A boy found naked in the parking lot of a Saskatoon restaurant sparked an investigation by Saskatchewan’s advocate for children and youth into group homes.
The report from Lisa Broda paints a troubling picture of a former youth group home in Saskatoon.
“This report reflects issues found not only within a Ministry of Social Services’ contracted group home for cognitively challenged, and extremely vulnerable children, but also reveals insights into the group home system generally,” Broda states.
“The incident that launched our investigation led to a broader review that revealed significant systemic oversight issues in the ministry, many of which have been the subject of concern to the advocate for children and youth for some time.”
The initial incident
Elijah, 7, was found naked, frightened, and non-verbal by staff just before 5 a.m. in the parking of a Tim Hortons in the north end of Saskatoon on June 2, 2020.
Elijah is not the boy’s real name.
He was unharmed and staff called Saskatoon police, who eventually called Mobile Crisis Services. Elijah was then taken to the Ministry of Social Services.
Staff at the group home did not notice Elijah was missing until a shift change at 7:30 a.m. He was last seen between 3 a.m. and 4 a.m. by the lone staff member working the night shift.
It was later found that the staff member was required to complete hourly room checks during the night.
Including Elijah, there were four children living at the group home at the time.
Elijah was eventually returned to the group home the same day he went missing.
Among the deficiencies found at the time by Social Services were the lack of staffing, staffing not trained to meet complex care needs, internal organizational issues, insufficient physical security systems and medical needs not constantly being met.
“In the weeks following this incident, significant concerns surfaced about staff abuse and neglect, including serious medical neglect of another child in the home,” Broda’s report states.
A month later, on or about July 8, the ministry received new concerns about the group home.
Those concerns included “medical and physical neglect allegations involving five group home staff and affect all four children in the group home,” the report states.
A child protection worker assigned to the case found there was inappropriate discipline, egregious medical neglect resulting in one child requiring hospitalization, lack of staff training and internal dysfunction.
The worker also found that a senior staff member had not been forthcoming or honest with certain information during the investigation.
“An official from the company acknowledged to our office that it accepted the concerns found in this investigation, particularly with training deficiencies, however added that it took some time for group home staff to fully appreciate the complex care needs of these four children,” Broda’s report states.
“While acknowledging the compliance deficiencies found in the July 2020 investigation, the company reported it did not believe the Ministry fully appreciated all aspects of the dynamics in the home. The company’s regional office conducted a follow-up investigation and gained greater understanding about the level of discord that had developed in the home.”
By the end of the month, the company informed the Ministry of Social Services it would discontinue running the group home due to several factors, including difficulty recruiting staff.
The advocate for children and youth investigates
Broda says that given the company would no longer be operating the group home, there was no need to investigate the events that took place or the issues at the group home.
However, she says her office was interested in how the Ministry of Social Services reflects on its own responsibility and oversight provided to contracted group homes.
“Our office has received ongoing concerns relating to the quality of care in group homes generally, which have been monitored and addressed through our advocacy operations, in cooperation with the Ministry,” Broda states in her report.
“The advocate has deep and persisting concerns about whether the ministry’s current oversight mechanisms constitute a comprehensive framework supported by adequate resources that ensures the highest quality of care and outcomes for young people who reside in group home care.”
Among the concerns raised by Broda are inadequate or unhygienic infrastructure, lack of competent and motivated staff, lack of availability or poor quality service, poor compliance with policy standards, and poor documentation and uses of information.
Broda says ministry staff were involved with the group home from its opening through to conducting investigations.
“However, the advocate questions whether initial planning efforts in this case and in general are adequate to ensure group home infrastructure is set up to meet the needs of its intended residents,” she writes.
“As a result of its June and July investigations, the ministry added monitoring and supports but conveyed that these are interim measures rather than a systemic shift in how it provides oversight to its group homes overall.”
Of concern for Broda is the increase in the number of youth group homes in the province and whether the growth has impacted the ministry’s ability to provide quality support and oversight.
She found that the current oversight mechanism failed to identify issues in Elijah’s group home before those became a crisis.
“In considering why the ministry did not detect these problems before there was a crisis, the advocate considered whether the ministry’s oversight structure was sufficiently robust to proactively, not reactively, monitor the quality of care being provided to children placed in group homes,” the report states.
Broda found that when the ministry reacts to what is already a breakdown in the system, it makes recommendations that it does not effectively monitor.
“It is critical that any oversight approach to group homes is one that requires a streamlined, sustainable, and operational approach that is resourced properly to ensure the high standards of care to which children are entitled and to the safety and protection of which is their right,” she writes.
She also found that the ministry does not adequately plan, resource or provide ongoing supports to group homes.
In Elijah’s case, Broda says it reveals a lack of thorough planning and support that otherwise would have contributed to the success of the group home.
“Enhanced planning and resourcing geared to the unique needs of each group home, targeted training supports, and streamlined and responsive communication, is imperative to better equip group homes to meet the challenging and complex needs of children and ensure the group home environment is conducive to a child’s development.”
For kids like Elijah who are on the autism spectrum, Autism Services of Saskatoon said their care should be considered from the start.
“Ensuring that when that group home is opening that it may be that you have to front-end some extra resources in there than what’s typically going to be down the road,” explained executive director Lynn Latta.
Latta said there needs to be more training available for group home staff on how to work with autistic children.
Broda is making three recommendations based on the findings her office made during the investigation.
First, she is calling on the Ministry of Social Services to enhance and redesign its group home oversight and accountability structure.
She says it needs to incorporate a leadership role that is responsible for the effective oversight of group homes.
There also needs to be the development of comprehensive “evidence-based quality-of-care definitions and standards that promote proactive, not reactive, responses to the care of children.”
It also needs to include evidence of quality-of-care standards and provide sufficient human and financial resources to be proactive, not reactive.
“The advocate further concludes that in its current state, the ministry’s oversight scheme does not fully meet its parental obligations to vulnerable children,” Broda writes.
“Without taking more control over the desired outcomes, more children in group home care will languish and not realize their fullest potential.”
Secondly, Broda wants the ministry to develop a permanent resource for group operators, including points of contact and support.
Her third recommendation is for the ministry to enhance its process for approving group home openings.
Broda says this includes identifying and verifying staff qualifications, and examining the unique needs of the children who will live at the group home.
“The advocate strongly urges the ministry to take up the challenge to review and renew its structure, to properly resource the group home system, and to provide support, comprehensive oversight, and accountability, so that children and youth who are placed in group homes will have the quality of care expected from a ministry who stands in place of a parent.”
The Ministry of Social Services said it accepts the recommendations in Broda’s report.
“The ministry will provide the advocate with details on how we will strengthen our programs and services based on these recommendations in our formal response to the report in the coming weeks,” Tobie Eberhardt, acting assistant deputy minister child and family programs with the ministry, told Global News in a statement.
“We appreciate the vital work of the Office of the Advocate for Children and Youth, and their efforts to ensure the safety and well-being of Saskatchewan’s children and youth.”
The ministry declined to comment on the specifics of the case that led to the report, citing privacy concerns.