investigation or assessment of an allegation of abuse, neglect, or harm of tamariki by the caregiver.
Of those cases reviewed through case file analysis in which the child was placed with an Oranga Tamariki caregiver, a review of the caregiver’s approval was due during the review period in 54 percent (238 of 442 cases).
Of those 238 cases, there was evidence that the review was completed on time in 26 percent (61 cases), the review was completed late in 50 percent (118 cases) and, at the time the case was reviewed, the review of the caregiver’s approval was overdue and not yet done in 25 percent (59 cases).
Difficulties in finding suitable homes
What we heard in some areas (this includes central Auckland, Canterbury and Te Tai Tokerau) is that there is an accute shortage of placement options, especially for tamariki with high and complex needs, behavioural disorders, substance use issues or disabilities. The reasons for the shortage include not enough approved non-kin caregivers, residences and family homes being closed, and increasing demand for specialist placements.
Caregivers told us that when tamariki and rangatahi are placed for emergency, temporary or respite care, these placements may be extended – sometimes for a long period, without tamariki, rangatahi or caregivers knowing how long the placements will last.
A parent of a child in care told us that their child was briefly returned to them at short notice because other placements had “broken down”. They said “[Oranga Tamariki] asked if I could look after her for a whole week. […] Then they ring me, say there’s a new caregiver, you need to drop her here, we will pick her up and take her away. No one looked back [to when she was with me] and said things are going well, they say nup, she’s going Home for Life. […] It was a big effect. She said to me, ‘why am I leaving, why am I going to them, I’m home with you’. I said, ‘they [Oranga Tamariki] have said this is how it needs to be.’ […] I was gutted, absolutely gutted. I thought yay, they were going to give me a chance.”
Whānau also spoke about their tamariki being placed in separate, geographically distant placements, which makes it difficult for them to maintain contact and regularly visit them all. Some tamariki we spoke to say being separated from siblings is one of the most painful parts of their experience of being in care.
We also spoke to Police and lawyers, who represent tamariki and rangatahi in care, and some told us that while they understand the reasons for the move away from residences, they were concerned about the impact of this. We heard about tamariki waiting in police stations, respite or temporary placements being extended or rangatahi being placed in motel accommodation with trackers. They told us that this risked re-traumatising tamariki or leaving them with the impression that “nobody wants them”.
We observe from Oranga Tamariki data that 186 tamariki and rangatahi spent a total of 6,151 nights in motel accommodation. The median length of stay in a motel was four nights. However, one rangatahi stayed in motel accommodation for over two years.
Oranga Tamariki told us that motel accommodation use is closely monitored at a national and regional level because they appreciate that it is not suitable.
Transitioning within and out of care
One of the key findings in last year’s report was that Oranga Tamariki responded well when tamariki first enter care, but that practices weaken across the duration of care. This finding continues to be reflected in both the data and what we heard about transitions within and out of care.
Transitioning between placements
When tamariki and rangatahi transition between care placements they can feel isolated. Oranga Tamariki policy states that social workers, and other kaimahi, “must support a positive and successful transition when tamariki come into care, move to live with a new caregiver, including residences, move into, between or out of a residence, return home or live permanently with a new whānau or family.” 
In Rangatiratanga, we outlined the mix of experiences tamariki and rangatahi have in decisions about their care placements. Over the 2021/2022 review period, tamariki moved to a new care arrangement in 28 percent of cases reviewed through case file analysis (210/756). Of those cases 55 percent were ‘planned transitions’, where Oranga Tamariki was aware of the transition in advance and planning could take place; the remaining 45 percent of cases were ‘unplanned transitions’ where the move was urgent and most, or all, of the planning steps took place after tamariki had moved to the new care arrangement (referred to as ‘unplanned transitions’).
When we spoke to tamariki and rangatahi about transitioning between placements they said they want to be told where they were moving to and why and be given time to think about what the move means. They also say they want the chance to visit the new placement and have a social worker check in with them.
Tamariki and rangatahi shared examples with us of the negative transition experiences they have had. A rangatahi said “Transition was a bit nerve wracking. Having to live from one place to another. I experience anxiety…My social worker did not communicate with me, I got no information. I was just moved from one place to the other, from one care placement to the next, to my parents and those sorts of things.”
Sharing information with prospective caregivers
When Oranga Tamariki staff share information about tamariki and rangatahi with prospective caregivers, it gives them time to make plans. When the transition involves tamariki and rangatahi moving to a new area, it gives time for them to be enrolled at a new school and healthcare provider.
Caregivers told us they had experienced situations when the tamariki or rangatahi did not have a plan, or Oranga Tamariki social workers were unwilling to share the plan, or parts of it, with the caregivers. They say that sometimes the plans do not include the details they think they need to take care of tamariki and rangatahi and keep them safe.
Care partner staff say that Oranga Tamariki social workers do not always understand the legal requirement to share information. They told us social workers sometimes withhold important information that they need to care for tamariki. They told us “We don’t get the All About Me Plan, we have to really push for it. Some of them say ‘no we can’t see that information.’ It’s critical for legal to be clear what we are entitled to see. Some say no
don’t get to see that information. But we know the legislation says we can have that information. The lack of information is dangerous. We have had tamariki with heart conditions and diabetes and no one knew. It wasn’t until [parent] wrote on the forms that we found out.”
An iwi social service provider told us about the ‘transitional whare’ that they established to provide care for tamariki. The purpose of this service is to provide a ‘stepping- stone’ for tamariki before they return home to their whānau. Kaimahi spoke about using support from their clinical psychologist and their wraparound services (which included health services and social workers in schools) to ensure a safe and stable placement for the tamariki until they could return home to their whānau. With reassessment and deployment of new strategies, tamariki settled well and quickly moved beyond their previously described “behavioural issues”. They also noted that information and assessments they received from Oranga Tamariki were out of date.
Whānau told us it is important to plan for tamariki returning home, so they understand what needs to happen. Whānau members and social workers say wraparound support is necessary during the transition period.
Oranga Tamariki social workers talked about how they build relationships with whānau and give them emotional and practical support. Several social workers told us about programmes such as multi-systemic therapy and functional family therapy, which they use to help whānau prepare for tamariki transitioning home.
However, we also heard that a lack of specialist support is impacting transitions between placements. A social worker told us “They [psychologists] are great for advice i.e., transitioning between placements. They are able to point us to their [child’s] natural contact. Lack of specialists mean up to nine months waitlist. The psychologists are getting burnt out and risk adverse. Massive systems issues”.
We also heard from care partner staff that there is not enough planning to ensure tamariki and rangatahi have a pathway to exit care and return to their whānau.
A care partner staff member said “Yeah. Social workers I really feel for. They look absolutely exhausted […] We have ten kids with us [at organisation] and four possibly have an exit plan, but the rest have nothing... They [Oranga Tamariki] go after the ones that are screaming the loudest and they openly say they know the kids are safe with you guys [care partner] so they [Oranga Tamariki] don’t stress about them…The kids’ lives are held up because they’re sitting in placement with no exit plan and now you risk institutionalising them.”
Transitioning to adulthood services
Emerging into adulthood is an important time for rangatahi. Oranga Tamariki set up its transition support service to support rangatahi during this time. The service provides a transition worker to help them plan for their future when they leave care.
Some care partners told us that the way services are implemented requires the establishment of a new relationship between the provider and rangatahi, and that this can be a barrier to achieving the best outcomes for rangatahi.
We spoke to Oranga Tamariki social workers about this service. Most were enthusiastic about increased use of transition services, but some admitted they felt there were gaps in eligibility criteria and others expressed reservations about the consistency of service quality.
An Oranga Tamariki staff member told us "I was working with the tamariki transitioning out of care. I was really surprised that most of those young people hadn’t been visited for about six months. My biggest thing I saw in that space, was lots of focus goes on younger tamariki. People lose sight of how vulnerable young people are that are exiting care. They need the right stability. They are just as vulnerable [as the younger tamariki]. What I have seen, lots of those young people are really unsettled. Social workers give them a food grant or buy them this but there is no meaningful planning. The entry to care is good but falls off towards the end. They [social workers] are waiting for timeframes to finish but they [rangatahi] don’t have the support. Especially for young people who have offending histories, success as a young adult is limited, without the right supports. We shouldn’t be doing a Transition to Independence referral when they turn 18 next week and we’ve forgotten."
Several organisations we spoke with, told us about the need for these services to be operated by a provider who has a meaningful connection with rangatahi.
A care partner told us “We do not have that contract for this. Sorry, before we [move] on I have a view about transition to independence. It is nonsense. [Oranga Tamariki] brings in this provider with no connections [to the rangatahi] and the time frame is short. Often the person who is assigned [to the rangatahi] does not turn up [for visits or planning] and it does not happen weekly. Why would you not have kaitiaki who already have the relationship with the rangatahi doing this planning and this engagement? Why would you bring in kaitiaki who only meet with rangatahi to tick the box? We have kaitiaki [within our organisation] with skills and [who] know that rangatahi. There is so much more that could be done in that space.”
Another care partner told us that they have a contract for transition services, but said it is difficult to plan transition to independence for rangatahi who are almost 18 years old. They told us that it is important to have more time to plan, and support, rangatahi to transition to adulthood.
A disability services provider raised the same issue. “They [rangatahi] might not actually be known to us because they’ve been with Oranga Tamariki for years. Oranga Tamariki will send a referral three months before their transition at 18 and then they’re yours. Preparation for transition should start at 15 at a minimum. Steps to independence don’t happen overnight. Need time to develop a relationship “three years easy”. You need years to trial things with the kids … put a safety net under them. If they say they want to transition back to whānau … it’s a significant piece of work. Six months out they [Oranga Tamariki] say they need Steps to Independence. Some haven’t seen their whānau in 10 years and then all of a sudden, they’re going back to their whānau … This isn’t good for the kids."
Oranga Tamariki has a “responsibility to assist rangatahi who are in, or have left, [its] long-term care or youth justice residential placements from the age of 15, to acquire the knowledge, skills, resources and supports they need to thrive.” It told us that in recent months it has carried out work to increase understanding of transition obligations and processes with frontline kaimahi and to promote earlier referral to a transition worker.
 Agency Compliance with Regulations 69 and 85 of the Oranga Tamariki (National Care Standards and Related Matters) Regulations (aroturuki.govt.nz)  Oranga Tamariki Practice Centre www.orangatamariki.govt.nz  www.orangatamariki.govt.nz  Oranga Tamariki response to our data request