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Recommendations

1. Undue delay in dealing with allegations of abuse

Findings

  • long delays in the allocation of cases involving allegations of abuse to social workers;
  • long delays in contacting people who had made allegations;
  • long delays before interviews commenced with the person subject to an allegation of abuse and in concluding assessments, and
  • significant delays in responding to complainants. 

Recommendations

  • identify the necessary resource level to manage the current and expected caseload and ensure that sufficient qualified staff are recruited and in place to provide a timely service;
  • ensure that electronic case management systems are in place and properly used to provide high quality management information so that trends are identified and managed;
  • review case prioritisation to satisfy managers that the most urgent cases are dealt with expeditiously;
  • properly resource the complaint function as dealt with below.

2. Right to fair procedures and due process

Findings

  • in some instances, the subject of an allegation of abuse was not provided with details of the allegations made against them in writing;
  • in some instances, the subject of an allegation of abuse was not advised they could bring a support person to interview;
  • adequate notes were not taken during the interview process;
  • notes taken were not shared with the person subject to an allegation of abuse for verification purposes;
  • the name of the person who made anonymous allegations was withheld from the person subject to an allegation of abuse which is not in keeping with Tusla’s Policy and Procedures for Responding to Allegations of Abuse and Neglect (Tusla’s September 2014 Policy);
  • the subject of an allegation of abuse was not given a copy of Tusla’s September 2014 Policy so that they could understand the process which lay ahead.

Recommendations

  • finalise and publish Tusla’s September 2014 Policy by October 2017;
  • provide training to all social work staff on the policy;
  • regularly audit a sample of case files to ensure that the policy is being followed.

3. Notetaking and Record Keeping

Findings

  • notes taken during interviews were shredded before their contents were verified with the person subject to an allegation of abuse;
  • inadequate or inaccurate notes were taken during the interview process;
  • Tusla’s September 2014 Policy was not followed which sets out how social work notes should be recorded and maintained.

Recommendations

  • reinforce the requirements of good note keeping as part of the training package;
  • where issues relate to individual practice, training and other learning and development responses such as mentoring, coaching and performance management should be considered;
  • consider the introduction of audio recording to avoid disputes about the content of interviews;
  • interview notes to be retained at least until a typed note of the interview is agreed with the person subject to an allegation of abuse. There are situations where the notes may never be agreed by attendees, in which circumstances, a record of the meeting with a note of the points of dispute should be retained.

4. Communication

Findings

  • social workers in some cases did not demonstrate good communication techniques and appeared to lack empathy;
  • counselling services and support should have been offered (as per National Standards) once the fostering placement ended in an unplanned way;
  • confidential communications issued to an incorrect address on two occasions.

Recommendations

  • each social worker should be required to ensure that they have up to date contact details for each open case and that these details are validated through supervision;
  • the medium of communication (e.g. email only) should be agreed with the individual in advance;
  • training should be provided to social workers where there is evidence through complaints or otherwise that communications have not been at the expected standard, to include Data Protection obligations or when the National Standards for Foster Care have been breached.

5. Support and training for staff

 

Findings

  • Tusla’s Staff Supervision Policy was not properly implemented in light of the failure by staff in the case studies to follow Tusla’s Policy and Procedures for Responding to Allegations of Child Abuse and Neglect;
  • delay in the provision of training for staff when new policies are introduced;
  • no evidence to suggest that auditing is taking place with regard to the implementation of all Tusla policies.

Recommendations

  • require Area Managers to document the action taken when shortcomings are identified and to record the outcome of such action; 
  • the annual training plan to include training for all staff on new policies which have been introduced;
  • comprehensive case audits to take place to ensure that all policies are being followed and that the desired outcomes are being achieved.  Any shortcomings identified to be addressed through ongoing reviews of policies and procedures, support for individual staff members and training programmes.

6. Management and recording of complaints and complaint handling

Findings

  • complaints not dealt with in a timely way and complainants not updated in line with the relevant complaints policy;
  • the tone of the response in some Complaints Officers’ reports was overly defensive;
  • use of independent advocacy not considered to support complainants;
  • mediation could have been used to resolve complaints in some instances to assist local/informal resolution;
  • training in complaint handling not provided to Complaints Officers;
  • no mechanism for Complaints Officers to share the learning from complaints;
  • while staff were trained to use the National Incident Management System (NIMS) to record complaints, not all staff were actually using it;
  • social work records not reviewed as part of the examination of some complaints;
  • lengthy delays in assigning review officers to conduct reviews.

Recommendations

  • all complaints to be properly recorded on the NIMS;
  • the use of the NIMS to be evaluated to ensure that it is fit for purpose in respect of categorising complaints, managing complaints and identifying trends arising from complaints;
  • dedicated Complaints Officers to be appointed across the regions and properly trained;
  • quarterly casebooks to be prepared to share learning at local, regional and national level;
  • managers at all levels and the Board to have clear visibility of complaint outcomes and to take responsibility for developing action plans and monitoring implementation and successful outcomes;
  • consideration to be given to changing the complaints process to eliminate the review stage and encourage earlier access to the Ombudsman. This would require a statutory amendment. In the interim, the review stage should be properly resourced, and shortcomings identified in complaint handling at this stage be used as a source of learning;
  • advocacy services should be made available to assist complainants as required;
  • consideration should be given to the use of mediation to help resolve complaints locally in the first instance;
  • consideration should be given to the development of easier access for individuals to complain (e.g. through electronic means such as the development of apps or through social media).

7. Signposting to the Ombudsman

Findings

  • information about the right to seek a review following the examination of a complaint not provided in every case;
  • significant number of complainants not advised of their right to make a complaint to the Ombudsman.

Recommendations

  • all staff should be made aware of their obligation to comply with notification proceedings as set out in “Tell Us” (Tusla’s Complaints Policy) and to provide reasonable assistance to individuals as provided for under Section 4A of the Ombudsman (Amendment) Act 2012;
  • the text for such notifications should be agreed with the Ombudsman’s Office.

The Ombudsman wishes to acknowledge that Tusla has already commenced implementation of some of these recommendations. However, he intends to ask Tusla to develop an action plan in order to monitor the implementation of them all. The Ombudsman will review outcomes within a specified timeframe.

 

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