Quality of care

Introduction

The theoretical and research-informed literature on residential care is quite consistent in the assessment of what contributes to a high quality of care in out-of-home placement settings. Given the ubiquity of attachment issues, trauma and post-traumatic stress, and lived experiences of abuse, neglect and abandonment, the core ingredient of meaningful, effective and ethical care in residential settings is the presence of strong caregiver-young person relationships (Brendtro, 2015; Fewster, 2014; Garfat, 2008; Gharabaghi & Stuart, 2013; Smith, Fulcher & Doran, 2013). Virtually all therapeutic approaches to care in out-of-home settings reinforce the critical importance of relational practice, and the closely associated presence of empathy, as building blocks for developmental assets and resilience (Phelan, 2015; Ungar, 2002; 2004). Some researchers, and some advocates, have argued compellingly that especially in the context of young people facing adversity, quality of care cannot be understood fully outside of the context of love, a fundamental developmental need and entitlement of children and adolescents (PACY, nd.; Ungar, 2015). A comprehensive child welfare handbook on resilience with a strong Canadian focus but contributions from global scholars, provides multiple contexts of resilience promotion in child welfare, all linked to relational practices and a strong expression of caring and love (Flynn, Dudding, & Barber, 2006).

Historically, quality of care considerations have for more than a century been tied to the emotional context of living away from home, and the necessity for human connection and a sense of belonging. Jane Addams wrote about this in 1909 in the context of Hull House, a settlement community in Chicago; Janus Korczack (1925) described his institutional home for young Jewish boys in Poland in the 1920s and 1930s in the context of love, rights, and youth participation; August Aichhorn used relational connections and fostering belonging in his work with ‘Wayward Youth’ in the 1930s; Fritz Redl and David Wineman (1957) identified the necessity of relationships and empathy in residential care in their work in Detroit in the late 1940s; and Bruno Bettelheim called for a Home for the Heart in 1974.

Currently, the Panel notes that there are no consistent mechanisms embedded in residential services across sectors that ensure the highest possible quality of care for children and youth, notwithstanding efforts on the part of many service providers to improve quality of care on an on-going basis. In recent years, MCYS has commissioned several initiatives to improve the quality of specific aspects of residential care, such as food and cultural competence (Healthy Eating Matters, 2008a; Achieving Cultural Competence, 2008b). Across all residential services, the government-operated licensing process serves to ensure compliance on the part of residential operators based on a set of standards that cover physical upkeep of the residence, completeness of client files, and the overall compliance of policy and procedures with Ministry standards (MCYS, 2015c). Youth justice custody facilities have additional licensing standards specific to that sector. There is broad agreement amongst MCYS staff, service providers and young people that the licensing process is neither designed to nor does it in practice measure quality of care.

A second mechanism in place in much of the children and youth mental health sector and some of the privately operated residential services is the accreditation process. While this process is generally seen as a quality improvement process, there is limited evidence that it in fact serves to improve quality in residential services, and research literature related to accreditation and its role in quality improvement shows mixed results. The Panel was unable to confirm differences in the quality of services provided based on whether or not an organization is accredited, and noted that organizations with the same level of accreditation appear to have variable capacity to deliver high end services. Furthermore, several agencies in the children and youth mental health sector, as well as CAS or society-operated residential services and most private service providers are not in fact accredited (Alkhenizan & Shaw, 2012; Bell, Robinson, & See 2013; Coll, Sass, Freeman, Thobro, & Hauser, 2013).

The everyday experience of young people in out-of-home care is impacted first and foremost by the quality of care provided in residential services. Such quality of care is a function of a wide range of factors that include the quality of human resources, the relationships among young people and between young people and care givers, the physical infrastructure of residential programs, the appropriateness of program routines, rules, and activities, and also the quality and accessibility of food, the attention to identity and developmental growth, the levels of physical and emotional safety, and the on-going connections to family, kin, friends and community (Anglin, 2003; Burns, 2006; Cairns, 2002; Smith, 2009). At the level of every day experience for young people living in residential services, the Panel was particularly impacted by the many stories of young people outlining rules, routines and program structures that appear archaic, controlling and compliance-focused, and bear little resemblance to the otherwise empathetic and friendly mission and vision statements of residential service providers. The general themes in these stories were often confirmed by observations by CAS workers with placements and licensing specialists with experience in a range of group homes.

At this time, the Panel notes that there are no universal, or even common, set of indicators, standards or concepts that might lend themselves to the measurements of quality of care in residential services across sectors, although some indicators are commonly utilized in specific service sectors (American Association of Children’s Residential Centers, nd). Given the rich diversity of service providers, it is not inherently problematic that measurement of universal indicators across sectors is limited, although the Panel believes that some foundational indicators can be articulated (see Indicators). More concerning is the incongruence between what organizations say they do and what is observable at the level of everyday experience.

In developing a framework for ensuring excellence in quality of care with the appropriate oversight, the Panel seeks to ensure that residential services are engaged in on-going quality improvement activities, while at the same time are subject to a much more transparent and accountable system of validating their claims related to quality of care.

The Panel is especially interested in significantly increasing transparency of quality of care issues in residential services. Families, young people themselves, and placing agencies and workers currently have very little meaningful information about quality of care in any given residential setting upon which to base a placement decision. The current service system has evolved without appropriate oversight, accountability or incentives to consistently focus on quality of care considerations and the everyday experiences of young people living in out-of-home care.

Issues

Models of residential care provision vary considerably across Ontario. Some service providers have invested significantly in introducing evidence-based practices, while others have engaged in iterative processes to learn from their own experiences. Service providers range in size from one-program organizations to multi-service, multi-site agencies with considerable human resources and physical infrastructure. In group care contexts, the implementation of evidence-based practices has been challenging. The Panel heard from many young people and also from front line staff that the philosophies, values and approaches embedded in evidence-based practices are not readily evident in every day experience of residential care. Some young people indicated a lack of empathy, personal attention, and meaningful engagement as symptomatic of their experience in group care settings. Staff members in group homes were at times unable to explain their approach to practice, and made few references to any particular theoretical framework, evidence-based practice or purposeful strategy in their work. In many cases, service providers, including supervisors themselves, were unable to articulate any supervision model that might assist and support front line staff in their complex work.

Perspectives from young people

Although not all youth the Panel spoke with were dissatisfied with the quality of care they were receiving, the Panel found that young people with extensive exposure to group care were most distressed about their experiences, regardless of whether these unfolded primarily within children and youth mental health residential treatment settings, CAS-operated group homes, or group homes operated by private residential service providers. Young people with mostly foster care experience expressed greater variation in the quality of their experiences, and in some instances reported very positive experiences. Nevertheless, most teenaged young people the Panel spoke with shared very negative experiences about either group care or foster care at some point in their lives, even if currently their experience was significantly more positive.

From the perspective of young people, many rules and regulations in group care settings appear unreasonable.

Examples of this include one service provider where young people are allotted a set amount of shampoo each month and then must pay for additional shampoo out of their allowance; in another setting, young people are required to spend inordinate amounts of time in their rooms without any direction of what to do during these times other than to occupy themselves quietly. Many young people we spoke to were concerned about their lack of access to the internet, and related hardware such as phones and tablets, pointing out that they are often left out of generationally ‘normal’ means of peer to peer communication. Youth also expressed major concerns about a lack of privacy in their lives, both in a physical context (no privacy for phone calls, peer to peer conversations, meetings with family members) and in a figurative context (no privacy for identity development, emotional ups and downs, sadness or other very personal experiences). Many young people expressed significant dissatisfaction with point and level systems in group homes, which they identified as very impersonal, objectifying ways of staff imposing control over them.

In the context of foster care, we heard stories from young people about being rejected because of their sexual orientation, discharged because of behaviour, left unsupervised, yelled at, not listened to, and in several instances being subjected to what was described as racism. In the context of residential treatment under the auspices of children and youth mental health centres, we heard many stories of having medications imposed without proper information about their purpose or their side effects, and we heard stories about restraints that young people deemed unnecessary, and levels of control and expectations of compliance that young people experienced as unhelpful. We also heard from foster parents about young people, and in particular First Nations youth, who were prohibited from speaking their language in a secure treatment context lest they were planning subversive activities. In general, young people’s understanding of treatment in a residential context related largely to medication and control. Of the nearly 300 young people the Panel spoke with, only very few, perhaps less than 10, connected treatment to a meaningful engagement with their families.

In the context of youth justice custody, the Panel encountered significant variations in young people’s descriptions of the quality of care they were experiencing. In a large, directly operated secure institution, the young people we spoke to were critical of much of the care they were receiving, and described their everyday experience as boring, not relevant to their needs, and discouraging in terms of their future prospects. In other (transfer payment) secure custody facilities, the Panel was surprised to hear from young people a high level of satisfaction and appreciation for the safety, care and empathy offered to them on a day-to-day basis. Based on conversations with youth, staff and management, the Panel noted that these facilities were all characterized by a highly developed understanding of relational child and youth care practice that permeated throughout all levels of human resources. In some instances, the level of creative program elements and youth engagement (including, for example, animal assisted initiatives and organized chess tournaments) impressed the Panel.

Transitions remain, as they have for many years, a major issue for young people in out-of-home care, whether these are transitions out of family and into care, transitions from one care setting to another, or transitions out of care and into emergent adulthood. The Panel found it troublesome that some features of such transitions that have been cited for decades as problematic continue to occur. This includes, for example, the use of garbage bags to transport young people’s belongings between placements. It also includes the lack of notice and preparation young people receive before being moved. In several cases, the Panel heard stories of young people being given no notice at all and instead being told they are moving only when the worker arrived to carry out the move. We heard of one young person being told that he would not be returning to his foster home on the return drive from summer camp, and he was moved into a new foster home right then and there. Some young people told us that they were tricked into believing that they were going out with their worker for lunch when instead they were moved from one placement to another. In the context of transitions out of care, young people overwhelming reported a lack of preparedness, insufficient supports and the very strong reactions to the loss of relationships with previous caregivers. While the Panel is encouraged by the MCYS investment in transition workers distributed across the province, and also by recent initiatives to support young people pursuing post-secondary education, much more needs to be done in this respect. Ultimately, the age of termination of funded residential service for young people in out-of-home placements, set at 18, may simply not be sustainable as the trend for the average age of young people in the general population leaving home continues to rise and is currently at 26 (Statistics Canada, 2015).

Perspectives about treatment and types of care settings

Based on targeted conversations with multiple service providers, the Panel found that residential services in Ontario are subject to a complex nomenclature that includes formal and informal designations such as residential treatment programs, specialized foster homes, treatment foster homes, intensive residential services, secure treatment, family-based care, family-based treatment and other terms (MCYS, 2015b). While some service providers have written statements about what they mean by treatment (Kinark, 2015), in its consultations, the Panel was unable to solicit a meaningful definition for residential treatment, and how it might be distinguished from other forms of residential care. Regardless of whether we asked executive management, front line staff, or young people themselves, descriptions of treatment rarely provided substantive comments beyond the imposition of structure and control on the one hand, and the availability of multiple disciplines on the treatment team on the other hand. No service provider we heard from distinguished between having multiple disciplines represented and offering an inter-disciplinary approach, suggesting that the concept of treatment currently remains somewhat nebulous in its meaning and application. Aforementioned references to evidence-based practices on the part of agency leaders were often not confirmed by front line staff, although there were some examples of a more thorough, and community-wide implementation of such practices in some instances, notably the Ottawa region where Collaborative Problem Solving has been introduced as a whole community framework for working with young people (Youth Services Bureau, 2015).

One element of critical importance in any therapeutic services context is the presence of excellent, consistent and meaningful supervision geared toward relational practice service settings with appropriate reflective and clinical content, including elements of supporting front line caregivers in the context of compassion fatigue, vicarious trauma, and self care. No service provider the Panel spoke with was able to identify a supervision model with any specificity; instead, the Panel heard vague references to performance management and case consultation in some service settings. The lack of emphasis service providers placed on the supervision process, and the apparent lack of supervisors with specific training in supervisory practices geared toward relational practice context is troubling.

The Panel explored in detail the residential services offered through a large children and youth mental health centre that focuses on assessment and treatment recommendations, and found that the residential services themselves appeared to be well regarded by young people, parents, as well as clinical and management staff. However, the services offered are short-term assessment services that end with clinical recommendations that parents told us can often not be implemented post-discharge. In spite of a very high level of parent satisfaction with the residential service itself, therefore, young people, parents or even the clinical and management staff could not confirm the usefulness of these services beyond the short term, and some parents suggested that the situation post-discharge became worse than pre-admission. Management and clinical staff readily acknowledged the lack of sustainability of outcomes of their residential service to be a major problem, but were unable to offer any solutions moving forward.

The various designations of other types of care settings often appeared somewhat ad hoc. We heard examples of treatment foster homes that were so called because one foster parent had earned an undergraduate degree in psychology in the 1960s; no other rationale was provided for referring to this home as a treatment foster home. Also, the Panel found a ‘family-based’ foster care that was teeming with paid shift staff, typically hired to work as one-to­one workers under Special Rate Agreements. We also met foster parents designated as Specialized Foster Homes who were themselves unable to explain in what ways their home was specialized. On the other hand, we also met foster parents designated as Regular Foster Care who were able to describe their approach to care in ways that far exceeded what we heard from treatment or specialized foster homes.

Perspectives on occupancy and population mix in group care

The maximum occupancy for group care programs outside of youth justice custody is dictated by the operator license issued by MCYS (MCYS, 2015c). In most cases, the Panel found that the maximum occupancy for group care programs ranges from a low of six to a high of 10, but can at times be as low as four and as high as 12 (MCYS indicated to the Panel that licensed occupancy ranges from a low of 3 to a high of 20, however, the Panel did not encounter these outliers and MCYS did not identify them). The Panel found significant variations in the occupancy trends across the group care sector (see Youth Justice for comments on open and secure custody). For example, occupancy in some children and youth mental health operated residential care is low and in private residential services, occupancy is high in some instances. However, the occupancies are falling in most cases, resulting in a rationalization of traditional privately operated group homes and an emergent trend for new, often unlicensed, smaller programs for young people with complex special needs. The Panel heard from both service providers and placing agencies that such unlicensed small programs are increasingly ubiquitous and provide an option for customized service for particularly challenging placement needs. The Panel is very concerned that such unlicensed programs often have untrained live-in staff supported by one to one workers under Special Rate Agreements, with limited oversight over quality of care or even safety considerations. The Panel notes that a young person died in one such program in Fall 2015 during a physical restraint.

The Panel heard consistently from all service providers that the profile of their clients has changed over the course of time, and all service providers without exception suggested that they serve only ‘the most complex young people in the system’, a phrase that was often followed up with ‘the ones that no one else is able to serve’. The logical improbability of these claims notwithstanding, the Panel is troubled by the mix of young people being served in group care. We found no evidence that group care programs are prepared for, qualified for, or in any way suitable for all of the clients they admit. During site visits at several agencies, the Panel encountered young people impacted by autism, FASD, developmental challenges, emotional disturbances, suicidal ideation, externalizing behaviours, various psychiatric disorders and also young people simply unable to receive care in their biological families all living together under the same program rules, routines, services, and supports, cared for by staff with limited training and pre-service education, and attending section 23 or private school programs on the premises or operated by the service provider in the community. While there is no comprehensive data available on client profiles in particular settings, the Panel believes that such a mix of young people is common practice across residential services. Further complicating the issue is what MCYS reports to be nearly 50% of youth beds being occupied by adults.

Explanations provided by management, supervisory or front line staff as to the relevance of therapeutic services to each of the young people residing in a particular program were altogether not compelling. CAS workers as well as case workers associated with young people identified as having complex special needs frequently used the term ‘warehousing’ as their way of describing the placements for the young people in their care. The Panel also received no meaningful explanation of how section 23 classrooms could meet the education needs and learning potentials of such a diverse group of young people.

Perspectives on violence and criminalization of young people

The Panel did not specifically focus its review on serious occurrences, and in particular physical restraints, nor on the issue of cross-over kids and youth, thus referred to because of their simultaneous involvement with child welfare/ children and youth mental health and youth justice. The Panel did hear from young people and from case workers that the criminalization of behaviour, and also the criminalization of young people impacted by autism, FASD and developmental challenges, continues to be concerning. During the Panel’s work, another major project was launched referred to as the Cross Over Kids Project, led by Dr. Judy Finlay from the School of Child and Youth Care at Ryerson University, and Justice Brian Scully from the 311 Court in Toronto. The preliminary work of this project, which is steered by a large community group involving all major youth serving sectors, MCYS, as well as a youth group representing lived experience as cross over kids, identified the on-going criminalization of young people in child welfare as a major concern (Finlay & Scully, 2016). The Panel supports the on-going work related to this project as a step forward in creating systemic change in this regard.

Also during the Panel’s work, the Provincial Advocate for Children and Youth, in association with Dr. Kim Snow from the School of Child and Youth Care at Ryerson University, undertook a review of serious occurrences in Ontario’s residential care sector (PACY, 2016). The preliminary results of this review, released to the Panel as documents of interest, indicate a troublesome level of violence in the form of physical interventions carried out by staff in some residential care settings and impacting in particular younger children and youth with significant developmental disabilities. Also during the Panel’s work, another young person died in an unlicensed residential program during a physical restraint. The Panel did review a series of child death inquests involving death by physical restraint and is deeply troubled by the repetitive and still unresolved recommendations for change from one inquest to the next (the Panel reviewed a total of eight inquests into the deaths of young people in care from 1998-2011).

Implications for recommendations

The Panel recognizes that no existing body or unit within either MCYS or the residential service system more generally is able to ensure that quality of care is a central component of system performance and accountability. As outlined in Governance, the Panel is therefore developing the concept of a Quality of Residential Care Branch/ Division, to be housed within MCYS, with functions that include the promotion of Quality of Care enhancement activities across sectors that specifically are focused on the one hand on the everyday experience of young people and a meaningful articulation and approach to measuring outcomes while on the other hand, on the trajectories of young people through the care system over time; the validation of any claims made by service providers about their strength and competencies, with both quantifiable and qualitative evidence to back up such claims; and a significantly more transparent approach to the public dissemination of Quality of Care activities, measures and performance pertaining to individual service providers across sectors.

The Panel believes that quality of care can only be ensured with strong oversight not only of the activities of individual residential programs, but also strong oversight of each young person’s journey through the care system, with rapid response and engagement in circumstances where placement changes occur, school changes may be necessary, or serious occurrence reporting may be indicative of quality of care problems. To this end, the Panel is developing recommendations that replace existing mechanisms such as crown ward reviews, agency-based reviews of private per diem operations where children and youth are placed, and licensing specialist checklist items vaguely related to quality of care with clearly identified functions in charge of overseeing and responding to placement or other activity in relation to young people across systems. In this context, the Panel is responding in particular to the experiences of young people who may enter out-of-home care through channels other than child welfare, such as youth justice custody or children and youth mental health, as well as young people who cross over some or all of these service sectors during their time in out-of-home care.

Young people’s voices are an important component of raising the quality of care in residential services (see Voice). The expertise that comes from the lived experience of young people, either current or retrospectively, must inform the design, governance and operation of the residential service system, and with respect to the Quality of Residential Care Division, must be a fully integrated component of all levels of work undertaken by the Division.

The Panel is developing a range of universal indicators designed to provide foundational evidence of quality of care considerations, such as the staff qualifications and professional development, supervision standards, the integration of young people’s voices, their engagement and participation in all levels of organizational activity, education and learning supports, family and community engagement activities, cultural competence and measures to embrace multiple identities, and others (See Indicators).

Given the differentiation of service providers across residential care sectors in Ontario, the Panel is developing a framework for validating the claims of service providers related to their strengths and competencies, with a view of limiting the exposure of young people to placements that are not well suited to meet their needs. All recommendations in this context will serve to ensure that young people receive the right service at the right time from the right service provider, based not on service provider rhetoric or marketing materials, but instead on information validated by the Quality Inspectorate, as part of the work of the Quality of Residential Care Branch/Division. To this end, service providers will be asked to produce a concept statement each year as part of their licensing renewal application (or new license application) that provides detailed information, in addition to evidence related to staff qualifications, on-going training and professional development, as well as data about client outcomes. Please refer to Appendix 2.

The Panel believes that the licensing process currently in place under the auspices of MCYS Regional Offices is an insufficient mechanism for accountability and performance enhancement with respect to quality of care. The introduction of the Quality Inspectorate serves to eliminate the licensing process as it currently exists and subsume some elements of that process into the quality inspection process instead. Some current licensing functions, such as measurable or identifiable compliance in the areas of physical infrastructure, human resources, and case file completeness, will continue to be performed as part of the Quality Inspection process. It should be noted that the position qualifications for the Quality Inspectors, and specifically the function of validating service provider claims about strengths and competencies, will be substantively different than the position qualifications for the current licensing specialist positions within regional offices. Therefore, a HR transition plan will be necessary in order to progress from current functions/qualifications to new recommended ones.

The Panel is seeking to mitigate the impact of a complex nomenclature that has developed within residential services over time without much consistency or system-wide context. To this end, recommendations related to the elimination of setting descriptors such as treatment, specialized or regular, and others are being developed in order to avoid inaccurate perceptions of service provision and to mitigate funding or per diem costing based on nomenclature rather than substantive evidence of a high quality of care with commensurate outcomes.