This section is based primarily on the information, data and analysis provided by each of the four agencies, as requested by the Monitor (refer to Appendices Two and Three). There was a small number of site visits made by the Monitor to understand the experience of frontline staff. The information requested focused on updates and continuous improvement work undertaken since the last report. Individual agency responses have been summarised under each heading and, where relevant, this includes responses to observations made in the Monitor’s previous report.

Throughout the remainder of the report, the Monitor has included sub-sections entitled Experience. These are the stories and experiences of frontline staff the Monitor had the privilege to meet and kōrero [1] with.


[1] Kōrero – to tell, say, speak, read, talk, address

Open Home Foundation

Open Home Foundation reported 12 cases of abuse and neglect over the past 12 months. It noted that in all these cases it provided support to the tamariki, rangatahi, whānau and caregivers through the process. Of the 12 cases, nine resulted in no finding, one was substantiated and two were still ongoing at the end of this reporting period.

Open Home Foundation reported to the Monitor that its policies and procedures were followed during its response to allegations of harm for individual tamariki and rangatahi. It also reported that it has strengthened the requirement for care plans to be updated following the outcome of an investigation or assessment. From the information received from Open Home Foundation, the Monitor has found that it is compliant with regulation 69.

Barnardos and Dingwall Trust

Barnardos and Dingwall Trust did not have any allegations of abuse or neglect so are not included in this section.

The following information was requested from Oranga Tamariki.

The June 2020 report noted that focus and improvement was needed in timeliness of investigations and assessments, and in letting tamariki and rangatahi know about the outcome of an assessment or investigation.

Please outline what action has been taken to improve:

  • the timeliness of investigations and assessments  arried out after an allegation has been made,  including caregiver reviews
  • practice to ensure tamariki and rangatahi are  informed of the outcome of their allegation.


As per regulation 69(2)(a), once an allegation of abuse or neglect has been made, Oranga Tamariki has the responsibility of deciding what action must be taken to address the concern. Its internal policy sets timeframes in which these processes must be carried out by.

When an Oranga Tamariki site receives a report of an allegation of abuse or neglect, it carries out a Safety and Risk Screen, which is the initial safety response, within the timeframes defined in its operational policies. The purpose is to review the safety of a child at that point in time and determine what steps or actions are required.

Reported data shows a high level of compliance with the safety screen requirements, with  84 percent completed within the required timeframe over the 12 months. However, data provided by Oranga Tamariki shows the timeliness of investigations and assessments of allegations of abuse or neglect is not consistently being achieved.

Percentage of Child and Family Assessments or Investigations completed within the required timeframes

Graph One – Percentage of Child and Family Assessments or Investigations completed within the required timeframes.

Graph Two - Percentage of Child and Family Assessments or Investigations completed in time by relevant group

Graph Two – Percentage of Child and Family Assessments or Investigations completed in time by relevant group.

Oranga Tamariki stated that some of the complicating factors resulting in delays to the timeliness of investigations include:

  • administrative delays.
  • individual tamariki circumstances, nature of the day-to-day management of care arrangements for tamariki or mental health concerns for tamariki.
  • caregivers not wanting to meet with social workers or caregivers refusing to accept the findings of the draft report.
  • assessments that involve non-government organisation partners, which involve professionals jointly managing the relationship.
  • other more isolated examples of system issues, historical allegations or transfer of case between sites.

From the cases analysed, Oranga Tamariki reported that where the delay related to the tamariki circumstances, day-to-day care arrangements or mental health concerns, there were high levels of support offered or in place to manage care arrangements and provide stability.

To improve timeliness, Oranga Tamariki reported it has established continuous improvement activities to grow compliance with regulation 69(2)(a) of the NCS Regulations. Some of these have already been implemented while others are in the developmental stage.

  • Monthly practice discussions with the regional senior advisors’ groups.
  • Engagement with regional teams to promote practice.
  • Development and presentation of practice briefing materials for practice leaders.
  • Mentoring and coaching support.

Oranga Tamariki informed the Monitor that its assurance activities are ongoing. The existing reporting mechanisms will be used to actively monitor and manage timeliness at a regional level. This is being supported by national policy documents, process charts and practice guidelines.

Oranga Tamariki advised the Monitor that it has established a role dedicated to providing national oversight of all reports of concern for children in care. This involves receiving regional updates and analysis, reviewing the data and providing feedback to regions. This role will be strengthened to include national oversight and feedback to sites around timeliness of investigations and providing feedback to te tamaiti. There has also been a new position established (Principal Advisor Care Standards) and their primary role is supporting the implementation of the National Care Standards.


In meeting with frontline staff at three sites, the Monitor was told that there are many different reasons why delays may occur. While staff comments do not reflect the views of the entire organisation, they do provide a snapshot of the experiences at those sites. The following are some of the views expressed by staff as to why delays can occur: 

  • Some staff have high caseloads, which require significant amounts of time and management.
  • Social workers prioritise the needs of tamariki over paperwork.
  • Police investigations do not always align with process and timeframes set in Oranga Tamariki policy.
  • Caregivers accessing legal advice can extend timeframes. 
  • High turn-over of staff.

While visiting the three sites, the Monitor was told about the positive partnership when working with the New Zealand Police during investigations of abuse and neglect. The staff the Monitor spoke with stated that the collaboration and open relationships that happen at site offices with the Police are positive. 

One social worker noted that their case load is “just so big” and when urgent cases come in, they do not have time to sit down with te tamaiti to explain the outcome to them. This task gets pushed down the list of things to do. “I am never on top of my work, a good day is when I am less behind in my work than I usually am.”

Reporting Outcomes to Tamariki, Rangatahi and Associated Parties

In relation to regulation 69(2)(c), the previous report indicated the Monitor would seek further clarification on how concerns about reporting outcomes are being addressed.

Closing the circle and reporting back to tamariki, rangatahi and their whānau is an important part of the allegation of abuse or neglect processes. Regulation 69 requires that the tamariki and rangatahi at the centre of an allegation are informed of the outcome of the investigation. International research indicates that after a disclosure of abuse, a meaningful response includes “post disclosure, the young person/child should be updated by telling them the outcome and a failure to do so exacerbates feelings of helplessness. Fear of a lack of action is also stated as a main reason why children don’t disclose.” [2]

The data provided to the Monitor by Oranga Tamariki over the 12-month period showed 28 percent of tamariki and rangatahi received feedback of the outcome of the investigation.


From meeting staff at the three sites, the Monitor heard from frontline staff that it is always the intent to inform people of the outcome of the investigation; however, there is inconsistency in the ways to record the outcomes of an investigation.

Some Oranga Tamariki staff commented that a combination of high caseloads and turnover of staff means that social workers from other teams may be allocated tamariki and rangatahi for short periods of time. This results in relationships not being formed and sometimes case notes are not up to date, so social workers find it difficult to engage. 

Oranga Tamariki staff highlighted some of the issues that get in the way of telling tamariki and rangatahi about the outcomes, including administrative delays, a child’s wellbeing and safety, the potential impact on a child’s mental health and shared care arrangements.

One social worker said to the Monitor, “if I had more time to spend with a smaller number of rangatahi, I could provide support to a whānau or caregiver under stress, so we don’t end up with a report of concern.”

Information is Recorded and Reported in a Consistent Manner

Regulation 69(2)(b) requires agencies to ensure that information is recorded and reported in a consistent manner. Oranga Tamariki provided the Monitor with data that has been gathered and analysed by the Safety of Children in Care Unit. This focused on the number of findings that were reviewed as ‘inaccurate’ and the number of findings recorded as ‘information missing’. ‘Inaccurate’, in this case, has been defined as either abuse not recognised or a non-abuse event wrongly assessed as abuse, or wrong abuse type defined. ‘Information missing’ included missing dates, and alleged abuser information and placement type wrongly captured or absent.

Data shows compliance is 87 percent for findings being entered correctly. However, in 54 percent of cases, records had information missing.

Update of Care Plans Following an Investigation

Oranga Tamariki reported that updating the care plan of tamariki and rangatahi following an investigation is an area of high performance and an area it has continued to improve on during the year.

Data provided shows Oranga Tamariki is 81 percent compliant with updating the care plan for te tamaiti following the outcome of a Child and Family Assessment or Investigation.

Graph Three - Percentage of care plans updated for te tamaiti following the outcome of a Child and Family Assessment or Investigation

Graph Three - Percentage of care plans updated for te tamati following the outcome of a Child and Family Assessment or Investigation. 


Some staff from the three sites told the Monitor they felt pressure and tension between visiting tamariki and rangatahi and completing paperwork on time. What was apparent across all sites is that the social workers we spoke to were passionate about the needs of the tamariki coming first.

Appropriate Steps are Taken

The following data showing compliance with individual requirements was provided by Oranga Tamariki.

Graph Four - Percentage of incidents that complied with each appropriate step

Graph Four – Percentage of incidents that complied with each appropriate step.

Oranga Tamariki Performance Requirements as per its Definition

Oranga Tamariki analysed its data to identify the percentage of cases where all aspects of the practice defined in its Overview of Care Standards Regulation 69 and 85 Practice Requirements, Monitoring Approach and Measures and Reporting Mechanisms (practice requirements) were met in response to allegations of harm for individual tamariki and rangatahi [3].

 Graph Four - Percentage of incidents that complied with each appropriate step

* Please note percentages do not add to 100 percent due to rounding.

Graph Five – Percentage of allegations of abuse or neglect that had a finding that complied with all aspects of regulation 69.

As noted in graph above:

  • all 12 practice requirements were recorded as being met for approximately one percent of tamariki and rangatahi
  • 59 percent of allegations were recorded as having six or more of the practice requirements met
  • 40 percent of allegations were recorded as having fewer than six of the practice requirements met.

From its own 12 practice requirements, Oranga Tamariki identified three areas of practice that it sees as potentially being of greatest importance for tamariki. These are:

  • to review a child’s plan
  • to ensure that support mechanisms are in place to address the impacts of harm
  • to confirm the communication of outcomes to tamariki

It reported that its compliance has improved from 19 percent compliant in the period 1 July 2019 to 30 September 2019, against these three measures, to 29 percent in the period 1 April 2020 to 30 June 2020. While there has been some improvement in the measure, records show that 71 percent of tamariki and rangatahi did not have these three most important practice requirements met.


[2] Palmer, Sally E; Brown, Ralph A; Rae-Grant, Naomi I; Loughlin, M Joanne. Child Welfare; Arlington  Responding to children's disclosure of familial abuse: What survivors tell us, Vol. 78, Iss. 2, (Mar/Apr 1999): 259-82

[3] Oranga Tamariki defines regulation 69 as emotional, physical and sexual abuse and neglect. Risk of harm caused by abuse or neglect when applied within regulation 69 is limited to abuse or neglect that is caused whilst in care or custody and therefore will not apply to the harmful impact of previous trauma arising from abuse or neglect prior to entry to care. For full definitions please refer to the Monitor’s initial report pages 69-74

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