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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 Chapter 10, 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.