Who is looking out for the Territory’s
Children?
REVIEW of the
EMERGENCY RESPONSE STRATEGY for
CHILDREN in CRISIS in the ACT
ANITA PHILLIPS
ACT PUBLIC ADVOCATE
MAY 2012
120635 Review of the ERS of Children in crisis in the ACT_TitlePg.pdf 1
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Who is looking out for the Territory’s children? Authors Anita Phillips Public Advocate of the ACT Donnita Medway Project Team Leader Wilhelmena Corby Research Officer Suzanne McGhie Research Officer ©Canberra, Australian Capital Territory, May 2012 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from the Territory Records Office, Community and Infrastructure Services, Territory and Municipal Services, ACT Government. GPO Box 158, Canberra City, ACT 2601 Any enquires regarding this publication should be directed to the: Public Advocate of the ACT, PO Box 1001, Civic Square, ACT, 2608 Telephone: (02) 6207 0707 Fax: (02) 6207 0688 TTY: (02) 6207 0130 Web: [email protected] Email: [email protected] Who is looking out for the Territory’s children? Mr Shane Rattenbury, MLA Speaker Legislative Assembly Canberra ACT 2601 Dear Mr Rattenbury I present to you the final report of the Review of the emergency response strategy for children in crisis in the ACT, requested by the Minister for Community Services, Ms Joy Burch. This Review was conducted by the Public Advocate of the ACT under Terms of Reference (TORs) that focused on the circumstances surrounding certain matters pertaining to Out of Home Care placements following emergency responses and other action taken on behalf of children and young people for whom the Territory has parental responsibility. The first three matters in the TORs were addressed in the Interim Report presented to the Assembly in October 2011. This Review briefly summarises that Interim Report and addresses the fourth matter set out in the Review’s Terms of Reference – A Review of the authorities and arrangements of children and young people currently in Out of Home Care for whom the Director‐General has parental responsibility. Yours sincerely Anita Phillips ACT Public Advocate 31 May 2012 Who is looking out for the Territory’s children? This page has been left blank 4 Who is looking out for the Territory’s children? Contents Acknowledgments 6
Executive Summary 7
Recommendations 9
Chapter 1 Background to Review 11 Chapter 2 Major Findings 17 Chapter 3 Intake 19 Chapter 4 Risk Assessments 23 Chapter 5 Decision Making 27 Chapter 6 Case Practice 31 Chapter 7 Child Centred Approach 37 Chapter 8 Kinship Placements 43 Chapter 9 Cultural Awareness 49 Chapter 10 Contact 55 Chapter 11 Record Keeping 59 Chapter 12 Readings 63 5 Who is looking out for the Territory’s children? Acknowledgments I wish to acknowledge the significant contribution of Wilhelmena Corby and Suzanne McGhie, who undertook the research of over one hundred files to provide the data that has informed this Review. Their work was supervised by Donnita Medway, who, as Project Manager, both guided the research and personally investigated complex cases. Elizabeth O’Dea provided the administrative support and produced the report for printing. This team worked tirelessly on the project, under Donnita’s professional and thorough leadership. I would also like to recognise the co‐operation of the Community Services Directorate (CSD) particularly the former Director General Martin Hehir and the acting Director General Natalie Howson who have assisted with the research project by permitting access to the CSD records and providing a separate physical space for the team to work in. I also appreciate that the Director General made available Roslyn Hayes, Principal Adviser, Rhonda Ustick, Demand Management Coordinator and Rachael Cormack, Senior Policy Officer to assist the review team. Their efforts in making the records available and support for the review team to access the electronic records ensured that the review progressed without any delays or major interruptions. I appreciate that being confronted with some of the findings in this process, may have caused some difficulties for them. Their professionalism is acknowledged and recognised. 6 Who is looking out for the Territory’s children? Executive Summary It is disappointing to have to report that this Review of the authorities and arrangements for children coming into the Care and Protection Service (C&PS) over the past three years, has revealed that the systemic problems identified in the Interim Report were not an aberration. Of necessity, the Interim Report was an urgent investigation of a crisis situation, and included recommendations for immediate action – such as the establishment of a reception centre, additional foster placements and mediation for the agency providing out of home care to the nine children subject of the enquiry. The good news is that since stage one of this Review was released in October 2011, the above and some further recommendations have been implemented by the Community Services Directorate (CSD), resulting in significant positive changes within C&PS However the Interim Report exposed other problems, such as those within the structure and systems that have resulted in a reactive culture. This has possibly developed over time as a defensive response to on‐going criticisms of C&PS practice, even since 2004 when Cheryl Vardon produced her Report – “The Territory’s Children”, ensuring safety and quality of care for children/young people. There were indications in the investigations for the Interim Report that these broader problems might be endemic within C&PS. Accordingly the methodology for Stage two of the Review, was developed to randomly select one hundred cases of children/young people, who have come into out of home care by way of an emergency response, and to examine these to see if the authorities and arrangements adopted were appropriate. It was anticipated that this approach would discover whether the failings outlined above were limited to the crisis period in May – July 2011, or were more wide spread and deep seated within the Care and Protection Service. Our investigation revealed some evidence of good practice, albeit inconsistent. Some of these positive findings were: 
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There were no further instances found where children had been placed with Northern Bridging Support Services nor with any agency not a “suitable entity”; Of the files reviewed there is no evidence that any child/young person is “lost” in out of home care. The current placement for each child/young person was able to be identified, with the exception of some “self selected” adolescents’ placements; Every child/young person had a file and a Children and Young Person’s Service (CHYPS) record; The Foster Care Agency files focussed on the child and provided a real picture of what was happening for the child; There was evidence of contact between the child and their parents/family; 7 Who is looking out for the Territory’s children? 
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The Child Protection Case Conference process is working well with evidence of case planning; The pre‐natal support process was also working, but not always carried through in the case planning of responses after birth; There were examples of very good casework, but this was not consistent throughout the individual file, and not apparent in every file. However, as is detailed in the chapters that follow, we found that practice did not reflect current policy and systemic deficiencies did not support good practice. Despite the best efforts and hard work of front line staff within the Care and Protection Service, they were battling against systems that failed to support them, lack of case supervision, all of which inevitably resulted in a reactive and defensive environment and workplace, and translated into examples such as: 
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Lack of a structured Child Protection Framework and inadequate practice guidelines. The consequences of the absence of these policy and practice guidelines were particularly demonstrated in Intake, Risk Assessment, Decision Making, Case planning and placement decisions; A pervasive reactive culture. The current environment tends to mirror the chaotic and complex nature of the clientele. A strategic, planned approach should result in a more measured and considered response to events; In general little or no feedback and support was provided for caseworkers from their supervisors and managers. Regular supervision and case management should be focussed on the development of skills, planning and review of casework; No evidence of a strategic overview. There was little evidence of direction or leadership and an apparent lack of appreciation by management, of the unique pressures of the specialised field of care and protection. This resulted in the systems one would expect in place to support a statutory child protection body, being inadequate (for example, a cumbersome electronic data base instead of a case management program), a lack of priority given to training and development of staff, failure to adapt resources to meet new priorities, and little emphasis on ensuring that the current policies are reflected in practice. These problems are exacerbated by broader systemic deficiencies within the Care and Protection Service. Emergency response practice should not operate in isolation from other services. Examples of issues that were identified as being part of the wider context are: 
The lack of evidence of early intervention and support as a response before Emergency Action is taken. Even when a history and other information about children and their families was available, proactive planning to identify and mitigate risks was not consistently applied; 8 Who is looking out for the Territory’s children? 
The content of affidavits and court reports is often not supported in the records by adequate forensic investigation and assessment based on interviews conducted. This has resulted in a lack of corroborating evidence to justify the emergency response;  The prevailing reactive environment, despite the legislation, does not prioritise a child centred approach. The records rarely include information such as an assessment of the child’s needs, or reflect an appreciation of the importance of speaking directly to the child;  The significance of a child’s cultural background was rarely referred to in assessments;  Planning for contact visits was according to a time table rather than being motivated by the goal of a positive experience for the child/young person;  The lack of a case management system and poor record keeping were evident throughout the files examined. To address these problems will require a concerted commitment to change. Any new direction and vision needs to be lead by senior management. A vital aspect of the support needed by caseworkers undertaking an extremely difficult role on behalf of the community, is a systemic commitment to case management and supervision. Improving responses to the needs of vulnerable children depends on a whole of directorate, in fact a whole of government approach. For change to be successful there needs to be a strategic and integrated response to organisational systems and administrative structures. CSD needs to demonstrate a commitment to this change at all levels of management, and to a shared responsibility to deliver improved services thereby taking some of this pressure off front line staff. Our recommendations are for changes, not just to the emergency response area, but across all of the Care and Protection Service and the wider Community Services Directorate. Recommendations 1. Develop a Strategic Framework for implementation over the next three years. This should encapsulate evidence based practice, case supervision and mentoring mechanisms, case management, planning and review, risk management and assessment processes, and forensic investigation, that will result in an environment of good practice. 2. Implement this Strategic Framework through a change management process that will address the current reactive culture. This should include the use of employee focus groups so that all staff have a common understanding of the desired culture that reflects the actions of a statutory child protection organisation. Such a change management strategy should include a review of the current systems and processes. 9 Who is looking out for the Territory’s children? 3. Review the current staff training and development regime, and ensure that this meshes with the strategic framework and is tailored towards the acquisition and development of skills, particularly for caseworkers and their supervisors. Training should be linked to competencies, and be included in the process for advancement to higher duties. 4. Development and formalisation of on‐going review mechanisms. There is a clear need for an internal monitoring and performance review process, dealing with complaints and ensuring that “duty of care’’ and natural justice are adhered to. In addition, an external oversight function, such as an Office of Children’s Guardian should be considered. In the interim the Public Advocate should be engaged to carry out a micro review, based on the method of this Review, at 3, 6, 9 and 12 months to monitor practice improvements or otherwise, and to report these findings directly to the Director‐General. 5. Review all Kinship care placements and the current processes. There is a need to improve initial assessments, include the needs of the children/young people to ensure their “voice” is heard, develop comprehensive case planning that includes the level of support required where there is evidence that the family needs the ongoing involvement of a statutory body, and create a review process to determine those Kinship families that no longer require ongoing support. 6. Cultural Awareness. The culture of all children/young people must be identified and appropriately supported, and the best use of available resources should be made to support Aboriginal and Torres Strait Islander children/young people. In addition the development of a program to support the cultural safety of children/young people from other cultures, particularly recently arrived refugees is strongly supported. All staff commencing in C&PS should receive training in cultural awareness. 7. Improve record keeping. C&PS needs to determine whether the primary record keeping function will be a paper file or an electronic system as currently neither function is efficient or effective. The decision needs to be supported by policy and include a mechanism for the child/young person to be able to access their record should they make such a request. Staff need to be trained in evidence based case recording where the decisions and the reasons for decisions are diligently recorded, and include the signature of the decision maker or delegated officer. In addition, CHYPS, the current electronic system, needs updating. Case management programs from other jurisdictions may assist to guide the purchase of this enhancement. 10 Who is looking out for the Territory’s children? 1. Background to Review The Minister for Community Services, Ms Joy Burch MLA, wrote to the then Director General, Community Services Directorate and instructed him to arrange for an immediate independent review of the circumstances regarding a specific placement of children/young people with a non‐government agency. The Director General wrote to the Public Advocate of the ACT on 14 September 2011 requesting she conduct a review into the following: 1. The emergency residential placement of children with Northern Bridging Support Services 2. The engagement and subsequent suspension of Northern Bridging Support Services 3. Compliance with the Children and Young People Act 2008, in relation to these matters 4. A review of the authorities and arrangements of children/young people in Out of Home Care for whom the Director General has parental responsibility On 22 September 2011, the Public Advocate responded to the Director General expanding on the Terms of Reference and setting out a time line to undertake the first three Terms of Reference, which would constitute an “Interim Report”. 1. The emergency residential placement of children with Northern Bridging Support Services. To review decision making processes, and to consider action taken to obtain suitable placements on each occasion that such placements have occurred, particularly including the circumstances surrounding the placement at the Barton Highway property in June 2011, and with special attention to what was in the best interests of each of the children involved. 2. The engagement and subsequent suspension of Northern Bridging Support Services. To review the terms of engagement, supervision and training provided, financial arrangements, staff checks, policy with regard to shadowing arrangements, appropriateness of accommodation, circumstances surrounding the ending of the arrangement, and the relationship and interaction between NBSS and Barnardos and the Community Services Directorate. 3. Compliance with the Children and Young People Act 2008, in relation to these matters. To review compliance in authorising NBSS to provide residential care, in placing children in care of NBSS, with reference to requirements regarding “suitable entity” status, minimising risk to children, and the compliance with financial and administrative arrangements related to these decisions. This work was undertaken by conducting interviews, research and other investigations with respect to these matters over a 2‐3 week period culminating in the Interim Report to the Legislative Assembly on 7 October 2011. 11 Who is looking out for the Territory’s children? The five Recommendations from the Interim Report were: 1. Urgently Review the Operations and Management Structure of the Emergency Response for Children in Crisis in the ACT. Interim Report The Public Advocate of the ACT should be engaged and resourced Recommendation to immediately undertake stage two of this Review. 2. Improve Emergency Response Processes Interim Report  The Director General Community Services Directorate, be called Recommendation upon to immediately establish a reception centre/facility as part of the Emergency response for children in crisis. The Director General Community Services Directorate, authorises that an Operations Policy and Procedures Manual for caseworkers and direct care staff be finalised and implemented as a priority. Recommendation  An inclusive review of the framework, provision and tendering for possible future process and the current practices in the non‐government sector in action relation to the current standards for Out of Home Care.  Investigate the number and type of reception and other Out of Home Care facilities, and other options for “places of care” for children who don’t fit into foster care, such as “residential” and other family group home placements so that inappropriate properties are never used in future. 3. Monitoring and Provision of Placements Interim Report The position of Children’s Guardian be resourced and formalised Recommendation under the auspice of the Public Advocate of the ACT. Recommendations  All support workers should be subject to stringent checks, including for possible future “working with Children”, as well as be trained and supervised, action irrespective of the direct services they are providing to children – transport, supervision, direct care etc. Whether all support workers should only be employed by “suitable entities”, or not, and whether the C&PS could develop a “pool” of support workers should also be investigated. This would be a small pool of Professional Crisis Foster Carers. These carers should be linked with the Response and Intervention Team, trained to understand the needs of children who have been abused and in crisis and equipped to respond immediately to any situation in terms of children presenting in crisis. 4. Early Intervention Interim Report Response and Intervention Teams should be relocated out to the Recommendation regions. 12 Who is looking out for the Territory’s children? Recommendation  Establishment of a Family Support program to perform outreach for possible future work with individual families as part of the regional RIT network. action The family should be viewed as the best option unless through the risk assessment process family strengths are diminished by weaknesses that leave the children/young people at high risk.  The development of the case worker’s role. The aim of this would be to support them to be more closely involved in decision making, including providing them with the supports, clinical and casework supervision, tools and a review of the financial delegations that would assist them to do this. 5. In addition there are separate recommendations specifically in relation to Northern Bridging Support Services. Interim Report An independent mediator be engaged to conduct mediation Recommendation between NBSS and C&PS. In addition, immediate payment of outstanding monies must be arranged. Recommendation  Detailed investigation of the issues surrounding allegations and for possible future serious concerns that lead to the suspension of the NBSS from action providing services.  Investigation around service provision including the practice of negotiating individual placements without having available transparent costings for the type of service requested. In response to the Interim Report the Minister for Community Services then made a request of the Public Advocate of the ACT to continue with the Review by undertaking the fourth Term of Reference: A Review of the authorities and arrangements of children/young people currently in Out of Home Care for whom the Director‐General has parental responsibility. Again, the Public Advocate expanded on the Term of Reference: To review the processes and decision making in relation to children/young people placed in Out of Home Care, considering placement policies; principles and practices; the tender process; determination of funding; the framework and standards for Out of Home Care and at least a preliminary statement as to how early intervention and family support can reduce the number of children requiring placement; and how the provision of such Out of Home Care can be improved. As the definition of Out of Home Care from the legislation is that provided by a “suitable entity”, the Review also investigated if any children were with entities not approved as “suitable”. At the same time the ACT Government brought forward a scheduled audit by the Auditor General which was intended to be much broader and would include a number of the arrangements outlined above leaving the Public Advocate to focus primarily on the response and decision making process for children/young people entering out of home care. 13 Who is looking out for the Territory’s children? The Public Advocate of the ACT proposal for the second stage of the Review Methodology: Stage two of the review would use a similar methodology to that of the first stage as documented in the Interim Report, whereby the Public Advocate of the ACT (PA ACT) examined the circumstances surrounding the emergency response that led to children/young people entering out of home care, and the authorities used and arrangements made with regard to their placement. For this second stage, the PA ACT would review a random selection of cases pertaining to children/young people in this same category. The PA ACT will:  Randomly select children/young people who have been placed in out of home care as a result of statutory intervention by way of an emergency response, and for whom the Director General now has parental responsibility.  Conduct a review and analysis of the decision making and authority processes of the casework files and electronic records of those children/young people randomly selected.  Examine the files and any other records of the agencies with whom the child/young person is placed against a list of criteria from the policy and guidelines.  Prepare a report for the ACT Legislative Assembly that includes findings and recommendations. Purpose: To identify practices that will help ensure the Emergency Response procedures are child‐centred, that enable practitioners to make the best decisions, where they feel supported and facilitated by the policies, systems and processes which enhance their ability to work directly with and for the children/young people for whom the Director General has parental responsibility. Time Line: It was anticipated that this second Stage of the Review would take 3 months. This however depended on resources (and other factors) and may need to be extended. The proposed methodology was further refined after the Community Services Directorate clarified that over the period 2009 to 2011 in excess of 300 children/young people had come into the out of home care system by way of Emergency Response. The PA ACT proposed the following:  A random selection of 100 children/young people who were placed in the out of home care system following statutory intervention by way of an emergency response and/or had experienced an unplanned change to an out of home care placement.  That the eldest child only of any sibling group would be the subject of the review.  That the ages of the children/young people would reflect the target group of care and protection, i.e. 0‐18years. 14 Who is looking out for the Territory’s children? The Community Services Directorate (CSD) accepted the proposed terms for the second stage of the Review and nominated a team of three to assist the PA ACT to access the files and electronic records. The commencement of the review was delayed due to the necessity to find space off site to accommodate the Team. The review commenced late January 2012. During the initial two days of the Review the CSD conducted orientation seminars to brief the Team on the roles and functions of the ACT Care and Protection Service. The ongoing task of the Team was to analyse cases against a list of practice processes developed from existing policies. Principles that underpinned the Review: 
Every child/young person in out of home care in the Territory has the right to expect their circumstances and wellbeing will be improved; 
When the Director General has parental responsibility for a child/young person the Director General is accountable to the child/young person; the ACT Government by way of the Legislative Assembly, the community, and the Public Advocate of the ACT;  When the Director General has parental responsibility, the Director General is required to know the identity and placement of each child/young person in out of home care, and to maintain accurate records about the individual child’s or young person’s history, life circumstances and wellbeing; 
The Director General is required in decision making to be open and transparent, as is appropriate, with the child/young person, their birth parents, extended family members, carers, caseworkers and community members to ensure that the “best interests” of each child/young person is paramount. 15 Who is looking out for the Territory’s children? This page has been left blank 16 Who is looking out for the Territory’s children? 2.
Major Findings 2.1 Introduction In 2004, the Vardon Report was produced, based on a comprehensive audit and case review process. The government responded through the budget process by providing additional resources and community support mechanisms to assist C&PS to undertake their statutory role. Whilst a number of the recommendations in that report, such as the activities to amend the Children and Young People Act, the separation of Care and Protection Service from the Department of Education, and elements of areas that impinge upon practice quality have been addressed, this Review unfortunately found that elements of the Vardon Report remain relevant today. The most significant of these are the delivery of child protection services such as ‐ the availability of resources; management styles; collaborative casework with other agencies; a continuous risk assessment process; a case management/case planning framework and inadequate record keeping ‐ all of which have an impact on decision making and the outcomes for children/young people. 2.2 Findings of Review Since the Vardon Report, the Care and Protection Service in the ACT has referenced low staff numbers and the difficulty to recruit and retain caseworkers as affecting the performance and duty of care provided. This situation is not unique to the Territory. Working in the statutory field of care and protection is tough, stressful and demanding. Care and Protection workers are continually confronted with extraordinary situations; are exposed to traumatic events, and required to make extremely difficult decisions in order to ensure the safety of a child/young person. Working for a statutory organisation means that staff are constantly required to make administrative decisions based upon the requirements of the legislation. Fluctuating levels of casework staff, supplemented by recruitment drives from overseas has resulted in a high percentage of staff with little immediate knowledge of the ACT community, and high turnover, coupled with a deficient case management and supervision strategy, all impact on the quality of the practice delivered. 2.3 Discussion Child Protection is possibly the most scrutinised and demanding of work environments. There is always a tension for practitioners between “strengths based, support focussed aspirations and the harsh, problem saturated, forensic reality ... of the ultimate responsibility for child safety.” (The Signs of Safety, WA Child Protection Practice Framework) Accordingly, caseworkers in Care and Protection Service need specialised training and support. They need regular feedback and debriefing sessions. They need support from experienced and knowledgeable case supervisors. They need to work in a total environment 17 Who is looking out for the Territory’s children? of commitment to improving outcomes for vulnerable children in our community, whilst working with the community. 2.4 Summary Unless C&PS can introduce and maintain consistent and effective systems to support the caseworkers, which includes regular and systemic case management, then caseworkers will be unable to perform at an optimal level. There is a risk that they could feel that the pressure is unrelenting; that their caseloads are too high; that they cannot act in accordance with their professional judgement. They may feel conflicted in situations where they have assessed that certain outcomes need to occur to support a child or the family but not have the confidence that their decision will be supported. Inevitably, despite their commitment for the critical work in this field, they will move on to a work environment that is not so challenging. Without significant reform of the systemic structure, staff within C&PS will perpetuate the current reactive culture and the work undertaken will mirror the chaotic and complex nature of the families who come into contact with the statutory system. The next chapters of this report analyse the specific areas of concern identified during the review of cases of emergency responses to children in crisis. 18 Who is looking out for the Territory’s children? 3.
3.1 Intake Introduction ‘Intake’ is the gateway to the C&PS system and provides a central point of access for referral and information. This is the first point of contact for a member of the community or a mandatory reporter seeking to make a report or discuss a concern about a child/young person. It is commendable that C&PS recognises the importance of screening concerns about children/young people so that they do not enter the statutory child protection system unnecessarily. C&PS has a clear pathway for dealing with information received from the community or mandatory reporters. A “Child Concern Report” is made, a “Child Protection Report” follows, then an “Appraisal” if there is still cause for concern. This is similar to other jurisdictions, and provides clarity for those receiving the information and is intended to guide decision making. To determine the context of the emergency response taken later in the process, it was necessary to examine the information gathered from this first point of contact with C&PS. 3.2 Findings of the Review 41 of the sample of 100 cases did not include information about family strengths and protective factors that might reduce risk 25 of the sample did not incorporate information about patterns of abuse or neglect 40 cases did not identify any formal and informal supports available to the family and the family’s willingness to access and accept supports The quality of the information in the Child Concern Reports/Child Protection Reports (CCCP) was varied. There were inconsistencies evident in the way the specifically designed formats and tools were utilised to gather the information, for example information was often incomplete and different names for the same person were recorded within the same document. In some cases information was entered under the wrong sub heading. There was a lack of consistency in the way the information gathered was used to inform the decision making. In some instances the decision or intended outcome only became apparent if the Team Leader provided an explanation at the end of the process. Many of the CCCP Reports contained large amounts of existing information already available on the electronic system. The format required a “summary” of the Child Report history. Using a “copy and paste” action C&PS copied a full chronological history of previous CCCP 19 Who is looking out for the Territory’s children? reports. Whilst this may have been appropriate, it did not necessarily alert the C&PS staff member to the most current information. In only 42 of the sample cases was an analysis of the key issues undertaken to alert the decision maker of new information within the CCCP report. A summary statement of the key issues may have been more useful. For example, such commentary as: “there have been over ten CCCP reports for this child from six different mandatory reporters with concerns about the child’s physical care, exposure to domestic violence, risk of physical abuse and neglect. There have been numerous referrals and supports provided to the parent in response to at least four of the previous CCCP Reports and there is currently casework support being offered by program A and program B.” This type of summary is much more useful as it clearly highlights the apparent safety issues. The Intake analysis section was often not completed or if it was completed it was merely a “copy and paste” of information already entered previously in the initial section of the report. This particular section of the form is the prompt for C&PS to bring all the known information to a summary and make a statement about what it all means in terms of the child’s needs now and flagging the options for C&PS at this stage of Intake. Although the C&PS worker is prompted by the electronic database at this stage “to continue risk assessment” there was little evidence that this was done. If it is believed that safety issues existed then the information collected moves onto a “Child Protection Report”. There is little clarity about the separation of these two documents. Once into the Child Protection Report in most cases the risk assessment undertaken was very limited and the analysis required did not always dissect, critique or examine the available information so as to reach an informed decision about whether a child/young person was at risk in the care of their parent/s. There was limited consistency in the section of approval and sign off. In 68 of the sample the caseworker had signed and dated the report and there was 64 situations where there was evidence of approval and sign off by the Team Leader. At times the sign off was an electronic signature at other times there was no signature or date recorded. The last page of the format is the facsimile form designed to inform mandated reporters of the intended outcome of a report. In 49 instances of the sample reviewed the CHYPS record of this page indicated that it was not completed and if it was there was nothing to suggest that it had been forwarded to the mandated reporter. 20 Who is looking out for the Territory’s children? 3.3 Discussion The Intake process is a key element of any Child Protection Practice Framework and requires consistent, clear, and accurate recording to track the process and to ensure that pertinent and relevant information is gathered and fully considered at each stage of the decision making. The information gleaned at Intake is likely to be the most current information available and provide the basis for ongoing quality assessment and case management. It is at this point that the information gathered can determine whether the matter needs to progress to a statutory response or other options for referral are apparent. In the absence of any contemporaneous notes it is difficult to corroborate any of the information recorded by way of the Intake process for the sample reviewed. The variable information recorded on the CCCP suggests that insufficient focus is placed on the initial discussions with the reporter, the process for gathering information and the write up of the CCCP Report. If a section is left blank then there should be an explanation as to why this is the case. The CCCP should provide a comprehensive picture about why and how decisions were made and provide a clearer direction about what needs to occur next. The current process may require more distinct signposts and a more detailed explanation as to why a particular pathway is taken or why it is important to gather this particular piece of information as well as what use it will be. For example, the triggers to recommend a referral, an “Initial Safety Visit”, a request to the police to check on the safety of a child and/or a referral for further appraisal. While there is nothing to prevent the caseworker from entering these details, the form itself does not prompt and guide the caseworker to extrapolate the key information that will guide what needs to happen next. 3.4 Summary The challenge for C&PS is to ensure that all staff engaged at the first point of contact for a community member or a mandatory reporter are very experienced in care and protection work, particularly risk assessment, and that they have access to tools that promote consistency and good decision making. The variety in the quality of the information found in the sample reviewed, highlights that C&PS needs to review the method and content of the current training system so as to better support the staff engaged in the ‘Intake process’. 21 Who is looking out for the Territory’s children? This page has been left blank 22 Who is looking out for the Territory’s children? 4.
Risk Assessment 4.1 Introduction Risk assessment should be a continuous process starting from the point where there is a requirement to determine if the care provided by the family of a child/young person is adequate and safe. Each decision must be based on an assessment of risk. Risk assessment is not a one‐off process but should occur at the time of each contact and afterwards. Risk assessment is paramount to child protection practice. It is on this basis that decisions are made such as recommendations for early intervention or in serious cases for a response such as temporally removing the child/young person. The first section in the “Child Protection Report” is titled “Risk Assessment”. This reflects the continuum of risk assessment. Staff are required to document the risk factors, protective factors and any mitigating factors in the child/young person’s current environment including any specific family issues. This section includes four headings: consequences, probability, protective factors and caseworker analysis. Presumably the intention of these heading’s is to prompt and guide the assessment of risk. 4.2 Findings of the Review 65 of the sample only contained information pertaining to the consequences of the risk and harm recorded 64 of the sample commented on the probability of the harm recurring or continuing 64 cases addressed the issue of any protective factors that existed within or externally to the family In the one hundred cases reviewed the quality of the risk assessment section, if completed at all, varied greatly. It was often difficult to determine on what basis decisions had been made that led to the statutory intervention. In none of the cases was there evidence of a measured response to an on‐going risk assessment. In every case the children/young people came into care via an Emergency Action where the child/young person is deemed to be in immediate need of care and protection. 
It was not always apparent from the information on either the physical file or CHYPS what the actual trigger had been that prompted the emergency response; 
There were only 6 cases where C&PS had not been engaged with or held information on the family. In other cases C&PS had known the family, often for extended periods prior to the emergency response; and; 23 Who is looking out for the Territory’s children? 
Evidence supports that there was an average of 10 previous child concern and/or child protection reports per child/young person. Whilst it is true to say that the review team did not look at every report, and that a number of the reports may have contained similar information, this could be indicative of a systems issue related to ongoing risk assessment and analysis of the available and new information. Prior to any intervention by way of an emergency response, The Children and Young People Act 2008 (the Act) provides a guide to decision makers at sections 403 to 415. An ‘Emergency Action’ allows for the transfer of daily care responsibilities to, relevantly, the Director General in situations where the child/young person is, or is likely to be, in ‘immediate need of care and protection’ unless ‘Emergency action’ is taken. The operation of these sections effects transfer of the daily care responsibility to the Director General, without the need for a court order, for a maximum of two working days. If, after the expiration of that time, no children’s court order is made to transfer parental responsibility, then the child must be returned to whoever has parental responsibility (usually the parent/s). In only six of the files reviewed were the children/young people unknown to C&PS before an emergency response was actioned. In all other cases the children/young people were previously known to C&PS and for the majority of children/ young people, multiple child concern/protection reports had been made prior to the emergency action. Despite the multiple reports of similar events/concerns from various sources, it was difficult for the reviewers to often ascertain which report triggered an emergency action and the reasons for such action. C&PS has confirmed that the findings of the Review are consistent in that the majority of children/young people enter care by way of an emergency action. This is despite the fact that the Act provides other alternatives to approach the Children’s Court for an order. Whilst on the one hand it is acknowledged that statutory intervention should only be considered when the level of safety for a child/young person is compromised, it is of real concern that the practice of current statutory intervention appears to be one of a reactive strategy, rather than a proactive planned process that utilises risk assessment to mitigate identified safety issues and analysis of the available information. The lack of proper recording of the details around decision making does not allow any confidence as to whether each of these emergency responses was the right action to take. However it highlights the failure to contextualise the possible risks and safety issues from the known history and information already available and to proactively plan to mitigate risk and plan for any possible change in circumstances that increases the safety issues for a child/young person. For example, in some circumstances there was no evidence that if such planning had occurred, that the plan was readily available to the After Hours Team. In such circumstances 24 Who is looking out for the Territory’s children? where C&PS had previously been involved with a family and such planning had been undertaken. Although C&PS state that the After Hours Team can access all the available records there were a few instances where children were placed into short term care with strangers. The reasons for this were not recorded. 4.3 Discussion It seemed that despite C&PS’s involvement with the child/young person prior to an emergency response, C&PS appeared to be reluctant to apply for care orders as part of that engagement. Rather, C&PS appeared to: 
Rely on an emergency situation to invoke the initial transfer of parental responsibility to the Director General; and then; 
Rely on the circumstances surrounding the emergency action and the child’s/young person’s history with C&PS as evidence to support the application to the Children’s Court for care orders. In addition to the specific provisions relating to children/young people with Aboriginal or Torres Strait Islander heritage, the Children and Young People Act 2008 directs that, unless ‘contrary to the best interests of the child’, decisions about care and protection must be guided by the principles set out in sections 9 and 350. In summary these are: 
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The child’s/young person’s sense of identity should be preserved or promoted (s 9); Their education or employment should be encouraged and, where possible, not be disrupted (s 9); Their individual characteristics and history should be considered (S 9); Parents or other family should have primary responsibility to provide care for a child/young person and parents or family should be given support to provide this care, (s 350(1)(a) & (b) but where parents or family are unable or unwilling to do so the government must provide, or share, that care (s 350(1)(c)); Where, because of the operation of the Act, the child/young person does not live with their family, contact should be encouraged (s350(1)(c)) but the child or young person’s safety and wellbeing override the parents’ interests (s 350(1)(e); An order for care and protection should only be made by the Children’s Court where making the order would be better than making no order (s 350). It is possible that in giving effect to these principles that C&PS has felt constrained to continue to provide support to parents or family rather than seek orders unless ‘drastic events’ demand an emergency response. It is not until C&PS concludes that the child’s/young person’s need for care and protection outweighs the desirability of maintaining care by ‘parents or other family’, that any response is initiated, and by then it usually has to be an Emergency Action. 25 Who is looking out for the Territory’s children? It was not always possible to conclude from the available C&PS records that the corroborating evidence supported the level of risk identified. The only detail available about why and what lead to the emergency response was contained in the affidavit attached to the application to the Children’s Court. It is difficult to conclude why this is the case as C&PS maintain that this detail is available in progress notes on CHYPS. In too many instances this forensic information was not evident, the result being that the primary source of information was the Affidavit. Unlike physical abuse, which can be more readily proved, e.g. by medical evidence, ‘neglect’ is usually cumulative and multifaceted. For this reason perhaps, it can be difficult to determine the point at which inadequate and less than ‘optimal’ care becomes harmful and the need for statutory intervention, rather than support, is required. 4.4 Summary Arguably, C&PS have opportunities to apply for Court orders at an earlier stage in its involvement with a family to avoid the trauma and disruption associated with emergency action. This could involve supervision orders in matters which do not warrant removal but require more intervention than merely a case plan or support plan due to the identified level of risk to the child. For example, where concerns for the long term health and well being of the child/young person exist, but efforts to support the parents or family have not been effective in bringing about changes in the carer capacity or any positive outcomes for the child/young person. Unfortunately there is a stigma for the child/young person and their family which accompanies C&PS’s involvement that is exacerbated when Court processes are commenced. C&PS is encouraged to consider a comprehensive review of the current practice framework to ensure that any emergency response is supported in their records by corroborating evidence, and that risk assessment is fundamental to all interactions and that case planning becomes an integral part of practice as does case management and case supervision. C&PS too needs to examine the current training regime to ensure that “investigative interviewing” is re‐introduced and risk assessment and case planning are key elements of the training offered. 26 Who is looking out for the Territory’s children? 5.
5.1 Decision Making Introduction In an emergency situation, particularly where C&PS has not engaged or had contact with a child/young person or their family, there is a heightened demand for skill in gathering information and analysing the relevant circumstances. The situation requires that while immediate action has to be taken which is effective in securing the child’s or young person’s safety and well being, there is also a need for further information gathering and decision making. Even in an emergency, the decision making must be transparent and as informed as the situation will allow. 5.2 Findings of the Review There were several examples of emergency action having been taken despite there being no immediate risk to the child/young person. For example, where the child was living safely with other relatives or significant others and the parent, albeit absent, was deemed as failing to provide care, or where a parent may ‘visit the home without authorisation’. It may be apparent that there needed to be a transfer of parental responsibility and the child’s or young person’s care was best ‘formalised’ by a Court order. In these circumstances pro‐
active planning could have acted to mitigate the immediate risk and resulted in much less disruption for the child/young person and a more measured approach to the Court application. 
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It appears that whether or not C&PS has been working with a child/young person and their family an emergency action preceded the application to the Children’s Court for care orders; There was no evidence in 40 of cases reviewed of the actions planned to be taken and the decisions made in the immediate period prior to an emergency response; Where neglect is the ‘issue’ C&PS appears to be reluctant to make applications for care orders – even when engaged with the family for extended periods and despite several (sometimes numerous) “Child Concern” and/or “Child Protection Reports”. C&PS appears to be prompted to make an application only after an emergency response has been taken – even where there is no documented evidence on record other than that contained in the affidavit; In only 55 of the situations was it apparent that the risk factors where incorporated in decision making at every stage of C&PS contact with a child/young person and their family; In only 33 of the sample was it evident that information was gathered from a wide variety of sources and critically analysed; 27 Who is looking out for the Territory’s children? 
For 33 of the cases there was little or no evidence of case planning decisions. Case planning must be rigorous and documented. 5.3 Discussion Policy and practice guidelines should be developed to ensure decision making and the reason for the decisions are documented in records. Such practice may foster more rigorous case work during the period of engagement with children/young people and their families, prior to removal being considered the appropriate option. The result may be that the engagement is more successful and less contentious. An emergency response may be avoided or at least strategies could be agreed beforehand to respond to emergency situations which might arise. Thus the level of trauma and disruption which normally surrounds an emergency response may be diminished, if not avoided. Whilst it is acknowledged that emergency response was sometimes undertaken at night or over a weekend, by after‐ hours staff or the police and thus there were resource limitations, it does not explain why the information about the important decisions taken – such as why the emergency response was considered necessary, who was informed and how decisions about the emergency placement were made ‐ are only recorded in the affidavit provided to the Children’s Court. Clearly the action taken, the reasons for doing so and the decisions involved need to inform the Affidavit but the corroborating evidence for such actions must also be recorded and available on the case record. Where C&PS had previous contact with the child, young person or their family and had the opportunity to gather and analyse information there is the expectation that an assessment of possible and probable events will have been undertaken. Munro (1999) warns that in child protection risks cannot be avoided and all outcomes cannot be predicted and planned for, however, where it is possible to do so, efforts should be made to plan for probable situations and to endeavour to minimise the child’s/young person’s experience of trauma and disruption should those situations arise. The emergency response procedure should not be utilised as a stage in the care and protection case management process. Whilst unexpected situations can occur, and an emergency response may be necessary, case planning can consider safety planning for children/young people should a crisis arise. The importance of evidence based decision making is highlighted in Munro’s 1999 paper ‘Common errors of reasoning in child protection work’. The paper, which examines reports of inquiries into child abuse, acknowledges that in the complex area of child protection work, some mistakes are inevitable. However, Munro concludes that while some mistakes which occur because of errors in the reasoning process of decision makers within the child protection system are predictable, and it may not be possible to eliminate these errors, their incidence and impact must be reduced. 28 Who is looking out for the Territory’s children? By acknowledging that intuition plays a role in case work, it must be tested and augmented by good use of information and analysis. There should be a focus on gathering information and ensuring that it, and the historical information held, is recorded in a way that enables a worker to challenge their preconceptions and bias when making decisions. Information should be gathered from a wide range of sources. This assists in reducing the likelihood that indicators are overlooked because, individually, events are not particularly dramatic. Information should be evaluated as a whole, not screened because it does, or does not, accord with the “case view” that has been formed. Historical information must be reviewed and incorporated into and assessed with more recent or contrasting information so that an accurate risk assessment can be undertaken. Use of ‘cut and paste’ information can give rise to the assumption that this information has already been ‘assessed’ and consequently information may not form part of the risk analysis. Historical information should be revisited and viewed in light of more recent information, which can result in a re‐characterisation of the risks and prompt a different response. Most importantly, Munro (1999) says, the decision maker must be encouraged to challenge their own conclusions and, when appropriate, change their mind. Munro encourages intra and inter‐disciplinary conferences/meetings as a means of information gathering. These venues can also provide an opportunity for critical analysis of the information obtained. However Munro does not recommend this forum for case management decision making. Munro considers that the tendency for ‘consensus’ may sometimes be an impediment to good casework. She believes that better decisions are made by, say, case worker and supervisor working together as this is a more supportive environment where critical analysis can be achieved – including recognising errors and changing one’s mind. 5.4 Summary A system that operates by waiting in the majority of cases until an Emergency Action is required prior to a child/young person coming into care, places undue pressure on all areas of C&PS which is already overwhelmed with competing priorities. When an emergency action is taken there is often little or no time for planning associated with the initial placement decisions. The urgency and pressure of the situation can result in a failure to follow processes. For example, this failure was evident from the review of the files of many of the children/young people placed in Kinship care. C&PS should be encouraged to utilise some of the other legislative procedures available, such as supervision orders, in a way that may either: 
support a family so that it is able to provide the necessary level of care for a child/young person; or; 29 Who is looking out for the Territory’s children? 
ensure that C&PS case planning during this period is such that the child/young person and, ideally, their family are better placed to face the transition in the event that care orders and out of home care becomes necessary. Child protection is complex, but the consequences of mistakes can be critical. It is essential that efforts are made to minimise errors. There is a need to gather and critically examine information from a wide range of sources, professional and otherwise. This information needs to be continually reviewed and assessed within the context of further information received. A child’s situation must be actively monitored and the observations made and information gathered as part of that process and incorporated into case management decisions. There is a need for rigorous and frequent case supervision for case workers and the work they are undertaking. This should include the supervisor actually reviewing information and documentation. Case strategy and decision making must be ‘reality checked’ and ‘critically challenged’ in order to minimise the impact of ‘over confidence’ in ‘initial assessments’ and thus the mistakes that can flow from bias in decision making. In making decisions about and when implementing case planning, C&PS should ensure that it obtains from and provides to relevant individuals and organisations, information which promotes the best outcome for the child/young person. Effective communication will help ensure good decision making. By encouraging information sharing C&PS is better able to assess the effectiveness of planning decisions and develop strategies for the future. Information gathered from C&PS workers’ direct observations and interactions, combined with information obtained from others who have contact with the child/young person and others involved in the child/young person’s life, is invaluable in this decision making and implementation process. 30 Who is looking out for the Territory’s children? 6.
Case Practice 6.1 Introduction C&PS involvement with children/young people and their families should reflect the performance of a statutory role, and a genuine desire among C&PS workers, to achieve the best outcome for a child/young person. A good case plan would identify the goal of the casework with objectives and measurable tasks linked to the assessed needs of the child. This would assist the worker to regularly review the work undertaken and inform whether the identified outcomes for each child/young person had been achieved. 6.2 Findings of the Review In 41 of the sample there was only partial or no record that a case plan had been developed after an emergency response Of the cases reviewed in 29, there was partial evidence and for 45, there was no evidence, that case reviews were undertaken between the C&PS caseworker and the supervisor. In 65 of the sample reviewed there was no record or only partial record of a Review of Arrangements meeting. From the review undertaken of the sample of C&PS files and the electronic data system (CHYPS) there was evidence of a failure to develop and/or record the strategy to be employed in order to achieve an outcome in the case of each child/young person. Further, the failure to regularly and systematically analyse and reflect on the success of any actions undertaken, or the failure to record this review, in relation to individual children/young people, meant that it was not evident what had been effective. It was therefore difficult to assess what future actions were indicated to achieve the best outcome for each child/young person. Where good assessment or review was undertaken, there was rarely any evidence that the information gathered was incorporated into ongoing case planning. Information captured in supervised contact reports, comprehensive family assessments, Kinship assessments, medical assessments, and information provided by carers, in particular Kinship carers was often not reflected or was subsequently lost in the ongoing case work. There was little indication in the records of liaison or involvement with other government or non government agencies, some of whom it could be assumed would have relevant information to assist C&PS in decision making and with assessments. 31 Who is looking out for the Territory’s children? The following examples highlight this practice: 
Even in situations where a carer expressed concerns as to their capacity to provide long term care for a child/young person, it was not clear that parallel planning commenced to identify and plan for an alternative placement;  Where a medical examination identified the need for follow up, only 30 of the cases examined provided evidence of how this recommendation was actioned;  It was rarely apparent how information set out in supervised contact reports was used to inform case planning. These reports were often very detailed and provided valuable information about interactions between the child/young person and significant people in their lives;  The files often contained a ream of urinalysis tests for one or both birth parent. There was little record of these reports being analysed or indeed utilised to inform decision making or case planning. Care Plans were usually generic and global. Too often they did not reflect with any degree of specificity regarding the particular needs of the child/young person. It was not apparent from most Care Plans that a rigorous review of previous case planning decisions had been undertaken. Care Plans did not usually identify in any detail how a review of previous decisions, if it had occurred, and the changing needs of the child/young person would be captured in the forward planning for the child/young person. Case planning activity was most evident around the time that the child/young person came into care, for example, following an emergency response, and during the period prior to the final Court Orders. Once Final Orders were granted and an ‘ongoing’ placement was found, it was not uncommon for the file to suggest that case work was limited to reacting to carers or other agencies and organisations demands, arranging contact or drafting Care Plans, Annual Reviews or, if necessary, applications to extend expiring orders. Where C&PS had care planning responsibility, such as when child/young person was in a Kinship placement, although Review of Arrangements (RoA) meetings were usually referred to in Care Plans and, when recorded, Case Worker Supervision Reports, RoAs were often not carried out with the frequency identified in the Care Plan. Given that in some instances RoA’s did not occur or were not held in accordance with what was stated in the Care Plan then this calls into question for those cases, whether any casework was undertaken during the period identified in the Care Plan. In the sample reviewed, where genograms (family trees) had been prepared for children/young people, for example, as part of a Child Protection Assessment Report (CPAR) or Kinship or Comprehensive Family Assessment, it was noted sometimes that the focus was on one side of the family, usually the maternal family, often to the exclusion of the other side of the family and sometimes to the exclusion of one parent, most often the father. 32 Who is looking out for the Territory’s children? Whilst it is accepted there may be a number of reasons for this, it was not evident in the records. In these particular instances it was often not clear what efforts had been made to explore with the child/young person and their family, members of the child/young person’s extended family and significant others with whom the child might have contact or who might be pursued as potential respite or alternative carers. It was often difficult in the cases reviewed to identify, from the information recorded on CHYPS or the file, the rationale for many of the case management decisions and actions including:  placement decisions immediately following emergency response – including what options were considered, how the child/young person was transported to placements and what action was taken to assess the child’s needs and carer’s capacity to meet those needs;  contact arrangements – including the rationale for contact, frequency and where it occurred, and whether supervised or not;  the nature and longevity of the orders sought. Other than the documents created in relation to the Children’s Court Application, and thereafter the Care Plan and Annual Review, there was little documented evidence of ongoing case management. It appeared from many records that once final orders were made by the Children’s Court, any actions taken were primarily reactive. There was very little evidence in C&PS records of proactive, pre‐emptive planning for children/young people in care. 6.3 Discussion It is acknowledged that every child’s/young person’s situation is unique and that there are unlikely to be ‘generic’ approaches to respond to a particular child’s/young person’s situation and that the pace of events can prevent a C&PS officer from recording every event or action at certain times during C&PS’s involvement, such as when an emergency response is taken. However, contemporaneous notes will provide an evidence base for the actions taken. In a few instances vulnerabilities which were clearly apparent and/or identified seemed to have been ignored in case planning and placement decisions by C&PS. As a consequence case actions were crisis driven and/or placement stability was impacted on. For example, there were instances of young people who had come in to care because of issues including absconding, challenging behaviours and substance abuse. There was no evidence that these issues had been addressed in case planning or at the time the young person was placed with carers. There was no validation that a placement plan was drafted. The circumstances in each case suggested the need for a placement plan, to be prepared in consultation with the young person and the carer, which not only identified the issues relating to the young 33 Who is looking out for the Territory’s children? person, but which incorporated strategies and protocols for responding to issues which might arise. This planning would have facilitated a measured response by, in particular, the carer and C&PS in the event that the anticipated situation arose. By involving the young person, the young person might have been more likely to take ownership of their behaviour or at least be less able to deny ownership. It is accepted that not every eventuality can, or should be anticipated. Documents which record the decision making process should state who was consulted/present and all documents should be dated and signed. Ideally documents should state why they were created, e.g. “Notes of meeting on 1 Jan 2013 to discuss actions surrounding and planning following Emergency Action taken on 29.12.12 in relation to Mary Smith (dob 12.12.12)”. This level of detail can be very important where multiple events are occurring and several people are involved. If known, people’s full name and role should be used – e.g. Mary Smith (child), John Smith (child’s father), Jane Citizen (C&PS case worker) and so on. Given that there is potential for extended engagement between the child/young person and C&PS, perhaps for 25 years in some cases, there is an indisputable need to record in each child’s/young person’s file corroboration of the information used in the decision making and the strategy and planning decisions. This information is needed to ensure the validity of ongoing case management. It is also important to retain so that it is available should the child/young person choose to inspect their C&PS files, even long after they have left care. Munro encourages workers to explore both positive and negative outcomes – what works, what does not work and why. This approach may inform case practice generally, but in the case of the individual child/young person it is essential to ensure that C&PS, which has the parental responsibility, is ‘on track’. Reactive decision making, case ‘drift’ and failure to reflect and actively monitor the circumstances for children/young people in care is likely to result in less than optimal and possibly negative outcomes. The key is ‘management’. All cases demand direction which can only be achieved by: “Good use of valid tools, such as forms, is worthwhile in many situations, but what must always be considered is why the information is being sought – ‘what question am I trying to answer?’ Simply completing a form without analysing the information gathered is of no use” (Munro). Given the uncertainty and inherent risks in child protection work – Munro says the only way to accommodate this adequately is to:  Aim to address and reduce risk;  Accept it may not be possible to eliminate risk; and  Continually measure success by assessing the effectiveness of the help provided. 34 Who is looking out for the Territory’s children? If there is no plan, there is no way to evaluate whether the care order relating to a child/young person is appropriate or has led to improvement in life circumstances. 6.4 Summary C&PS staff need a better developed practice framework based on relevant policies and regular and active supervision of their case work. More focus needs to be directed at supporting and training the C&PS staff to use the available tools effectively to guide and reflect quality case work. This could be best achieved by regular, professional case supervision. There is a need for ongoing monitoring and review of each child’s and young person’s situation to ensure that case planning responds to their changing needs as they develop and their individual circumstances change. Effective use of good case management tools can assist in recording the information used in decision making; promoting critical analysis; and ongoing monitoring, evaluation and review. Regular, case specific supervision of case workers by senior officers is essential. During case supervision workers need to be provided with guidance and feedback on case direction. This not only avoids ‘case drift’ and inaction, but ensures that information is recorded and knowledge is not ‘lost’. The supervisor has responsibility to:  identify the need for involvement of other service providers;  bring objectivity and experience;  alert the case worker to gaps in information gathering;  escalate issues, if necessary;  continually review actions and strategies to promote child focused positive outcomes;  schedule the next supervision and provide a check list and time frame for actions;  document, date and sign the supervision report in conjunction with the caseworker. In addition to conducting case supervision with caseworkers, supervising officers should also take part in active engagement with children/young people and their carers and family. By working in tandem with the responsible case worker, supervisors can develop a rapport and ‘hands on’ familiarity and relationship with cases. This provides opportunities for extending skills in less experienced officers and leads to a real team approach to casework so that no individual caseworker is left with sole responsibility for a child/or young person and if necessary this facilitates transfer of cases between workers and ensures that absences or staff changes do not disrupt case planning. Whilst the review team accepts that caseworkers and their immediate supervisors discuss situations and may possibly agree on how best to deal with a situation there is no evidence of these joint decisions on record and certainly no written details of any situations where there is no consensus about the way to progress a particular matter. 35 Who is looking out for the Territory’s children? Case management must include:  An approach that is child focused and ‘in child’s/young person’s best interests’ – who is this child, what is this child’s needs: ‘Have you checked the children?’  Planning – evidence based, documented, ongoing, pre‐emptive not reactive.  Supervision – regular, documented, used to provide case direction and opportunity for training/identify skills deficit etc.  Engagement – with child/young person and others in child’s life (family, parents, carer) by C&PS caseworker and supervisor.  Reflective practice – why is this child in care, what have we done, has it worked, what should we do/do differently.  Communication – ensure information flow between all people/service providers involved with the care of a child/young person.  Accurate and thorough record keeping, documenting assessments and decisions throughout the process. 36 Who is looking out for the Territory’s children? 7.
7.1 Child Centred Practice Introduction “Child centred” practice is closely related to the principles which underpin the Children and Young People Act 2008. The general intent of the Act is to focus on the responsibilities of family, and to support families, to care for children. The principles also outline the obligations of government if statutory intervention is required to protect a child/young person. Intervention is usually invasive and the principles direct that such intervention should, as far as possible, result in minimal disruption to the child/young person’s family relationships, education and other important aspects of their life. The term ‘child centred practice’ is best described as a process that ensures “the child/young person is seen and kept in focus throughout assessment and that account is always taken of the child’s perspective”, (Institute of Child Protection Studies, 2006). The ACT Charter of Rights for Children and Young People in Out of Home Care (the Charter) that was launched in November 2009 outlines clearly what children/young people in Out of Home Care should be able to anticipate whilst they remain in care. The Charter specifies that children/young people can expect the following: “The right to be safe and looked after The right to be respected The right to be treated fairly The right to have fun, play and be healthy The right to be heard The right to privacy and have your own things The right to ask questions about what is happening to you The right to have contact with the people you care about and know about your family and cultural history The right to go to school The right to talk to people about things you don’t understand” The principles of the Act and the Charter must direct practice and ensure that at all stages C&PS seeks to involve the child/young person. 37 Who is looking out for the Territory’s children? 7.2 Findings of the Review In 36 cases sampled where a child/young person was removed from their family there was no record of them being accompanied to the emergency placement by the caseworker who undertook the emergency response. In 35 cases of the sample the emergency carer was not or only partially given information about the child’s/young person’s needs. In only 43 situations did a caseworker phone within 24 hours to check if the child/young person was settled in the placement in accordance with the pilot standards for out of home care. The pilot standards for out of home care stipulate that a caseworker visit the child/young person within 5 working days of placement. This did not occur in 47 cases of the sample. In 21 of the cases there was no evidence that the child/young person was spoken to about a proposed placement or that their views are recorded. Although the Charter clearly articulates the necessity for C&PS to engage with children/young people, and seek their opinions, the Review found that in 30 cases of the sample there was no or only partial indication that this had occurred. In these cases the views of children/young people were not sought, and in a number of situations where they did speak out their concerns these did not appear to be given any weight. The review team found that a greater focus on child centred practice would be desirable in the Territory. In 27 of the cases there was no record that the subject child/young person had been interviewed separately from the alleged perpetrator of the abuse. There was little emphasis placed on planning for the key transitional points of life from childhood to adolescence; the developmental needs of children/young people; a proactive approach to facilitating children/young people’s positive interaction with family, school, community and society, or any consistent method to provide opportunities for children/young people to be involved in planning and decision making. When the opportunity existed for them to attend a planning meeting there was evidence to suggest that only 50 cases of the sample were invited. Too often the records contained comments such as the “child is too young” or “has high support needs, therefore is unable to state their views”. Whilst comments of this kind may be appropriate in a number of cases due to age, there are many ways in which a child/young person’s view can be obtained (e.g. observing the child, interacting with the child, partaking in related artistic activities with the child). 38 Who is looking out for the Territory’s children? Section 359 of the Act compels the decision maker to consider the views and wishes of a child/young person. From the records it appears that 30 of children/young people in the sample were not spoken to at the point of statutory intervention (emergency response) and prior to removal from the care of their parent/parents. They appeared to have little or no say in what had happened, what was happening to them and what would happen in the future. Notably, there was often little or no information about the child/young person and how they responded to the emergency situation. In only 51 cases of the sample was there any information about how their needs were assessed, if they were assessed, how those needs were addressed and in only 50 of the cases was there any record or partial record of how the detail of any assessed needs were relayed and/or met. In 2 or 3 instances it was apparent that the child/young person had moved between several placements in the very early period following the emergency response. However these placements were neither officially recorded nor was there any documentary evidence of the planning which prompted these placement changes. Without corroborating evidence of visits and conversations in the records it is difficult to assume how information is obtained directly from children/young people given that there is no certainty for the allocated caseworker to remain involved with the case. Over the review period the average number of caseworkers assigned per child was greater than 3. This lack of evident ongoing engagement with the child/young person led the Review Team to assume that often only historical information was utilised to inform “Child Protection Assessment Reports” (CPAR) and additional reports such as “Care Plans” and “Annual Review Reports”. There was the impression that assessments written to support processes, such as an application to extend a Care Order, relied on past information from the records or feedback from foster care agencies or Kinship carers rather than on information gathered as a result of engagement with the child/young person or indeed their parents. There was little available information to support the attendance of children/young people at any Court Case Management Conferences, Case Conferences or Review of Arrangement meetings. Whilst it is accepted that in the circumstances of Court matters attendance would only be appropriate for those of a mature age, it is considered acceptable practice that there would be some record of whether an invitation had been forthcoming and a record of the child/young person’s decision about attendance at such decision making forums and even more so that there is some evidence of their views and wishes on record and made available to the meeting should they choose not to attend. It is also rare for the records to indicate that a visit has been undertaken by C&PS after the initial intervention by way of emergency action. It is stipulated in the OoHC Standards that a visit is to occur within 5 days of the placement being made. The sample of the records reviewed suggests that much of the work undertaken by C&PS is undertaken by phone or 39 Who is looking out for the Territory’s children? email. Thus there is little opportunity for the child/young person to engage or develop a trusting relationship with C&PS so that they could feel safe to share their views and concerns. The C&PS files, unlike the Foster Care Agency files, did not contain any photographs of the child/young people (there were some photos scanned onto the electronic record). There was little obvious record of personal documents such as school reports, and award certificates. As there was evidence of children/young people moving between several placements, the C&PS documents are very important as they provide the only records of their childhood. There is evidence that C&PS has developed an assessment framework based on Bronfrenbrenner’s ecological model which provides the caseworker the opportunity to focus on the needs and strengths of the child/young person. However, the risk and needs of the child/young person were often written in the context of the parent’s behaviours. It appeared that children/young people were often not seen or spoken to alone, either prior to or after emergency intervention. In particular little was known about the circumstances and needs of the child/young person before or after placement. 7.3 Discussion By not seeking and allowing the child/young person to tell their story, the opportunity is lost to learn more about the child/young person’s experiences in the care of their birth parents or in the care of their current carer. This information is vital when making decisions about the child/young person and in order to assess their individual needs. With the exception of the Foster Care Agency files, the majority of C&PS files provided little sense of the child/young person. Much of the information recorded related to what the parent/s was or was not doing. This is disconcerting as C&PS retains case work responsibility for the majority of cases of the children/young people that are in Kinship placements. Munro (2011) confirms that if a child/young person is not consulted and if the nature, frequency and quality of the consultation is not adequate then mistakes will occur. These findings were similar to those in the Vardon Report in 2004. That report noted that “children told the review that they did not feel respected and were not always involved in decisions that affected them and were rarely kept informed about what was happening about their situations”. In the majority of instances the findings did not support what is described in the C&PS Practice Paper F1 “Child Centred Engagement.” This document clearly outlines the need to “see, observe, engage and talk” to children/young people. In all these incidences there had been opportunity to engage and support the children, so that they felt listened to and for C&PS to glean more understanding about the children’s experiences in care or in the family 40 Who is looking out for the Territory’s children? home. If C&PS did engage with the children/young person there was little or no evidence to support that this occurred or indeed any recorded reason as to why it did not happen. 7.4 Summary When C&PS did engage with the child/young person and serious consideration was given to the child/young person’s views, creative solutions were often found and fully supported. This scenario was more likely to be found on the Agency Foster Care files than on the C&PS records. As these records represent the life stages of the individual child/young person it is imperative that this information focuses on the child/young person and what has happened in their life. As many support documents as possible should be kept, so that if as an adult the individual seeks access to their file, the life history is available. The Review was not able to identify recorded reasons for not engaging children/young people in the process. Maybe this is another symptom of the frenetic, reactive culture of the organisation and staff turnover. 41 Who is looking out for the Territory’s children? This page has been left blank 42 Who is looking out for the Territory’s children? 8.
8.1 Kinship Placements Introduction The ACT Out of Home Care Framework for 2009 to 2012 outlines the planning strategy for the Kinship Care program over a three year period. The framework clearly articulates that the Kinship care program: “will be retained and will continue to be case managed by Office of Children Youth and Family Support (OCYFS). The Kinship care program operates in a similar manner to a foster care program, particularly in providing children/young people with case management, casework and support services and in authorising and supporting carers”. The C&PS monthly data reports, confirm that there has been a significant increase in the number of placements with Kinship carers. According to the Vardon Report, in 2002/2003 there were 170 children in ACT Agency Foster Care and 125 children in Kinship care. Data provided by the Community Services Directorate shows that at the commencement of the Review in January 2012 there were 207 children in ACT Agency Foster Care and 295 children in Kinship care. The growth in Kinship care presents a number of challenges for C&PS. The Out of Home Care framework, the policy and carer guidelines clearly stipulate that Kinship carers should receive support equal to that provided to foster carers. Foster care support is provided by specialist funded non‐government agencies. The challenge for C&PS is how to replicate support to Kinship carers within existing resources knowing full well that this program is likely to increase. To meet this challenge C&PS has taken steps to: 
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fund and support a Kinship Carer Support group similar to that of the Foster Care Association and; support an agency to sponsor a Grandparent Support Group; commence recruitment of a specialist team of Kinship support workers. Kinship carer families are likely be more vulnerable, experience complex family relationship issues and be susceptible to matters pertaining to generational differences, age and deteriorating health than foster carers. Therefore these placements require a greater level of support and case management to ensure that they are able to meet the needs of the children/young people in their care than is currently being provided by C&PS. 43 Who is looking out for the Territory’s children? 8.2 Findings of the Review In 74 of the sample there was evidence that Kinship placements were explored For 20 of Kinship placements there was no or only a partial record that a preliminary Kinship assessment had been completed. In 23 of the cases sampled there was no record or only a partial record of completion of the suitability information notice and declaration form for Kinship carers. For 10 of Kinship carers there was no record that a Police check had been undertaken. C&PS have since clarified that this information is held in a different area of CHYPS. This highlights the inherent difficulties with the CHYPS system and confirms the difficulties the review team found with the record keeping. The review found that the goals outlined in the Out of Home Care Framework did not in any way reflect the current practice in Kinship care. The growth in Kinship placements has been significant and any efforts to strengthen the existing placements have fundamentally fallen short of the expectation that Kinship Carers receive assistance equal to that of Foster Carers. In the majority of cases reviewed, Kinship placements were considered prior to placing a child/young person with a Foster Care Agency. The Act and Care and Protection policies require that due diligence be exercised both prior and subsequent to the placement of a child/young person in Out of Home Care. Given that C&PS are required to undertake all tasks in respect of Kinship care there were deficiencies in practice from the onset of involvement with a Kinship Carer. Some of these are as follows:  The Preliminary Kinship Assessment includes a question about the need for all other adult household members in the proposed household to have a Police Record check. This assessment, and assessments in other sections of this form, was often incomplete;  The C&PS Policy (at Chapter D2.2: of the Policy Manual) on the Kinship Approval Process provides a Home Safety Guideline Checklist for completion and inclusion in the Preliminary Kinship Assessment. The checklist has questions about matters such as smoke alarms, smoking in the household, storage of alcohol and hazardous material and equipment, vehicle registration and fitted child restraints in vehicles. The Review Team did not find any examples where this checklist had been completed at any stage of the assessment process;  If a child/young person is to remain in a Kinship placement then C&PS is required to undertake a Comprehensive Kinship Assessment (CKA). In approximately one quarter 44 Who is looking out for the Territory’s children? 
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8.3 of the Kinship placements reviewed, the CKA had not been commenced and a similar number had not been completed; Of the CKA reports that were commenced, a significant number were inadequate or incomplete; Many of the assessment reports gave undue weight to the information provided by the carer. Despite the fact that contradictory information was known to C&PS and was documented on the child’s files, it was not apparent that this information was addressed with the carer or included in the assessment; In the majority of cases there was no evidence of any assessment of the child’s or young person’s placement needs; Too frequently decisions about the child/young person were based on the needs of the carer; In some cases where it was known that the placement was highly vulnerable there was often inadequate or no support available; There was no evidence of case plans for these children/young people, therefore little monitoring or review was evident; Whilst in most cases there was a care plan, these were considered too generic; The process of review for placements is a Review of Arrangements Meeting. For Kinship placements the Stage 2 Review has highlighted that these meetings either did not occur or that there is no record of such review meetings for 60 placements; Whilst the majority of Kinship carers appeared to be grandparents there was no evidence of planning for the child’s age related transition periods, generational issues, respite or succession to another placement if age or health matters arise; Whilst most Kinship carers appeared to receive financial support in a timely manner upon placement, there were some instances where this was not the case and there was some delay in arranging for children/young people’s personal affects to be taken to the placement; In too many instances the Specific Parental Authority which authorises the Kinship carer to provide care on behalf of the Director General was delayed or not signed and dated by the delegate; In a number of instances available information suggested that there may have been another adult residing in the household and this did not appear to have been tested or explored by C&PS. Discussion While the emphasis on seeking Kinship placements from the outset, accords with the principles to be applied when making decisions under the Act and supports the aim to keep children/young people connected with family and significant others, more is required of the Care and Protection system than merely placing children/young people in Kinship care. 45 Who is looking out for the Territory’s children? Many Kinship carers are identified in an emergency situation and the placement is often unplanned. Many Kinship carer families are themselves quite vulnerable. Given that many children/young people in care have high needs due to the trauma they have experienced, providing care for these children/young people can increase the vulnerability of the carer and this in turn impacts on the care they can provide to the child/young person placed with them. Planning can be useful when aiming to achieve the objective of stability and continuity for a child/young person. This objective should include ongoing monitoring and review of the placement to ensure that it results in the best outcome for the child/young person. C&PS should engage and collaborate with the child/young person and carer to develop, monitor and review the placement. Failing to identify or address known risks to a placement increases the likelihood of placement breakdown and the associated disruption and trauma for the child/young person and the Kinship carer. Monitoring, planning and review of placements will assist to minimise such disruptions. C&PS’s involvement should be in response to the child’s/young person’s circumstances and identified needs, not whether they are in an agency or kinship placement. Hislop, Horner, Downie and Hay, (2004) reported the results of a study that investigated the experiences of children in grandparents Kinship care. The study found that “although most grandchildren appear to develop well in the care of their grandparents, some may not progress so positively. Several factors are likely to be responsible for this discrepancy, including the early life experiences of these children, their current relationship with family members and other individuals, participation in community life, temperament and personality style, resources available to them, and the type of coping strategies they employ to deal with life’s hurdles. Resources and assistance for these families is essential to ensure that the responsibilities associated with the parenting role, complicated by the generation gap, do not prevent best outcomes for grandparents and grandchildren”. 8.4 Summary When it is considered to be in a child’s/young person’s best interests for them to be placed with or continue to reside with Kinship carers, the Kinship carer assessment and case planning processes must thoroughly explore and identify the best way to:  support the Kinship placement and to reduce vulnerability (for both the child/young person and the carer family); 46 Who is looking out for the Territory’s children? 
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increase the carer’s capacity; promote placement stability and; primarily, enhance the child’s or young person’s optimal development now and in the longer term. Children/young people entering care are likely to have experienced deprivation and trauma. The Care Plan which C&PS is required to develop should demonstrate the way in which it is intended to address and ameliorate the impact of these experiences on the child’s or young person’s future development. Thorough initial assessment and ongoing monitoring of Kinship placements is essential to ensure that any vulnerability is identified and, if possible, addressed. This case work must include an ongoing assessment of the impact of the placement on the carer family and therefore the Kinship family’s capacity to provide the necessary level of care for the child/young person. The nature and degree of support will vary depending on the specific situation. Ultimately, the decision of whether or not to maintain the placement must always be in response to the fundamental question of what is in the best interests of the child/young person. C&PS should consider undertaking a comprehensive review of all current Kinship placements to: 
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Clearly identify the needs of the individual child/young person; Identify and address any risk or safety issues associated with the placement; Develop case plans that articulate what action is required to support the placement and include review time lines; Clarify those family placements that are stable and no longer require statutory support. When undertaking Comprehensive Kinship Assessments all family members should be included so that placements can be seen as a whole of family commitment and factors such as respite can be included as part of the ongoing care arrangements. 47 Who is looking out for the Territory’s children? This page has been left blank 48 Who is looking out for the Territory’s children? 9.
Cultural Awareness 9.1 Introduction Aboriginal and Torres Strait Islander children/young people: The current C&PS Policy and Procedure C1 “Intake” endorsed 30 May 2011 formalises the need to confirm cultural status. In section 1.4.9 “It is essential that Care and Protection staff seek information about whether a child is Aboriginal and/or Torres Strait Islander in order to provide culturally appropriate and respectful interventions.” “Centralised Intake staff must ask callers about a child’s Indigenous status when a Child Concern Report is received, using the Australian Bureau of Statistics question format: “Is the child of Aboriginal or Torres Islander origin, or both?” The policy and procedures further clarify that “Where this information is not known by the caller, it is very important that Care and Protection Services staff attempt to seek this clarification of a child/young person’s indigenous status during the assessment and/or appraisal processes “ and further “all staff are expected to update the View Person field as a priority, as soon as the information is available to them”. The Children and Young People Act 2008 is specific in relation to Aboriginal and Torres Strait Islander children/young people in respect of the obligations of the Director General prior to removal from their birth family and also once parental responsibility is assumed by the Director General, particularly in relation to the priorities for placement in Out of Home Care. Prior to removal of Aboriginal and Torres Strait Islander children/young people from their birth family the Act, outlines the principles that apply when making a decision; 1) “a decision maker must have regard to the following principles where relevant, except when it is, or would be, contrary to the best interest of a child/young person: (a) The child’s or young person’s sense of racial, ethnic, religious, or individual or cultural identity should be preserved and enhanced” In the Act the principles for Aboriginal and Torres Strait Islander children/young people provide clear direction to guide the decision maker when it becomes necessary for intervention by C&PS. These principles are as follows: (a) “the need for the child/young person to maintain a connection with the lifestyle, culture and traditions of the child’s or young person’s Aboriginal or Torres Strait Islander community. 49 Who is looking out for the Territory’s children? (b) submissions about the child/young person made by or on behalf of any Aboriginal or Torres Strait Islander people or organisations identified by the director general as providing ongoing support services to the child/young person’s family. (c) Aboriginal and Torres Strait Islander traditions and cultural values (including Kinship rules) as identified by reference to the child’s or young person’s family and Kinship relationships and the community with which the child/young person has the strongest affiliation”. Other Cultures: The ACT as a multicultural society has always had people from a diverse number of cultures within the population. Many such cultures who settled in the area after World War II have well developed cultural networks. In recent years, the ACT has become home to additional cultures, most of whom have not had time to develop networks. In addition, many of these recent arrivals have suffered considerable trauma before leaving their homeland of origin. It was particularly evident in Stage one of the Review and also in this Stage that when those families come into contact with the Child Protection system they are not being afforded the benefit of decision making that takes into account their cultural differences, particularly in respect of parenting standards and the trauma experienced in their country of birth and during the journey to settle within Australia. Whilst Care and Protection at least have a number of policies directed at working with the Aboriginal and Torres Strait Islander communities no such policies exist for children/young people from other cultures. The absence of a Cultural and Linguistically Diverse (CALD) policy designed to increase awareness, community education and confidence in culturally diverse communities, could send a message to care and protection staff, that it is unimportant to be aware of or learn about the significant differences between what is acceptable within Australia and the cultural norms and practices of other societies. CALD policies in a number of other jurisdictions have led to the development of more specific programs to work with cultural communities. 9.2 Findings of the Review Aboriginal and Torres Strait Islander Children Of the 100 children/young people reviewed, 27 (or 27%) identified as Aboriginal or Torres Strait Islander. The Aboriginal and Torres Strait Islander population for 0 – 17 years within the ACT is reported to be around 2% of the total number of children/young people in the ACT. Taking this into account the number of Aboriginal and Torres Strait Islander children/young people for whom the Director General has parental responsibility, is grossly over represented in the Out of Home Care system. Therefore the development of policies 50 Who is looking out for the Territory’s children? and procedures that ensure that these children maintain strong links with their culture, community and country, are critical. Other findings highlighted the impact of the delay in C&PS clarifying the cultural status of some of the children/young people whose records were reviewed. For example, 
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After making numerous requests for clarification a Foster Care Agency was notified by C&PS eight months after placement that a child was Aboriginal. This was verified in the agency case notes. This situation is of real concern given that there were thirteen “Child Concern/Protection Reports” for this child prior to intervention by way of an emergency response. Each of these reports recorded no identified cultural information; Another aboriginal child was referred to a Foster Care Agency for a placement but there was no reference to their cultural status; There was evidence in one particular situation of a referral to the Aboriginal and Torres Strait Islander Unit (ATSI). This referral and subsequent engagement by ATSI occurred quite ‘late’ in the process after the emergency response and removal of the child. A cultural plan was eventually completed but it was not extensive and so late into the placement that it had little influence on decisions made on behalf of the child. There is little evidence in the records of the principles being utilised prior to or indeed after intervention by C&PS for the Aboriginal and Torres Strait Islander children/ young people. The available evidence did not verify any contact or collaboration with the identified Aboriginal and Torres Strait Islander communities or indeed any support services known to be involved with the family or providing supports to the family. Without such verification it would appear that intervention and removal of these children/young people was conducted without, or with virtually no, consultation or any input from the communities or support services whose involvement may have assisted with the decision making and acted to prevent the children/young people being removed from Kinship and community connections. There is little evidence of involvement by the internal C&PS ATSI Unit. There were some isolated examples of emails forwarded to the ATSI Unit advising that an ATSI child/young person had been removed from their birth family. These emails did not specify what involvement or input from the ATSI unit was being requested, if any, and the response was acknowledgement of the email with the comment “let us know if you require ATSI assistance”. There does not appear to be any collaborative relationship between the internal ATSI unit and C&PS, the consequences of this are that the majority of ATSI children do not benefit from early input or indeed any support from those who may be most qualified to comment on cultural and community aspects as they relate to each child/young person. 51 Who is looking out for the Territory’s children? There was limited evidence of the ATSI unit being involved in the development of Cultural Plans for some of the children/young people. In most instances Aboriginal and Torres Islander children/young people whose circumstances were reviewed did have a cultural plan, however, these cultural plans varied in quality and usefulness. The protocol further outlines the aim of the Cultural Plan “is to identify and plan for issues relating to the cultural well‐being of the child/young person, including the following proposals for enhancement and preservation of the identity of the Aboriginal and Torres Strait Islander child/young person:” by  “reconnecting him/her to family;  Strengthening identity and knowledge of his/her culture; and;  Sustaining cultural links when the Aboriginal and Torres Strait Islander child/young person is placed in out of home care”. The “Cultural Plans” reviewed in the main provided limited information about reconnection and strengthening identity, and they mostly relied on an attachment that included details of all the available Aboriginal and Torres Strait Islander services or annual activities within the ACT. These plans depended on the carer to take on the responsibility to link the child with these services or to organise their attendance at pertinent annual activities such as NAIDOC week events. These “Cultural Plans” were often not developed in a timely manner and were not completed until well after the child/young person had been in a placement for 12 months. The completion of the Cultural Plan usually coincided with the Annual Review Report prepared for each child/young person in Out of Home Care. To highlight this, in the case of one child, the client information record which is a document located at the front of each file volume and is designed to capture in summary form up to date information relevant to the child/young person. This child’s identity was recorded as “Australian Caucasian”. Throughout the file there are references to the family’s indigenous status. It is acknowledged that a parent can elect not to have their child identify with an indigenous culture, particularly if the heritage has been eroded over generations and no identifying features exist. However, if this was the situation then it would be expected that the parent’s decision would be clearly documented. This does not appear to have been the case in this matter and in support of this finding a cultural plan for the child was finally completed in 2011. Other Cultures During the review three separate children reviewed were from a particular Asian culture. On one file there was evidence that a caseworker had made an effort to research the cultural background. But in doing so seemed only to find the history associated with the period prior to the 1970’s. After this period, war and a new regime decimated the country by 52 Who is looking out for the Territory’s children? exterminating educated families and destroying families’ values and morals. Children were left to survive alone without the support of parents and extended family. Many eventually escaped in very dangerous circumstances and spent many years living in refugee camps before coming to Australia. The trauma experienced by generations continues to impact on this culture’s ability to provide good parenting due to the absence of any parent role model. Even though these three children are now placed in Out of Home Care, C&PS rely on the birth family from whom the children were removed to maintain the cultural links even though the family members may have no real understanding of their own culture and history. There is little on the files or the electronic records to support the involvement of other agencies or other designated multicultural organisations, who are specifically tasked to provide support to other cultures. This needs to be rectified as the knowledge and information available through these organisations could add value to the decision making in respect of each child/young person. The policy manual only includes a process on how to use Interpreters, focusing on the importance of planning prior to the involvement of Interpreters. 9.3 Discussion It was of concern to the Review Team that nine of the 100 children/young people reviewed had not had their cultural status determined at the time of the review. Six of these children/young people were in Kinship care and three in Foster Care. Two were on final care orders and had been in out of home care since November 2010 and seven on Interim Orders dating from November 2010 to December 2011. Whilst it is possible that none of these children are of Aboriginal or Torres Strait Islander culture or any other culture, the concern is that although mechanisms exist from the first point of contact with C&PS for this issue to be clarified, this was not the case. In many instances, this information may not be known by the person making a report, however the culture should be established by caseworkers at the time of intervention. This information is critical to the planned outcome for the child/young person, in particular placement decisions. In the case of these nine children/young people the fact that their culture has not been confirmed may be another example of a failure to record or update the information. Good practice would suggest that if circumstances prevented child protection staff from complying with the principles, then an explanation for this would be clearly documented, as would the plan to establish and/or continue contact with community, culture and an outline of any proposed efforts to bring about reunion with family or community. The Care and Protection Policy Manual, “Chapter B2.1: Protocol between Aboriginal and Torres Strait Islander Services and Care and Protection Services”, (2010), spells out the role 53 Who is looking out for the Territory’s children? and describes the relationship between the Aboriginal and Torres Strait Islander Unit (ATSI) and C&PS, however this relationship was not apparent in the cases examined. The policy specifies that the ATSI Unit, has a responsibility to “receive and assess and determine a response to referrals for family support and foster/residential placement for ATSI children/young people” and to “work in partnership with C&PS and other OCYFS staff carrying out the core responsibilities of OCYFS operational areas”. These connections are considered to be of the utmost importance for Aboriginal and Torres Strait Islander children/young people to facilitate their return to country, to engage in ceremonies, and to preserve their place in their Kinship system. These and other children from other cultures who have suffered much trauma should be afforded opportunities to experience their culture outside of the immediate family so as to understand the historical and positive aspects of their culture. 9.4 Summary The limited involvement by any internal or external designated ATSI support service is of real concern to the Review Team given that for the period covered by this Review, Care and Protection has primarily recruited caseworkers from the United Kingdom. Non‐indigenous Australians are regularly criticised for their lack of understanding of Aboriginal and Torres Strait Islander cultural issues and insensitivity around or failure to ensure maintenance of links to the culture. It would therefore seem imperative that C&PS prioritises as a minimum response cultural awareness training for all C&PS staff, involving key indigenous leaders. This training needs to be continuous and to be utilised to enhance relationships between Child Protection Services and the Aboriginal and Torres Strait Islander communities and services. Cultural background must be taken into account in any needs assessments conducted on behalf of a child/young person. This information can be vital when planning for the child in a placement and necessary to ensure that the children/young people are afforded opportunities to link with and experience aspects of their culture. The Review does not propose that cultural background be used as an excuse for standards in conflict with Western culture, the tension lies within knowing what is acceptable within Australian parameters and other cultures. C&PS needs to develop a Culturally and Linguistically Diverse (CALD) program in conjunction with a relevant agency to provide cultural awareness training for all Care and Protection staff as part of their orientation. 54 Who is looking out for the Territory’s children? 10. Contact 10.1 Introduction Overall, there seemed to be commitment by C&PS to the Contact Frequency Guidelines contained in the Policy Manual. More often than not contact was arranged more frequently than the minimum levels outlined in the Guide. The concern for the Review team is that the individual child/young person’s needs are not necessarily best met by applying guidelines in a generic way. Suggested guidelines should not replace professional expertise. When considering contact there are fundamental questions that can guide C&PS to determine if contact is beneficial for the child/young person. Some of these issues are highlighted in a research paper commissioned by the NSW Department of Community Services in 2005. The questions challenge workers to constructively think through the reason for organising contact and considering the impact of contact on the child/young person. Given the amount of supervision provided for contact visits and the associated costs, this is an indication of the level of concern held by staff about safety issues at contact. It may well be that reduced contact is in the child’s/young person’s best interests and needs to be considered. 10.2 Findings of the Review The contact arrangements for 93 of children/young people were evident The review team acknowledges that contact arrangements were established for almost all of the children/young people. From the review sample whilst it was clear that contact was in place in most instances it was not always clear why the contact was happening and more particularly if the contact was in accordance with the child/young person’s wishes and for a clear purpose. Contact arrangements seemed at times to be haphazard and arbitrary without any explanatory documentation. For example, a situation where there was frequent contact with a grandparent but no contact with a birth parent. It would be expected that the reasons for the non‐contact with a parent would be clearly articulated. The contact proposal or plan was not always clearly documented in the Care Plan. Statements about contact were usually written in general terms such as “contact should occur to meet the child/young person’s needs”. There was no evidence that the child/young person had ever been spoken to about contact. This is also supported in the section of the Care Plan titled “views and wishes”. Contact was rarely, if ever, recorded as part of the wish list for a child/young person. Many of the Contact plans that were included tended to lack any detail about the purpose of the proposed contact. There was no evidence that any plan included a rationale for 55 Who is looking out for the Territory’s children? contact or took into account the factors of a child/young person’s overall circumstances, developmental level, and daily routine, the child/young person’s attachment needs or whether restoration was likely in the future. If the care plan recorded a plan for restoration, the plan was generic and not developed with a particular child/young person in mind. Restoration plans need to focus on the needs of the child/young person not on what is expedient for the adults or other parties. Restoration plans need to be supported by caseworkers, monitored and reviewed. Too frequently the contact arrangements seemed very complex. The schedule for all parties was such that it would be difficult for the arrangements to be achieved. The more complex the arrangements, the more likely something was to interrupt what was proposed. This often led to tensions between C&PS, Foster Care Agencies, contact and transport agencies, carers and families. In the main the contact arrangements were resource intensive. The resources required included C&PS hours to organise and re‐organise contact, funding to provide transport and supervision at contact visits and the involvement of agency staff if the child was in foster care. Children/young people often experienced a number of different workers transporting and supervising contact visits. In most situations C&PS did not attend contact visits at any stage of the contact arrangements. There was little evidence that the children’s views about how this ongoing interaction with different workers was for them, or the experience of visiting a parent in “artificial” environments. If a child is on a long term order then contact planning should revolve around the child/young person’s activities, needs etc. Consideration of the carer’s and other people’s needs can then be taken into account. Contact services provided very comprehensively written reports describing in a narrative format all the activities and behaviours of the parties at contact visits. These included details about times of arrival and departure by the parties and some description about the child’s presentation prior to, during and following visits. 10.3 Discussion Contact should only occur to meet the child’s needs, not to provide more information about the parent’s behaviours, the child/ parent relationship or to prevent the child/young person forming new relationships within a placement. There was no validation of the information provided in the contact reports. Whilst some of the files contained an accumulation of contact reports it appeared that the reports had been filed without reading due to the fact that there was no record of a signature or that 56 Who is looking out for the Territory’s children? anyone had noted and dated the information. It was not obvious that the reports had been analysed and the critical aspects utilised to inform any ongoing assessment of the child/young person’s needs. For example, if for instance a contact agency informed the C&PS that there were difficulties during contact visits, such as the parent falling asleep, appearing drug effected, or taking the child aside to have private conversations which could be deemed harmful to the child, this did not appear to trigger a thorough review of contact arrangements. Contact should be considered in the context of the child/young person’s best interests as well as any ongoing risk of harm. The ACT Children’s Court has determined that the child is in need of care and protection and transferred parental responsibility to the Director General. It is those same people seeking contact that the court deemed were not providing adequate care to the child/young person. Neil and Howe, (2004) advocate “that the overriding principle in making decisions about contact must be that contact facilitates one or more of a child’s developmental needs”. They further highlight that contact is “not good in itself” and should only occur in the context of child/young person’s wishes and feelings. Identifying and establishing or encouraging contact between the child/young person and members of their extended family and significant others in their life, is a way of constructing a network around the child to mirror highly functioning family units. This could be relevant for case planning by facilitating the child’s/young person’s connection with their family, history and culture. It can also allow for contingency planning and may be a means of providing placement support, such as by identifying respite carers, with positive outcomes for both child/young person and carer. Stable, positive placement of a child/young person has been consistently identified as a factor which contributes to positive outcomes for children/young people in care. 10.4 Summary The level of supervision organised for contact visits in many cases suggested C&PS were concerned about safety issues. Consideration should be given by C&PS for caseworkers to undertake transport and contact visits in the initial phase of a placement. This will allow for the caseworker to build a relationship with the child/young person and for C&PS to assure themselves that contact is in the best interests of the child and they are safe. Once the contact arrangements are settled then transport and supervision can be handed over to an agency. C&PS staff need to be supported through case management to develop comprehensive “workable’ contact plans for children/young people which are based on their needs, and provide the details of the purpose for contact and clearly link to the goals of the care plan. Planning also needs to evidence that the views of the child, their parent/s and the carer have been considered. 57 Who is looking out for the Territory’s children? This page has been left blank 58 Who is looking out for the Territory’s children? 11. Record keeping 11.1 Introduction The document ‘Records Management – Your guide to record keeping in the Department of Disability Housing and Community Service’ (2008) (the ‘Record Keeping Guide’), sets out clearly the importance of and need for ‘the creation, collection and use of accurate information as records’ to facilitate the capacity ‘to operate efficiently and effectively’. Not only are records used in the day to day operation of C&PS, but are also intended to ‘meet accountability and evidentiary requirements’. Children/young people and their families who are involved with C&PS may wish at any time to inspect the records relating to that involvement. That interest and right may extend well beyond a child/young person leaving care. It is extremely important that records maintained by C&PS reflect the decisions, and decision making processes, which relate to the particular child/young person during the time of the C&PS involvement. The Record Keeping Guide says that a record should generally reveal ‘what, when, how, why’ and ‘who’. The Record Keeping Guide states that as a minimum, the record must include the date, the position title of the ‘creator’ and the document must be attributed a ‘meaningful title’. The Record Keeping Guide also stresses the importance of maintaining records which are ‘full and accurate’ to ensure their integrity and promote transparent decision making. If there is a clear understanding of why records are being created, generated, completed and/or retained, then better record keeping should be achieved. 11.2
Findings of the Review In 18 of sample cases there was no or only partial record of the Comprehensive Kinship Assessment on file or CHYPS. In 27 of cases there was no record of a birth certificate or a Medicare number. For 64 cases of the sample documentation (EA2 Form) – Emergency Action Parental Responsibility format was not completed and available on record. In only 47 of the sample records was the EA3 Form “Emergency Action Information to parents” completed and evidence available that it had been given to parents. There was no record or only a partial record of any interviews conducted prior to an emergency response with a parent/s for 41 of the sample cases. CHYPS, as an electronic record keeping system, was difficult to navigate and did not provide a streamlined overview of case work or the information recorded. Although the ‘section dividers’ within the physical files identified how information should have been stored, this 59 Who is looking out for the Territory’s children? was not consistently adhered to. It appeared that information, if recorded elsewhere, was missing from the physical file. In addition, the format of information that was printed from CHYPS and retained on the physical file, such as case notes and emails, meant that it was difficult to access quickly or easily. Documents that were designed to promote information gathering and analysis, such as the Child Concern and Child Protection Reports, were often incomplete or, in some instances, information recorded was incorrect. The basis for the analysis of risk and the conclusions drawn from the information recorded was not always apparent. When inadequate or incorrect information was referred to or relied on in the analysis, the conclusions made or decisions taken were necessarily less reliable and effective or inappropriate. As a consequence in some instances risks were not identified, and in others, responses were not appropriate to the circumstances. Better collection and recording of information and better analysis of this information in the context of existing data should give rise to better outcomes. In some instances where there are several children in a family group, with differing needs, there were times when the majority of information recorded on a child’s/young person’s file related to siblings and masked the fact that case work was being undertaken in relation to the particular child/young person whose file was being reviewed. Or more commonly, in other cases, once Final Orders were in place, and the child/young person was in Kinship care, the lack of documentation would suggest that little or no active case work was being undertaken. There appeared to be limited availability of documentation which could be used as Case Planning tools, apart from the initial intake documents, Care Plans and documents associated with Court processes. As a result case planning seemed to be based, predominantly, on emails and progress notes recorded in CHYPS. It was often difficult to identify how case planning decisions were made, such as placement decisions, contact arrangements, cultural planning, educational and employment decisions. There was rarely a formal record of whether, and if so how and when, information was provided to relevant people including the child/young person, carers, parents and other service providers. Occasionally the fact that information or a document was provided to someone was mentioned in case notes or in the Affidavit filed in court. Even when, as in the Annual Review format, there was provision to formally record that the document had been provided to individuals this was rarely or incorrectly completed. The back page of the “Child Concern/Protection Report” that was intended to provide feedback to a Mandated Reporter, was only completed in 49 instances in the sample, and there was no record of completion on CHYPS or indeed if the mandated reported had been notified of the intended response by C&P. 60 Who is looking out for the Territory’s children? 11.3 Discussion The failure to record information thoroughly meant that it was not always evident that new information received was incorporated into and viewed within the context of existing information, such as previous CCCP reports, so that an accurate and current assessment of the child’s/young person’s circumstances could be made. The sensitive nature of information necessarily collected and recorded as part of child protection work makes the need for staff awareness about confidentiality and privacy extremely relevant. For this reason it was very concerning there was an unacceptable number of misfiled documents on files which related to other individuals who were not connected with the particular child/young person being reviewed. In addition, on occasions, incorrect information was recorded about a child/young person or their family that could have had implications for the decisions made in relation to those particular children/young people. However it was clear that predominantly the physical files reviewed were not a complete record of the case. In addition, it appeared that some information, such as hand written notes, were not retained at all as it was rare to find any contemporaneous notes of events such as interviews with people. Thorough, accurate, timely and accessible record keeping of relevant information provides the best opportunity for well informed and transparent decision making. Importantly the decision maker must clearly identify the information used in arriving at a recommended response and must provide sufficient information about the decision making process that others can scrutinise that process. As part of that ‘transparency’ the file should record who else has provided, and been provided with, information relating to the assessment and decision making. Records should be dated (including year) and include the author’s name, title and signature and identify other people present or involved (full names and titles if appropriate). Records should state why the record has been created and its, or the information it records, intended use. Records should state to whom they have been given, when and why, and the use of headings and numbering can help to make documents easier to read and understand. 11.4 Summary Where there was documentary information on file, such as from third parties e.g. medical records, supervised contact reports, police information; there was rarely any record to reflect that this information had been ‘read and considered’ as part of the assessment and decision making process in relation to a child’s/ young person’s circumstances. It sometimes became apparent, from reading C&PS reports etc, that information had been ‘factored in’ to 61 Who is looking out for the Territory’s children? an analysis of a child’s/young person’s situation, but most files did not record when specific information had been received and when it had been read. By recording that information has been considered and some comment as to the nature and impact of that information, the reader is more confident about the integrity of decisions that are made. From the perspective of case work in child protection, this should enhance the opportunity for well informed, transparent case planning. Well maintained client records facilitate good case supervision and review and provide the best opportunity for well managed and recorded action plans. Ideally, this approach to file keeping would reduce ‘case drift’. The Record Keeping Guide specifically states that: “shared drives on your computer including CHYPS and TRIM are not record keeping systems. These are merely storage areas. The normal practice is that electronic records on these drives should be printed and placed on file.” It is important to be able to confirm that all appropriate information has been provided to relevant people. 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