2013 November Report of the Auditor General of Canada Safety of Schools and Childcare Facilities in Nunavut

2013 November Report of the Auditor General of Canada

This report is also available in Inuktitut (PDF 527 KB)

Safety of Schools and Childcare Facilities in Nunavut

Main Points

Introduction

Focus of the audit

Observations and Recommendations

Safety of childcare facilities

The Department of Education is not inspecting childcare facilities as required
The Department licenses facilities with little evidence that deficiencies found during inspections are corrected
Early childhood officers lack guidance on completing and documenting inspections
The Department of Community and Government Services does not conduct fire inspections in accordance with its own procedures
Fire inspection reports do not specify who is to address identified deficiencies

Safety of schools

Principals are not conducting required emergency evacuation drills
There are significant shortcomings in completing, following up on, and tracking school safety inspections
Roles and responsibilities for school safety are not well understood by the two departments

Conclusion

Letters to the departments

About the Audit

Appendix—List of recommendations

Exhibit:

1—Inspections of childcare facilities are not conducted as required

Main Points

What we examined

Responsibility for ensuring the safety of students in schools and children in childcare facilities is shared by the Department of Education and the Department of Community and Government Services.

We looked at how the departments of Education and Community and Government Services have carried out their responsibilities in this area, focusing on the inspections they are required to conduct in school and childcare facilities. These include fire inspections in both types of facilities, as well as boiler and electrical inspections in schools. We also focused on the annual inspections the Department of Education is required to conduct in childcare facilities and the emergency evacuation drills that principals are required to conduct in schools.

Audit work for this report was completed on 31 May 2013. More details on the conduct of the audit are in About the Audit at the end of this report.

Why it’s important

The departments of Education and of Community and Government Services are required under various acts to carry out inspections to ensure the safety of occupants in childcare and school facilities. Inspections are intended to identify sources of potential harm so that childcare facility and school administrators can mitigate them, working to protect the children in their care and the staff they employ. This is particularly important because some of the children in care are very young, including infants.

What we found

The departments have responded. The departments agree with all of the recommendations. Their detailed responses follow the recommendations throughout the reports.

Introduction

1. In Nunavut, the Department of Education and the Department of Community and Government Services both have responsibilities related to the safety of schools and childcare facilities. They carry out these responsibilities mainly through inspections. The Fire Marshal, appointed by the Minister of Community and Government Services, conducts fire inspections of schools and childcare facilities. The Department of Education appoints early childhood officers, who carry out inspections of childcare facilities. Officials and contractors with the Department of Community and Government Services conduct electrical and boiler inspections in schools.

2. Inspections allow the departments to determine and ensure the safety of schools and childcare facilities. The inspections may identify sources of potential fires or accidents, or other safety threats needing to be addressed by school and childcare facility administrators. This is particularly important because the facilities provide care for children who may be under five years old, including infants.

Focus of the audit

3. Our audit examined whether the Government of Nunavut’s Department of Education and its Department of Community and Government Services complied with their key responsibilities related to safety in schools and childcare facilities.

4. We focused on the inspections that the departments are required to conduct, including fire inspections in both types of facilities, as well as boiler and electrical inspections in schools. In childcare facilities, we also focused on the annual inspections that the Department of Education is required to conduct.

5. More details about the audit objectives, scope, approach, and criteria are in About the Audit at the end of this report.

Observations and Recommendations

Safety of childcare facilities

6. As of December 2012, there were 52 licensed childcare facilities in Nunavut. Under the Child Day Care Act, the Department of Education is responsible for inspecting childcare facilities annually. The Department’s early childhood officers carry out the inspections. Many licensing requirements pertain to health and safety. Critical safety requirements under the Child Day Care Standards Regulations include

7. We examined whether the Department of Education licensed childcare facilities in Nunavut according to the Child Day Care Act and its regulations, standards, and procedures. Specifically, we looked at whether the Department

8. We took a random sample of 35 licensed childcare facilities. For these, we reviewed and analyzed the 2010, 2011, and 2012 inspection reports and related documentation. We also interviewed officials of the Department of Education at headquarters and in the territory’s three regions.

The Department of Education is not inspecting childcare facilities as required

9. We found that only 33 percent of the inspections we reviewed over a three-year period were conducted every 12 months, as required by the Child Day Care Act (Exhibit 1). The average time between inspections was 15 months. One quarter of the inspections were more than 4 months late. In one instance, we found that more than two years had passed since the previous inspection of the childcare facility. Departmental staff explained that staff shortages, travel conditions, and limited accommodation in small communities contributed to delayed inspections.

Exhibit 1—Inspections of childcare facilities are not conducted as required

Bar chart showing percentage of compliance with required inspections of childcare facilities

[Exhibit 1—text version]

10. During our audit work, we noted the Department’s practice of issuing letters of permission. The Department adopted this practice to allow childcare facilities to operate until an inspection could occur or a formal licence could be issued. However, we found that the Department does not have any authority to issue letters of permission or allow childcare facilities to operate under them. Further, there are no policies or directives that define this practice. Of our sample of 35 childcare facilities, we found that 33 had operated under a letter of permission at some time during the three years we examined. Twenty-one childcare facilities operated under such a letter for more than four months. In one case, a childcare facility operated under a letter of permission for almost a year. This meant that the childcare facilities were operating without a valid licence, which is against what the Child Day Care Act requires.

11. Recommendation. The Department of Education should

The Department’s response. Agreed. The Department of Education has taken immediate action and stopped issuing letters of permission. The Department has identified all licensed early childhood facilities currently operating under letters of permission and immediately established a schedule to complete inspections to ensure all facilities hold a valid licence by the end of 2013.

We have begun issuing licences for two years rather than one and have moved to a ten-month inspection cycle. Moving to a ten-month cycle will help ensure that we meet the requirement for annual facility inspections as per subsection 7(1) of the Child Day Care Act, and allow flexibility to mitigate any possible delays such as staffing or weather-related issues.

The Department will develop a system to streamline reporting and document sharing. This system will include a reminder system, shared calendars, and spreadsheets to help identify upcoming inspections.

The Department licenses facilities with little evidence that deficiencies found during inspections are corrected

12. Inspections enable early childhood officers to identify non-compliance with safety requirements contained in the Child Day Care Standards Regulations. In the inspection reports we reviewed, 40 percent indicated that the childcare facility had not met the criminal record check requirement and 48 percent had not met the requirement for every staff member to have a first aid certificate.

13. When an inspection identified deficiencies, the Department did not ensure that they had been corrected before it issued a licence. We found that only 17 percent of the files we reviewed contained evidence of follow-ups to check for correction of identified deficiencies in critical safety requirements (Exhibit 1). In most cases where there was no evidence of follow-up, the Department still issued a licence. Consequently, some childcare facilities do not meet the licensing requirements but are allowed to operate with known deficiencies that could put children at risk.

14. Recommendation. The Department of Education should ensure that corrective action is taken on all non-compliance issues identified in childcare facility inspection reports before it issues licences.

The Department’s response. Agreed. By completing facility inspections on a ten-month cycle, we can issue a preliminary report and ensure the early childhood program has time to follow up. This will include the development of a comprehensive follow-up process for early childhood officers.

The Department will conduct pre-inspection interviews with facility directors. This process should identify common issues found in many early childhood programs, such as up-to-date insurance, potential solutions, and issues that may lead to revocation of a licence.

Conducting interviews will allow early childhood facilities to address problem areas, renew insurance if necessary and arrange timely fire, health, and Workers’ Safety and Compensation Commission inspections prior to the licensing inspection.

The Department of Education will work with the Department of Community and Government Services’ Fire Marshal’s Office, the Department of Health’s environmental health officers, and the Workers’ Safety and Compensation Commission to develop simple communication protocols between all of the relevant parties. These protocols will help ensure that all appropriate reports and documentation are provided to the necessary contacts (licensed early childhood facility, early childhood officers, Director of Child Day Care Services).

Early childhood officers lack guidance on completing and documenting inspections

15. We examined whether the Department of Education provided clear guidance on the requirements in the Child Day Care Act and the related regulations to be followed by early childhood officers when conducting inspections of licensed childcare facilities. Guidance is critical to ensuring that early childhood operators comply with and consistently apply the Act and its regulations. It is especially important since the Department is responsible for inspecting childcare facilities throughout the territory’s three regions.

16. We found that officers lack guidance about how to rate the way that childcare facilities comply with the Child Day Care Act and its regulations. The result has been that early childhood officers apply ratings inconsistently. For example, two officers each found facilities that did not meet evacuation drill requirements; one officer indicated that the facility was compliant with the regulations, while the other indicated non-compliance. Officers mentioned a lack of training and unclear guidance about applying the regulations. Further, we found no guidance for officers on when or how to conduct follow-ups, or on how to document a follow-up after it is completed.

17. Recommendation. The Department of Education should clarify guidance related to the inspection of childcare facilities. This guidance should include requirements to follow up on deficiencies and also to maintain and review inspection documentation, including reports by the territory’s Fire Marshal.

The Department’s response. Agreed. The Department of Education will work with Community and Government Services (CGS) to review existing reporting structures.

We will conduct a review of the inspection reporting function to create a streamlined approach for identifying and addressing deficiencies. The Department will adopt a compliance rating system in the re-design of the inspection form for early childhood facilities. This approach will also provide a mechanism to identify issues that require CGS’s attention, where the facility maintenance is its responsibility, and ways to escalate urgent issues.

The Department will develop additional resources for early childhood officers to guide them in conducting facility inspections that include a plain language guide of the Child Day Care Act, checklists, and supporting reference materials. Additionally, the system mentioned in response to recommendation 11 will track all inspections and deficiencies, and identify the need for follow-up.

We are committed to developing an operations manual for early childhood facilities that includes a plain language guide to the Child Day Care Act, and best practices to ensure programs are well-run. The manual will help facilities to better prepare for annual inspections and identify points of contact to facilitate follow-up on deficiencies.

The Department of Community and Government Services does not conduct fire inspections in accordance with its own procedures

18. We examined whether the Government of Nunavut’s Department of Community and Government Services complied with its major responsibilities related to safety in childcare facilities. According to the Fire Prevention Act, the Fire Marshal is to complete fire inspections of buildings, including childcare facilities. The Act does not specify the frequency but the Department’s internal procedures indicate that inspections are to be performed twice a year. We looked at whether twice-yearly Fire Marshal inspections were completed in 2010, 2011, and 2012 for the 35 childcare facilities we randomly sampled. We also interviewed officials from the Department of Education and the Department of Community and Government Services.

19. We found that for the three years we examined, a Fire Marshal inspection was conducted twice yearly about one third of the time (see Exhibit 1). In the case of two of the childcare facilities in our sample, the Fire Marshal did not carry out any fire inspections in 2010, 2011, or 2012.

20. Recommendation. The Department of Community and Government Services should ensure that fire inspections of childcare facilities are carried out in accordance with its internal procedures.

The Department’s response. Agreed. While the Department of Community and Government Services (CGS) is conducting fire inspections in accordance with the Fire Prevention Act, the Department will take measures to provide better clarity with regard to the frequency of inspections.

A consultant will be hired in fall 2013 to conduct a performance assessment of the Protection Services division, which encompasses the Office of the Fire Marshal. This review will look at the Fire Prevention Act to ensure inspection schedules are in line with and comparable to other jurisdictions, to ensure that roles and responsibilities are clearly defined in the Act, and to ensure that internal processes or procedures are achievable based on existing resources.

Fire inspection reports do not specify who is to address identified deficiencies

21. Once the Fire Marshal completes a report, it is provided to the childcare facility administrators. For the facilities in our sample, Fire Marshal inspections found deficiencies including blocked exits, improper storage of combustibles, and an inadequate number of smoke detectors.

22. When deficiencies are identified, we found that inspection reports do not specify who should address them. We also found that, no matter how severe an identified deficiency might be, the follow-up to check whether it has been corrected does not occur until the next fire inspection.

23. The Department of Education does not play a role in ensuring that deficiencies identified as part of the Fire Marshal’s twice yearly inspections are addressed. For example, before early childhood officers issue a childcare facility licence, they are not required to ensure that deficiencies noted by the Fire Marshal in previous inspections have been addressed.

24. Recommendation. The Department of Community and Government Services should

The Department’s response. Agreed. The Protection Services division within Community and Government Services (CGS) will undergo a review of existing practices, procedures, and policies in fall 2013. Fire inspection reports will be examined during this review to ensure that the form includes an area denoting which department is responsible for follow-up.

The departments of CGS and Education will immediately identify key contact persons in their departments to receive, coordinate, and respond to inspection requests and reports.

CGS implemented in April 2013 new facility management guidelines to streamline the process for preventative and regular maintenance work orders from client departments. The new guidelines, emergency contact information, work order forms, and work order escalation procedures have been communicated with the Department of Education and are available to all Government of Nunavut staff on the CGS website. CGS will provide further direction on these new guidelines to the Department of Education as requested.

The Department of Community and Government Services met with the Department of Education in July 2013 to discuss establishing a communications protocol for reporting progress on fire inspection reports. This protocol will improve communication between departments on addressing deficiencies in the inspection reports.

Safety of schools

25. Inspecting and assessing school facilities, planning and conducting emergency evacuations, and performing regular maintenance are all ways of ensuring the safety of school facilities. The Department of Education and the Department of Community and Government Services share responsibilities for the safety of school facilities.

26. According to the Education Act, a school principal shall ensure the safety of students, staff, and others on school premises. Further, in accordance with the directions of the District Education Authority, a school principal is to ensure that school facilities and equipment are properly maintained and in good condition. The Department of Community and Government Services is responsible for inspecting, repairing, and maintaining Government of Nunavut buildings, including schools.

27. We examined whether the Department of Education and the Department of Community and Government Services complied with their key responsibilities related to the safety of school facilities under the Education Act, the Fire Prevention Act, the Electrical Protection Act, the Boilers and Pressure Vessels Act, and related regulations, standards, and procedures.

Principals are not conducting required emergency evacuation drills

28. Regular emergency evacuation drills are critical to school safety. An emergency evacuation drill trains students and staff in the procedures to be followed during an emergency. It also tests the adequacy of the emergency plan.

29. According to the Department of Education’s Operations Manual for Nunavut Schools, schools attended by children must have at least three fire evacuation drills in the first two months of the school year and should average one drill a month for the other months of the year. To determine whether principals were conducting emergency drills, we looked at compliance with the requirements for emergency evacuations in the eight schools we audited for the 2010–11 and 2011–12 school years. We reviewed documentation such as principals’ monthly reports, which include data about evacuation drills performed. We also interviewed Department of Education officials, including principals.

30. From our review of principals’ monthly reports for the eight schools we audited, we found that none of the principals carried out the required number of evacuation drills. Departmental officials informed us that some evacuation drills may have been held but not mentioned in the principals’ monthly reports. However, officials at three schools informed us that they had not conducted all the required drills during the 2012–13 school year. Failure to conduct the required evacuation drills increases the risk that students will not be able to evacuate a building safely in an emergency. Not conducting drills jeopardizes students’ safety.

31. Recommendation. The Department of Education should ensure that school principals conduct evacuation drills, as required.

The Department’s response. Agreed. The Department of Education is looking at ways to engage principals in addressing safety-related topics. The importance of evacuation drills will be addressed at the fall 2013 regional principal meetings. Community and Government Services (CGS) will present at the regional meetings to clarify the responsibilities of each department and the principals’ role in conducting and reporting evacuation drills.

The Department is reviewing pan-Canadian policies and procedures on fire safety in schools to adopt possible best practices. Adopting best practices should allow for more effective tracking of fire drill and fire alarm inspections, which are conducted by CGS. The Department will also be changing its protocol on the number of annual fire evacuations to be consistent with the National Fire Code’s requirement.

The Department will review the principals’ monthly reporting template in order to simplify the process for principals and streamline data collection to produce reliable and up-to-date information; this includes tracking fire drill evacuations in schools.

The Regional School Operations offices will conduct a review of their file management practices and look for ways to improve the collection and storage of vital documents like those related to fire safety.

There are significant shortcomings in completing, following up on, and tracking school safety inspections

32. Safety inspections of school facilities ensure that schools are safe for students and staff. Inspections can identify issues needing immediate attention or regular maintenance. Various acts require safety inspections to be performed in Government of Nunavut buildings, including schools.

33. We sought to determine whether, to maintain safe school facilities, the Department of Community and Government Services conducts safety inspections and follows up on subsequent recommendations or safety reports. For this purpose, we looked at compliance with the requirements for fire, electrical, and boiler inspections in the case of the eight schools we audited for the 2010–11 and 2011–12 school years. To determine whether the Department of Education maintains safe school facilities, we interviewed principals, with the aim of finding out what they knew about the completion of the required safety inspections by the Department of Community and Government Services and how they responded when inspections were not conducted. We reviewed inspection reports for the 2010–11 and 2011–12 school years, as well as any related documentation provided by the departments. We also interviewed departmental officials.

34. Fire inspections. The Fire Prevention Act requires fire inspections to be conducted but does not specify the frequency. However, as with childcare facilities, the Department of Community and Government Services’ internal procedures indicate that inspections are to be carried out twice a year in schools. We found that fire inspections were performed twice a year in only five of the eight schools we audited.

35. Each fire inspection is conducted by the Fire Marshal. The inspection report indicates when deficiencies must be addressed but does not specify who should address them. The follow-up to check whether deficiencies have been corrected does not occur until the next fire inspection, regardless of whether action should have been taken earlier.

36. In the eight schools we reviewed, we found that 60 percent of the deficiencies reported had been identified in at least one previous inspection. For example, inspections at six of the eight schools had more than once identified deficiencies related to emergency lights that did not function. Further, we found that the Fire Marshal identified safety risks as many as nine times. For example, one school had doors that needed to be closed for safety reasons, since they acted as fire barriers. Nine inspections found that the doors were left open, even though the previous inspection reports had identified this deficiency.

37. Monthly and annual fire alarm testing inspections. To conduct inspections, the Fire Marshal relies in part on the inspection work performed by contractors or other Department of Community and Government Services employees. We looked at whether one of the inspections on which the Fire Marshal relies—fire alarm testing—was performed as required by the Department’s internal procedures. For all eight schools we audited, the Department could not provide us with evidence of any of the monthly fire alarm tests required. With regard to annual inspections, we found that only two of eight schools were inspected annually as required during the 2010–11 and 2011–12 school years.

38. Officials informed us that they have documentation problems but also are not performing some inspections as they should. This means that critical safety tests are either not conducted or not documented, with the result that the Fire Marshal cannot rely on the work as part of his inspections. This situation jeopardizes the safety of students and staff. Further, the Department of Community and Government Services is not aware of potential risks within Nunavut schools.

39. Boiler and electrical inspections. The Electrical Protection Act and the Boilers and Pressure Vessels Act require electrical and boiler inspections to be conducted, but do not specify the frequency. However, the Department of Community and Government Services made an internal decision to conduct boiler and electrical inspections annually. For the eight schools we audited, we found that not one of the schools had annual electrical inspections completed. Only two of the eight schools had boiler inspections performed in the 2010–11 school year. None of the schools we audited had boiler inspections completed in 2011–12.

40. The Department informed us that it had stopped performing the annual boiler and electrical inspections because it had to redirect resources toward performing mandatory inspections of newly built houses under the Nunavut Housing Trust. Officials indicated that they intend to resume inspections now that the number of new houses needing inspection has declined.

41. The Department also informed us that electrical equipment and boiler inspections overlap with another type of inspection they are conducting (preventative maintenance inspections). However, we found that these inspections were not conducted either according to the Department’s internal procedures. None of the schools we audited had preventative maintenance annual inspections of their electrical equipment in 2010–11 or 2011–12 and none of the schools had preventative maintenance annual inspections of their boilers in 2010–11. Only three of the eight schools we audited had annual inspections in 2011–12.

42. Deficiencies known since 2010. Our findings are consistent with reports commissioned by the Department of Education in 2010. These reports found many deficiencies in Nunavut schools, including missing or empty fire extinguishers. We found that the Department of Community and Government Services and the Department of Education are working to address the findings from the 2010–11 assessments. Nevertheless, many issues remain outstanding.

43. Recommendation. The Department of Community and Government Services should

The Department’s response. Agreed.

Fire inspections:

The departments of Community and Government Services (CGS) and of Education will immediately identify key contact persons in their departments to receive, coordinate, and respond to inspection requests and reports.

While CGS is conducting inspections in accordance with the Fire Prevention Act, the Act will be reviewed in fall 2013 to ensure its regulations regarding inspection schedules are clearly defined and are in line with other jurisdictions.

Fire inspection reports will also be reviewed in fall 2013 to ensure that the reports clearly list which department is responsible for following up on deficiencies.

The Department of Community and Government Services met with the Department of Education in July 2013 to discuss establishing a communications protocol for reporting progress on fire inspection reports. This protocol will improve communication between departments on addressing deficiencies in the inspection reports.

Monthly and annual fire alarm testing inspections:

CGS is responsible for performing monthly tests of fire alarm systems and performing or contracting the annual certification of the fire alarm system. Administrative protocols will immediately be put in place to ensure inspectors file monthly reports of inspections with CGS, follow up on any deficiencies, and advise the Department of Education when tests are taking place in schools.

Boiler and electrical inspections:

CGS will look at overlap between the Property and Asset Management division responsible for maintaining boilers and electrical equipment and the Protection Services division responsible for certification and tracking inspections. Better administrative processes will be put in place by fall 2013 to ensure that all inspections are properly communicated between divisions and follow-up is conducted to ensure repairs or deficiencies are addressed.

Roles and responsibilities for school safety are not well understood by the two departments

44. To minimize risks to children in schools, the Department of Education and the Department of Community and Government Services must clearly understand their roles and responsibilities related to the safety of facilities. A lack of understanding and accountability increases the risk that school facilities will be unsafe, potentially affecting the health and safety of students and staff.

45. We found that responsibilities regarding the safety of school facilities are documented but not always fulfilled. In addition, some school administrators told us that they do not know whether the inspections to be performed in their school are up to date. In these situations, it is difficult to find out whether there are safety risks in the affected schools.

46. Further, we found that there were communications issues between the Department of Education and the Department of Community and Government Services. For example, principals told us that they receive little information on the work performed by the Department of Community and Government Services, including whether an issue has been addressed or progress has been made.

47. Recommendation. The Department of Education and the Department of Community and Government Services should work together to

The Department of Community and Government Services’ response. Agreed. The departments of Community and Government Services (CGS) and Education will immediately identify key contact persons in their departments to receive, coordinate, and respond to inspection requests and reports.

The Department of Community and Government Services is working with the Department of Education to implement new tools that will assist in tracking and following up on inspection reports in schools. These tools include fire safety guides in each school, checklists for preventative maintenance, and fire safety checklists (fire drills, fire alarm testing, inspections, and so on). It is anticipated that these materials will be available by the end of 2013.

In addition, the Department of Community and Government Services has arranged with the Department of Education to present workshops on facilities management, requesting work orders and work escalation orders to all school principals in fall 2013.

The Department of Education’s response. Agreed. The Department recognizes the importance of implementing an effective communications protocol. To address this need, the Department is reviewing the policies related to fire safety in schools in other Canadian jurisdictions to adopt possible best practices.

The Department will work with Community and Government Services (CGS) to clarify the role of principals with respect to fire safety. As mentioned, CGS will be presenting to principals during the regional principals’ meetings.

With regard to information sharing, the Department will collaborate with CGS to develop and institute protocols with respect to fire safety, escalation procedures, and maintenance issues. These protocols will identify primary contacts to receive important reports and information. These will include contacts in both departments as well as environmental health officers, who will provide copies of their reports and inspections for follow-up, reporting, and tracking. These protocols will help ensure transparency and accountability between both departments and a more stringent adherence to safety procedure in schools across Nunavut.

Conclusion

48. We concluded that the Government of Nunavut’s Department of Education and its Department of Community and Government Services have not complied with their key responsibilities related to the safety of schools and childcare facilities.

49. The Department of Education does not inspect licensed facilities every 12 months, as required by the Child Day Care Act and its related regulations, standards, and procedures. Further, there is little evidence that deficiencies identified in the inspection reports are corrected before a licence is issued.

50. The Department of Education does not meet the requirements for emergency evacuation drills, as set out in the Operations Manual for Nunavut Schools. Both departments also lack understanding of their roles and responsibilities related to the safety of facilities. As a result, the Department of Education and the Department of Community and Government Services do not ensure that they conduct follow-ups and address deficiencies found in inspections and other safety reports.

51. The Department of Community and Government Services does not conduct safety inspections in accordance with its internal procedures.

Letters to the departments

52. In view of the serious nature of our findings, in June 2013 we sent letters to the deputy ministers of Nunavut’s Department of Education and its Department of Community and Government Services. Our aim was to raise concerns requiring immediate attention regarding inspections in schools and childcare facilities. We also sought to provide to the departments an early opportunity to take the necessary actions, with the aim of ensuring that their obligations were properly addressed. The departments have responded, acknowledging the importance of the situation and setting out the actions each plans to implement to correct the deficiencies.

About the Audit

All of the audit work in this report was conducted in accordance with the standards for assurance engagements set out in The Canadian Institute of Chartered Accountants Handbook—Assurance. While the Office adopts these standards as the minimum requirement for our audits, we also draw upon the standards and practices of other disciplines.

As part of our regular audit process, we obtained management’s confirmation that the findings reported in this report are factually based.

Objective

The objective of the audit was to determine whether the Government of Nunavut’s Department of Education and its Department of Community and Government Services complied with their key responsibilities related to safety in schools and childcare facilities.

Scope and approach

We examined the Government of Nunavut’s Department of Education because it is the department responsible for the licensing and inspection of childcare facilities in the territory. We also examined the Department of Community and Government Services with regard to its responsibilities for the safety of schools and childcare facilities.

We looked at whether the Government of Nunavut’s Department of Education and its Department of Community and Government Services complied with their key responsibilities related to the safety of schools and childcare facilities.

The audit included all three regions of Nunavut. We visited eight schools in five communities, and reviewed files from all of these schools covering the 2010–11 and 2011–12 school years.

Our audit was designed not to assess the safety of a facility, but rather to examine the processes that the two departments have in place to manage and mitigate risks with respect to the safety of facility occupants.

We audited the Department of Education’s inspection files related to 35 childcare facilities for the years 2010, 2011, and 2012. We chose these files at random from a list of licensed childcare facilities operating in Nunavut. We did not audit individual childcare facilities.

We reviewed the Government of Nunavut’s laws, regulations, policies, and guidance on the safety of schools and childcare facilities. We also interviewed officials from the Department of Education and the Department of Community and Government Services, as well as school staff and representatives of District Education Authorities.

Criteria

To determine whether the Government of Nunavut’s Department of Education and its Department of Community and Government Services complied with their key responsibilities related to safety in schools and childcare facilities, we used the following criteria:
Criteria Sources

The Department of Education inspects licensed childcare facilities in Nunavut in accordance with the Child Day Care Act and its related regulations, standards, and procedures.

  • Child Day Care Act
  • Child Day Care Standards Regulations

The Department of Education maintains safe school facilities by ensuring that

  • safety inspections are carried out,
  • recommendations resulting from inspections or other safety reports are followed up and addressed, and
  • requirements for fire drills or emergency evacuations are complied with.
  • Education Act
  • Operations Manual for Nunavut Schools (2007)

The Department of Community and Government Services maintains safe childcare facilities by

  • conducting fire inspections as deemed necessary, and
  • ensuring that recommendations resulting from fire inspections are followed up and addressed.
  • Fire Prevention Act

The Department of Community and Government Services maintains safe school facilities by

  • conducting safety inspections as deemed necessary, and
  • ensuring that recommendations resulting from inspections or other safety reports are followed up and addressed.
  • Fire Prevention Act
  • Electrical Protection Act
  • Boilers and Pressure Vessels Act

Management reviewed and accepted the suitability of the criteria used in the audit.

Period covered by the audit

The audit covered the period between 1 July 2009 and 31 May 2013. Audit work for this report was completed on 31 May 2013.

Audit team

Assistant Auditor General: Ronnie Campbell
Principal: Michelle Salvail
Director: Jo Ann Schwartz

Alexandre Boucher
Maria Pooley
Jamie Singh
Conal Slobodin

For information, please contact Communications at 613-995-3708 or 1-888-761-5953 (toll-free).

Appendix—List of recommendations

The following is a list of recommendations found in the report. The number in front of the recommendation indicates the paragraph where it appears in the report. The numbers in parentheses indicate the paragraphs where the topic is discussed.

Recommendation Response
Safety of childcare facilities

11. The Department of Education should

  • carry out childcare facility inspections annually, as required, and
  • ensure that all childcare facilities in operation have a valid licence. (6–10)

The Department’s response. Agreed. The Department of Education has taken immediate action and stopped issuing letters of permission. The Department has identified all licensed early childhood facilities currently operating under letters of permission and immediately established a schedule to complete inspections to ensure all facilities hold a valid licence by the end of 2013.

We have begun issuing licences for two years rather than one and have moved to a ten-month inspection cycle. Moving to a ten-month cycle will help ensure that we meet the requirement for annual facility inspections as per subsection 7(1) of the Child Day Care Act, and allow flexibility to mitigate any possible delays such as staffing or weather-related issues.

The Department will develop a system to streamline reporting and document sharing. This system will include a reminder system, shared calendars, and spreadsheets to help identify upcoming inspections.

14. The Department of Education should ensure that corrective action is taken on all non-compliance issues identified in childcare facility inspection reports before it issues licences. (12–13)

The Department’s response. Agreed. By completing facility inspections on a ten-month cycle, we can issue a preliminary report and ensure the early childhood program has time to follow up. This will include the development of a comprehensive follow-up process for early childhood officers.

The Department will conduct pre-inspection interviews with facility directors. This process should identify common issues found in many early childhood programs, such as up-to-date insurance, potential solutions, and issues that may lead to revocation of a licence.

Conducting interviews will allow early childhood facilities to address problem areas, renew insurance if necessary and arrange timely fire, health, and Workers’ Safety and Compensation Commission inspections prior to the licensing inspection.

The Department of Education will work with the Department of Community and Government Services’ Fire Marshal’s Office, the Department of Health’s environmental health officers, and the Workers’ Safety and Compensation Commission to develop simple communication protocols between all of the relevant parties. These protocols will help ensure that all appropriate reports and documentation are provided to the necessary contacts (licensed early childhood facility, early childhood officers, Director of Child Day Care Services).

17. The Department of Education should clarify guidance related to the inspection of childcare facilities. This guidance should include requirements to follow up on deficiencies and also to maintain and review inspection documentation, including reports by the territory’s Fire Marshal. (15–16)

The Department’s response. Agreed. The Department of Education will work with Community and Government Services (CGS) to review existing reporting structures.

We will conduct a review of the inspection reporting function to create a streamlined approach for identifying and addressing deficiencies. The Department will adopt a compliance rating system in the re-design of the inspection form for early childhood facilities. This approach will also provide a mechanism to identify issues that require CGS’s attention, where the facility maintenance is their responsibility, and ways to escalate urgent issues.

The Department will develop additional resources for early childhood officers to guide them in conducting facility inspections that include a plain language guide of the Child Day Care Act, checklists, and supporting reference materials. Additionally, the system mentioned in response to recommendation 11 will track all inspections and deficiencies, and identify the need for follow-up.

We are committed to developing an operations manual for early childhood facilities that includes a plain language guide to the Child Day Care Act, and best practices to ensure programs are well-run. The manual will help facilities to better prepare for annual inspections and identify points of contact to facilitate follow-up on deficiencies.

20. The Department of Community and Government Services should ensure that fire inspections of childcare facilities are carried out in accordance with its internal procedures. (18–19)

The Department’s response. Agreed. While the Department of Community and Government Services (CGS) is conducting fire inspections in accordance with the Fire Prevention Act, the Department will take measures to provide better clarity with regard to the frequency of inspections.

A consultant will be hired in fall 2013 to conduct a performance assessment of the Protection Services division, which encompasses the Office of the Fire Marshal. This review will look at the Fire Prevention Act to ensure inspection schedules are in line with and comparable to other jurisdictions, to ensure that roles and responsibilities are clearly defined in the Act, and to ensure that internal processes or procedures are achievable based on existing resources.

24. The Department of Community and Government Services should

  • ensure that the Fire Marshal’s reports specify who is responsible for addressing deficiencies identified in fire inspections; and
  • in collaboration with the Department of Education, follow up on the deficiencies to ensure that they are addressed in a timely manner. (21–23)

The Department’s response. Agreed. The Protection Services division within Community and Government Services (CGS) will undergo a review of existing practices, procedures, and policies in fall 2013. Fire inspection reports will be examined during this review to ensure that the form includes an area denoting which department is responsible for follow-up.

The departments of CGS and Education will immediately identify key contact persons in their departments to receive, coordinate, and respond to inspection requests and reports.

CGS implemented in April 2013 new facility management guidelines to streamline the process for preventative and regular maintenance work orders from client departments. The new guidelines, emergency contact information, work order forms, and work order escalation procedures have been communicated with the Department of Education and are available to all Government of Nunavut staff on the CGS website. CGS will provide further direction on these new guidelines to the Department of Education as requested.

The Department of Community and Government Services met with the Department of Education in July 2013 to discuss establishing a communications protocol for reporting progress on fire inspection reports. This protocol will improve communication between departments on addressing deficiencies in the inspection reports.

Safety of schools

31. The Department of Education should ensure that school principals conduct evacuation drills, as required. (25–30)

The Department’s response. Agreed. The Department of Education is looking at ways to engage principals in addressing safety-related topics. The importance of evacuation drills will be addressed at the fall 2013 regional principal meetings. Community and Government Services (CGS) will present at the regional meetings to clarify the responsibilities of each department and the principals’ role in conducting and reporting evacuation drills.

The Department is reviewing pan-Canadian policies and procedures on fire safety in schools to adopt possible best practices. Adopting best practices should allow for more effective tracking of fire drill and fire alarm inspections, which are conducted by CGS. The Department will also be changing its protocol on the number of annual fire evacuations to be consistent with the National Fire Code’s requirement.

The Department will review the principals’ monthly reporting template in order to simplify the process for principals and streamline data collection to produce reliable and up-to-date information; this includes tracking fire drill evacuations in schools.

The Regional School Operations offices will conduct a review of their file management practices and look for ways to improve the collection and storage of vital documents like those related to fire safety.

43. The Department of Community and Government Services should

  • ensure that all its inspections are carried out in accordance with its internal procedures,
  • identify who is responsible for addressing the deficiencies found during inspections, and
  • ensure that deficiencies have been addressed. (32–42)

The Department’s response. Agreed.

Fire Inspections:

The departments of Community and Government Services (CGS) and of Education will immediately identify key contact persons in their departments to receive, coordinate, and respond to inspection requests and reports.

While CGS is conducting inspections in accordance with the Fire Prevention Act, the Act will be reviewed in fall 2013 to ensure its regulations regarding inspection schedules are clearly defined and are in line with other jurisdictions.

Fire inspection reports will also be reviewed in fall 2013 to ensure that the reports clearly list which department is responsible for following up on deficiencies.

The Department of Community and Government Services met with the Department of Education in July 2013 to discuss establishing a communications protocol for reporting progress on fire inspection reports. This protocol will improve communication between departments on addressing deficiencies in the inspection reports.

Monthly and annual fire alarm testing inspections:

CGS is responsible for performing monthly tests of fire alarm systems and performing or contracting the annual certification of the fire alarm system. Administrative protocols will immediately be put in place to ensure inspectors file monthly reports of inspections with CGS, follow up on any deficiencies, and advise the Department of Education when tests are taking place in schools.

Boiler and electrical inspections:

CGS will look at overlap between the Property and Asset Management division responsible for maintaining boilers and electrical equipment and the Protection Services division responsible for certification and tracking inspections. Better administrative processes will be put in place by fall 2013 to ensure that all inspections are properly communicated between divisions and follow-up is conducted to ensure repairs or deficiencies are addressed.

47. The Department of Education and the Department of Community and Government Services should work together to

  • clarify their roles and responsibilities related to school safety, and communicate them to staff; and
  • identify and share the information that is needed, including inspection reports, to ensure that identified deficiencies are addressed. (44–46)

The Department of Community and Government Services’ response. Agreed. The departments of Community and Government Services (CGS) and Education will immediately identify key contact persons in their departments to receive, coordinate, and respond to inspection requests and reports.

The Department of Community and Government Services is working with the Department of Education to implement new tools that will assist in tracking and following up on inspection reports in schools. These tools include fire safety guides in each school, checklists for preventative maintenance, and fire safety checklists (fire drills, fire alarm testing, inspections, and so on). It is anticipated that these materials will be available by the end of 2013.

In addition, the Department of Community and Government Services has arranged with the Department of Education to present workshops on facilities management, requesting work orders and work escalation orders to all school principals in fall 2013.

The Department of Education’s response. Agreed. The Department recognizes the importance of implementing an effective communications protocol. To address this need, the Department is reviewing the policies related to fire safety in schools in other Canadian jurisdictions to adopt possible best practices.

The Department will work with Community and Government Services (CGS) to clarify the role of principals with respect to fire safety. As mentioned, CGS will be presenting to principals during the regional principals’ meetings.

With regard to information sharing, the Department will collaborate with CGS to develop and institute protocols with respect to fire safety, escalation procedures, and maintenance issues. These protocols will identify primary contacts to receive important reports and information. These will include contacts in both departments as well as environmental health officers, who will provide copies of their reports and inspections for follow-up, reporting, and tracking. These protocols will help ensure transparency and accountability between both departments and a more stringent adherence to safety procedure in schools across Nunavut.

 

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