The state child welfare agency lacks the personnel and necessary tools to consistently fulfill its fundamental mission of protecting children from abuse and neglect, according to a sharply critical management review that was delivered to Governor Charlie Baker this week.
The report adds to the picture of widespread dysfunction at the Department of Children and Families that has emerged over the last two years as the agency has contended with a series of tragedies involving children who have died or were abused under its watch.
The review, commissioned by the Legislature last year, found that at the same time DCF’s frontline social workers are contending with soaring caseloads, the agency has lost 40 managers, or 17 percent of its management positions, as a result of Baker’s push to trim the state payroll through early retirement incentives.
In addition, the report said, there is no clearly articulated agenda to improve DCF, insufficient accountability, and reactionary decision-making that is often a response to the latest crisis. And while DCF generates dozens of reports on the demographics of the children it serves and the number of visits made by caseworkers, it is not crunching that data in a way that would allow managers to identify trends.
It is therefore no surprise that employee morale is low and workers speak openly about stress and trauma, the report said.
“I have been here for 38 years, but it has never been this bad,” said one veteran caseworker quoted in the report.
The review was conducted by the Ripples Group, a Boston consulting firm, which interviewed 19 DCF executives and conducted 18 focus groups with more than 120 caseworkers, supervisors, and program managers.
The full results of the study are not due until November, but the Office of the Child Advocate, an independent state agency that was charged with overseeing the study, decided to release the preliminary findings Wednesday, saying they were “compelling and time-sensitive” and warranted prompt action by the Baker administration.
The head of the office, Gail Garinger, who is stepping down Friday, delivered the report to Baker on Tuesday and to leading House and Senate lawmakers on Wednesday.
“There is no shortcut to transformation,” the report warned. “Instead, a massive, coordinated undertaking that balances urgency with the organization’s capacity to change is needed on multiple fronts.”
Garinger said Wednesday that the agency should add seasoned managers to its executive team, which has generally been composed of social workers who are not trained to run large organizations.
“The report I received from the Ripples Group confirmed what I have been hearing for years — DCF management is not structured or resourced to support its workforce,” she said in a statement. “As I leave the OCA, I feel a sense of urgency to communicate with executive and legislative leaders about the findings of the Ripples Group to date.”
Andrea Grossman, a DCF spokeswoman, said Wednesday that many of the problems the report cited were also highlighted in a report released last week that examined the case of a 7-year-old Hardwick boy who fell into a coma after his father allegedly beat him and refused to provide him with food and water.
That report found that, despite the fact that 16 DCF workers were assigned to different aspects of the boy’s case, the agency missed multiple warning signs that he was being abused, and never thoroughly reviewed all of the reports from the multiple counselors involved in his care.
Baker said last week that the Hardwick case would lead to a raft of policy changes to ensure DCF managers more carefully review reports of abuse and neglect.
“The department has already implemented some systemwide recommendations, in addition to hiring 300 new social workers and a $35.5 million increase in this year’s budget, and is aggressively pursuing others focused on improving the level of care delivered to the children the department serves,” Grossman said in a statement.
The administration added that although 40 managers have taken early retirement this year, the state has hired 14 replacements, meaning the department has lost only 26 total. A spokeswoman said the department has the authority to fill the remaining positions immediately.
Lawmakers commissioned the new management review following the death of Jeremiah Oliver, a Fitchburg boy who went missing in December 2013 after DCF social workers failed to make regular visits to his home. His body was found on the side of a highway in April 2014.
Oliver’s death led to the resignation last year of the commissioner, Olga I. Roche, who had been appointed by Governor Deval Patrick, and to a major review by the Child Welfare League of America that faulted DCF for inadequate staffing and technology and “grossly out of date” policies to protect children.
This year, Baker appointed a new commissioner: Linda S. Spears, who had been at the Child Welfare League for 22 years and had led the league’s review of the department. Still, DCF is struggling with systemic problems and tragedies involving children under its watch.
In March, Garinger’s office released a confidential survey of 1,558 DCF employees that found workers coping with decrepit office conditions, poor morale, and an influx of cases and new rules sparked by Oliver’s death and other scandals.
Last month, several weeks after the Hardwick boy fell into a coma, a 2-year-old girl died and a 22-month-old was found in critical condition in a foster home in Auburn that was being monitored by 10 DCF supervisors, managers, and case workers. A DCF review of that case is expected later this month.
DCF workers were quoted expressing concern that the agency often operates in crisis mode, which can add to a sense of confusion.
“We are constantly pulled or pushed in another direction,” one worker said. Said another: “DCF is no longer focused on the core values, and has shifted to a high level of anxiety in regards to news media stories.’’
Michael Levenson can be reached at mlevenson@
globe.com. Follow him on Twitter @mlevenson.