The government should enact a new Care Safety Act and include any legislative measures required to establish a national care safety regulatory framework and to give effect to the Inquiry’s recommendations, in particular and at a minimum:
A new comprehensive National Care Safety Strategy, required by law, on the prevention of and response to abuse and neglect in care should include: goals, objectives and targets that consider future generations.
The government should establish a new standalone Care Safe Agency, with an independent Board to oversee it. The Care Safe Agency should be tasked with functions that include:
The independent Care Safe Agency should be required to report annually to a parliamentary select committee on the implementation of the Inquiry’s recommendations and its other functions.
Before the independent Care Safe Agency is established, the government should review the roles, functions and powers of other government agencies involved in the care system to identify and address any duplications or gaps.
Until the Care Safe Agency is established, as an interim measure the government should enable the new Care System Office responsible for implementing the Inquiry’s recommendations (Recommendations 123- 124) to perform the functions in Recommendation 41 above, so far as is practicable.
The government should review all legislation and regulations relating to the care of children, young people, and adults in care to identify and address any inconsistencies, gaps or lack of coherence in the relevant statutory regimes.
The State, faith‑based entities (including indirect care providers) and others involved in the care system should be guided by the following Care Safety Principles for preventing and responding to abuse and neglect when making decisions, performing functions or exercising powers and duties in relation to the care of children, young people and adults in care:
The government should:
The government should:
create a system for the accreditation of all State and faith-based entities providing care directly or indirectly for children, young people or adults in care.
provide in legislation that, unless a State or faith-based entity providing care directly or indirectly is accredited, it will not be allowed to operate and will be penalised in a manner consistent with Recommendation 47.
The government should:
The leaders of all State and faith‑based entities providing care directly or indirectly should ensure there is effective oversight and leadership of safeguarding at the highest level, including at governance or trustee level where applicable.
The leaders of all State and faith‑based entities providing care directly or indirectly should ensure that safeguarding is a genuine priority for the institution, key performance indicators are in place for senior leaders, and sufficient resources are available for all aspects of safeguarding.
All State and faith‑based entities providing care directly or indirectly should ensure they collect adequate data on abuse and neglect in care and regularly report to the governing bodies or leaders of each institution, based on that data, so they can carry out effective oversight of safeguarding.
The government should:
The government should:
create a system for the accreditation of all State and faith-based entities providing care directly or indirectly for children, young people or adults in care.
provide in legislation that, unless a State or faith-based entity providing care directly or indirectly is accredited, it will not be allowed to operate and will be penalised in a manner consistent with Recommendation 47.
The government should:
The leaders of all State and faith‑based entities providing care directly or indirectly should ensure there is effective oversight and leadership of safeguarding at the highest level, including at governance or trustee level where applicable.
The leaders of all State and faith‑based entities providing care directly or indirectly should ensure that safeguarding is a genuine priority for the institution, key performance indicators are in place for senior leaders, and sufficient resources are available for all aspects of safeguarding.
All State and faith‑based entities providing care directly or indirectly should ensure they collect adequate data on abuse and neglect in care and regularly report to the governing bodies or leaders of each institution, based on that data, so they can carry out effective oversight of safeguarding.
All State and faith‑based entities providing care directly or indirectly should ensure they collect adequate data on abuse and neglect in care and regularly report to the governing bodies or leaders of each institution, based on that data, so they can carry out effective oversight of safeguarding.
The senior leaders of all State and faith‑based entities providing care directly or indirectly to children, young people and adults should take active steps to create a positive safeguarding culture, including by:
All State and faith‑based entities providing care directly or indirectly should have safeguarding policies and procedures in place that:
The government should create a system of professional registration for all staff and care workers who are not already covered by a professional standards regime. The Care Safe Agency should be empowered to establish and maintain standards of training, conduct and professional development and with the power to enforce these through fitness to practice procedures. The government should consult on the scope and nature of the professional registration system and phase in the introduction of the system.
The government should:
All State and faith‑based entities providing care directly or indirectly to children, young people and adults in care should ensure all prospective staff, volunteers and any other person working with children, young people or adults in care (‘prospective staff’) have a satisfactory report from the applicable vetting regime and up to date registration status.
All State and faith‑based entities providing care directly or indirectly to children, young people and adults in care should ensure their pre‑employment screening checks include:
The Care Safe Agency should develop a workforce strategy for the care sector that includes:
All State and faith‑based entities providing care directly or indirectly to children, young people and adults in care should recruit for and support a diverse workforce, including in leadership and governance roles, so far as practicable reflecting the care communities they serve and care for.
The government should create a system of professional registration for all staff and care workers who are not already covered by a professional standards regime. The Care Safe Agency should be empowered to establish and maintain standards of training, conduct and professional development and with the power to enforce these through fitness to practice procedures. The government should consult on the scope and nature of the professional registration system and phase in the introduction of the system.
All State and faith‑based entities providing care directly or indirectly to children, young people and adults in care should ensure that the same rules and standards in relation to vetting, registration, training and working conditions that apply to employees, apply equally to volunteers or others with equivalent access to children, young people and adults in care, and in particular, faith‑based entities should ensure the same rules apply to people in religious ministry and lay volunteers as to employees.
All State and faith‑based entities providing care directly or indirectly to children, young people and adults in care and relevant professional registration bodies should ensure they have appropriate policies and procedures in place to respond in a proportionate way to complaints, disclosures or incidents of abuse and neglect,
Where a complaint has been substantiated, State and faith‑based entities providing care directly or indirectly and relevant professional bodies should take steps to ensure the person or people responsible are held accountable, including:
All State and faith-based entities providing care directly or indirectly and relevant professional registration bodies should report all complaints, disclosures, or incidents to the Care Safe Agency, whether substantiated or not substantiated following investigation.
The government should enable, in legislation, the Care Safe Agency to collate and keep a centralised database of complaints, disclosures or incidents of abuse and neglect of children, young people and adults in care, for the purposes of:
The government should introduce legislation where necessary to create a coherent mandatory reporting regime which:
The government should prioritise and accelerate current work to close care and protection residences, which perpetuate the institutional environments and practices that led to historic abuse and neglect in care.
The government should, as a priority, support and invest in the development of disability and mental health, educational and youth justice models of care that do not perpetuate the institutional environments and practices including segregation that led to historic abuse and neglect in care.
The government should take steps to ban pain compliance techniques in any care setting for children, young people and adults in care.
The government should ensure there are adequate frameworks in place to govern the use of restrictive practices for children, young people and adults in care to minimise the use of those practices (ensuring they are used only as a last resort) and provide for adequate safeguards and checks.
The government should prioritise and accelerate work to minimise and eliminate solitary confinement in all care settings as soon as practicable, with an emphasis on person‑centred and culturally appropriate approaches to reduce the use of solitary confinement safely.
All State and faith‑based entities providing direct or indirect care to children, young people and adults should review physical building and design features to identify and address elements that may place children, young people and adults in care at risk of abuse and neglect. This should include: consideration of how best to use technology such as CCTV cameras and body cameras without unduly infringing personal privacy, including taking into account any applicable guidance documents and the legal requirements for the collection of personal information under the Privacy Act 2020.
The government should: provide sufficient investment to enable children, young people, and adults in care to have access to an independent advocate of their choosing to support them to understand and exercise their rights, specifically: each child, young person and adult in care and protection, youth justice, disability and mental health settings should have access to an individual independent advocate.
The Care Safe Agency should develop a career pathway for people with previous lived experience of care towards becoming an independent advocate.
All State and faith-based entities providing care directly or indirectly should seek the best possible understanding of the background, culture, needs and vulnerabilities of every child, young person, and adult in their care, and should include the protection and enhancement of the mana and mauri of Māori in care.
The government and all relevant decision‑makers should review existing policy, standards, and practice to ensure that all involuntary care placements are suitable and support connection to whānau and community. This includes placements being located as close as reasonably practicable to the family or whānau of the children, young person or adult in care.
All State and faith‑based entities providing care directly or indirectly should review existing policies and practice to ensure they promote and support the maintenance of connections and attachment to family and whānau wherever possible and appropriate.
All State and faith‑based entities directly or indirectly providing care to children, young people, Deaf, disabled people, and people who experience mental distress should adopt and comply with best practice guidelines for record keeping and data sovereignty
All State and faith‑based entities providing care directly or indirectly to children, young people or adults should, together with the person in care, document an account of their life during their time in care.
All State and faith‑based entities providing care directly or indirectly to children, young people or adults should be required to retain records relating to alleged abuse and neglect in care for at least 75 years in a separate central register, to allow for delayed disclosure and redress claims or civil litigation.
The government should consider, in consultation with the Privacy Commissioner, whether existing information sharing provisions are sufficient to enable adequate sharing of information to prevent and respond to abuse and neglect in care, or whether additional tools are needed. This work should consider the recommendations of the Australian Royal Commission into Institutional Responses to Child Sexual Abuse, “establishing a national information exchange scheme across sectors”. The purpose of the review should be to ensure all bodies (whether State or non-State) providing care to children, young people or adults can access the information they need to prevent and respond to abuse and neglect. The review should consider, among other things, whether non-State bodies should be empowered to share information more readily with both State and non-State bodies to prevent and respond to abuse and neglect.
The government should:
The government should ensure that there are no unreasonable barriers preventing all responsible oversight bodies from investigating complaints, proactively monitoring the care system, and collaborating as appropriate to enable a whole of system view, including:
The responsible oversight bodies should:
The government should take all practicable steps to ensure the ongoing safety of children, young people, and adults in care at Gloriavale.
The government should establish a Care System Office later to become the Ministry for the Care System that:
The new Care System Office should be responsible for:
The government and faith-based institutions should take any and all
actions required to give effect to the Inquiry’s recommendations set
out in this report and the Holistic Redress Recommendations in He
Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui,
including changes to investment, public policy, legislation or regulations,
operational practice or guidelines.
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