Performance Assurance

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Audit of Offender Complaint and Grievance Process

Internal Audit
378-1-246

PDF

May 26, 2009

Table of Contents

Executive Summary

Sections 90 and 91 of the Corrections and Conditional Release Act require that Correctional Service Canada provide "a procedure for fairly and expeditiously resolving offenders’ grievances on matters within the jurisdiction of the Commissioner"1 and that "every offender should have access to this process without negative consequence".2 The offender complaint and grievance process provides offenders with a means of redress when they are dissatisfied with an action or decision by a staff member.3 The Corrections and Conditional Release Regulations describe the four-level process from a complaint at the institutional level to a grievance at the national level.

  • Complaint (Institutional Level)
  • 1st Level Grievance (Institutional Level)
  • 2nd Level Grievance (Regional Level)
  • 3rd Level Grievance (National Level)

Providing offenders with a fair, impartial and expeditious complaint and grievance process is mandated by law and it also has many benefits. It encourages offenders to deal with issues in a pro-social manner; it empowers them and provides another forum whereby their concerns can be heard and dealt with appropriately. The process can also be used as a monitoring tool to identify trends that are linked to increased tension or discontent among the inmate population. The number of complaints and grievances submitted has increased slightly on an annual basis with a larger increase in the most recent fiscal year. In addition, approximately 27% of the offender population uses the complaint and grievance process.

Organizationally, the offender complaint and grievance process falls under the responsibility of the Offender Redress Branch of the Policy and Research Sector at National Headquarters. Annually, CSC spends over $3 million4 on this process, including expenses reported by the regions.

Furthermore, under Part III of the Corrections and Conditional Release Act, the Correctional Investigator is mandated as an ombudsman for federal offenders. The primary function of the Office is to investigate and bring resolution to individual offender complaints. The Office as well, has a responsibility to review and make recommendations on the Correctional Service's policies and procedures associated with the areas of individual complaints to ensure that systemic areas of concern are identified and appropriately addressed.5 Over the years, the OCI has made repeated recommendations in its annual report to improve the complaint and grievance process. As part of its response to the OCI in June 2007, CSC committed to conduct an audit of the offender complaint and grievance process in fiscal year 2008-2009 to review progress on initiatives taken in this area.

More specifically, the objectives established for this audit were as follows:

  • To provide reasonable assurance that the management framework in place supports the resolution of offender complaints and grievances promptly and fairly (equitably/ consistently) at the lowest level possible; and
  • To provide reasonable assurance that CSC is in compliance with the legal and policy requirements related to the offender complaint and grievance process.

In order to conclude on these objectives, we reviewed the overall framework for the offender complaint and grievance process. We reviewed key documentation; examined processes, procedures and databases; and carried out visual inspections in 10 institutions visited. In addition, a total of 76 interviews were conducted with staff at the national, regional and local levels, and inmates who were members of the Inmate Committee or employed as Inmate Grievance Clerks in all institutions visited.

Overall Conclusion

The key elements of a management framework are in place to support the offender complaint and grievance process. While there is room for improvement in some areas, policies are in place and they are consistent with relevant legislation; training tools exist for staff involved in the process; roles and responsibilities are understood; informal resolution is occurring within institutions of all security levels; and some reporting and monitoring mechanisms are in place.

Nevertheless, our audit showed that attention is required in the following areas:

  • Within the policy, definitions of the following require further clarification:
    • High Priority/Urgent complaints and grievances;
    • Sensitive complaints and grievances; and
    • Frivolous/Vexatious complaints and grievances.

In addition, the definition and intent of the multiple griever status is unclear, the use of an Outside Review Board as a value-added mechanism is uncertain, and there are inconsistencies in CSC’s policy and procedures with respect to the processing of complaints and grievances that relate to the authority to render a decision for 1st level grievances related to the Chief Health Services;

  • Additional training is needed, and the availability of training tools needs to be better communicated
  • Enhancements to analysis, communication, and information sharing on performance results are required to ensure improvement of CSC’s practices.

In general, the offender complaint and grievance process is in compliance with legislation and relevant CSC policy and procedures. While there is room for improvement in some areas, information relating to the process is available to all inmates; complaint and grievance forms are available to all inmates; both official languages are respected in the process; a high level of compliance exists when processing offender complaints and grievances; mechanisms are in place to help ensure implementation of corrective action issued from all levels within the process; and offender complaint and grievance information is shared on a need-to-know basis.

Nevertheless, our audit showed that attention is required in the following areas:

  • Inmate handbooks at the institutions are not always consistent with policy;
  • There are challenges in meeting timelines for response to complaints and grievances, and extensions have increased significantly at the 1st and 2nd levels in the last year;
  • Clarification is needed with respect to the requirement to collect and review complaints and grievances on weekends and holidays from inmates on segregation/cell-confinement status; and
  • Improvements can be made with respect to the completeness and quality of file content, including the documentation of corrective action taken, and in the protection of offender complaint and grievance documentation.

Recommendations have been made in the report to address these areas for improvement. Management has reviewed and agrees with the findings contained in this report and a Management Action Plan has been developed to address the recommendations (see Annex C).

1.0 Introduction

Sections 90 and 91 of the Corrections and Conditional Release Act (CCRA) require that Correctional Service Canada (CSC) provide "a procedure for fairly and expeditiously resolving offenders’ grievances on matters within the jurisdiction of the Commissioner"6 and that "every offender should have access to this process without negative consequence".7 The offender complaint and grievance process provides offenders with a means of redress when they are dissatisfied with an action or decision by a staff member.8 The Corrections and Conditional Release Regulations (CCRR) describe the four-level process from a complaint at the institutional level to a grievance at the national level.

  • Complaint (Institutional Level)
  • 1st Level Grievance (Institutional Level)
  • 2nd Level Grievance (Regional Level)
  • 3rd Level Grievance (National Level)

A complaint is the first step in the process and is meant to be answered by the manager directly responsible for the person or area that is the subject of the complaint. If the offender is not satisfied with the decision at the complaint level, he/she may submit a grievance to the Institutional Head (if incarcerated) or the Director of the Parole District (if on a form of release). Offenders can appeal a response from the 1st level to the 2nd level, and a response from 2nd level to the 3rd level. Finally, Commissioner’s Directive (CD) 081 Offender Complaints and Grievances states: "Grievers who are not satisfied with the final decision of the complaint and grievance process may seek judicial review of this decision at the Federal Court within the time limit prescribed at subsection 18.1 (2) of the Federal Courts Act". The CCRR provides direction to reduce conflicts of interest, and includes provisions that allow the initial review of a grievance at the next level if the grievance relates to the decision-maker. For example, a grievance against an Institutional Head would be initiated at the 2nd level, and a grievance against a Regional Deputy Commissioner (RDC) would be initiated at the 3rd level.

Providing offenders with a fair, impartial and expeditious complaint and grievance process is mandated by law and it also has many benefits. It encourages offenders to deal with issues in a pro-social manner; it empowers them and provides another forum whereby their concerns can be heard and dealt with appropriately. The process can also be used as a monitoring tool to identify trends that are linked to increased tension or discontent among the inmate population.

There are numerous legislative and policy documents governing the inmate complaint and grievances process including:

  • The Corrections and Conditional Release Act (CCRA);
  • The Corrections and Conditional Release Regulations (CCRR);
  • Commissioner’s Directive 081 - Offender Complaints and Grievances;
  • The Offender Complaint and Grievance Procedures Manual; and
  • The Grievance Code Reference Guide.

Organizationally, the offender complaint and grievance process falls under the responsibility of the Offender Redress Branch (OR) of the Policy and Research Sector at National Headquarters (NHQ). At the institutional and regional levels, a designated employee is responsible for managing the offender complaint and grievance process to support the Institutional Head and RDC, who have decision making authority. Annually, CSC spends more than $3 million9 on this process, including expenses reported by the regions.

Statistical Background

Table 1 summarizes the total number of offender complaints and grievances by type of submission. As illustrated in the table, the number of complaints and grievances submitted each year increased slightly on an annual basis over the past four fiscal years, with a larger increase in the most recent fiscal year.

Table 1
Total Number of Offender Complaints and Grievances10

Complaint / Grievance Type Fiscal Year
2005 / 2006 2006 / 2007 2007 / 2008 2008 / 2009
Complaint 12,762 13,123 13,423 16,994
1st Level 2,681 3,032 3,160 4,222
2nd Level 2,361 2,444 2,785 3,600
3rd Level 1,333 1,254 1,441 1,893
Total 19,137 19,853 20,809 26,709

Table 2 below shows that the total proportion of offenders using the complaint and grievance process has remained fairly stable over time, varying between 23% and 27% since fiscal year 2003/2004.11 In addition, some offenders are submitting several grievances a year. It was suggested that the Prairie region’s statistics may be lower due to the high aboriginal population in the region; we were informed that many aboriginal offenders prefer to discuss their issues rather than submitting formal complaints/grievances in writing.

Table 2
Proportion of Offenders who use the Complaint and Grievance Process (2008/2009)12

Region Number of Grievances Offender
Population
Number of Grievers13 Proportion of Population that Grieve Average Grievances per Griever
Atlantic 3,738 2,279 721 32% 5.18
Quebec 8,498 5,469 1,697 31% 5.01
Ontario 4,900 6,236 1,546 25% 3.17
Prairies 4,597 5,564 1,280 23% 3.59
Pacific 4,897 3,444 1,151 33% 4.25
Total 26,709 22,992 6,271 27% 4.26

Figure 1 summarizes the average number of complaints and grievances per inmate at the various security levels.

Figure 114
Average Number of Complaints and Grievances per Inmate by Security Level

Figure 1 summarizes the average number of complaints and grievances per inmate at the various security levels.

Office of the Correctional Investigator (OCI)

The Correctional Investigator is mandated by Part III of the Corrections and Conditional Release Act as an Ombudsman for federal offenders. The primary function of the Office is to investigate and bring resolution to individual offender complaints. The Office as well, has a responsibility to review and make recommendations on the Correctional Service's policies and procedures associated with the areas of individual complaints to ensure that systemic areas of concern are identified and appropriately addressed.15

Over the years, the OCI has made repeated recommendations in its annual report to improve the complaint and grievance process. The following exerpts were taken from the past two OCI annual reports:

2006/2007

  • "Over the years, our Office has repeatedly concluded in its annual reports that the existing procedure is dysfunctional in terms of expeditiously resolving offender grievances, most notably at the national level. The system has been ineffective in dealing with the chronic backlog of cases."
  • A recommendation that: "the Correctional Service immediately audit its operations to ensure it meets its legislative requirement to resolve offenders’ complaints and grievances fairly and expeditiously. This audit should examine the use of grievance information and trend analysis to implement strategies to prevent future complaints and to systematically address areas of offender concern."

As previously noted in the Executive Summary, as part of its response to the OCI’s 2006/2007 annual report, CSC committed to conduct an audit of the offender complaint and grievance process in fiscal year 2008-2009.

2007/2008

  • "This past year, the Correctional Service revised its Commissioner's Directive CD 081 on the internal offender complaints and grievances system [...] In the end, the CSC revised CD 081 and adopted extended timeframes for response to grievances at the Commissioner's level. The new timeframes moved from 25 days to 80 days for routine grievances and from 15 days to 60 days for high-priority grievances."
  • "It is evident that the huge increase in response times within a system that has for decades been criticized for its inability to respond in a thorough, objective and timely fashion places at issue the Correctional Service's commitment to ensuring that offender grievances are resolved in a fair and expeditious manner."
  • A recommendation that: "the Minister direct the Correctional Service to immediately re-instate the response times at the Commissioner's level of the Offender Grievance and Complaint System at 15 days for priority grievances and 25 days for non-priority grievances, and that the Correctional Service take the necessary steps to comply with those timeframes."

In its response, CSC committed to review the timeliness of response to offender complaints and grievances at the end of 2008/2009, and to ensure that the timeframes remain an element of its efforts to optimize the complaint and grievance system as a means of resolving offender problems and be a useful tool for managers.

2.0 Audit Objectives and Scope

Audit Objectives

The audit objectives were:

  • To provide reasonable assurance that the management framework in place supports the resolution of offender complaints and grievances promptly and fairly (equitably/ consistently) at the lowest level possible; and
  • To provide reasonable assurance that CSC is in compliance with the legal and policy requirements related to the offender complaint and grievance process.

Specific criteria related to each of the objectives are included in Annex A.

Audit Scope

The audit was national in scope and reviewed the management framework in place to support compliance with relevant CDs and various legislative requirements. The audit included visits to a number of institutions in all five regions, and interviews with staff and inmates. The audit examined the systems and procedures in place; in particular, the audit examined a representative sample of inmate complaints and grievances from April 1, 2007 to September 30, 2008 from every region and every level of security.

Excluded from the scope were community offices, given the limited number of complaints and grievances related to community operations. In fiscal year 2007/2008, only 0.6% (128/20,810) of the total number of offender complaints and grievance came from the community.

3.0 Audit Approach and Methodology

Evidence was gathered through:

  • Interviews: 76 interviews were conducted with national, regional and local Grievance Coordinators, Directors in OR at NHQ, managers responsible for responding to offender complaints and grievances, members of an Outside Review Board (ORB) and Inmate Grievance Committee (IGC), NHQ/RHQ Grievance Analysts, and inmates who were typically members of the Inmate Committee or employed as Inmate Grievance Clerks.
  • Review of Documentation: Relevant documentation such as policies, procedure manuals, training material, and monitoring and reporting information was reviewed.
  • File Review: A sample of randomly selected responses to complaints and grievances was reviewed at every level to determine compliance with legislation and policy and to assess the effectiveness of the elements of the management framework. Subject matter experts from NHQ and the Quebec Region joined the audit team for the fieldwork portion of the audit, with file reviews being their primary responsibility. The sample included:
    • 27 complaints (women offenders);
    • 28 first-level grievances (women offenders);
    • 57 complaints (male offenders);
    • 51 first-level (institutional) grievances (male offenders);
    • 53 second-level (regional) grievances;
    • 42 third-level (national) grievances; and
    • 3 additional interaction complaints/grievances (discrimination, staff performance and harassment/sexual harassment).
  • Observation: Observation was done to confirm availability of forms, access to the toll-free OR number, confidentiality of information, etc.
  • Analytical Review: Analytical reviews were performed throughout the audit in order to identify trends, including best practices.
  • Site Visits: Ten institutions were selected based on the number of grievances per offender at the institution. We selected an institution within each security classification (minimum/medium/maximum) that had high, medium, and low proportions in this regard.16 We also ensured that women’s institutions would be included. Finally, the audit team conducted audit work at each of the five RHQs and at NHQ. A full list of the sites visited can be found in Annex B. Upon completion of the site visits in each region, the team held exit meetings to debrief senior management on relevant findings. In addition, a debriefing was held at NHQ with the Assistant Commissioner, Policy and Research Sector17. Draft reports were provided to senior management for comments and preparation of the Management Action Plan.

4.0 Audit Findings and Recommendations

4.1 Management Framework

We assessed the extent to which an appropriate management framework is in place to support the resolution of offender complaints and grievances promptly and fairly at the lowest level possible. This included a review of directives and guidelines, training material, organizational structure, roles and responsibilities, informal resolution practices, and reporting and monitoring mechanisms.

4.1.1 Policies and Procedures

We expected to find that CSC’s policies and procedures are clear and consistent with relevant legislation, such as the CCRA and CCRR.

CSC’s current policy and procedures for offender complaints and grievances are consistent with relevant legislation; however, certain definitions require more clarity.

CD 081 - Offender Complaints and Grievances was updated in October 2008 and contains key information as it relates to the offender complaint and grievance process. Our comparison of the CD with the CCRA and CCRR did not reveal any inconsistencies. In addition, staff mentioned that, for the most part, there is clear understanding of the policy and it is adequate to support their needs. However, staff interviewed noted that certain definitions require clarification; they are listed below:

  • High Priority/Urgent complaints and grievances;
  • Sensitive complaints and grievances; and
  • Frivolous/Vexatious complaints and grievances.

Staff mentioned that the definitions of high priority and urgent complaints and grievances are vague, and require further clarification. Also, some Institutional Grievance Coordinators did not fully understand the difference between a sensitive and urgent complaint/grievance. Uncertainty also exists in determining when a complaint or grievance should be considered frivolous/vexatious, as the current definitions allow for subjective interpretations in this regard. For example, at an institution in the Atlantic region, the notion of frivolous complaints/grievances did not exist; as a result, all complaints/grievances are responded to regardless of their content. Further clarification of these definitions will help ensure appropriate processing of complaints/grievances so that life, liberty, and security of offenders is protected, and complaints/grievances without merit will not hinder the process.

Section 4.2.2 of this report also demonstrates that the lack of clarity in these definitions results in lower compliance for the processing of these types of complaints/grievances.

The definition and intent of the multiple griever status is unclear.

CD 081 states that an offender considered to be a multiple griever is "one who submits so many complaints and/or grievances that the volume impacts on the capacity of the Service to respond to complaints and/or grievances by others or hinders other grievers' access to the process". Interviews with staff revealed that a clearer definition of a multiple griever is required, as they were unsure of when to assign the multiple griever designation.

Furthermore, staff questioned the need for multiple griever status, as assigning such a status does not limit the number of complaints and/or grievances that these offenders can submit. CD 081 states: "Where multiple griever status is confirmed, the Institutional Head will ensure that all routine complaints and grievances are responded to and that this is done in as timely a manner as complaint and grievance caseloads permit. The multiple griever will be advised of the timeframe extensions or the number of grievances that will be investigated each month". We heard from staff that the minimal benefit gained from an offender being declared a multiple griever is outweighed by the procedure required for such declaration, as complaints and grievances coming from a multiple griever must still be logged, documented, given a response, etc.

The use of an Outside Review Board as a value-added mechanism is uncertain.

As defined in CD 081, an Outside Review Board (ORB) is "a committee of members of the community, other than staff members or offenders. It is established to review first level grievances and make recommendations to the decision-maker. The Outside Review Board is only available at the institutional level". An ORB is not an automatic review mechanism; it will only be engaged after an inmate has requested a review of the Institutional Head’s decision prior to going to the second level of the grievance process. The policy also clearly states that an ORB provides a recommendation to the Institutional Head, rather than acting as a decision-making body in the process.

Interviews with both staff and inmates revealed that many question the amount of value that an ORB adds to the offender complaint and grievance process. For example, an Inmate Grievance Clerk explained that an ORB has never been requested at the institution as inmates feel that it slows down the process in terms of receiving a response. In addition, it was stated that once an Institutional Head has rendered a decision, it is highly unlikely that he/she will reverse the decision. Therefore, a recommendation from the ORB only seems to serve as a feedback mechanism for the Institutional Head.

Policies and procedures related to health services complaints and grievances are inconsistent.

Interviews with staff indicated some confusion with respect to the new health services reporting relationship. The Offender Complaint and Grievance Procedures Manual (March 2008) states that "A complaint/grievance must be responded to by the supervisor of the person who is the subject of the complaint/grievance." For complaints against the institutional Chief Health Services, some staff were unsure why the Institutional Head is responsible for making the decision (as per CD 081) rather than the Manager Clinical Services at RHQ. It appears that there is a contradiction within CSC’s body of policy and procedures in this regard, and this should be clarified.

4.1.2 Training

We expected to find that training and information relating to the complaint and grievance process is provided to staff at all levels.

Although some training is available, improvement is required in this area.

Nationally, there is no formal training related to the offender complaint and grievance process. Documentation review and interviews with staff at NHQ indicated that the process is not one of CSC’s National Training Standards (NTS), but it is covered as part of the Assistant Warden and Deputy Warden NTS when the OR group at NHQ has the time and resources available for its facilitation. In addition, the OR group at NHQ has been able to visit a few regions to provide training to staff, but this training is irregular as it only occurs when resources are available. Through interviews, OR at NHQ indicated that providing additional training would be beneficial; it was suggested that training could be done once per year in each region to keep staff up to date with policy and legislative updates. Resourcing was cited as the main reason why training on a regular basis across the country is not provided.

Only 46% (31/67) of interviewees had received any form of training related to the complaint and grievance process. Among those respondents, the type of training varied significantly as only some had received formal training from the OR group at NHQ. However, informal training such as peer-to-peer, job shadowing, and referencing to CD 081 and the Offender Complaint and Grievance Procedures Manual18 was more common. Furthermore, 65% (20/31) of those who had received any form of training felt that the training was sufficient, and 74% (23/31) felt that the training was received in a timely manner. In most instances, however, the training was only considered timely when peer-to-peer or job shadowing was done; formal training was rarely received in a timely manner.

Interviews with staff, particularly at the institutional and regional levels, emphasized that those who had not received any training would find some beneficial, while most that had received training also thought that additional training would be beneficial.

Training tools exist; however, their availability is not well-communicated.

Training tools are available to all CSC staff via its intranet site19, regardless of whether the staff member has received any type of formal complaint/grievance training. For example, the site provides an electronic copy of the Offender Complaint and Grievance Procedures Manual and the Grievance Code Reference Guide. It also gives examples of responses to all grievance codes. All of this information is available through the OR Knowledge Management Module.

Interviews with staff, particularly at the institutional and 2nd levels revealed that many were unaware of these mechanisms or of their availability through the Knowledge Management Module. The OR group at NHQ expressed the view that staff involved in the process should be aware of these resources as they provide information that will help them perform their duties, particularly in the absence of formal training. It is evident that further communication of the availability of these resources is required to ensure awareness.

4.1.3 Roles and Responsibilities

We expected to find that the roles and responsibilities with respect to the offender complaint and grievance process are defined, understood and documented.

Staff involved in the complaint and grievance process understand their roles and responsibilities, although complaint/grievance duties are not defined and documented for most of those involved in the process.

93% (63/68) of staff interviewed felt that their roles and responsibilities are clearly defined. In addition, staff indicated that their roles and responsibilities are generally understood. These attestations are further supported in section 4.2.2 of this report, which shows that compliance with the processing of complaints/grievances is strong in most areas.

We were able to collect job descriptions from many of the staff that we interviewed. Through analysis of this documentation, we determined that not all of those involved in the process have their complaint/grievance responsibilities explicitly stated in their job descriptions. Those that did not contain a statement to this effect were typically job descriptions for decision makers: positions such as Assistant Wardens and other managers within the institutions. Although the roles and responsibilities are not explicitly stated in all of these job descriptions, staff members are generally aware of their complaint/grievance-related responsibilities, as discussed above.

4.1.4 Informal Resolution

We expected to find that processes are in place to ensure the informal resolution of issues where possible/appropriate.

Informal resolution processes are in place within the institutions.

CD 081 states that "Wherever possible, the resolution of the complaint should be achieved through informal resolution, such as mediation, negotiation, interviews, or other means". Interviews with Wardens, Institutional Grievance Coordinators, responding managers, and inmate grievance workers/members of the Inmate Committee indicated that efforts were being made within the institutions to resolve offenders’ issues informally. We found that informal resolution most often takes place between a staff member and the offender through their regular daily interaction. For example, an offender and his/her parole officer may engage in discussion regarding an issue that the offender has relating to the case management process. Examples of more structured informal resolution mechanisms that are used at certain institutions across the country include aboriginal healing circles and the use of a full-time staff mediator. These mechanisms are important because they help decrease the number of grievances at higher levels. In addition, interaction between the offender and staff members helps build rapport between both parties and also encourages offenders to deal with issues in a pro-social manner.

4.1.5 Reporting and Monitoring

We expected to find that reporting and monitoring mechanisms are in place to ensure information relating to offender complaints and grievances is used to improve CSC practices.

Reporting and monitoring mechanisms are in place; however, limited analysis, communications and information sharing are being conducted to improve CSC practices.

All three levels within the complaint and grievance process have implemented measures to report on and monitor the process. A reporting and monitoring tool that is available to all staff involved in the process is RADAR, which is a "suite of reports that allow staff and managers to access offender information".20 RADAR contains information such as: active local, regional, and national grievances; overdue grievances; grievances submitted by offenders while on segregation status; active complaints and grievance for women offenders, etc. RADAR is a tool that can be used for a variety of tracking purposes, including monitoring complaint/grievance response dates, collecting performance information and conducting trend analysis. Another tool that provides similar information and is available to all CSC staff is the Corporate Reporting System (CRS), which is "designed to access information from a wide variety of data sources and display it in a user-friendly format. It contains graphs, tables and very powerful analytical features to assist any employee who requires information on the Service's performance".21 Through interviews, we determined that the level of use of these tools varied significantly among all three levels in the process. As the owner of the information within the systems, OR at NHQ uses the information on a regular basis. Use decreased at the 2nd level and the systems were used very infrequently at the institutional level.

Although the use of RADAR and CRS was low at the institutional level, each site we visited provided evidence through document collection and/or interviews that complaint/grievance due dates are being tracked to help ensure a timely response, and to remind applicable staff when grievance responses are due. Although no locally standardized tracking tool exists for this purpose, each site has developed its own22 based on its needs, and these tracking tools are serving their intended purpose. Information relating to grievance due dates will be brought up (typically at morning briefings) with management at each level on an ad-hoc basis when significant or unique issues require managerial attention.

For the most part, these tracking tools are also able to identify trends relating to issues within the institutions, as the grievance code is typically captured when a complaint/grievance is entered. At the institutional level, some of the sites visited (i.e., women’s institutions, men’s minimum security institutions) noted that the volume of complaints/grievances is very low, and thus tracking trends in terms of common issues is irrelevant. If trends are identified at any level of the process, management will typically be advised on an ad-hoc basis, either through informal discussion, oral briefings at management meetings, or formal reporting. Although trend information is available, little analysis is being done in terms of identifying systemic issues. Interviews with OR indicated that communication with the sectors at NHQ is limited, and there should be more sharing of information. Furthermore, there are no formal mechanisms in place to identify and share good practices. At the local and regional levels, Grievance Coordinators explained that they do not usually interact with their counterparts in other institutions or regions, respectively. If clarification or explanation is required, the Coordinators will typically consult with someone involved in the process at the level above them (local Coordinators may also consult with NHQ). In some regions, however, meetings have occurred whereby Coordinators can discuss common issues and outstanding questions that they may have. It was mentioned that these meetings are also an excellent forum for identifying best practices. Staff at both the institutional and regional levels felt that they would benefit from regularly scheduled meetings for these purposes.

Performance information relating to compliance with timeframes can be misleading.

Currently, CSC defines a response to a complaint/grievance as "late" if the original timeframe is not met (for those with no extension to the timeframe), or if an extended timeframe is not met (for those who received an extension). This can be misleading since there is no limit on the number of extensions that can be issued for responses to complaints/grievances. In reviewing the data, it may seem that CSC is doing well with respect to responding to complaints/grievances in a timely manner, when in fact there could be a significant number of extensions issued on the original timeframes. We reviewed the timeliness of response and note in Section 4.2.2 concerns with respect to the number of extensions being issued at 1st and 2nd levels. Given the commitment made in June 2008 to the OCI to ensure timeframes remain an element of CSC’s efforts to optimize the complaint and grievance process, it is important to enhance the monitoring mechanisms in place in that regard.

Conclusion

The key elements of a management framework are in place to support the offender complaint and grievance process. While there is room for improvement in some areas, policies are in place and they are consistent with relevant legislation; training tools exist for staff involved in the process; organizational structures are well defined, documented, and are generally understood; roles and responsibilities are understood; informal resolution is occurring within institutions of all security levels; and some reporting and monitoring mechanisms are in place.

Nevertheless, our audit showed that attention is required in the following areas:

  • Within the policy, definitions of the following require further clarification:
    • High Priority/Urgent complaints and grievances;
    • Sensitive complaints and grievances; and
    • Frivolous/Vexatious complaints and grievances.

In addition, the definition and intent of the multiple griever status is unclear, the use of an Outside Review Board as a value-added mechanism is uncertain, and there are inconsistencies in CSC’s policy and procedures with respect to the processing of complaints and grievances that relate to the authority to render a decision for 1st level grievances related to the Chief Health Services;

  • Additional training is needed, and the availability of training tools needs to be better communicated; and
  • Enhancements to analysis, communication, and information sharing on performance results are required to ensure improvement of CSC’s practices.
Recommendation 1

The Assistant Commissioner, Policy and Research should:

  • Clarify the definition of high priority, urgent, sensitive, frivolous and vexatious complaints and grievances;
  • Review the multiple griever status and assess its role in ensuring the efficiency and effectiveness of the offender complaint and grievance process and, as needed, provide additional guidance for its implementation;
  • Review the practices related to the Outside Review Board and, as needed, provide additional guidance;
  • Ensure consistency of policy and procedures as they relate to the authority to render a decision for 1st level grievances related to the Chief Health Services; and
  • Enhance the processes and procedures for analyzing performance information and trend analysis including timeliness of response and sharing information with various stakeholders.


Recommendation 2

The Assistant Commissioner, Policy and Research, in collaboration with the Assistant Commissioner, Human Resource Management, should enhance training available to staff and the communication of training tools that are available.

4.2 Compliance with Legal and Policy Requirements

We examined the extent to which CSC’s offender complaint and grievance process complies with various legal and policy requirements. This included a review of the accessibility of the process, processing of complaints and grievances, priority complaints and grievances, completeness and quality of the content of responses to complaints and grievances and of the file, corrective action, and confidentiality of the process.

4.2.1 Accessibility of the Process

We expected to find that processes are in place to ensure that offenders have access to the complaint and grievance process.

Information relating to the process is available to all inmates; however, there are instances where the information in the institutional inmate handbook is inaccurate.

Through observation and interviews with both staff and inmates, the audit team was able to determine that information relating to the process is available through a variety of sources within institutions, including: the inmate handbook, CDs in the library, inmate grievance workers, and word-of-mouth.

In addition, six of the 10 institutions that we visited had orientation modules whereby an inmate was provided with information relating to the complaint and grievance process as a sub-set of the orientation. For example, when an inmate arrives at Riverbend Institution, he will be taken around the institution to be introduced to each of the areas. Part of this orientation is a meeting with the Chief of Administration, whereby the complaint and grievance process is explained. A subsequent sign-off occurs to verify that the inmate has received the orientation.

Good Practice

Kingston Penitentiary has a television channel that provides institutional information to inmates, including information relating to the offender complaint and grievance process.

When an offender first arrives at an institution, he/she will be provided with an inmate handbook. These handbooks explain many of the rules of the institution, processes that occur within the correctional system, general expectations, etc. The audit team reviewed the inmate handbooks at each of the institutions we visited, and found that information relating to the complaint and grievance process is provided in each of them. While reviewing the handbooks, however, we found some inconsistencies with respect to response timeframes that are indicated in the handbook and the actual timeframes that are established in CD 081. These discrepancies are listed below:

Table 3
Inmate Handbook Inaccuracies

Handbook Handbook Statement Policy Statement
Bath Institution (January 2009) The response time for complaints and all levels of grievances are 25 working days. 3rd Level Routine Priority - Within eighty (80) working days of receipt by the decision-maker.
Complaints/grievances may be designated "high priority".  Those given this designation will be responded to within 15 working days. 3rd Level High Priority - Within sixty (60) working days of receipt by the decision-maker.
Kingston Penitentiary
(October 2007)
High priority complaints shall be responded to within 15 working days and low priority complaints shall be responded to within 25 working days [...] These timeframes apply to grievances at all levels. 3rd Level High Priority - Within sixty (60) working days of receipt by the decision-maker.

3rd Level Routine Priority - Within eighty (80) working days of receipt by the decision-maker.
Nova Institution (June 2008) Complaint - [...] you should receive an answer within ten working days. Complaint High Priority - Within fifteen (15) working days of receipt by the decision-maker.

Complaint Routine Priority - Within twenty-five (25) working days of receipt by the decision-maker.
Nova Institution (June 2008) 2nd level grievance - [...] you should receive a response ten working days from the date of receipt of the grievance. 2nd Level High Priority - Within fifteen (15) working days of receipt by the decision-maker.

2nd Level Routine Priority - Within twenty-five (25) working days of receipt by the decision-maker.
3rd level grievance - [...] You should have a response within ten working days. 3rd Level High Priority - Within sixty (60) working days of receipt by the decision-maker.

3rd Level Routine Priority - Within eighty (80) working days of receipt by the decision-maker.

These inaccuracies may lead to an inmate’s expectations that CSC cannot meet, and there is a possibility that the offender will grieve the fact that he/she did not receive a response within the timeframe indicated in the inmate handbook. In turn, this may increase complaint/grievance volume within the process. Furthermore, it may be beneficial for CSC to develop a standard section relating to the offender complaint and grievance process for the inmate handbook, as opposed to each institution preparing its own material. As needed, supplementary local information could be added to the section. This could reduce the risk of inaccuracies with policy.

As stated in CD 081, "A national toll-free phone number is available to grievers to inquire about the complaint and grievance process or to ask specific questions about third level grievances they have filed, such as the status of the grievance or the implementation of a corrective action".

The review of the inmate handbooks indicated that the toll-free number is provided to all inmates at each of the institutions that we visited. In addition, 7 of the 10 institutions we visited have the toll-free number posted on a common phone number access list beside the phones in the units. A subsequent review of the toll-free log obtained from OR at NHQ indicates that inmates across the country have been making use of this resource, as 3554 calls were made in fiscal year 2007/2008.

Complaint and grievance forms are available to all inmates regardless of where they are housed within the institution.

Observation conducted by the audit team noted that complaint and grievance forms are available for inmates in a variety of locations throughout the institution. In all institutions visited, an inmate could obtain forms from a staff member working in their unit or from their Parole Officer. In addition, forms were available in locations such as: common areas, the Inmate Committee office, an Inmate Grievance Clerk’s office, the library, etc. It should be recognized that form availability is also maintained in segregation units, as forms were available either in boxes in the unit, or from a Correctional Officer.

Both official languages are respected in the complaint and grievance process.

For 99% (249/251) of applicable files we reviewed, the response to a complaint/grievance was written in the same language as the original submission from the offender. Interviews with both staff and inmates revealed that staff and/or inmates may be available to help with translations upon request, or the complaint/grievance can be sent out by CSC for translation. In addition, interviews with staff and inmates indicated that resources are available for offenders who may be illiterate and have a difficult time completing a complaint/grievance form on their own. Most often, an offender will have a peer to help him/her with the submission, or his/her Parole Officer would be able to help. At some institutions, English-as-a-second-language peers are available to provide assistance.

4.2.2 Processing of Complaints and Grievances

We expected to find that the processing of complaints and grievances is completed in compliance with relevant policies and procedures.

With some exceptions, a high level of compliance exists when processing complaints and grievances; however, improvement is required when meeting timeframes for response, and in the designation of priority complaints and grievances.

Interviews with Institutional Grievance Coordinators did not reveal any serious concerns with respect to the processing of complaints and grievances. File reviews indicated strong processing compliance in most areas as outlined below:

Table 4
Compliance with Policy and Procedures

Compliance Criteria23 Rate of Compliance
Submission signed by Grievance Coordinator 210/235 (89%)
Date of receipt indicated on file 204/235 (87%)
Appropriate grievance code assigned 202/238 (84%)
Receipt of submission acknowledged to inmate 249/261 (95%)
Appropriate referrals to Health Services 17/20 (85%)
Letter on file when timeframe was extended 33/42 (79%)
Assigned to the appropriate division/individual for response 155/161 (96%)
Conflict of interest avoided with respect to decision maker 159/162 (98%)
Inmate attests to withdrawal 24/74 (32%)
Group complaints / grievances: single offender representative identified 4/4 (100%)
Group complaints / grievances: submission signed by all offenders involved in the complaint / grievance 3/4 (75%)
Appropriate due date indicated in response 240/255 (94%)

As stated in CD 081, "No complaint or grievance may be withdrawn by a griever unless the matter is resolved, the nature of the resolution is recorded and the griever attests to this resolution in writing. The matter will be recorded as resolved and will be signed by the griever and a staff member". Table 4 indicates that improvements can be made with respect to offenders attesting to the withdrawal of his/her complaint/grievance as only 32% (24/74) of withdrawals were compliant in this regard. Interviews with staff suggested that poor compliance may be found in this area because it is often difficult to get an offender to sign the attestation, even if he/she has verbally agreed that a resolution occurred. The attestation is important, however, because it helps reduce the likelihood that a complaint/grievance is withdrawn against an offender’s wishes when it should have gone through the regular complaint/grievance process.

At one of the institutions visited, a CSC staff member is employed as a full-time complaint/grievance mediator. When an inmate completes a complaint or grievance form, it is sent to the mediator who will then interview the inmate to attempt to resolve the complaint/grievance informally. If informal resolution occurs, the complaint/grievance is considered closed and processing does not occur, which is contrary to the policy requiring that all complaint/grievance forms be recorded and processed accordingly. Nevertheless, if informal resolution does not occur, the form will be sent to the Institutional Grievance Coordinator and the complaint/grievance goes through the formal process (logged in OMS, assigned to decision-maker for response, etc.)

Although interviews with staff from that institution revealed that the use of the mediator is an effective step in resolving issues, it is not consistent with policy and poses risk to CSC as the inmate could be under the impression that the completion and submission of a CSC form would suggest that the complaint/grievance is going through the formal process. In turn, he may be expecting a response to the complaint/grievance within the applicable number of working days indicated in policy, starting on the day he filled out the form. In fact, the number of working days would not start being counted until the Institutional Grievance Coordinator receives the complaint/grievance from the mediator. In addition, the current process poses a risk that not all forms that should be entered into the system are recorded, and vice-versa.

With respect to compliance with timelines, data extracted from the CRS is presented in Table 5 below:

Table 5
Late Responses by Grievance Type24

Complaint / Grievance Level Fiscal Year
2005/2006 2006/2007 2007/2008 2008/2009
Complaint 1,031/12,762
(8%)
920/13,123
(7%)
989/13,423
(7%)
1,243/16,983
(7%)
1st Level 328/2,681
(12%)
397/3,032
(13%)
353/3,147
(11%)
331/4,147
(8%)
2nd Level 93/2,361
(4%)
107/2,444
(4%)
88/2,771
(3%)
99/3,580
(3%)
3rd Level25 285/1,333
(21%)
66/1,254
(5%)
12/1,438
(1%)
0/1,888
(0%)
Total 1,737/19,137
(9%)
1,490/19,853
(8%)
1,442/20,779
(7%)
1,673/26,598
(6%)

Although there has been a reduction in the number of late responses over the four year period listed above, a significant number of complaints and grievances are still not provided with a response within established timeframes. Furthermore, it should be noted that when extensions are issued, the responses are not considered late unless they are not provided within the extended timeframe.

As illustrated in Table 6, the fact that the number of extensions issued at the 1st and 2nd levels are increasing indicates that performance with respect to meeting timelines is not improving.

Table 6
Number of Extensions issued by Grievance Level and Fiscal Year26

Complaint/ Grievance Level Fiscal Year
2005/2006 2006/2007 2007/2008 2008/2009
Complaint 620/12,762
(5%)
1,186/13,123
(9%)
1,080/13,423
(8%)
1,238/16,994
(7%)
1st Level 224/2,681
(8%)
366/3,032
(12%)
393/3,160
(12%)
554/4,222
(13%)
2nd Level 1,132/2,361
(48%)
970/2,444
(40%)
1,083/2,785
(39%)
1,792/3,600
(48%)
3rd Level27 1,048/1,333
(79%)
808/1,254
(64%)
801/1,441
(56%)
205/1,893
(11%)
Total 3,024/19,137
(16%)
3,330/19,853
(17%)
3,357/20,809
(16%)
3,789/26,709
(14%)

Furthermore, even after timeframes for response at the 3rd level were lengthened, 11% of grievances in fiscal year 2008/2009 required an extension. For complaints and grievances in fiscal year 2008/2009 that required an extension, the response was provided to the offender within an average of 16 to 28 calendar days following the initial due date28.

Interviews with staff indicated that the primary causes for the extensions were the procedural requirements relating to processing. For example, at the 3rd level, consultations with sectors at NHQ will occur to provide recommendations relating to the grievance, or to gather policy-related information so that the analyst can make an informed decision. Staff explained that this process is time consuming, as responses from the sectors are not always timely. An employee being consulted may not be able to devote time to the issue given his/her regular workload, and the grievance process may not be given priority. This, in turn, makes it difficult to respond to the grievance within established timeframes. Difficulties in meeting the original timeframe also occur when an analyst at 2nd/3rd level requires additional background information relating to the grievance to provide an informed response. We were told that due to regular operational duties, staff at the institutional level may have difficulties providing the information in a timely manner.

As part of our file review, we also assessed if high priority, urgent, sensitive and harassment complaints and grievances were identified in compliance with the policy and some concerns were noted.

Table 7
Priority Complaint/Grievance Compliance

Compliance Objective Rate of Compliance
When applicable, submissions were appropriately classified as:  
High Priority 31/46 (67%)
Urgent 1/8 (13%)
Sensitive 4/14 (29%)
Harassment 7/11 (64%)

These types of complaints/grievances have shorter timeframes for response (i.e., 15 days for high priority vs. 25 days for routine at the institutional level). As highlighted in section 4.1.1, interviews with staff suggested that the definitions of high priority, urgent, and sensitive complaints and grievances in CD 081 require further clarification. Reviews of file documentation further illustrate the need for clarification in this regard, as several complaints/grievances that should be considered priority were not processed as such. Furthermore, some Institutional Grievance Coordinators indicated uncertainty about which type of complaint/grievance should be given priority in deciding between urgent and high priority complaints/grievances. The following definitions are stated in CD 081:

  • High priority complaints and grievances concern matters that have a direct effect on life, liberty or security of the person or that relate to a griever’s access to the complaint and grievance process. Other complaints and grievances are designated routine priority.
  • Urgent complaints or grievances are those that would result in irreparable adverse consequences to the griever if not immediately resolved (at some identified juncture in less than fifteen (15) days).
  • Sensitive complaints and grievances contain information whose disclosure must be significantly restricted due to the nature of the information contained or the potential adverse effects of its disclosure.

Confusion exists with respect to the requirement to collect and review complaints and grievances on weekends and holidays from offenders on segregation/cell-confinement status.

In October 2008, CD 081 was revised with an amendment to ensure that complaints and grievances submitted by segregated offenders are identified and monitored. The revised CD 081 now states that "The Institutional Head must ensure that complaints and grievances are collected and reviewed daily". As a follow-up to this revision, the Assistant Commissioner, Policy and Research issued a requirement that "Wardens are required to send a confirmation to their Assistant Deputy Commissioner, Institutional Operations (ACDIO), who in turn will confirm with me, no later than November 14, 2008, that all processes have been put into place". We were able to verify that all of the sites visited have issued confirmation in this regard.

However, interviews revealed that some sites were unsure whether the requirement to collect and review segregation complaints/grievances on a daily basis applied to weekends and holiday. A few sites indicated that these complaints and grievances will only be picked up and reviewed on the following Monday, which proves non-compliance in this regard. It is imperative that sites pick up and review complaints and grievances from offenders on segregation/cell confinement status on a daily basis to ensure that the process is available to all offenders, regardless of their status.

4.2.3 Completeness and Quality of Content and File

We expected to find that there is sufficient information in the response and on file to support the decision rendered.

There is room for improvement with respect to the completeness and quality of file content; particularly, evidence of an attempt to interview the inmate and documentary evidence supporting the decision.

As indicated in the table below, file reviews showed that there is room for improvement in some areas with respect to the completeness and quality of file content:

Table 8
Completeness and Quality of File Content

Compliance Objective29 Rate of Compliance
There is evidence on file of an attempt to interview the inmate 104/254 (41%)
Rationale on file explains the decision rendered 223/241 (93%)
Documentary evidence (i.e., policy reference, references to specific decision records, etc.) supporting the decision is maintained on file 137/192 (71%)
Response on file clearly addresses issues identified in submission 225/244 (92%)

There was evidence on file in only 41% (104/254) of applicable cases that there was an attempt to interview the offender. This is a critical step in the process as it helps the decision-maker to gather background information relating to the submission, or to receive clarification from the offender with respect to the issue(s) that is being brought forward. Interviews with staff suggested that compliance may be low in this regard as interviews are difficult to conduct if the offender has been transferred to a new institution, or is in the community on a form of release. It is important, however, for these interviews to be conducted to help ensure a quality response to the offender’s submission.

Similarly, compliance could be improved with respect to the amount of documentary evidence supporting the decision that is on file (i.e., policy references). This becomes increasingly important if a complaint/grievance is denied at one level and is later elevated to higher levels. Without sufficient documentation on file, analysts at the higher level will have to consult with the level that denied the complaint/grievance to obtain further information, or he/she may have to gather their own documentation; a process that is time consuming and may lead to an extension being issued.

Through interviews, the audit team found that discussions at management meetings and reviews of previous decisions occur to ensure consistency in responses to common issues. In addition, CD 081 states that "Decision-makers should solicit and obtain information from operational and policy experts before making decisions on matters requiring specialized knowledge". Interviews with decision-makers confirmed that they consult CSC’s sectors when appropriate to help ensure an informed decision is made, and to provide a quality response.

4.2.4 Corrective Action

We expected to find that there is a process in place to ensure the implementation and follow-up of corrective action resulting from individual complaint and grievance responses.

Although mechanisms are in place for implementation of corrective action issued from all levels of the process, there is room for improvement with respect to the documentation of corrective action being implemented.

In general, interviews with staff and documentation analysis revealed the following with respect to corrective action:

  • Complaint/1st level: Correspondence will be issued to the appropriate decision-maker indicating corrective action to be taken, but there is no standardized follow-up procedure being conducted to ensure its implementation. Most sites track corrective action through the Institutional Grievance Coordinator’s tracking sheet, and the decision-maker will advise the Institutional Head’s office when the corrective action is complete. We found that formal follow-up may not be necessary at these levels due to a low volume of complaints and grievances at some institutions (women’s and men’s minimum security) and the nature of the content of others. For example, corrective action that required an immediate remedy (i.e., providing an inmate with an amenity) would be reported as complete following the action, and therefore would not require follow-up.
  • 2nd/3rd levels: The Institutional Head’s tracking system will indicate when corrective action is due, and reminders will be sent out to the affected decision-maker to ensure implementation. As a secondary control in this regard, the 2nd and 3rd levels will follow up with the institutions to confirm that the corrective action is complete.

As indicated in the table below, file reviews indicated the following with respect to corrective action documentation:

Table 9
Corrective Action Documentation Compliance

Compliance Objective30 Rate of Compliance
File indicates that when the decision is "upheld" or "upheld in part", relevant corrective action is identified in the response to the offender, when appropriate 44/47 (94%)
Evidence of corrective action being implemented is maintained on file 34/45 (76%)
Evidence of meeting the timeframe for corrective action is maintained on file 28/43 (65%)

Of applicable cases, only 76% (34/45) of the files we reviewed provided evidence that appropriate corrective action was implemented. In addition, evidence with regard to timeframes for the implementation of corrective action was included in only 65% (28/43) of the applicable files that we reviewed.

4.2.5 Confidentiality of the Process

We expected to find that the confidentiality of information relating to complaints and grievances is restricted to a "need-to-know" basis.

Complaint and grievance information is shared on a need-to-know basis; however, there is room for improvement with respect to the protection of offender complaint and grievance documentation.

Interviews with staff and inmates revealed that information is shared on a need-to-know basis. In addition, three of the institutions we visited had inmates employed as complaint and grievance workers, and we were able to confirm through interviews and document collection that each of them had signed a confidentiality agreement.31 Decision-makers explained that they will only provide the general situation and subject matter of the complaint/grievance to the relevant sector(s) while doing a consultation. The only time an offender’s name will be revealed to the staff member being consulted will be to obtain information relating to the offender, in which case the need-to-know is established.

Observation and interviews with staff at all levels demonstrated some positive practices with respect to the protection of offender complaint and grievance documentation. Controls such as: sealed envelopes, locked boxes, locked offices, locking mechanisms for cabinets, IT security and "protected B" markings were in place to help ensure confidentiality at the majority of the sites that we visited.

Good Practice

Some institutions have locked boxes designated for offender complaints and grievances. This practice helps ensure the protection of confidential information, and limits the distribution of such on a need-to-know basis.

However, the following are examples of poor practices that were observed during the audit:

  • Documentation was left unattended on a desk in an administrative area where staff and the inmate cleaner have access. In addition, documentation was being circulated around the institution without being protected in a folder. All of this documentation should have been protected in accordance with "protected B" guidelines;
  • At an RHQ office, analysts did not have locked cabinets where protected information could be stored, and the building’s cleaners have access to the office after hours; and
  • At an RHQ office, facsimiles could arrive overnight when office cleaners would be present.

These types of practices may pose a number of risks to CSC, including: breaches of privacy; legal action; and institutional, staff and inmate security.

Conclusion

In general, the offender complaint and grievance process is in compliance with legislation and relevant CSC policy and procedures. While there is room for improvement in some areas, information relating to the process is available to all inmates; complaint and grievance forms are available to all inmates; both official languages are respected in the process; a high level of compliance exists when processing offender complaints and grievances; mechanisms are in place to help ensure implementation of corrective action issued from all levels within the process; and offender complaint and grievance information is shared on a need-to-know basis.

Nevertheless, our audit showed that attention is required in the following areas:

  • Inmate handbooks at the institutions are not always consistent with policy;
  • There are challenges in meeting timelines to respond and extensions have increased significantly at the 1st and 2nd levels in the last year;
  • Clarification is needed with respect to the requirement to collect and review complaints and grievances on weekends and holidays from offenders on segregation/cell-confinement status; and
  • Improvements can be made with respect to the completeness and quality of file content, including the documentation of corrective action taken and in the protection of offender complaint and grievance documentation.
Recommendation 3

The Regional Deputy Commissioners should ensure that inmate handbooks provide information consistent with legal and policy requirements.


Recommendation 4

The Assistant Commissioner, Policy and Research, in collaboration with the Regional Deputy Commissioners, should improve compliance by:

  • Reviewing the timeliness of response and the number of extensions, and take the necessary steps to improve the results;
  • Providing clarification to staff with respect to the collection and review of complaints/grievances on weekends and holidays from inmates on segregation/cell-confinement status; and
  • Reinforcing the need to maintain complete file information, and to protect confidential documentation.

 

Annex A

Audit Objectives and Criteria

Objectives Criteria
1. To provide reasonable assurance that the Management framework in place supports the resolution of offender complaints and grievances promptly and fairly (equitably / consistently) at the lowest level possible. 1.1 Policies and procedures - CSC policies and procedures are clear and consistent with relevant policy and legislation.
1.2 Training - Training and information relating to the complaints and grievance process are provided to staff at all levels.
1.3 Roles and responsibilities - Roles and responsibilities are defined, understood and documented with respect to offender complaints and grievances.
1.4 Informal resolution - Processes are in place to ensure the informal resolution of issues where possible / appropriate.
1.5 Reporting and monitoring - Reporting and monitoring information relating to offender complaints and grievances (performance information, trend analysis, follow-up on previous reviews) is used to improve CSC practices.
2. To provide reasonable assurance that CSC is in compliance with the legal and policy requirements related to Offender complaints and grievances process. 2.1 Accessibility of the process - Processes are in place to ensure that offenders have access to the complaints and grievance process.
2.2 Processing - The processing of complaints and grievances is completed in compliance with relevant policies and procedures.
2.3 Priority complaints and grievances - Complaints and grievances designated as high priority, urgent, sensitive or harassment are processed in compliance with policies and procedures.
2.4 Completeness and quality of content and file - There is sufficient information in the response and on file to support the decision.
2.5 Corrective action - There is a process in place to ensure the implementation and follow-up on corrective action resulting from individual complaint and grievance responses.
2.6 Confidentiality of the process - The confidentiality of information relating to complaints and grievances is restricted to a "need to know" basis.

Annex B

Location of Site Visits

National Headquarters

Atlantic Region
Regional Headquarters
Nova Institution for Women - Multi-Level Security
Westmorland Institution - Minimum Security

Quebec Region
Regional Headquarters
Joliette Institution - Multi-Level Security
Donnacona - Maximum Security

Ontario Region
Regional Headquarters
Bath Institution - Medium Security
Kingston Penitentiary - Maximum Security

Prairie Region
Regional Headquarters
Stony Mountain Institution - Medium Security
Riverbend Institution - Minimum Security

Pacific Region
Regional Headquarters
Mission Institution - Medium Security
Pacific Institution - Multi-Level Security

Annex C

Audit of the Offender Complaint and Grievance Process
Management Action Plan

Recommendation Action Summary OPI Planned Completion Date
Recommendation 1:
The Assistant Commissioner, Policy and Research32 should:
  ACPR  
  • Clarify the definition of high priority, urgent, sensitive and frivolous/vexatious complaints and grievances
Consult Managers at locations which the audit team identified as having problems with these definitions and a reliable sampling of other institutional and regional managers to ascertain gaps in current definitions and explanations.   Consultation complete by end July 2009

Bulletins sent by end October 2009

Review of Manual and Policy completed by end November 2009
  Enhance training by including revisions in the Respondent Self Study Module and by posting additional cases presenting these situations on the Infonet -- Knowledge Management module   Self-study module revised by end December 2009

New cases posted on KM by the end of October 2009
  • Review the multiple griever status and assess its role in ensuring the efficiency and effectiveness of the complaint and grievance system and, as needed, provide additional guidance
Changes have been made for inclusion in OMSR which will streamline and facilitate the process for identifying those offenders who are having a significant impact on the process at their site.  The designation process will be automated and all criteria identified in policy for designating and managing a multiple griever has been integrated in the OMSR.   OMSR is expected to be implemented in May 2010
  ORD will review and assess what improvements can be made to the current "Multiple Griever" status and include consideration and analysis of extending multiple griever procedures to second and third level of the grievance process.   Analysis and Assessment Summer/ Fall 2009

Presentation of Findings to EXCOM December 2009
  • Review the practices related to Outside Review Boards and, as needed, provide additional guidance
ORD has conducted focus groups in three regions dealing, in part, with best practices and problems associated with ORB law, policy and use.   Results of focus group discussions compiled by end July 2009
  ORD will launch a pilot project in the Ontario Region with law students and graduate students in criminology and related fields conducting ORB reviews, in concert with community members who are knowledgeable of CSC operations to determine whether changes to the memberships of ORBs may enhance acceptance and use of the boards.   Consultations completed and management model adopted by end September 2009-06-15

Identification of participants and training completed by end October 2009

Pilot project to be completed by end of April 2010

Report to ACPR by end  June 2010
  • Ensure consistency of policy and procedure as they relate to the authority to render a decision for 1st level grievances related to the Chief of Health Services
HS Sector has conducted reviews of health services grievances focusing on processing and content of HS complaints and grievances at the institutional and regional level.   Report available on infonet.

A further analysis of the complaints, first and second level grievances submitted in 2007-2008, along with strategies to address findings is expected to be completed in 2009.
  Checklist and bulletin explaining the relation between HS’ new governance structure and the authorities identified in the CCRA for the redress process has been prepared and is currently available on the infonet.   Completed
  A joint communication will be issued to the HS community identifying the relationship between HS and OR and the tools developed to assist HS in managing this process.   November 2009
  The OR manual will be reviewed to enhance clarity of the relationship with HS as it pertains to the grievance process.   November 2009
  • Enhance the processes and procedures for analyzing performance information and trend analysis, including timeliness of response and sharing of information with various stakeholders.
ORD will communicate further information to the regions and institutions pertaining to the availability of Data and Knowledge Management tools and to promote their use by managers in identifying trends and systemic issues.   Information provided to RDC’s and IH’s by end October 2009
  ORD will also produce an annual trends document on information arising from complaints and grievances for consideration by the SDC and subsequent referral to EXCOM   Draft document provided to SDC by end December 2009
Recommendation 2:
The Assistant Commissioner, Policy and Research in collaboration with the Assistant Commissioner Human Resources Management should:
  ACPR
ACHRM
 
  • Enhance training available to staff, and communication of training tools that are available
ORD is devising a computerised autonomous learning tool to provide training to institutional and regional grievance coordinators in the requirements of CD 081 and the Offender Complaints and Grievance Manual.   Tool provided and training completed for initial users by end December 2009

Through to March 2010
 
  • ORD will undertake initiatives to strengthen the level of functional guidance provided to the redress staff in the field by  undertaking measures:
   
 
  • to develop and implement regular forums and other opportunities for strategic communication and dialogue between ORD and regional/institutional management and staff
   
 
  • to establish a community of practice and expertise analogous to those that have been built in other functional areas (e.g. HR)
   
Recommendation 3:
The Regional Deputy Commissioners should:
  RDCs  
  • ensure that inmate handbooks provide information that is consistent with law and policy
ORD will provide RDC’s with a list of the information that must be included in inmate handbooks related to the offender redress system.   September 2009
  RDC’s will ensure amendments are made based on the advice of ORB and other staff they deem appropriate.   Amended handbooks completed by end fiscal year 2009/10
Recommendation 4:
The Assistant Commissioner, Policy and Research in collaboration with the Regional Deputy Commissioners should improve compliance by:
Data will be forwarded to RDC’s regarding timeliness of responses, use of extensions and timely completion of corrective actions. ACPR
RDCs
Fall 2009
  • Reviewing the timeliness of responses and the number of extensions and taking the necessary steps to improve the results
ORD in conjunction with Regional counterparts will:
  • will establish appropriate service/ timeliness commitments for Priority and Routing Grievances at the 1st and 2nd level.
  • will review extension criteria to clarify when and for what reasons extensions can be applied and to allow for enhanced monitoring regarding the application of extensions
ORD to develop a more robust monitoring and compliance assurance function as part of the grievance process to enhance timeliness, compliance with policy and procedures and overall quality assurance.
  Commence Summer Fall 2009 to be completed by April 2010
  • Providing clarification to staff with respect to the collection and review of complaints/grievances on weekends and holidays from inmates on segregation/cell confinement status.
Immediate communication from ACPR will be sent to RDC, to remind them of their obligation with daily review and collection of grievances from segregation   Completed June 8, 2009
  • Reinforcing the need to maintain complete file information and to protect confidential information
ORD in consultation with ATIP and Departmental Security will identify gaps and risks related the processing of files and provide the necessary guidelines and/or adjustments to process to minimize the associated risks.   Bulletin by end of October 2009
Manual revised by November 2009


1 CCRA , section 90

2 CCRA, section 91

3 CCRR, Section 74 (1)

4 Email correspondence with NHQ Finance

5 OCI: http://www.oci-bec.gc.ca/index-eng.aspx

6 CCRA, section 90

7 CCRA, section 91

8 CCRR, Section 74(1)

9 Information received from NHQ Finance

10 Corporate Reporting System, Data as of: 2009-04-12

11 ibid

12 Corporate Reporting System, Data as of: 2009-04-12

13 The total may not equal the sum of the regions due to inter-regional transfers during the fiscal year.

14 Corporate Reporting System, Data as of: 2009-03-08. This figure represents all inmates, not just those who have submitted a complaint(s)/grievance(s).

15 http://www.oci-bec.gc.ca/index-eng.aspx

16 Complaints and grievances submitted by offenders with multiple griever status were excluded from the proportion count to ensure that sites would not be selected based on their volume.

17 Subsequent to the approval of the audit report by the Audit Committee, the position of Assistant Commissioner, Policy and Research has been changed to Assistant Commissioner, Policy

18 Infonet: http://infonet/corp_dev/rights_redress_resolution/ia/about_rrr_ia_e.shtml

19 Infonet: http://infonet/corp_dev/rights_redress_resolution/ia/kmmg-mgsg_e.shtml

20 Infonet: http://infonet/radar/home_e.shtml

21 Infonet: http://infonet/pa/corporate_e.asp

22 With the exception of Pacific Institution, which uses the tracking tool developed by Mission Institution.

23 Compliance criteria were assessed based on the number of files that were applicable for each circumstance.

24 Data as of: 2009-04-12. Fiscal Year 07/08 and 08/09 exclude grievances that are currently deferred, and previously deferred, now active, but not yet provided with a response.

25 The decrease in the number of late responses at the 3rd level in fiscal year 2008/2009 could be attributed to the fact that timeframes at the 3rd level were extended in October 2007 (from 15 working days for high priority and 25 working days for routine priority to 60 working days for high priority and 80 working days for routine priority).

26 Corporate Reporting System, Data as of: 2009-04-12

27 Timeframes for response at the 3rd level were extended in October 2007.

28 Information provided by OR at NHQ based on data from CSC's data warehouse.

29 Compliance objectives were assessed based on the number of files that were applicable for each circumstance.

30 Compliance objectives were assessed based on the number of files that were applicable for each circumstance.

31 CSC form 1189: Acknowledgement - Privacy Issues

32 Subsequent to the approval of the audit report by the Audit Committee, the position of Assistant Commissioner, Policy and Research has been changed to Assistant Commissioner, Policy.