PART 2.2 DEPARTMENT OF CHILD, YOUTH AND FAMILY SERVICES CHILD CARE SERVICES

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1 PART 2.2 DEPARTMENT OF CHILD, YOUTH AND FAMILY SERVICES CHILD CARE SERVICES

2 Executive Summary Under the Child Care Services Act (the Act), the four Regional Health Authorities (RHAs) are responsible for the day-to-day administration of the provisions of the legislation within each region with respect to the licensing and monitoring of child care services in the region. The Department of Health and Community Services (the Department) had overall responsibility for child care services in the Province (responsibility was assumed by the new Department of Child, Youth and Family Services during 2009). As at January 2009, there were 170 licensed child care centres throughout the Province and 68 family child care homes. Of the 68 family child care homes, 57 were affiliated with 2 agencies (Eastern and Western), and 11 were in regions without agencies or directly licensed by the RHAs. In total there were 6,032 available spaces for child care, comprised of 5,621 at child care centres and 411 at family child care homes. Although the Department and the four RHAs have made progress in implementing our previous recommendations relating to licensing and monitoring of child care services in the Province, our current review indicated that there are still issues within the child care services as follows: Monitoring - Child Care Centres Policies at the Department of Health and Community Services require that RHA officials make monthly visits where possible to child care service providers and formally evaluate each provider at least annually or more frequently if the situation requires. Our review of 34 files from the four RHAs identified the following deficiencies: Operators In 14 files there were 28 instances relating to child care centre operators where files did not contain the required documentation or evidence that the requirements were waived by the Regional Director as follows: 1 - no evidence that the application had been approved; 7 - no evidence of a current Level II Certification for Child Care Services; 6 - no evidence of a current first aid certification; Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

3 9 - no evidence of a current Child Protection Records Check; and 5 - no evidence of a current Certificate of Conduct. Staff In 13 files there were 30 instances relating to 79 staff at child care centres where files did not contain the required documentation or evidence that the requirements were waived by the Regional Director as follows: 5 - no evidence of a current Early Childhood Education Certification for Child Care Services; 7 - no evidence of a current first aid certification; 7 - no evidence of a current Child Protection Records Check; 8 - no evidence of a current Certificate of Conduct; and 3 - no evidence of a record of immunization. Two additional files did not contain a staff summary document which is used to identify staff and monitor all of the required documentation along with expiry dates. Inspections There were 8 instances where there was no evidence that the required annual inspections by RHA officials had been performed. The annual inspections were not performed as follows: 3 - Eastern (Urban); 2 - Central; and 3 - Western. Only 1 RHA (Central) had a preprinted form detailing all of the areas that were required to be checked during the monthly visits. The other 3 RHAs used a preprinted form which only had a section for comments and actions required. As a result, the 3 RHAs could not readily demonstrate that all areas were checked as required. Violations In 11 files there were 14 instances where RHA officials did not issue violation orders even though there was a non-compliance with the Act and Regulations. These instances included such things as: 38 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

4 in 2 instances an employee had been on site without a current Child Protection Records Check; a recurring issue identified during three visits to a centre over a four month period, where there were limited or no files maintained for children at the centre; a homeroom lead staff did not have the required Level I Certification for Child Care Services; equipment and materials were blocking a centre s emergency exit; at one centre a medicine cabinet was not locked; no documentation on file for substitute staff working at the centre; and at one centre children were being taken for walks without first aid kit/supplies. Licensing of Child Care Centres Contrary to the Act and Regulations, child care centres did not always submit, within the timeframes prescribed, applications and documentation specified for licensing and continuing operation. Our review of 34 files from the four RHAs identified the following deficiencies: in 15 files the centres applied for licence renewal after the 60 day minimum notice prior to licence expiry. Centres applied for licence renewal from 2 days to 58 days prior to licence expiry; in 9 files there was no evidence on file during our review to show evidence of current liability insurance; and in 1 file there was no evidence of follow-up during the licensing process to determine whether the centre met the condition of having all medications in a locked container. Family Child Care Homes The Act and Regulations outline a number of application requirements relating to the issuance of a licence to operate a family child care home. Our review of 13 files for family child care homes for three RHAs (Labrador- Grenfell had no family child care homes) identified the following issues with regards to family child care homes affiliated with licensed child care agencies: Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

5 in 1 file there was no evidence of an application for renewal of approval; and in 6 files the facilities submitted renewal applications dated after the date of expiration on the prior approval. In these cases, the facilities operated without approval for between 2 days and 28 days. Background The Child Care Services Act (the Act) and Child Care Services Regulations provide the legislative framework for control over the provision of child care services in the Province. Under the Act, child care refers to the care and supervision of a child for a part of a day by a person other than the child s parent, guardian, relative, other caregiver, or a person employed by one of these individuals to care for the child in the child s home. For purposes of the Act, children may be cared for in either: a licensed child care centre which is defined as a location other than a home and has a maximum enrolment of 60 children; a licensed family child care home which is defined as a provider s home which has a maximum of 8 children; or an approved family child care home which is defined as a provider s home which has a maximum of 8 children and affiliated with one of the two licensed child care agencies (Eastern and Western) in the Province. Family child care homes with less than 5 children are not required to be licensed; however, they can be licensed if they so choose. As Figure 1 shows, as at January 2009, there were 170 licensed child care centres throughout the Province and 68 family child care homes. Of the 68 family child care homes, 57 were affiliated with 2 agencies (Eastern and Western), and 11 were in regions without agencies or directly licensed by the RHAs. The Figure also shows there were a total of 6,032 available spaces for child care, comprised of 5,621 at child care centres and 411 at family child care homes. 40 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

6 Figure 1 Child Care Services Number of Centres and Family Homes As at January 2009 Region Child Care Centres Number of Centres Spaces Available Family Child Care Homes Number of Homes Spaces Available Eastern (Urban) 101 3, Eastern (Rural) Total - Eastern 112 4, Central Western Labrador-Grenfell Total 170 5, Source: The Department of Health and Community Services Note 1: 30 of these homes report to the Family and Child Care Connections Family Child Care Agency and 1 reports to the Regional Health Authority Note 2: 27 of these homes report to the Family Outreach Resource Centre Family Child Care Agency and 2 report to the Regional Health Authority Note 3: These homes report directly to the Regional Health Authority The Department of Health and Community Services (the Department) had overall responsibility for child care services in the Province (responsibility was assumed by the new Department of Child, Youth and Family Services during 2009). There is a Provincial Director of Child Care Services at the Department, who is required to review, monitor and update child care policies, establish standards and qualifications for persons involved in child care delivery, and determine licensing and facility requirements. Under the Act, each of the four Regional Health Authorities (RHAs) may appoint a regional director of child services who is responsible for the day-to-day administration of the provisions of the legislation within each region, with respect to the licensing and monitoring of child care services in the region. The regions are shown in Figure 2. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

7 Figure 2 Regional Health Authorities Child Care Regions The Department of Government Services, based on an agreement with the Department of Health and Community Services and the four RHAs, is responsible for conducting inspections of all licensed child care facilities. Under the agreement, inspectors located at the various Government Service Centres are responsible for conducting fire and life safety, and environmental health inspections for the facilities. 42 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

8 Results of our previous review In 2003 we completed a review of child care services and identified several significant findings as follows: There were instances where child care facilities were issued licences even though the licensing requirements were either not met or did not continue to be met. Neither of the two family child care agencies (St. John s and Western) operating in the Province at that time were licensed. Monitoring of child care services was not always performed in accordance with policy. Violation orders were not always issued on a consistent basis for significant breaches of the Act. The required annual fire and life safety, and environmental health inspections were not always conducted by the Department of Government Services. Audit Objectives and Scope Audit objectives The objective of our review was to determine whether the Department had adequate systems and processes such that: applicants approved for child care licences met the application requirements of the Child Care Services Act and Regulations; and licensees were monitored to assess their compliance with the Child Care Services Act and Regulations. Audit scope Our review covered the period of 1 April 2007 to 31 August We completed our review in November Our review included discussions with Departmental and RHA officials, and an examination of files from the four RHAs across the Province to determine whether child care facilities operated and were monitored in accordance with the Child Care Services Act and Regulations. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

9 Detailed Observations This report provides detailed audit findings and recommendations in the following sections: 1. Licensing of Child Care Centres 2. Monitoring of Child Care Centres 3. Family Child Care Homes Files were selected for review from the four RHAs. Figure 3 shows the number of samples selected for each RHA along with the number of child care centres and family child care homes associated with each RHA. Figure 3 Child Care Services Sample Distribution Child Care Centres Family Child Care Homes Region Number of Centres Number of Samples Number of Family Homes Number of Samples Eastern (Urban) Eastern (Rural) Total - Eastern Central Western Labrador-Grenfell Total Source: The Department of Health and Community Services as at January Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

10 1. Licensing of Child Care Centres Overview The Child Care Services Act and Child Care Services Regulations outline a number of application requirements relating to the issuance of a licence to operate a child care service. These requirements include such things as: completed application form, information on licensee, a copy of the certificate of incorporation (if applicable), floor plans, municipal approval, insurance policy with required clauses, child program submission, and information relating to the Operator. In order for the facility to operate, fire and life safety, and environmental health inspections must be completed by Government Services. In addition, approval is required from the Director of Child Care Services. See Appendix A for a summary chart of findings. Licensing issues: Eastern (Urban) We reviewed the files of 21 centres in the Eastern (Urban) region to determine whether licensing requirements had been met. We identified the following issues: 10 of the 21 centres applied for licence renewal after the 60 day minimum notice required for a licence renewal submission. Application dates ranged from 3 to 56 days prior to expiration; 5 of the 21 centres did not contain evidence of current liability insurance. The policies on file expired between 15 January 2009 and 4 July 2009 and no evidence of renewal was on file as of 31 August 2009; and 3 of the 21 centres had instances where conditions had been placed on the approval of the licence, and there was no evidence on file to indicate that adequate follow-up had been performed. Instances included inadequately qualified staff and an unlocked medicine cabinet. Licensing issues: Eastern (Rural) We reviewed the files of 2 centres in the Eastern (Rural) region to determine whether licensing requirements had been met. We identified the following issue: 1 of the 2 centres had an instance where a condition had been placed on the approval of a licence, and the condition had not been met. The licensee was required to meet set nutrition guidelines and subsequent visits to the centre indicated that the requirement was not being met. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

11 Licensing issues: Central We reviewed the files of 5 centres in the Central region to determine whether licensing requirements had been met. We identified the following issue: 3 of the 5 centres applied for licence renewal after the 60 day minimum notice required for a licence renewal submission. Application dates ranged from 46 to 52 days prior to expiration. Licensing issues: Western We reviewed the files of 4 centres in the Western region to determine whether licensing requirements had been met. We identified the following issues: 2 of the 4 centres applied for licence renewal after the 60 day minimum notice required for a licence renewal submission. Application dates were both 26 days prior to expiration; and 3 of the 4 files did not contain evidence of current liability insurance. The policies on file expired between 15 May 2008 and 27 July 2009 and no evidence of renewal was on file as of 31 August Licensing issues: Labrador- Grenfell We reviewed the files of 2 centres in the Labrador-Grenfell region to determine whether licensing requirements had been met. We identified the following issue: 1 of the 2 files did not contain evidence of current liability insurance. The policy on file expired 3 November 2007 and no evidence of renewal was on file as of 31 August Recommendations The Department should ensure that: child care centres submit all required documentation and applications specified for the licensing and relicensing processes within the timeline prescribed by the Act and Regulations; and documentation required for continued licensing, such as insurance policies and Government Services inspections, continue to be updated and maintained. 46 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

12 2. Monitoring of Child Care Centres Overview After a child care licence is issued, each of the RHAs is required to monitor the licensees to determine whether they operate in accordance with the requirements of the Child Care Services Act and Child Care Services Regulations. The Act provides various compliance and enforcement options. These enforcement options include issuing a violation order, issuing a varied licence, suspension or cancellation of a licence, and refusal to renew a licence. The Department of Health and Community Services has developed policies outlining the monitoring activities that must be undertaken to determine whether child care service providers operate in accordance with the requirements of the Act and Regulations. These policies include the requirement to make monthly visits where possible to child care service providers and to formally evaluate each provider at least annually or more frequently if the situation requires. These visits are carried out primarily by social workers, although child care consultants are also part of the process and work to help ensure adequate programs are in place. We reviewed files from across the Province and found that while the monitoring process has improved in recent years, there are still a number of deficiencies. See Appendix A for a summary chart of findings. Based on our review, we made the following observations on: 2A. Operator Documentation 2B. Staffing Information 2C. Inspections 2D. Visitations/Violation Orders 2A. Operator Documentation Introduction The operator of a child care centre serves as the onsite manager and director of the facility. An operator requires prior approval of the Director of Child Care Services for the region and must meet a higher level of qualifications than a standard employee. Operators are responsible for developing and delivering a specialized child care program. Documentation and approval of the operator must be in place at the time of licensing, and the RHA is required to ensure that up to date credentials for the operators are maintained at all times. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

13 When approving an operator, the RHA requires that individuals submit an application, meet requirements of Level II Certification for Child Care Services, have a current first aid certification, a current Child Protection Records Check, a current Certificate of Conduct, and a record of immunization. In certain circumstances, the educational and work qualifications may be waived by the Regional Director. Operator issues: Eastern (Urban) We reviewed the files of 21 child care centres in the Eastern (Urban) region to determine whether operator information was collected and monitored by the RHA. We identified the following issues: 1 of the 21 files did not contain an application form on file for the operator. The application form provides for the approval of the operator by the Regional Director. As a result, we could not determine if the operator had the required credentials; 6 of the 21 files did not contain documentation that the operator had current Level II Certification for Child Care Services. This certification must be renewed every three years. In addition, 1 of the 6 files indicated that prior to the current operator, the centre did not have a qualified operator managing the centre for 6 years. A prior licensing condition required the operator to complete their Level II Certification for Child Care Services. This condition was applied in 2002 and continued until a new operator took over in 2008; 7 of the 21 files did not contain documentation that the operator had a current Child Protection Records Check. This documentation is required by all centre employees and requires renewal every three years; 5 of the 21 files did not contain documentation that the operator had current first aid certification. This documentation is required by all centre operators and requires renewal every three years; and 4 of the 21 files did not contain documentation that the operator had a current Certificate of Conduct. This documentation is required by all centre employees and requires renewal every three years. Operator issues: Eastern (Rural) We reviewed the files of 2 child care centres in the Eastern (Rural) region to determine whether operator information was collected and monitored by the RHA. We did not identify any issues. 48 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

14 Operator issues: Central We reviewed the files of 5 child care centres in the Central region to determine whether operator information was collected and monitored by the RHA. We identified the following issues: 1 of the 5 files did not contain documentation that the operator had current Level II Certification for Child Care Services. This certification must be renewed every three years; 1 of the 5 files did not contain a current Certificate of Conduct for the operator. This documentation must be renewed every three years; 1 of the 5 files did not contain documentation that the operator had current first aid certification. This documentation is required by all centre operators and requires renewal every three years; and 1 of the 5 files did not contain a current Child Protection Records Check for the operator. This documentation must be renewed every three years. Operator issues: Western We reviewed the files of 4 child care centres in the Western region to determine whether operator information was collected and monitored by the RHA. We identified the following issue: 1 of the 4 files did not contain evidence of a current Child Protection Records Check. Operator issues: Labrador- Grenfell We reviewed the files of 2 child care centres in the Labrador-Grenfell region to determine whether operator information was collected and monitored by the RHA. We did not identify any issues. 2B. Staffing Information Introduction Child care centres, when hiring, are required to ensure that staff: meet requirements of early childhood education; have appropriate security documents; and provide immunization records. All of this information should be readily accessible on site at the child care centre. In certain circumstances, the educational and work qualifications may be waived by the Regional Director. RHA officials have staff summary sheets that track all staff information, along with expiry dates. These staff summary sheets are required Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

15 to be kept up to date as part of the monthly visit routine and are needed to determine whether individuals with access to children under the care of the centre meet the requirements of the Act. Staff issues: Eastern (Urban) We reviewed the files of 21 child care centres in the Eastern (Urban) region to determine whether staff information was collected and monitored by the RHA. We identified the following issues: 5 of the 21 centre files did not contain evidence to show that a total of 24 staff had a current Child Protection Records Check; 6 of the 21 centre files did not contain evidence to show that a total of 18 staff had current First Aid Certification; 3 of the 21 centre files did not contain evidence to show that a total of 10 staff had immunization records on file; 6 of the 21 centre files did not contain evidence to show that a total of 11 staff had a current Certificate of Conduct; and 5 of the 21 centre files did not contain evidence to show that a total of 11 staff had a current educational certification for the position they were holding. Staff issues: Eastern (Rural) We reviewed the files of 2 child care centres in the Eastern (Rural) region to determine whether staff information was collected and monitored by the RHA. We did not identify any issues. Staff issues: Central We reviewed the files of 5 child care centres in the Central region to determine whether staff information was collected and monitored by the RHA. We identified the following issues: 2 of the 5 centre files did not contain evidence to show that a total of 2 staff had a current Certificate of Conduct on file; and 2 of the 5 centre files did not contain evidence to show that a total of 2 staff had a current Child Protection Records Check. 50 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

16 Staff issues: Western We reviewed the files of 4 child care centres in the Western region to determine whether staff information was collected and monitored by the RHA. We identified the following issue: 1 of the 4 centre files did not contain evidence to show that 1 staff had a current first aid certification. Staff issues: Labrador- Grenfell We reviewed the files of 2 child care centres in the Labrador-Grenfell region to determine whether staff information was collected and monitored by the RHA. We identified the following issue: neither of the 2 centre files contained any staff summary sheets. Therefore, it cannot be determined if the centres staff meet the required qualifications or have provided the required documentation. 2C. Inspections Introduction Child care centres are required to undergo annual inspections from the Department of Government Services for annual fire and life safety, and environmental health inspections. These inspections are also required as part of both the licensing and re-licensing process. Additionally, social workers and child care consultants from the RHAs are required to complete annual inspection reports on each centre. Inspection issues: Eastern (Urban) We reviewed the files of 21 child care centres in the Eastern (Urban) region to determine whether the required annual inspections were carried out. We identified the following issues: 1 of the 21 files did not contain evidence that an annual inspection was completed by the social worker in the last year; and 2 of the 21 files did not contain evidence that an annual inspection was completed by the child care consultant in the last year. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

17 Inspection issues: Eastern (Rural) We reviewed the files of 2 child care centres in the Eastern (Rural) region to determine whether the required annual inspections were carried out. No issues were identified. Inspection issues: Central We reviewed the files of 5 child care centres in the Central region to determine whether the required annual inspections were carried out. We identified the following issue: 2 of the 5 files did not contain evidence that an annual inspection had been completed by the social worker in the last year. Inspection issues: Western We reviewed the files of 4 child care centres in the Western region to determine whether the required annual inspections were carried out. We identified the following issue: 3 of the 4 files did not contain evidence that an annual inspection was completed by the social worker in the last year. Inspection issues: Labrador- Grenfell We reviewed the files of 2 child care centres in the Labrador-Grenfell region to determine whether the required annual inspections were carried out. No issues were identified. 2D. Visitations/Violation Orders Introduction Where possible, RHA officials are required to visit centres on a monthly basis to ensure that the centres are operating in accordance with the Act and Regulation. When violations of the Act or Regulations are identified at a centre, it is subject to a formal violation being issued by the RHA. All violations must be posted at the centre for minimum of 30 days, in an area so that it is displayed to all visitors. Where a situation is deemed to be less severe or a one-time occurrence verbal warnings (documented on files), written notice, and formal warning letters may be issued to the centre. Severe violations that endanger child safety or repeated violations may result in revocation of licence or financial penalties of up to $5,000. While complaints from parents or employees are a source of investigation, the primary responsibility for identifying centre issues is with inspectors through the monthly visitations they perform. 52 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

18 Generally, formal violations are issued in situations where there is a demonstrated lack of supervision, staff-child ratio not maintained, lack of safety documentation (Certificate of Conduct and Child Protection Records Check), breaches related to infant care, and repeated breaches of the Act and Regulations. Figure 4 provides statistics on the number of violation orders issued during the period 1 April 2007 to 31 August Figure 4 Child Care Centre Violation Statistics For the Period 1 April 2007 to 31 August 2009 Over Licence Capacity Health, Safety, Cleanliness Missing Staff Documentation Violation Order Classification Licence Conditions Ratio Exceeded Unsupervised Children Failure to Report Incident Misc Total Region Eastern (Urban) Eastern (Rural) Central Western Labrador -Grenfell Total Source: Regional Health Authorities As Figure 4 shows, from 1 April 2007 to 31 August 2009, 78 violation orders were issued. Examples of the violations include: 5 violation orders were issued for instances related to health and safety or cleanliness at the centre. For example, at one centre there were cleaning supplies accessible to children, screens missing from windows, fire drills not completed, and an unsanitary changing area. 25 violation orders were issued for instances where complete documentation was not on file for centre staff. For example, a current Child Protection Records Check or Certificate of Conduct had not been obtained by centre staff. 5 violation orders were issued for instances where licence conditions were not met. For example, one centre failed to meet licence conditions regarding providing age appropriate materials for children, another centre exceeded the licensed age range. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

19 8 violation orders were issued for supervisory issues. For example, two instances where a child was able to leave the centre unobserved and had to be searched for; in one of these situations the centre was issued an additional violation for failing to notify the RHA of the incident. 6 violation orders were issued for instances where an incident/injury report was not completed when warranted. Two of these were issued in relation to supervisory issues noted above. 12 violation orders were issued for miscellaneous offenses such as operating for 2 days without a licence, incomplete child registers, inappropriate methods of discipline, and having a child care staff member under the age of 18. Our review indicated that when violation orders were issued, there was adequate support that proper protocol was followed. However, the policy was inconsistently applied. We identified instances where we felt a violation order should have been issued but was not. Violation issues: Eastern (Urban) We reviewed the files of 21 centres in the Eastern (Urban) region to determine whether violation orders were issued in accordance with policy when warranted. We identified the following instances where a violation order should have been issued but was not: an employee had been on site without a current Child Protection Records Check; reoccurring issues concerning limited or no files for the children at a centre were indentified during three visits to the centre over a four month period; at one centre, the insurance policy had been outstanding for 3 months and employee files did not contain all required documentation; a homeroom lead staff did not have the required Level I Certification for Child Care Services; at one centre, there was no documentation on file for an individual working at a child care centre; 54 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

20 issues with staff documentation missing and certifications not being met were identified during two visits to a centre over an eight week period; at one centre, personal information relating to children was not being kept in a secure location; a reoccurring issue was identified during three visits to a centre over a five week period where the centre was not posting the Act or Regulations in a public area that was accessible to parents; at one centre, an employee was working without a current Child Protection Records Check; at one centre, equipment and materials blocked a centre s emergency exit; at one centre, a medicine cabinet was not locked; and at one centre, during two visits, no documentation was on file for substitute staff working at the centre. Violation issues: Eastern (Rural) We reviewed the files of 2 of the centres in the Eastern (Rural) region to determine whether violation orders were issued when warranted. We did not identify any significant instances where a violation order should have been issued but was not. Violation issues: Central We reviewed the files of 5 of the centres in the Central region to determine whether violation orders were issued when warranted. We did not identify any significant instances where a violation order should have been issued but was not. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

21 Violation issues: Western We reviewed the files of 4 of the centres in the Western region to determine whether violations orders were issued when warranted. We identified the following instances where a violation order should have been issued but was not: children were being taken for walks without first aid kit/supplies; and a staff member was on site without having obtained a Child Protection Records Check. Violation Issues: Labrador- Grenfell We reviewed the files of 2 of the centres in the Labrador-Grenfell region to determine whether violation orders were issued when warranted. We did not identify any significant instances where a violation order should have been issued but was not. Monthly visit forms Only 1 RHA (Central) had a preprinted form detailing all of the areas that were required to be checked during the monthly visits. The other 3 RHAs used a preprinted form which only had a section for comments and actions required. As a result, the 3 RHAs could not readily demonstrate that all areas were monitored as required. Recommendations The Department should ensure that: all required documentation is on file for the operators as required by the Act and Regulations; all centre staff in contact with children meet the requirements of the Act and Regulations; annual inspections by social workers, consultants, and Government Services are performed and documented as required by the Act and Regulations; and violation orders are issued in accordance with the Act and Regulations when warranted. 56 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

22 3. Family Child Care Homes Introduction Private homes used by individuals to provide child care for up to six children under the age of twelve, are required to be licensed by the Province as family child care homes. Two regions, Eastern (Urban) and Western, have licensed agencies responsible for approving and monitoring the family child care homes. In all other regions, the RHA is responsible for licensing and monitoring of family child care homes. The agencies are licensed under the same conditions as child care centres. No issues were found with licensing and monitoring of the two agencies. The Child Care Services Act and Child Care Services Regulations outline a number of application requirements relating to the issuance of a licence to operate a family child care home. These requirements include such things as: completed application form; information on provider; floor plans; municipal approval and adequate insurance policy. In order for the facility to operate, fire and life safety, and environmental health inspections must be completed by Government Services. In addition, approval is required from the Director of Child Care Services. Findings We reviewed the files of 13 family child care homes in the Province to determine whether there were any issues relating to licensing or the monitoring of facilities. We identified the following issues with regards to family child care homes affiliated with licensed child care agencies: 6 of the 13 facilities submitted renewal applications dated after the date of expiration on the prior approval. Applications are required to be submitted a minimum of 60 days prior to expiration. Application dates ranged from 2 to 28 days after prior approval expired. 1 of the 13 files did not contain any application for renewal of approval. Figure 5 shows a summary of findings related to the family child care homes reviewed. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

23 Figure 5 Child Care Services Summary of Findings Family Care Homes Sample Eastern Urban Renewal Deadline Approval Issues No Renewal Application on File Total Issues Home 1 0 Home 2 X 1 Home 3 X 1 Home 4 X 1 Home 5 0 Home 6 0 Sub-Total Central Home 7 0 Sub-Total Western Home 8 X 1 Home 9 0 Home 10 X 1 Home 11 X 1 Home 12 X 1 Home 13 0 Sub-Total Total Issues Recommendation The Department should ensure that all required documentation is on file for family child care homes and providers as required by the Act and Regulations. 58 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

24 Department s Response Introduction The Department agrees that improvements can be made to ensure that legislated requirements are met. As a line department with direct management of this service, the formation of the new Department of Child, Youth and Family Services (CYFS) will strengthen the ability to monitor and audit program activities The Department wishes to note that in the AG s 2003 report the following were identified and have been addressed by the Province: The two Family Child Care Agencies in the province are licensed. Annual reports specific to Child Care Services are provided by the regions and include information on monitoring visits by regional staff and information on violations of the legislation. Informational materials on regulated/unregulated child care services have been prepared and widely distributed. All complaints of alleged illegal child care are investigated if sufficient information is provided by the referral source. A risk assessment tool has been developed and will be implemented in the near future to provide more consistency in actions taken by the Regions when standards are not being met by child care centres. The recommendations in the AG s 2009 report have been addressed below in the same order as they appear in that document. 1. Licensing Child Care Centres [page number] Recommendation: The Department should: ensure that child care centres submit all required documentation and applications specified for licensing and re-licensing processes within the timelines prescribed by the Act and Regulations and Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

25 Response: The intent of this regulation is to allow the regional staff sufficient time to process the application before the existing licence expires. The regions make considerable efforts to remind licensees to submit their re-licensing documents according to the time frame required by the Child Care Services Regulations and avoid the risk of children and families being displaced. At no time was a centre without a licence due to the licensee s application being received less than 60 days prior to expiry of the existing licence. Recommendation: ensure that documentation required for continuing licensing such as insurance policies and Government Services inspections continue to be up-dated and maintained. Response: An audit tool was developed by the Department in consultation with the Regional Directors to assist with file monitoring at the field level and some regions are currently using this tool. The new Department of CYFS will develop a provincial quality system to monitor documentation required for licensing to verify compliance with requirements. Monitoring Child Care Centres [page number] Recommendation: The Department should ensure that: all required documentation is on file for the operators as required by the Act and Regulations all centre staff in contact with children meet the requirements of the Act and Regulations. Response: Child Care Services Regulations (Section 21) allows the Regional Director to waive qualifications and experience requirements under certain circumstances. There is no ability to waive the requirement for First Aid, Certificate of Conduct, Child Protection Records Check or immunization record. Annual inspection by a social worker is required to check for the proper documentation and that requirements are met in this area. Currently, 60 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

26 the Department requests regions to submit information once a year on the qualifications and experience of operators and staff in child care centres. This provides a snapshot in time to audit compliance with the requirements. It includes a section to capture information on situations where academic qualifications and/or experience has been waived and under what conditions. As part of the development of its provincial quality system, the new department will review this program area to determine appropriate strategies for monitoring. Recommendation: annual inspections by social workers, consultants and Government Services are performed and documented as required by the Act and Regulations. Response: It should be noted that the annual assessment includes a number of elements that can be assessed at different times throughout the twelve months. The Department s future monitoring system will allow verification that all components are completed as required. Recommendation: violation orders are issued in accordance with the Act and Regulations when warranted. Response: Regional Directors determine if a violation order should be issued and the decision is based on a number of considerations such as level and immediacy of risk to children; how often this particular non-compliance has occurred; the history of compliance of the centre or home. There is a variety of sanctions an inspector can use when a centre or family child care home is not in compliance with regulations. These include verbal warnings, written warnings, violation orders, varied license with conditions, and revocation of a license or refusal to issue a license. It is not clear from the report if the context surrounding each of the examples was considered when giving the opinion that a violation order should have been issued in a particular situation. To provide for more consistency in determining appropriate sanctions, a risk assessment process is being developed by the province. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

27 3. Family Child Care Homes Recommendation: The Department should ensure that all required documentation is on file for family child care homes and providers as required by the Act and Regulations. Response: The Department agrees with this recommendation which relates to licensing. The new Department of CYFS will develop a provincial quality system to monitor documentation required for licensing to verify compliance with requirements. Eastern RHA s (Urban) Response The following is provided in response to the recommendations of the Auditor General in his report on Child Care Services. AG Recommendation # 1 The Department should ensure that child care centers submit all required documentation and applications specified for the licensing and relicensing processes within the timeline prescribed by the Act and Regulations. EH Urban Response: This region is committed to working with licensees to ensure that child care centers continue to provide services for children and families with minimal disruption. Regional Child Care Services staff would prefer to receive the required documentation within the 60 day timeframe but recognize that this is not always possible for a variety of reasons. While provincial policy outlines that applications not received within 60 days of the expiry of a license may result in a disruption in service, this is not considered to be in the best interest of children and families by this region. Regional Child Care Services staff regularly communicate with licensees, and will do so again, to remind them of their responsibility under the provincial regulations to submit their application and accompanying documentation within the required timeframes. 62 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

28 AG Recommendation # 2 The Department should ensure that documentation required for continued licensing, such as insurance policies, and Government Services inspections continue to be updated and maintained. EH Urban Response: Regional Child Care Services staff are aware of the requirement to keep documentation for licensing up to date. Until recently, staff have been using a manual system to keep-in-view licensing requirements. During the past year, Regional Child Care Services staff have received training on the use of the provincial Client Referral Management System (CRMS) - Child Care Services Licensing module. This computer program is used to record all data related to a child care center, including expiry and review dates for inspections, reports, insurance policies, and incorporation documentation. The computer program tracks overdue items needing follow up and staff are expected to ensure that any documentation required for continued licensing is acquired. The region notes that all centers have up to date insurance coverage as required in provincial policy although it is acknowledged that a current copy was not always in the active file. This Auditor General review has highlighted the need to ensure staff maintain current copies of this documentation on the center active file. Communication with regional staff to ensure that copies of current insurance policies are placed on the center active file has occurred. No issues were raised in the Auditor General s report with respect to Government Services Inspections for this region. AG Recommendation # 3 The Department should ensure that all required documentation is on file for the Operators as required by the Act and Regulations. EH Urban Response: Provincial policy requires that the initial records and licensing application of the Operator are required to be kept on file at the regional child care services offices. In Eastern Health urban, a separate section of the child care center file is maintained for Operator information. When a center is relicensed and there is no change in Operator, the Operator information is to be copied and carried forward to the new licensing file. Regional Child Care Services staff have verified that that all required documentation had been obtained for the Operator documentation issues identified by the Auditor General but acknowledges it was not on the new licensing file. This review has highlighted Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January

29 the need to change a file management practice in the program and this will change immediately. AG Recommendation # 4 The Department should ensure that all center staff in contact with children meet the requirements of the Act and Regulations. EH Urban Response: This region acknowledges the importance of center staff meeting the requirements of the provincial Act and Regulations. Regional Child Care Services staff continue to work with centers to ensure they are aware of the provincial requirements regarding staff documentation and to implement a consistent process to ensure documentation, such as Certificates of Conduct, Child Protection Record Checks, Immunization records and First Aid Certificates, are completed as required. This documentation is to be maintained in the files at child care centers and is checked by Regional Child Care Services staff when they visit a center. Regional staff are then expected to update the Staff Summary forms. Due to frequent staff changes in some child care centers, Regional Child Care Services staff maintain updated Staff Summary forms on Eastern Health s computer network. The Auditor General s report has highlighted an important file management practice for the region which we are addressing. Regional Child Care Services staff have verified that required documentation was updated on the Staff Summary forms but updated hard copies were not on file. This review has highlighted the need to also have a hard copy placed on each center file to ensure an up to date hard copy is available at all times. Regional Child Care Services staff have been directed to change this practice immediately. AG Recommendation # 5 The Department should ensure that annual inspections by social workers, consultants, and Government Services are performed and documented as required by the Act and Regulations. 64 Annual Report, Part 2.2, January 2010 Auditor General of Newfoundland and Labrador

30 EH Urban Response: Since the fiscal year, Eastern Health has identified annual inspections as a key performance indicator for the Child Care Services program and is working towards 100% compliance within the timeframe outlined in provincial policy. The issue of inspections not being completed annually by Government Services Center officials was not identified as an issue for this region. AG Recommendation # 6 The Department should ensure that violation orders are issued in accordance with the Act and Regulations when warranted. EH Urban Response: Eastern Health acknowledges the importance of issuing violation orders when appropriate and as required. Over the past few years, the region has worked to develop consistent practices in the issuing of violation orders to centers and to communicate these practices to centers. The social worker is expected to make a determination whether a violation is needed or whether another means of addressing issues could be effective in changing the practices of the center. These include: providing support and direction to the center on how to address the issue, verbal warnings (documented in the file), written notice on a Visit Summary Form, and formal written warning letters to the operator and licensee. Recommendation # 7 The Department should ensure that all required documentation is on file for family child care homes and providers as required by the Act and Regulations. EH Urban Response: Since 2008, the agency responsible for approving family child care homes has implemented changes to its policies for family child care homes. Child care providers are expected to complete a new application when their original approval requires renewal. As a result of the Auditor General review, the agency will require that child care providers submit applications for renewal 60 days prior to the expiry of their approvals. Auditor General of Newfoundland and Labrador Annual Report, Part 2.2, January