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State Abuse Survivors aotearoa New Zealand

Care System Recommendations

Recommendation 45

Establishing a Care Safety Act

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:

  1. to embed the Care Safety Principles for preventing and responding to abuse and neglect in care (Recommendation 39)
  2. to require a National Care Safety Strategy to prevent and respond to abuse and neglect in care (Recommendation 40)
  3. to establish a new independent Care Safe Agency to lead and coordinate the care system, act as the regulatory agency, and promote public awareness of preventing and responding to abuse and neglect in care (Recommendation 41)
  4. to create a duty of care, and strengthen and clarify the accountabilities of all State and faith‑based care providers and staff and care workers (Recommendation 47)
  5. to provide for the creation of care standards (Recommendation 47)
  6. to provide for an accreditation scheme for care providers (Recommendation 48)
  7. to provide for the professional registration of staff and care workers (including volunteers) who are not otherwise subject to a professional registration scheme (Recommendation 57)
  8. to provide for penalties, sanctions and offences for State and faith‑based care providers and staff and care workers who fail to comply with statutory and non‑statutory standards of care (Recommendation 47)
  9. to provide for mandatory reporting (Recommendation 69)
  10. to provide for a comprehensive and strengthened pre‑employment screening and vetting regime for all staff and care workers (Recommendation 58).

Care system recommendations

Recommendation 40 - National Care Safety Strategy

Recommendation 41 - Establishing an independent Care Safe Agency

Recommendation 41 - Establishing an independent Care Safe Agency

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.

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Recommendation 41 - Establishing an independent Care Safe Agency

Recommendation 41 - Establishing an independent Care Safe Agency

Recommendation 41 - Establishing an independent Care Safe Agency

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:

  1.  whole of system leadership on preventing and responding to abuse and neglect in care

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Recommendation 42

Recommendation 41 - Establishing an independent Care Safe Agency

Recommendation 42

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.

Recommendation 43

Recommendation 43

Recommendation 42

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.

Recommendation 44

Recommendation 43

Recommendation 44

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.

Recommendation 46

Recommendation 43

Recommendation 44

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 Care Safety Principles

Recommendation 39

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: 

  1. Care Safety Principle 1: The care system should recognise, uphold and enhance the mana and mauri of every person in care: 
    1. each person in care lives free from abuse and neglect and their overall oranga (wellbeing) is supported in a holistic way.
    2. care providers understand and provide for each person and their unique strengths, needs and circumstances
    3. the importance of whānau and friendships is recognised and support from family, support networks and peers is encouraged, to enable people in care to be less isolated and connected to their community. 
    4. people in care are celebrated and nurtured.
  2. Care Safety Principle 2: People in care should participate in and make decisions affecting them to the maximum extent possible and be taken seriously: 
    1. people in care can participate in decisions that affect their lives, with the assistance of decision-making supports and / or an independent advocate they have chosen, where required.
    2. people in care can access abuse and / or neglect prevention programmes and information. 
    3. staff and care workers are aware of signs of abuse and / or neglect and facilitate ways for people in care to raise concerns.
    4. people who are currently or have previously been in care can participate in decision-making and policy-making about the care system.
  3. Care Safety Principle 3: Whānau and support networks should be involved in decision‑making processes wherever possible and appropriate: 
    1. connections between people in care and their whānau and support networks are actively supported, and whānau and support networks can participate in decisions affecting the person in care wherever possible and appropriate.
    2. care providers engage in open communication with whānau and support networks about their abuse and neglect prevention approach.
    3. whānau and support networks are informed about and can have a say in organisational and system‑level policy.
    4. whānau, hapū, iwi and Māori can participate in decision-making processes about their mokopuna and uri.
  4. Care Safety Principle 4: The State, faith‑based entities (including indirect care providers) and others involved in the care system should give effect to te Tiriti o Waitangi and enable Māori to exercise tino rangatiratanga:
    1. whānau, hapū, iwi and Māori exercise the right to tino rangatiratanga over kāinga and are empowered to care for their tamariki, rangatahi, pakeke Māori and whānau according to their tikanga and mātauranga
    2. the Crown actively devolves to Māori policy and investment decisions about the care system, design and delivery of supports and services for, and specific care decisions about, tamariki, rangatahi and pakeke Māori.
    3. until the realisation of principle 4(ii), Māori and the Crown should collaborate on policy and investment decisions about the care system, the design and delivery supports and services for, and specific care decisions about, tamariki, rangatahi and pakeke Māori. 
    4. tamariki, rangatahi and pakeke Māori who need care live as Māori and are connected to their whānau, hapū, iwi, whakapapa, whenua, reo and tikanga.
    5. wellbeing for tamariki, rangatahi and pakeke Māori is understood and supported through an ao Māori worldview, encompassing tapu, mana, mauri and wairua.
  5. Care Safety Principle 5: Abuse and neglect prevention should be embedded in the leadership, governance and culture of all State and faith‑based entities (and indirect care providers) involved in the care system, including government agencies, faith leaders, care providers and staff and care workers: 
    1. leaders across the care system champion the prevention of abuse and neglect in care. 
    2. prevention of abuse and neglect is a shared responsibility at all levels of the care system.
    3. governance arrangements in agencies and entities ensure implementation of measures to prevent abuse and neglect in care and there are accountabilities and obligations set at all levels.
    4. risk management strategies focus on abuse and neglect prevention. 
    5. codes of conduct set clear behavioural expectations of all staff and care workers.
  6. Care Safety Principle 6: Care providers should recognise, uphold and implement human rights standards and obligations, the Enabling Good Lives principles, and recognise and provide for diverse needs including Deaf, disabled people, and people experiencing mental distress: 
    1. people in care are supported and provided accessible information to understand their rights. 
    2. care providers have human rights standards embedded in their policies and practice.
    3. care providers understand people’s diverse circumstances and respond effectively to people who are at increased risk of experiencing abuse and / or neglect.
    4. Enabling Good Lives principles underpin all support for disabled people, including culturally appropriate support as determined by whānau hauā, tāngata whaikaha and tāngata whaiora, to enable and empower disabled people to live well, participate in their community without segregation or institutionalisation and make decisions about their lives.
  7. Care Safety Principle 7: Staff and care workers should be suitable and supported: 
    1. all stages of recruitment, including advertising and screening, emphasise the values of caring for people in care, safety of people in care and prevention of abuse and neglect.
    2. staff and care workers have regularly updated safety checks.
    3. staff and care workers receive appropriate induction and training and are aware of their responsibilities to prevent abuse and neglect, including reporting obligations.
    4. staff and care workers receive appropriate training to ensure they have cultural competency.
    5. education programmes for staff and care workers include units focused on understanding and preventing abuse and neglect in care.
    6. supervision and people management include a focus on preventing abuse and neglect.
  8. Care Safety Principle 8: Staff and care workers should be equipped with the knowledge, skills and awareness to keep people in care safe through continuous education and training: 
    1. staff and care workers receive training on the nature and signs of abuse and neglect in care.
    2. staff and care workers receive training on organisational and national abuse and neglect prevention policies and practices.
    3. staff and care workers are supported to develop practical skills in safeguarding children, young people and adults in care.
    4. staff and care workers have the appropriate cultural knowledge.
  9. Care Safety Principle 9: Processes to respond to complaints of abuse and neglect and neglect should respond appropriately to the person (e.g., child‑focused or young person‑focused or adult in care‑focused) in a timely manner: 
    1. everyone in care and their whānau and support networks have access to information, decision‑making supports to engage in complaints processes.
    2. care providers have complaint handling policies appropriate for the people in care which clearly outline roles and responsibilities, approaches for responding to complaints and obligations to act and report.
    3. effective complaints processes are understood by people in care, staff and volunteers and whānau and support networks and are culturally appropriate.
    4. complaints are taken seriously, responded to promptly and thoroughly, and reporting, privacy and employment law obligations are met.
  10. Care Safety Principle 10: Physical and online environments should minimise the opportunity for abuse and neglect to occur: 
    1. risks in online and physical environments are mitigated whilst upholding the right to privacy and ensuring wellbeing of people in care.
    2. online environments are used in accordance with organisations’ codes of conduct.
  11. Care Safety Principle 11: Standards, policy and practice should be continuously reviewed, including from time to time independently reviewed, and improved: 
    1. care providers regularly review standards, policy and practice to prevent and improve responses to abuse and neglect in care.
    2. complaints and concerns are analysed to identify systemic issues, both within organisations and within the care system as a whole.
    3. people who are currently or have previously been in care are enabled to participate in reviews of standards, policy, practice.
  12. Care Safety Principle 12: Policies and procedures should document how each care provider will ensure that people in care are safe: 
    1. safeguarding practice is prioritised and integrated throughout the organisation.
    2. policies and procedures embed safeguarding and abuse and neglect prevention measures.
    3. procedures are accessible and easy to understand.
    4. stakeholder consultation informs the development of policies and procedures.
    5. leaders champion and model compliance with policies and procedures.
    6. staff and care workers understand and implement the policies and procedures.

Care system safety standards recommendations

Recommendation 47

Recommendation 47

Recommendation 47

The government should: 

  1. establish a duty of care in the Care Safety Act that applies to all State and faith-based entities providing care directly or indirectly for children, young people and adults in care, and staff and care workers. 
  2. provide for the Care Safe Agency to set, monitor, and enforce consistent and comprehensive care safety rules and standards (legislated and non-legislated). 
  3. provide for a range of meaningful sanctions and penalties for individuals and State and faith-based entities providing care directly or indirectly for: 
    1. failure to comply with the duty of care under the Care Safety Act. 
    2. failure to comply with care safety rules and standards.
  4. provide for offences, including significant monetary fines and imprisonment, for the most serious failures to comply.

Recommendation 48

Recommendation 47

Recommendation 47

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.

Recommendation 49

Recommendation 47

Recommendation 49

The government should: 

  1. provide for the Care Safe Agency to investigate complaints or reports of abuse or neglect in the care of registered charities, rather than requiring a separate investigation into the same wrongdoing by Charities Services.
  2. provide for the Care Safety Act to require that registered charities that care for children, young people or adults in care must comply with care standards.
  3. provide for deregistration of a charity from the register as one of the available suite of sanctions for non‑compliance with care standards. 
  4. amend the Charities Act 2005 to ensure alignment with the Care Safety Act. 

Recommendation 50

Recommendation 50

Recommendation 49

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.

Recommendation 51

Recommendation 50

Recommendation 51

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.

Recommendation 52

Recommendation 50

Recommendation 51

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.

Care system safety standards recommendations

Recommendation 47

Recommendation 47

Recommendation 47

The government should: 

  1. establish a duty of care in the Care Safety Act that applies to all State and faith-based entities providing care directly or indirectly for children, young people and adults in care, and staff and care workers. 
  2. provide for the Care Safe Agency to set, monitor, and enforce consistent and comprehensive care safety rules and standards (legislated and non-legislated). 
  3. provide for a range of meaningful sanctions and penalties for individuals and State and faith-based entities providing care directly or indirectly for: 
    1. failure to comply with the duty of care under the Care Safety Act. 
    2. failure to comply with care safety rules and standards.
  4. provide for offences, including significant monetary fines and imprisonment, for the most serious failures to comply.

Recommendation 48

Recommendation 47

Recommendation 47

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.

Recommendation 49

Recommendation 47

Recommendation 49

The government should: 

  1. provide for the Care Safe Agency to investigate complaints or reports of abuse or neglect in the care of registered charities, rather than requiring a separate investigation into the same wrongdoing by Charities Services.
  2. provide for the Care Safety Act to require that registered charities that care for children, young people or adults in care must comply with care standards.
  3. provide for deregistration of a charity from the register as one of the available suite of sanctions for non‑compliance with care standards. 
  4. amend the Charities Act 2005 to ensure alignment with the Care Safety Act. 

Recommendation 50

Recommendation 50

Recommendation 49

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.

Recommendation 51

Recommendation 50

Recommendation 51

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.

Recommendation 52

Recommendation 50

Recommendation 51

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.

recommendations about safeguarding & Workforce

Recommendation 53

Recommendation 53

Recommendation 53

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.

Recommendation 54

Recommendation 53

Recommendation 53

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: 

  1. designating a safeguarding lead with sufficient seniority.

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Recommendation 55

Recommendation 53

Recommendation 55

All State and faith‑based entities providing care directly or indirectly should have safeguarding policies and procedures in place that:

  1. are consistent with the Care Safety Principles (Recommendation 39).

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Recommendation 56

Recommendation 56

Recommendation 55

  1. All State and faith‑based entities providing care directly or indirectly should have safeguarding policies and procedures that address, at a minimum:
  2. how the entity providing care directly or indirectly will protect children, young people and adults in care from harm.
  3. how the entity providing care directly or indirectly will comply with the applicable standards and principles.
  4. how people can make complaints about abuse and neglect to the entity, the Care Safe Agency or independent monitoring entities (Recommendation 65).
  5. how complaints, disclosures and incidents will be investigated and reported, including reporting to the Care Safe Agency, professional bodies or NZ Police and other authorities (Recommendation 65).
  6. the protections available to whistleblowers and those making good faith notifications of abuse and neglect.
  7. how the entity providing care directly or indirectly will use applicable information‑sharing tools.
  8. how the entity will publicly and regularly report on these matters.

Recommendation 57

Recommendation 56

Recommendation 57

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.

Recommendation 58

Recommendation 56

Recommendation 57

The government should:

  1. provide in the Care Safety Act for a comprehensive and consistent pre‑employment screening and vetting regime, so that all entities seeking to engage a person to care for children, young people or adults in care (whether as an employee, contractor, volunteer or otherwise and whether in a State or faith‑based institution providing care directly or indirectly context) have timely access to comprehensive information to ensure the person is safe and suitable for the relevant role.
  2. ensure the regime for children’s worker safety checking remains fit for purpose.
  3. consider whether to introduce a barring regime like that established by the Safeguarding Vulnerable Groups Act 2006 in the United Kingdom.

recommendations about safeguarding & Workforce

Recommendation 59

Recommendation 61 - Care Sector Workforce Strategy

Recommendation 59

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.

Recommendation 60

Recommendation 61 - Care Sector Workforce Strategy

Recommendation 59

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:

  1.  thorough reference checks, including asking direct questions about any concerns about the applicant’s suitability to work with children, young people or adults in care.
  2. employment interviews that focus on determining the applicant’s suitability to work with children, young people or adults in care.
  3. critically examining an applicant’s employment history and / or written application (for example to identify and seek an explanation for gaps in employment history, or to explain ambiguous responses to direct questions about criminal history).
  4. verifying the applicant’s identity, education and qualifications.
  5. assessing the ability of caregivers, including foster parents and volunteers, to build relationships and provide consistent, sensitive and responsive care, including being able to meet the cultural needs of the people they care for.

Recommendation 61 - Care Sector Workforce Strategy

Recommendation 61 - Care Sector Workforce Strategy

Recommendation 61 - Care Sector Workforce Strategy

The Care Safe Agency should develop a workforce strategy for the care sector that includes:

  1. ensuring there are enough people with the right skills, experiences and values to meet the needs of people in care including developing strategies to address skill gaps.

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Recommendation 62

Recommendation 62

Recommendation 61 - Care Sector Workforce Strategy

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.


Recommendation 63

Recommendation 62

Recommendation 63

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.

Recommendation 64

Recommendation 62

Recommendation 63

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.

recommendations about Responsiveness

Recommendation 65 - Complaints

Recommendation 65 - Complaints

Recommendation 65 - Complaints

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,

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Recommendation 66

Recommendation 65 - Complaints

Recommendation 65 - Complaints

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: 

  1. professional disciplinary action
  2. reporting to the relevant professional registration body or bodies.
  3. reporting to the Care Safe Agency.
  4. reporting to NZ Police
  5. reporting in accordance with any other applicable information sharing or mandatory reporting obligations.

Recommendation 67

Recommendation 65 - Complaints

Recommendation 67

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.

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Recommendation 68

Recommendation 68

Recommendation 67

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: 

  1. reinvestigation, if considered necessary or appropriate.
  2. having a whole‑of‑system view to ensure that: 
    1. proven perpetrators cannot move between geographic locations, professions or care settings without detection.
    2. people subject to multiple unsubstantiated complaints from different geographic locations, professions or care settings can be identified and steps taken if considered proportionate and appropriate.
  3. creating an evidence base and undertaking data analysis to create new insights into perpetrator behaviours, which can in turn inform new prevention and response strategies and practices.

Recommendation 69

Recommendation 68

Recommendation 69

The government should introduce legislation where necessary to create a coherent mandatory reporting regime which: 

  1. applies to all State or faith‑based entities providing care directly or indirectly to children, young people and adults in care.
  2. applies to all staff and care workers who work for the entities, outlined in (a) above, including foster parents, volunteers, chief executives, trustees, board members, clergy and lay people and people in religious ministry who receive disclosures of abuse and neglect during religious confession.
  3. ensures obligations are clear, consistent, established in legislation and should include protections from liability for those making good faith notifications.
  4. ensures access to timely advice on reporting obligations.

Recommendation 70

Recommendation 68

Recommendation 69

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.

recommendations Minimising Institutional environments

Recommendation 71

Recommendation 71

Recommendation 71

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.

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Recommendation 72

Recommendation 71

Recommendation 71

The government should take steps to ban pain compliance techniques in any care setting for children, young people and adults in care.

Recommendation 73

Recommendation 71

Recommendation 73

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.

Recommendation 74

Recommendation 74

Recommendation 73

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.

Recommendation 75

Recommendation 74

Recommendation 75

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.

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Recommendation 76

Recommendation 74

Recommendation 75

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.

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recommendations to empower people in care

Recommendation 77

Recommendation 77

Recommendation 77

The Care Safe Agency should develop a career pathway for people with previous lived experience of care towards becoming an independent advocate.

Recommendation 78

Recommendation 77

Recommendation 77

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.

Recommendation 79

Recommendation 77

Recommendation 79

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.

Recommendation 80

Recommendation 81 - Record-Keeping Principles

Recommendation 79

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.

Recommendation 81 - Record-Keeping Principles

Recommendation 81 - Record-Keeping Principles

Recommendation 81 - Record-Keeping Principles

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

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Recommendation 82

Recommendation 81 - Record-Keeping Principles

Recommendation 81 - Record-Keeping Principles

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.

recommendations about monitoring care systems

Recommendation 83

Recommendation 83

Recommendation 83

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.

Recommendation 84

Recommendation 83

Recommendation 83

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.

Recommendation 85

Recommendation 83

Recommendation 85

The government should: 

  1. review the roles, functions and powers of independent monitoring and oversight entities to identify and address any unnecessary duplication and encourage collaboration.
  2. consolidate the existing care and protection and youth justice independent monitoring and oversight entities into a single entity.

Recommendation 86

Recommendation 88 - Gloriavale

Recommendation 85

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: 

  1. reviewing and addressing any barriers or constraints in the entities’ enabling legislation.
  2. ensuring the entities are adequately resourced.


Recommendation 87

Recommendation 88 - Gloriavale

Recommendation 88 - Gloriavale

The responsible oversight bodies should: 

  1. investigate complaints about care workers, State and faith-based care providers and / or the Care Safe Agency, including both proactive and reactive site visits.
  2. proactively monitor the way in which State and faith-based care providers and the Care Safe Agency investigate and respond to complaints
  3. proactively monitor the care system, including collaboratively to ensure a whole of system view, as appropriate.
  4. publish reports on their activities including on the outcomes of specific investigations or other monitoring functions.
  5. share information with the Care Safe Agency, including: 
    1. data, statistics and other information about the prevalence and nature and extent of abuse and neglect in care.
    2. insights about abuse and neglect in care including the effectiveness of different practices to prevent and respond to abuse and neglect in care.
    3. refer the results of their investigations and other monitoring functions to enforcement or regulatory bodies including NZ Police, the Charities Commission or the Care Safe Agency.

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Recommendation 88 - Gloriavale

Recommendation 88 - Gloriavale

Recommendation 88 - Gloriavale

The government should take all practicable steps to ensure the ongoing safety of children, young people, and adults in care at Gloriavale.

Recommendations to estblish a care system office

Recommendation 123

Recommendation 123

Recommendation 123

The government should establish a Care System Office later to become the Ministry for the Care System that:

  1. is independent from, and has no association with, the government agencies currently involved in the care system (including those involved in historic claims processes and in implementing the Holistic Redress Recommendations in the Inquiry’s interim report He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui).
  2. is set up within one of the central agencies (the Treasury, Te Kawa Mataaho Public Service Commission or the Department of the Prime Minister and Cabinet) as a departmental agency 
  3. does not employ senior officials or middle management who have been involved in the care system as described in (a) above.

Recommendation 124

Recommendation 123

Recommendation 123

The new Care System Office should be responsible for: 

  1. leading the implementation of 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.
  2. eading and coordinating the work of government agencies involved in the care system.
  3. establishing and then monitoring the independent Care Safe Agency
  4. providing advice on the content of the Care Safety Act (Recommendation 45) and then administering the new Act.
  5. providing whole of system advice to government on the care sector, settings and system.

Recommendation 125

Recommendation 123

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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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