This report provides an update to the Minister for Children and the New Zealand public on the extent to which the four agencies who have custody of children are compliant with regulations 69 and 85 (and, to the extent that it applies, regulation 86) of the National Care Standards (NCS) Regulations 2018 (NCS Regulations). The four agencies are Open Home Foundation, Barnardos, Dingwall Trust and Oranga Tamariki (the agencies).

This report covers the period from 1 July 2019 to 30 June 2020.

Regulation 69 outlines the duties of the Chief Executive when allegations of abuse or neglect are made about children and young people in custody and care. Regulation 85 requires information to be provided to the Independent Children’s Monitor (the Monitor) and regulation 86 requires that the agency must monitor its own compliance with the NCS Regulations (see Appendix One).

The Monitor has previously published two reports, which are available on the Monitor’s website [1]. This report provides an overview of 12 months of data, unless otherwise stated, from 1 July 2019 to 30 June 2020. As well as using data provided by the agencies, the Monitor visited three Oranga Tamariki sites and one Open Home Foundation service centre to talk with staff to gain insight and provide a frontline perspective.

This report completes Phase One of the Monitor’s initial monitoring programme, which has focused solely on regulations 69 and 85 (and, to the extent it applies, regulation 86). The Monitor will start monitoring all the NCS Regulations from 31 December 2020.



The role of the Monitor is to oversee the Oranga Tamariki system.[2] The Oranga Tamariki Act 1989 and NCS Regulations set out requirements that must be met for tamariki and rangatahi in care. They also require the chief executive of an agency with tamariki or rangatahi in its care or custody to monitor its own compliance with the NCS Regulations. Agencies must design self-monitoring systems that collect information to enable the Monitor to fulfil its monitoring role and make sure that those systems provide for continuous improvement, as well as address areas of practice that require improvement.

The Monitor’s role is to objectively assess compliance with the delivery of the NCS Regulations. The Monitor is therefore reliant on agencies having the necessary assurance systems and processes in place, as well as the ability to supply the Monitor with information that is necessary for it to carry out its functions.

[2] The term ‘Oranga Tamariki system’ is used to describe not only the early intervention, statutory care, protection, youth justice and transitions support systems as outlined in the Oranga Tamariki Act 1989, but also other agency services provided to children and young people under the Act (for example health, education and disability services, including by NGOs). It also includes services provided by Children’s Agencies to the core populations of interest to Oranga Tamariki as defined under the Children’s Act 2014, including children who have early risk factors for future involvement in the statutory care, protection and youth justice systems.

This report provides an overview of the 12-month period from 1 July 2019 to 30 June 2020.

It includes information gathered from visiting a number of frontline workers at three Oranga Tamariki sites and one Open Home Foundation service centre. As described in the two previous reports, the Monitor’s Outcomes Framework [3] is used to measure outcomes for tamariki and rangatahi in relation to the delivery of the NCS Regulations. Each of the regulations have been mapped to one of the six outcomes, with regulation 69 mapped to Aroha. The outcome of Aroha is defined as tamariki and rangatahi feel loved, supported, safe and cared for, and are capable of receiving kindness through love and giving love to others. How allegations of abuse of tamariki and rangatahi are handled is relevant to how they can feel loved, supported and safe.

In assessing compliance with regulation 69, the Monitor looks at an organisation’s policies and procedures, as well as agency data that outlines how well those policies and procedures are complied with. From a policy and procedure perspective, all four agencies are compliant with regulations 69, 85 and 86.

Barnardos and Dingwall Trust reported that they did not receive any allegations of risk of harm caused by abuse or neglect for the 12-month period. Therefore, testing compliance or making a visit to one of their sites was not required for this report.

Open Home Foundation reported that it received 12 allegations of abuse or neglect about te tamaiti in their custody. The investigations into these allegations were carried out by Oranga Tamariki, with Open Home Foundation providing support to the tamariki, rangatahi, whānau, and caregivers through the process. In nine of the 12 cases, abuse was not found. Two of the investigations were ongoing at the time of receiving this data and, in one case, abuse was substantiated. Open Home Foundation followed its own policy and procedures through the investigations and these actions were compliant with regulation 69. In visiting a community-based Open Home Foundation service centre, the Monitor’s staff noted the positive working relationship between its centre and the local Oranga Tamariki site.

Oranga Tamariki reported that it received 1,831 allegations of risk of harm caused by abuse or neglect regarding tamariki and rangatahi in its care or custody. In 612 cases, a decision was made at the National Contact Centre or at the local site that no further assessment was required. Accordingly, 1,219 cases needed further investigation.

Over the last year, Oranga Tamariki has continued to show a higher level of compliance when initially responding to an allegation of abuse or neglect. In 84 percent of cases the initial safety screen was completed on time, in 81 percent of cases a child’s plan was reviewed following the allegation and in 87 percent of cases recording was completed correctly.

Oranga Tamariki provided information to the Monitor about the 1,092 allegations with a finding that had been reviewed by the Safety of Children in Care Unit. Overall, Oranga Tamariki was partially compliant with regulation 69.

Data provided by Oranga Tamariki showed that recorded compliance was low when:

  • informing the child of the outcome of an investigation (28 percent compliance)
  • informing the parent/guardian of the outcome of an investigation (32 percent compliance)
  • completing investigations or assessments on time (41 percent compliance).

Oranga Tamariki reported on data relating to the number of tamariki and rangatahi where all relevant aspects of regulation of 69(2) (a-d) were met. As defined in its Overview of Care Standards Regulation 69 and 85 Practice Requirements, Monitoring Approach and Measures and Reporting Mechanisms (practice requirements) [4], it has 12 practice requirements relating to this regulation. It reported that only one percent of all cases had recorded that all 12 practice requirements met. In 39 percent of cases, fewer than six requirements were met.

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. For tamariki and rangatahi to achieve the outcome of Aroha, it is especially important for them to feel safe and cared for.

Although performance has remained largely unchanged across the year, Oranga Tamariki has made improvements to its assurance processes and reported a greater focus on compliance with regulation 69. For example, Oranga Tamariki has reported a range of activities to improve timeliness and created a new role to provide oversight across all reports of concern for children in care. In addition, three new assurance processes have been put in place and are referred to later in the report.

It was reported by staff at three Oranga Tamariki sites that positive local leadership has assisted in building capability of staff in relation to the processes associated with regulation 69. Some staff spoken with noted the need for further training and development to improve practice. The Monitor acknowledges that the number of staff it was able to engage with during the visits was small.

Through reporting and from monitoring visits, all agencies noted the positive relationships with local iwi, and the collaborative approach to building and growing these relationships.

In the Monitor’s previous reports, it was noted that there was a lack of visibility over the initial decision-making at the National Contact Centre or local site and, in particular, the cases where a No Further Action decision was made. Oranga Tamariki reported that changes have been made and that they began sampling decisions this year. They also advised that the National Contact Centre is reviewing processes to build increased visibility of these decisions.

From this sampling, Oranga Tamariki reviewed 69 reports of concern between 1 April 2020 to 30 June 2020 where a No Further Action decision was made. They reported that of these decisions, only 14 were classified as relating to incidents alleging possible abuse or neglect for children in care. The balance was identified by Oranga Tamariki as ‘reporting errors’ (20), ‘non-abuse events’ (33) or ‘relating to incidents that occurred prior to coming into care’ (2).

Having looked at the decision-making of the 14 cases, Oranga Tamariki determined that in nine cases the rationale for the No Further Action decision appeared inaccurate. This prompted further follow up with sites, to either ensure that records properly reflected the decision-making, or to ensure that an assessment or investigation occurred.

Due to the high number of cases where inaccuracy was apparent, the Monitor will continue to seek data and information on action Oranga Tamariki is undertaking to improve decision-making. This will be an area of ongoing focus for the Monitor’s future reports.


[3] The Monitor’s Outcomes Framework is available at:
[4] This document is available in Appendix B of the Monitor’s initial report (December 2019).

Each agency was required to provide to the Minister for Children a response to the Monitor’s second report, dated June 2020. The agencies responded positively to the report and have demonstrated a commitment to undertaking continuous improvement activities to embed policy and practice that comply with the NCS Regulations. The agencies’ individual responses are available in full on the Monitor’s website.[5]

Oranga Tamariki acknowledged that further work is required to embed policies and processes regarding regulation 69 into practice. This was reflected in what staff told the Monitor during the monitoring visits. Some of the current improvements underway were detailed in its response and built into its multi-year transformation journey to ensure compliance with all NCS Regulations.

The Monitor acknowledges that the retrospective nature of current monitoring means that the impact of the actions taken in response to the previous report will not be realised within the timeframe of this report. However, if these initiatives have been successful the Monitor would expect to see evidence of improved performance by the time it next reports on compliance in late 2021 for the period 1 July 2020 to 30 June 2021.




Background on the Role and Function of the Independent Children’s Monitor

The Monitor was established on 1 July 2019. It carries out its role by monitoring, assessing and providing assurance of the extent and quality of compliance under the Oranga Tamariki Act 1989 and the associated NCS Regulations.

As noted previously, the Monitor’s functions are being phased in over time and this report concludes Phase One, which focused on regulations 69 and 85 of the NCS Regulations. Phase Two, commencing from 31 December 2020, focuses on compliance with all aspects of the NCS Regulations. Phase Three is the intended longer-term expansion of the Monitor. This will broaden the scope of monitoring of compliance to the entire Oranga Tamariki system, at a date that is yet to be determined.

Building the Monitor’s Capability

Since September 2020, the Monitor has increased the size of its Operations Team ahead of starting Phase Two monitoring. The Monitor has three new operational teams based in Tāmaki Makaurau, Whanganui-a-Tara and Ōtautahi.[6] These new teams will help the Monitor to grow and develop relationships with local communities.

Development of the Monitoring Approach to Support the Outcomes Framework

To support the Outcomes Framework, the Monitor has developed its Monitoring Approach. This includes the monitoring programme, monitoring requirements, assessment plans, operational policies and processes, as well as tools and resources. Within the Monitoring Approach an Assessment Matrix[7] has been developed for the Monitor to use when visiting communities to verify the data provided to it by the four agencies with statutory responsibilities. 

The five dimensions of the Assessment Matrix are:

  1. People
  2. Culture and Leadership
  3. Tools and Resources
  4. Services and support work well for me
  5. Services and support work well together

Pilot Programme 

In preparation for Phase Two of the Monitor’s function, the Monitor has been working with agencies and communities to undertake a pilot programme to test aspects of the Monitoring Approach. The Monitor has had the privilege to engage with three communities who are connected to, and work within, the Oranga Tamariki system. The insights gained from this mahi[8] will allow the Monitor to adapt processes and systems that will assist it to work in a way that is mana enhancing for the communities it visits. It is expected that the evaluation of this pilot will be completed in December 2020 and this will feed into the overall monitoring approach in 2021.

Ethics Code

The Monitor has finalised its Ethics Code[9] (the Code), which describes how it will ethically and safely engage with tamariki, rangatahi, whānau and caregivers.

The Monitor recognises that tamariki and rangatahi are at the centre of the work it does and seeks to reflect their views, as well as those of their whānau and caregivers. The Code recognises the vulnerability for these participants in sharing their stories and provides guidance and standards that will be applied during the Monitor’s engagements. 

The Code was developed by the Monitor following consultation with key agencies including Oranga Tamariki, Ministry of Social Development, Office of the Children’s Commissioner and the expert services of Professor Tim Dare of the University of Auckland.

[6] Tāmaki Makaurau – Auckland, Whanganui-a-Tara – Wellington, and Ōtautahi – Christchurch.
[7] The Assessment Matrix can be found at
[8] Mahi – work  
[9] The Ethics Code can be found at

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