The following information was requested from Oranga Tamariki.

  • Provide a detailed flowchart or process map describing the assurance processes in place to meet the requirements of regulation 69 relating to decision-making at the National Contact Centre and sites
  • Provide any evidence of assurance that the systems and processes in place to identify any allegations of abuse or neglect are working as per your policy, in particular the assurance processes relating to whether all/any allegations have been identified and reported.

Please also provide:

  • any insights from analysis of data that have resulted in a change to practice and any action plans that have been put in place to improve performance
  • an update on the Performance Management Framework, including the development of the new reporting suite that allows sharing of performance information across the organisation, as detailed in Oranga Tamariki feedback to the Monitor (Second Reporting Cycle Supplementary Questions)
  • any information and data relating to site self-assessments relevant for regulation 69
  • information, results and reporting relating to the Quality Practice Tool, and site quality practice checks relevant to regulation 69.

No Further Action Decision-Making

In response to regulation 69(1), the June 2020 report highlighted a new process implemented by Oranga Tamariki for allegations of neglect or abuse. This process is related to tamariki or rangatahi in care where it is determined that no further investigation or assessment is required.

The Monitor wrote in the June 2020 report that Oranga Tamariki had begun sampling decisions where no further investigation was required. This was being done to assess the quality of decision-making. Of the 1,831 allegations received, in 612 cases a decision was made at the National Contact Centre or a local site that No Further Action was required. Putting the assurance process in place is a positive step as Oranga Tamariki need to have confidence that decision-making is robust.

Oranga Tamariki undertook a review of a sample of the 156 reports of concern for children in care from 1 April 2020 to 30 June 2020. The random sample size was 69 entries, relating to 51 distinct incidents. The nature of concerns and subsequent rationale for the No Further Action required response were classified as per the following graph.

Graph Six - Results of reviewed allegations of abuse or neglect that resulted in No Further Action Needed

Graph Six – Results of reviewed allegations of abuse or neglect that resulted in No Further Action needed. [1]

From its own data and analysis, Oranga Tamariki reported that 14 instances reflected allegations of abuse or neglect for children in care. After further analysis, five out of the 14 cases were reported by Oranga Tamariki to have been accurately determined as requiring No Further Action. Considering the number of cases where the decisions were inaccurate, the Monitor has asked Oranga Tamariki what steps it is taking to improve decision-making accuracy.

For the nine cases where the decision appeared inaccurate, Oranga Tamariki contacted local sites to follow up with these tamariki and rangatahi and their whānau.

Oranga Tamariki stated, ‘Our Business Implementation and Operational Support teams provide targeted support to NCC, Sites and Regions when trends and issues like this are identified. The monitoring of NFA decision making is being strengthened. There is no intention to expand the sampling at this stage.’

The Monitor recognises that Oranga Tamariki will continue regular assurance and assess how its quality control of reaching the decision of No Further Action is determined. Due to the high number of cases where Oranga Tamariki reported the decision appeared inaccurate, the Monitor will continue to seek data and information on what Oranga Tamariki is doing to improve decision-making. This will be an area of ongoing focus for the Monitor’s future reports.


In meeting with staff at the three sites, the Monitor was given insight into the assurance processes carried out at each stage of managing an allegation of abuse or neglect. The Monitor acknowledges that this is not a full representation of all staff working across Oranga Tamariki.

Staff were able to demonstrate that they had a working knowledge of the process that applies to regulation 69. At some sites that were visited, copies of flow charts, process maps and checklists, which have been developed to suit their site, were provided to the Monitor as evidence of their knowledge. 

During the Monitor’s visits, frontline staff identified that further training and clarification of roles and responsibilities when dealing with regulation 69 would be beneficial to their social work practice.  



  • Abuse of Children in Care (AOCIC) – entries that related to incidents alleging possible abuse or neglect whilst the child was subject to a custody status and therefore would require an assessment or investigation
  • Report of Concern (ROC) error – those where a report of concern was wrongly created
  • Non Abuse Event – those that did not require a Child and Family Assessment or Child Protection Protocol investigation with Police
  • Pre Care – concerns related to incidents that occurred prior to children being subject to a custody status and therefore not reportable under requirements of regulation 69. 

Performance Management Framework  

Oranga Tamariki reported that it is currently in the process of refreshing its framework to ensure decision-makers and social workers have access to the data and information. The framework is in the late stages of development, and the initial tools to support sites to drive performance are in the prototype phase at two of its 60 sites.

The framework tools will cover the key elements of the NCS Regulations and, in most cases, directly replicate key metrics that will be monitored. This will allow sites to manage their own data and make improvements as needed. The initial focus of these tools is to support sites to lift performance when working with tamariki and rangatahi in care. Oranga Tamariki expects framework tools to be widely available across the country in early 2021. 

This work aligns with regulation 86(1)(a).

Quality Practice

As well as using the site self-assessment tool, as required in regulation 86(1)(a) and (b), Oranga Tamariki reported that it initiated another continuous improvement process. The Quality Practice Tool. This covers the Oranga Tamariki Practice Standards [2], the NCS Regulations and one thematic area of interest each quarter. It also focuses on the quality of practice in order to support continuous improvement in case work. The tool is used monthly, with one month in three focused on the National Care Standards. It provides a structured mechanism for sites to track their progress by applying a set of questions quarterly [3] to a random sample of children in care by practice leaders and it uses a rating scale for each question from fully to not applicable.

The purpose of this tool is to provide feedback to staff, and monitor trends and themes identified in practice across a site, enabling additional practice improvement opportunities to be identified and addressed. At a national level, this information is used to support strategic and operational decision-making.

A further level of assurance has been undertaken by the PPG within Oranga Tamariki. The PPG undertook a random sample of 281 case files of tamariki in care or custody for longer than three months and reviewed whether there was a new allegation of abuse or neglect while still in State care. If the finding was yes, the PPG undertook a further investigation to confirm if a new report of concern had been entered.

In 36 out of 281 cases (13 percent), the PPG found information that indicated there were circumstances of potential harm that required further assessment in the previous 12 months.  

It was found that a new report of concern was not made for 15 of these cases where it would have been the appropriate response. When PPG-led case file reviewers identify a case in which it appears that an allegation has been made, but a report of concern has not, the case is escalated to the site for their follow up.


When visiting Oranga Tamariki sites, the Monitor noted that practice varies from site to site, which allows for sites to respond flexibly to local needs, relationships and initiatives. For example, one site initiated a change in process at that site that meant the practice leader no longer had oversight of individual allegations of abuse or neglect. Previously when they had oversight of a case, the practice leader was able to identify gaps in practice that would then lead to tailored training for staff at that site. In contrast, another site holds a cross-team case consult when an allegation of abuse or complaint is made. At these consults, the social worker takes the lead in addressing the allegation and the case is then further reviewed by the site leadership team to ensure any practice gaps are identified.


[2] Practice standards are the benchmarks for social work practice for Oranga Tamariki. For more information see the Oranga Tamariki website  
[3] A period of three months.

The Safety of Children in Care Unit

The ongoing work of the Safety of Children in Care Unit is a positive step forward for Oranga Tamariki as it looks to improve the outcomes for tamariki and rangatahi in State care. Oranga Tamariki reported that the Unit’s role is to ensure a greater understanding of harm and the circumstances in which it happens. It can identify emerging trends and patterns to inform continuous practice improvement across Oranga Tamariki. This enables Oranga Tamariki to focus on the areas of practice that are under-performing for tamariki and rangatahi in care, as well as their whānau and caregivers.

The establishment of this Unit and its continuing work is a tangible demonstration of the commitment Oranga Tamariki has made to continuous improvement.

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