Introduction

Background

1. The Northwest Territories has some of the highest rates of addictions and substance use in Canada. According to the Government of the Northwest Territories’ 2019–20 annual report on the territory’s health and social services system, indicators such as the rates of smoking and heavy drinking in the territory had not significantly changed over recent years. According to the report, these rates were about 2 times higher and 1.5 times higher, respectively, than the national averages. The report also noted that adults and youth were hospitalized for harm caused by substance use, mainly alcohol and cannabis, at a rate that was over 3 times the national average.

2. The Northwest Territories has a vast geographic area with a population of about 45,000 residents. Slightly fewer than half of its residents live in Yellowknife. About half of the territory’s 33 communities have fewer than 500 residents, and many of these communities are remote and accessible only by plane or winter roads. The vastness of the territory and the remoteness of many communities create challenges for the delivery of addictions services^{Definition 1}. Additionally, roughly half of the territory’s population identifies as Indigenous. It is important for all Northwest Territories residents, including individuals from the territory’s diverse Indigenous cultures, to feel safe and respected when accessing health and social services.

3. Furthermore, social determinants of health—things like housing, education, and involvement with the criminal justice system—can influence whether a person develops an addiction. Indigenous social determinants, including colonization and systemic racism, can also influence addictions. It is important for the health and social services system to consider these factors.

4. For many years, the Government of the Northwest Territories has recognized that improvements are needed to address addictions in the territory. Here are 2 examples:

• In 2012, the Minister of Health and Social Services created a forum to determine the direction of mental health and addictions programs. This resulted in the 2013 Healing Voices report.
• The Department of Health and Social Services developed a 2016–21 framework to strengthen the mental health and addictions system in the territory.

5. Also, in 2015, the Government of the Northwest Territories released Meeting the Challenge of Reconciliation: The Government of the Northwest Territories Response to the Truth and Reconciliation Commission Calls to Action. The response recognized the importance of incorporating Indigenous knowledge into the delivery of health services and the need for health care professionals to have cultural sensitivity training.

6. The Department of Health and Social Services. The Department of Health and Social Services is mandated to promote, protect, and provide for the health and well‑being of the people of the Northwest Territories. The department is responsible for setting objectives and priorities for the territory’s health and social services system. This includes both ensuring that eligible residents have access to health and social programs and services and supporting wellness programs at the community level, including those that help people affected by addictions. The department is also responsible for determining how health and social services resources within the department, including human resources, should be allocated.

7. Health and social services authorities. Three health and social services authorities are responsible for delivering services, including addictions services, in line with the department’s objectives and priorities for the health and social services system (Exhibit 1). The 3 health authorities are as follows:

• the Northwest Territories Health and Social Services Authority, created in 2016 following the amalgamation of 6 health authorities
• the Hay River Health and Social Services Authority
• the Tłı̨chǫ Community Services Agency

These health authorities are responsible for managing their own financial, human, and other resources. The Northwest Territories Health and Social Services Authority conducts strategic human resources planning on the department’s behalf. It is also responsible for operating the Stanton Territorial Hospital.

8. Indigenous governments and non‑government organizations. Some addictions services, such as on‑the‑land healing programs, are delivered by Indigenous governments and non‑government organizations through agreements with the department or the health authorities. These groups may also provide services funded by other means, independent of the Government of the Northwest Territories.

Focus of the audit

9. This audit focused on whether the Department of Health and Social Services and the health and social services authorities provided addictions prevention and recovery services to meet the needs of Northwest Territories residents.

10. This audit is important because addictions are a significant concern in the Northwest Territories. Addictions can have serious health and social consequences. They can affect families, education and employment opportunities, social integration, and financial stability. The Northwest Territories health and social services system plays a critical role in providing addictions services to its residents.

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

Findings, Recommendations, and Responses

Overall message

12. Overall, we found that, despite many commitments, the Department of Health and Social Services and the health and social services authorities did not do enough to provide residents with accessible, coordinated, and culturally safe addictions services. Furthermore, they did not know whether addictions services assisted all residents effectively in meeting their desired outcomes. We found concerning shortcomings in the provision of addictions services, from ensuring equitable access to services for all residents to ensuring that services are culturally safe for Indigenous clients and that aftercare services are sufficient to support clients’ recovery goals.

13. The Department of Health and Social Services and the 3 health and social services authorities have taken some steps to improve services. For example, they have made some adjustments to services to better meet residents’ needs. The department also established the Indigenous Advisory Body to provide advice and guidance on the health and social services system. However, neither the department nor the health authorities had determined how they would provide equitable access to addictions services for all residents across the territory. While we found that addictions services varied over time and by location across the territory, it was not clear whether this was part of the system’s design or due to deficiencies in the system.

14. We were also concerned by a lack of coordination needed to connect clients with the services they required even though it has been 20 years since the department committed to better coordinate the health and social services system to improve residents’ access to services. The department and the health authorities need to do more to deliver on their commitments to provide equitable, culturally safe programs to help people impacted by addictions access the care they need, for their own well‑being and that of their communities.

Ensuring access to addictions prevention and recovery services

The Department of Health and Social Services and the health and social services authorities did not do enough to provide accessible and coordinated addictions services

15. We found that the Department of Health and Social Services and the health and social services authorities had not identified how to ensure that all residents had equitable access to addictions services. This made it difficult to know whether some services could have been more accessible to residents. We also found that there were limited aftercare services to support clients’ recoveries. In addition, we found a lack of system-wide processes to help health authority staff connect clients with some of the services they needed, despite the department’s commitment 20 years ago to better coordinate services across organizations.

16. The analysis supporting this finding discusses the following topics:

• Lack of clarity on how to achieve equitable access
• Limited aftercare support
• Gaps in coordination of services across providers

17. This finding matters because services should be accessible to residents who are seeking help for an addiction. Because various organizations provide addictions services and individuals can enter the system at different points, the system needs to be coordinated to help individuals move through it.

18. Addictions services in the Northwest Territories’ health and social services system focus on the person and their individual goals. Clients play a key role in identifying what services they would like to access and when they are ready to do so. This includes enabling clients to refer themselves to counselling.

19. Addictions recovery is an ongoing process, and people often access services, such as facility-based addictions treatment,^{Definition 2} more than once. Many services contribute to preventing, treating, and maintaining an addiction-free lifestyle, depending on when the individual accesses them. For example, counselling can help clients develop preventative coping strategies, recover from an addiction, or maintain ongoing sobriety as an aftercare service. Developing an aftercare plan is an important step to help people identify services that will help them to maintain the outcomes that they have achieved.

20. The Government of the Northwest Territories’ 2017–20 strategic plan for the health and social services system includes a guiding principle to ensure equitable access to care and services. Twenty years ago, the department committed to integrating the health and social services system to improve access to services, including those for addictions.

21. Our recommendations in this area of examination appear at paragraphs 30, 31, 35, and 39.

Lack of clarity on how to achieve equitable access

22. We found that neither the Department of Health and Social Services nor the health and social services authorities determined what equitable access to addictions services across the territory would look like in practice. The department and the health authorities also did not identify the actions required to achieve their commitment to providing equitable access to services. As a result, it was not clear whether the fact that the availability of addictions services varied over time and by location was part of the system’s design or due to deficiencies in the system.

23. According to the Government of the Northwest Territories’ 2017–20 strategic plan for the health and social services system, ensuring equitable addictions services would require considering the most vulnerable when developing programs and policies to reduce systemic and avoidable health disparities. Furthermore, the government’s 2016 commitment to building a culturally respectful system indicated that achieving equitable services means that barriers, including geographic remoteness, would not affect the services people seek.

24. We found that the availability of services varied over time and by location across the territory. For example, the Matrix Model, a treatment program designed to address the psychological and educational aspects of addictions, was available only in a small number of communities at any point during our audit period. In contrast, mental health services from trained counsellors were available to all residents through the Community Counselling Program, but residents had different types of access to them: Some communities had resident or visiting counsellors, and others relied on virtual or phone counselling services. Furthermore, other services were launched only recently or were in the early stages of development. This variability meant that some services may not always have been available when residents tried to access them.

25. Even when services were available to all residents, it was not clear whether the system’s design reduced barriers to address health disparities. For example, residents of most communities had to travel to access detox services, which were available on a case‑by‑case basis in Yellowknife, Inuvik, and Hay River or through facility-based treatment centres outside the territory. Additionally, residents wishing to access other facility-based addictions treatment had to leave the territory to obtain this service. Having some services only in certain locations could cause barriers for some individuals, such as those with concerns about treatment not reflecting their culture. The department stated that by entering into service agreements with multiple treatment centres outside the territory, it could maximize the treatment options available to residents.

26. Furthermore, we found that the department and the health authorities did not take sufficient action to ensure that addictions services for Indigenous residents were culturally safe (see paragraphs 47 to 55). Given the legacy of colonization, having culturally safe services is critical to facilitate equitable access for some Indigenous clients.

27. We also found that although the department identified residents’ addictions service needs using several avenues, including forums, community consultations, and client surveys, it did not formally assess the needs of subpopulations, such as refugees or other non‑Indigenous racialized groups. This was despite the department’s recognition in its 2018–20 cultural safety action plan that some subpopulations, including members of the immigrant and refugee communities, expressed that they had challenges accessing care. Without identifying the needs of various subpopulations likely to have increased barriers to access, it is unclear to us how the department and the health authorities could know how to reduce these barriers and equitably meet their needs.

28. Although the Government of the Northwest Territories had not officially adopted the Sustainable Development Goals in the United Nations’ 2030 Agenda for Sustainable Development, our audit aligned with the goal of good health and well‑being (Goal 3) and the related target of strengthening the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol (target 3.5). Our findings about equitable access to services indicated challenges related to the coverage of treatment interventions for substance use disorders (indicator 3.5.1). Without equitable access to services, some residents of the Northwest Territories may not have been able to obtain the services they needed to meet their addictions recovery goals.

29. Despite the problems identified, we found that as of September 2020, there were no wait times for initial appointments with a counsellor in 6 of 7 health and social services regions. In our view, it is important that individuals in distress who wish to speak to a counsellor be able to do so. We also found that the department and the health authorities adapted how they delivered services in response to the coronavirus disease (COVID‑19)^{Definition 3} pandemic. For example, the health authorities ramped up virtual and telephone care for residents wanting addictions services during the pandemic. This included helping people get the technology required to access virtual services.

30. Recommendation. The Department of Health and Social Services and the health and social services authorities, in collaboration with Indigenous governments and communities, should determine how to achieve their commitment to providing equitable access to addictions services in the Northwest Territories, including related timelines, and take the required actions. This should include identifying where and how services should be made available to reduce barriers to access, given the operating environment and related challenges.

The department’s and the health and social services authorities’ response. Agreed.

See the List of Recommendations at the end of this report for detailed responses.

31. Recommendation. The Department of Health and Social Services, in collaboration with the health and social services authorities and relevant stakeholders, should identify the addictions prevention and recovery needs of diverse subpopulations.

The department’s response. Agreed.

See the List of Recommendations at the end of this report for detailed responses.

Limited aftercare support

32. We also found problems with aftercare services for some people who attended facility-based addictions treatment programs in southern Canada. We reviewed files from a random sample of 32 clients who attended a program between 2018 and 2021 following a referral through the Community Counselling Program. We tested the aftercare planning and services that the health authorities were required to provide to these individuals. We found that the health authorities did not provide the aftercare supports that their clients needed to support their recovery goals (Exhibit 2).

33. Our finding that aftercare plans were created for only 2 of the 32 clients whose files we reviewed was particularly troubling, especially because all 32 applications indicated that they had been created. Health authority officials told us that aftercare planning was done informally and was documented throughout the client’s file in case notes. Having documented plans that the clients agreed to before treatment could help the counsellors and clients prepare strategies and services that could support clients when they returned home. Aftercare plans could also facilitate continuity of care if there was a change in counsellor. While we saw many examples of counsellors identifying clients’ needs after their treatment in southern Canada and offering help in response, the unavailability of services sometimes limited the referrals that counsellors could make.

34. We also found that in the 2019–20 fiscal year, the Department of Health and Social Services increased the On the Land Healing Fund from $1.2 million to $1.8 million annually to help Indigenous governments and non‑governmental Indigenous organizations to improve land‑based addictions treatment, including aftercare programming. However, some Indigenous groups told us that administrative requirements made accessing the fund difficult. We found that the fund’s budget was not always exhausted: The unspent funds during the period covered by our audit ranged from $20,000 in the 2016–17 fiscal year to $624,000 in 2019–20 fiscal year.

35. Recommendation. The Department of Health and Social Services and the health and social services authorities should

• develop a standard approach to aftercare planning
• ensure that clients who attend facility-based addictions treatment programs have an aftercare plan before they leave for treatment
• facilitate access to aftercare services needed when clients return to the Northwest Territories

The department’s and the health and social services authorities’ response. Agreed.

See the List of Recommendations at the end of this report for detailed responses.

Gaps in coordination of services across providers

36. We found that gaps remained in coordination 2 decades after the Department of Health and Social Services made a commitment to better coordinate the health and social services system to improve residents’ access to services.

37. There were gaps in the processes to help health authority staff understand how they could connect clients entering the system at different access points to the addictions services provided by various organizations. For example, we found that none of the health authorities had established a process for counsellors to help clients move from the Community Counselling Program to services offered by Indigenous governments. A formal system-wide referral process was in place only to coordinate services for individuals requesting access to or returning from facility-based addictions treatment. However, we also found that the Hay River Health and Social Services Authority and the Tłı̨chǫ Community Services Agency had established processes to refer clients to the Community Counselling Program from service providers under these health authorities.

38. We found that the department and the health authorities took some steps to improve coordination by establishing interdisciplinary positions, locating counsellors with other health services, and creating discussion forums. However, counsellors were only co‑located on a part‑time basis and discussion forums did not occur in some regions. Furthermore, some of these actions were taken as recently as 2021, a long time after the department committed to better coordination.

39. Recommendation. The Department of Health and Social Services and the health and social services authorities, in collaboration with Indigenous governments, communities, and service providers, should work to improve the coordination of addictions services across the territory by

• creating formalized referral processes to help connect clients to the required services
• evaluating the key positions that can facilitate referrals across services and where these should be located

The department’s and the health and social services authorities’ response. Agreed

See the List of Recommendations at the end of this report for detailed responses.

The department and the health authorities did not take sufficient action to ensure that addictions services were culturally safe

40. We found that the Department of Health and Social Services and the health and social services authorities did not take sufficient action to ensure that addictions services were culturally safe for Indigenous residents. Limited action was taken to remove barriers to cultural safety^{Definition 4}. For example, we found that traditional Indigenous systems of experience and expertise were not recognized in hiring processes. We also found that policies were not reviewed to ensure that they supported a culturally safe system.

41. The analysis supporting this finding discusses the following topic:

• Limited efforts to ensure cultural safety of addictions services

42. This finding matters because Indigenous people in the Northwest Territories disproportionately face challenges with addictions. Increased cultural safety removes barriers to accessing services and helps to counter the effects of colonialism on the services that are available and on the way that they are delivered. This increases the likelihood that addictions services will meet the needs of Indigenous clients and help them achieve their recovery goals.

43. Indigenous people disproportionately experience negative health and social outcomes when compared to non‑Indigenous people in Canada. According to the Department of Health and Social Services’ 2017 and 2018 data, Indigenous residents are

• almost 6 times more likely than their non‑Indigenous peers to be hospitalized due to substance use
• about 3 times more likely to smoke
• about 1.5 times more likely to drink heavily

44. The Indigenous peoples of the Northwest Territories are not a single, homogenous group. They represent several different cultures, including (but not limited to) various Dene subgroups, Métis, and Inuvialuit. Part of the Government of the Northwest Territories’ commitments to provide health and social services includes working to ensure that all aspects of health and social services are culturally safe for everyone.

45. The 2016 document, Building a Culturally Respectful Health and Social Services System, included cultural safety best practices that the department had identified and commitments to how to improve the cultural safety of the health and social services system, including addictions services. These related to developing and reviewing policies, increasing workforce diversity, training staff, and incorporating traditional knowledge.

46. Our recommendation in this area of examination appears at paragraph 55.

Limited efforts to ensure cultural safety of addictions services

47. We found that the Department of Health and Social Services and the health authorities did not take sufficient action to ensure that addictions services were culturally safe for Indigenous residents.

48. We found that the human resources strategy for the health and social services system did not address how to increase the number of Indigenous employees in the system, a best practice that the department had identified in its commitment to cultural safety. Additionally, we found that neither the department nor the health authorities knew how many residents used the Government of the Northwest Territories’ programs targeted at encouraging local residents to seek employment in the system. This limited their ability to know whether they needed additional measures to facilitate increased Indigenous and local representation. At the time of our audit, the Northwest Territories Health and Social Services Authority was updating its 2015 human resources strategy.

49. We also found that neither the department nor the health authorities considered how to recognize traditional Indigenous systems of experience and expertise when hiring for positions in addictions services. Instead, they remained focused on the need for applicants to have formal post‑secondary education that results in Western-style qualifications. The focus on this type of education creates a barrier to employment for many Northwest Territories residents.

50. Related to this, we found that the department and the health authorities did not incorporate traditional Indigenous knowledge into measures to determine whether their services were helping clients achieve their desired outcomes (see paragraph 64). Some Indigenous organizations told us that they felt that department officials did not adequately understand Indigenous cultures and traditions.

51. We also found that the department did not try to measure the cultural safety of most addictions services until it launched the Addictions Recovery Survey in 2021, during our audit. Furthermore, we found that the department’s attempts to measure the cultural safety of the Community Counselling Program through client surveys were not effective because they did not collect information on the clients’ ethnicity. The results of surveys conducted in 2016 and 2018 indicated that more than 90% of respondents felt that their counsellor respected their culture, needs, preferences, or values. However, without information on clients’ ethnicity, the department did not know if this finding applied to Indigenous clients. At the time of our audit, the department was running another Community Counselling Program survey that asked clients to specify whether they were Indigenous, but it did not ask which Indigenous group clients were from.

52. We also found that the department did not review policies to ensure they reflected the cultural safety of addictions services, a commitment made in 2016. We noted that the new Community Counselling Program standards and operating procedures, approved in May 2021, provided direction to promote cultural safety. Other than this, the health authorities did not have policies on cultural safety, which would have reinforced its importance.

53. In 2019, the department released the Caring for Our People: Cultural Safety Action Plan, 2018–2020, which included a vision for the health and wellness of Indigenous people in the Northwest Territories and identified specific actions that would be taken in the health and social services system. The action plan stated that it was based on community collaboration. We found that the department’s own tracking of progress on this action plan indicated that the majority of actions were still in progress. While we recognize that improving cultural safety in the health and social services system is a significant undertaking that takes time, only a few of the action items identified in 2019 were indicated as completed by the department at the time of our audit.

54. However, we found that the department and 2 health authorities took some positive steps related to cultural safety:

• The department established the Indigenous Advisory Body to provide advice and guidance on the health and social services system.
• The department created the Community, Culture and Innovation Division within the department that would lead work on cultural safety. At the time of the audit, staffing of this division was still in progress.
• The department and 2 regions of the Northwest Territories Health and Social Services Authority provided some cultural safety training in addition to the mandatory cultural training that all Government of Northwest Territories employees must take.
• Since 2020, the Tłı̨chǫ Community Services Agency and 1 region of the Northwest Territories Health and Social Services Authority each created a position to support cultural safety of services in the communities they served. We were informed that as of July 2021, the Tłı̨chǫ Community Services Agency had not yet been successful in staffing its position.

55. Recommendation. The Department of Health and Social Services and the health and social services authorities, in collaboration with Indigenous communities and governments, should work to improve the cultural safety of addictions services. This should include

• reviewing their policies to identify any barriers to delivering culturally safe addictions services and working to remove these barriers
• developing and implementing a strategy to adapt its current hiring approach to formally recognize the value of Indigenous qualifications

The department’s and the health and social services authorities’ response. Agreed.

See the List of Recommendations at the end of this report for detailed responses.

Measuring outcomes for clients

The department and the health authorities did not know whether addictions services were effective

56. We found that the Department of Health and Social Services and the health and social services authorities did not know whether their addictions services were effective in helping residents achieve their desired outcomes. They did not sufficiently measure clients’ outcomes or use data to analyze trends.

57. The analysis supporting this finding discusses the following topic:

• Client outcomes not measured

58. This finding matters because without measuring the performance of addictions services, the department and the health authorities cannot know whether the system helps clients achieve their goals or where to make changes to improve services for residents. Measuring performance would also help the department and the health authorities know if funds are being used in the most effective way. Thus, it is critical that the department and the health authorities collect and analyze relevant information to ensure that services are being delivered as required and that they measure and understand the results being achieved.

59. Our recommendations in this area of examination appear at paragraphs 66 and 67.

Client outcomes not measured

60. We found that neither the Department of Health and Social Services nor the health authorities collected or analyzed targeted data to expose trends about outcomes for clients, including those from diverse subpopulations. Instead, data collection and analysis were limited to periodic reviews of aggregated data. This was despite the fact that monitoring and evaluating outcomes had been identified as a priority area for action in the 2016 strategic framework for mental health and addictions.

61. We found that neither the department nor the health authorities analyzed Community Counselling Program data to identify clients’ outcomes. Program data was stored in paper-based client files and was never compiled in a disaggregated way to facilitate this type of analysis. Officials from the department and the Northwest Territories Health and Social Services Authority told us that they used aggregated Community Counselling Program data to identify trends and provide the rationale for new services. Beginning in the 2020–21 fiscal year, the Northwest Territories Health and Social Services Authority and the Hay River Health and Social Services Authority collaborated on a database that they could use to capture disaggregated client data. At the time of our audit, this database was in the pilot stage of implementation.

62. We found that the department did collect disaggregated data about clients who accessed facility-based addictions treatment, but it did not routinely analyze it. We analyzed this data and found trends that the department may want to explore to better understand the factors that can lead to improvements in service delivery and assessment. For example, the percentage of clients in facility-based addictions treatment from one Indigenous group was almost twice as high as its percentage of the general population. We also found that the department was aware of the number of individuals who did not finish treatment and, as part of its 2021 Addictions Recovery Survey, was trying to understand the reasons why. Targeted analysis of these trends might help to inform services.

63. We also found that the department reported information related to 2 of the indicators for the United Nations’ Sustainable Development Goal 3: the harmful use of alcohol and the prevalence of tobacco use. According to the department’s 2019–20 annual report, results from Statistics Canada’s Canadian Community Health Survey indicated that in the 2017–18 fiscal year, the proportion of Northwest Territories residents who reported heavy drinking was 29% and the proportion who reported daily or occasional smoking was 35%. These results reinforce the importance of collecting and analyzing disaggregated data to understand how well addictions services are working and the changes that are required.

64. Additionally, we found that the department did not establish outcome indicators specific to most of its services. Before 2021, the department only measured outcomes for 2 of its services: the Community Counselling Program and an awareness campaign. For the counselling program, the department conducted a periodic survey of clients to determine their satisfaction on 2 measures: clients’ satisfaction with the overall changes in their lives since starting counselling and their satisfaction with changes to the original concern that brought them to counselling. In 2021, for the first time, the department also administered an addiction recovery experiences survey to clients who had accessed addictions services. It included a question on whether clients were satisfied with overall changes in their lives.

65. None of the health authorities measured outcomes for addictions services, except for the Hay River Health and Social Services Authority. It measured outcomes for 1 of its services in 2016.

66. Recommendation. The Department of Health and Social Services and the health and social services authorities should determine the disaggregated data required to understand whether addictions services are working, including for diverse subpopulations, collect and analyze the data to identify trends or anomalies, and use this information to adjust services as needed.

The department’s and the health and social services authorities’ response. Agreed.

See the List of Recommendations at the end of this report for detailed responses.

67. Recommendation. The Department of Health and Social Services and the health and social services authorities should collaborate with Indigenous governments and communities to establish desired short-, medium-, and long‑term outcomes for addictions services and indicators to measure them, including using Indigenous outcome measures. They should use these indicators to monitor the results related to addictions services and adjust those services as necessary.

The department’s and the health and social services authorities’ response. Agreed

See the List of Recommendations at the end of this report for detailed responses.

Conclusion

68. We concluded that despite commitments in the areas of equitable access, coordination of services, and cultural safety of services, the Department of Health and Social Services and the health and social services authorities did not do enough to provide addictions prevention and recovery services to meet the needs of Northwest Territories residents.

69. Neither the department nor the health authorities determined how they would provide equitable access to addictions services for residents. Thus, it was unclear whether the variability of addictions services over time and by location was part of the health and social services system’s design or due to deficiencies in the system. Furthermore, we found gaps in the coordination of services across providers 2 decades after the department committed to better coordinate the health and social services system to improve residents’ access to services.

70. The department and the health authorities also did not take sufficient action to ensure that addictions services for Indigenous residents were culturally safe or to know whether their addictions services were effective in helping residents achieve their desired outcomes.