Province blasted in report prompted by discovery of non-verbal child in Saskatoon parking lot

Group home system lacks legislated standards of care and appropriate oversight that could have identified and prevented the alleged abuse and neglect in a Saskatoon home for disabled kids before their safety was put at risk, Child and Youth Advocate says

Saskatchewan Child and Youth Advocate Lisa Broda. Submitted photo.

The below story includes allegations of child neglect that might be upsetting to some readers

A scathing new report blasts the Ministry of Social Services for “significant systemic oversight issues” after a seven-year-old non-verbal group home resident was discovered naked and frightened in a Saskatoon Tim Hortons parking lot last June.

Staff arriving at work to open the store found the boy, identified in the report as Elijah (not his real name), at 5 a.m. His Lawson Heights group home didn’t notice his absence until 7:30 that same morning. He had last been seen in his room by a staff member conducting rounds between 3 and 4 a.m. The group home was 1 km away from the parking lot where Elijah was found.

The report, released by Child and Youth Advocate Lisa Broda Wednesday morning, looks into the events that led up to the June 2 incident and, while not examining the group home system as a whole, identifies symptoms of an underfunded, under resourced system without appropriate oversights or controls – oversights and controls, the report says, that could have identified issues with the group home in question before Elijah went missing.

Inspections were rare and didn’t look at standards of care, only compliance with procedures, she found, and staff didn’t have the training or resources required to care for intellectually-disabled children with complex needs.

Broda’s report credited the ministry with responding appropriately and both investigating and offering support to the home after the incident, but noted that those actions were all reactionary and temporary. Instead, she wrote, more needs to be done to establish standards of care and ensure they’re being met before lives of the most vulnerable are put at risk. 

Those standards, she said, would help address the concerns about group homes often forwarded to her office by children, parents and staff members.

The June incident wasn’t the only complaint filed at the Lawson Heights group home, which has since changed operators.

A little over a month after the incident that led to Elijah’s discovery in a Tim Horton’s parking lot, more allegations about the care home were forwarded to the Ministry of Social services detailing medical and physical neglect.

All but one of the allegations were substantiated, including inappropriate discipline, neglect ranging from a lack of sufficient COVID protocols (despite hosting an immunocompromised child, no precautions were put in place to protect from spread of COVID-19) to “egregious” medical neglect resulting in one child requiring hospitalization for malnourishment, and a lack of staff training.

While this was happening, though, some case workers and ministry officials had flagged concerns with that particular group home. 

In May, Elijah’s caseworker flagged ongoing issues with his behaviour, such as violent incidents and cases of his running away from the group home and from staff members.

“She questioned the level of supervision provided in the group home adn the training staff had to work with children with autism,” the Advocate wrote.

Staff ratios were also questioned, with only two staff members caring for four children with intellectual disabilities and complex needs. A supervisor commented that the operator – a national, for-profit group home operator with other facilities in the province – did not seem to be skilled and expressed concern about a lack of communication, organization and insufficient skill to care for autistic children.

Indeed, an investigation conducted by the ministry into the care home found:

Inadequate communication

Staff not having access to management when faced with critical or difficult decisions

Staff not aware of policy requirements, such as the requirements for responding to and reporting allegations of abuse

Training standards were not met, such as crisis intervention training, cultural awareness, sucide intervention, food safe handling, or universal precautions. Some staff had no previous experience working with children with disabilities.

Physical restraints were being used despite a company policy prohibiting their use,

Failure to comply with policies for child development and monitoring progress

Lack of proper covid precautions. 

Insufficient sensory and therapeutic tools

Poor staff culture including “lack of respect toward leadership and colleges which appeared to manifest itself in quality of care concerns.”

The group home’s operator gave up the contract later. Their other group homes, serving greater numbers of children for short-term stays in government care, were found to be in better compliance.

The ministry also stepped in, appointing a temporary liaison to communicate weekly with the home to ensure it met all standards and had any support it required.

A new company took over operations in September and reduced the number of kids in the home from four to three while simultaneously increasing staffing.

With the changes implemented, the Advocate chose not to pursue an investigation into the group home further. However, they were concerned that the neglect, abuse and incident with Elijah were able to occur in the first place.

“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.”

The concerns aren’t new, the Advocate said, and represent similar complaints received from children, youth, adults and ministry staff for years.

In fact, in 2017, the Advocate recommended the ministry take action to improve oversight and resources provided to group homes.

They recommended that quality of care standards be created and embedded into the legislation. They also recommended that fulsome cyclical reviews or inspections be created to measure compliance, and that the ministry be granted the ability to conduct unannounced inspections to hold operators responsible for meeting standards of care.

Four years later, Broda wrote, “to our understanding these proposals have not been adopted.”

The investigation into Elijah’s case and subsequent look at the Ministry of Social Services policies and procedures relating to group homes for vulnerable youth led Broda to release three more recommendations designed to help address the gaps that led to the concerns identified at Elijah’s group home.

Broda identified deficiencies in the oversight of both the set up and operation of group homes, including a lack of a mechanism to ensure standards of care are being met.

Speaking with ministry staff, Broda identified that they, too, voice the same frustrations, but without more resources, little can be done.

Resources, Broda said, may be the reason these deficiencies developed in the first place. She noted in her report that over the past seven years, facilities for kids in care have transitioned from public-sector facilities to privately-operated group homes. She also noted that in just the past four years, the number of group home spaces have increased by more than 38 per cent, while proper funding and resources haven’t kept up with that growth.

Staff said the needs of group homes include dedicated resource workers and comprehensive training similar to provisions for foster homes.

As it stands, inspections are done only on program standards, not standards of care, and even those are infrequent due to a lack of staff and funding. They are focused more on  adherence iwh physical standards, completeness of files, policies and minimum standard, Broda said.

“The use of a comprehensive quality-of-care framework, one that clearly defines roles and responsibilities, quality standards and identifies what evidence and variables of quality are to be measured, is necessary to demonstrate whether quality standards are being met,” her report said.

“Had such guidance existed, it would have placed the Ministry in a better position to identify issues in the Lawson Heights group home before these became chronic, leading these most vulnerable of children to be neglected.”

Even then, Broda wrote, the current system is reactionary, and includes multiple departments and ministries, leading to uncertainty and confusion that results in children falling through the cracks. It also lacks resources to be fully effective.

“Staff warned that the lack of resources was impeding its ability to complete the reviews intended to keep the ministry aware of issues before they become critical,” Broda wrote.

She also found fault with the process that went into setting up and approving Elijah’s care home. It didn’t assess needs or verify qualifications. It didn’t start with the right level of security to manage youth with complex needs, something flagged by the operator in correspondence with the province.

“The advocate finds it untenable to leave to chance that group home staff have the requisite skills to fully care for and ensure children in these group homes thrive,” Broda wrote.

She added that a single, unified governance structure needs to be set up to ensure care home facilities are set up to meet the needs of the residents they purport to serve, and when operating, are kept up to high standards. 

In all, Broda wrote, youth group home concerns “are symptomatic of systemic shortcomings in ministry oversight.

“The ministry;s oversight scheme does not fully meet its parental obligations to vulnerable children.”

To read the full report, visit The full recommendations are listed in full below:

Recommendation #1: That the Ministry of Social Services enhance and re-design its group home oversight and accountability structure to:

 • incorporate a leadership role that is responsible for the effective oversight of group homes;

 • develop comprehensive evidence-based quality-of-care definitions and standards that promote proactive, not reactive, responses to the care of children; 

• articulate what evidence is needed to demonstrate that group homes are meeting quality-of-care standards; and, •

 include sufficient human and financial resources to enable timely and proactive reviews of group home care.

 Recommendation #2: That the Ministry of Social Services develop a permanent resource for group home operators, which provides a clear point of contact, support, and resources such as skill development.

Recommendation #3: That the Ministry of Social Services enhance its process for approving group home openings to include identifying and verifying the qualifications and training of staff and examining the unique needs of the children who are the intended residents to determine what unique features should be included in the group home