hsqf ndis service provider self-assessment workbook web viewexamples of appropriately skilled ......

Human Services Quality Framework Self-Assessment Workbook

For providers registering with the National Disability Insurance

Scheme (NDIS) in Queensland

Version 2.2 November 2017

ContentsIntroduction...........................................................................................................................................2

Workbook Instructions..........................................................................................................................2

Requirements........................................................................................................................................2

Submission Form...................................................................................................................................3

Further Information...............................................................................................................................3

Self-Assessment Submission Form........................................................................................................5

Declaration............................................................................................................................................6

Self-Assessment Workbook...................................................................................................................7

Acknowledgement:

The Department of Communities, Child Safety and Disability Services acknowledges the valuable contribution of HDAA in developing and designing this self-assessment system for providers registering to deliver services for the National Disability Insurance Scheme in Queensland.

HSQF Self-assessment workbook - For providers registering with the NDIS in Queensland Version 2.3 December 20171

IntroductionThe Human Services Quality Framework (HSQF) is a system for assessing and improving the quality of human services and promoting quality outcomes to people who access these services. The HSQF is part of Queensland’s existing quality assurance and safeguards framework that will apply during the transition to the National Disability Insurance Scheme (NDIS) in Queensland or until the national quality and safeguards framework is implemented, whichever is sooner. The framework applies to providers registering to deliver disability services that are prescribed in the Disability Services Regulation 2017 Schedule 1.

The Department of Communities, Child Safety and Disability Services’ (DCCSDS) has developed a suite of resources to assist providers to understand the requirements of the HSQF and demonstrate how they meet the Human Services Quality Standards.

A self-assessment system for new providers seeking registration with the NDIS is available at www.communities.qld.gov.au/hsqf . This system allows providers to track progress in implementing the Standards and should be used together with the HSQF Self-assessment Guide - For providers registering with the National Disability Insurance Scheme in Queensland.

Workbook instructions1. Complete the self-assessment (also refer to section titled Requirements below) ensuring

that: each standard and indicator is directly responded to safeguarding requirements identified against specific standard indicators are addressed

2. Identify improvements and where relevant, record proposed actions and timeframes into a Continuous Improvement Action Plan – this must be submitted along with the self-assessment workbook

3. Ensure that the Self-Assessment Submission Form is completed and the Declaration is signed and witnessed (refer to the template in the self-assessment workbook)

4. To ensure version control of the self-assessment workbook and continuous improvement action plan, both documents should be saved as a PDF before submitting to DCCSDS.

5. Submit the self-assessment and continuous improvement action plan to DCCSDS via the following email link: [email protected]

6. Schedule and take action to resolve any identified improvement.

RequirementsWhen completing the self-assessment, providers need to respond to the specific requirements listed in the self-assessment workbook. These requirements cover Core safeguarding requirements (such as policy, procedures, processes, and/or systems) that must be in place prior to the provider delivering prescribed disability services for the NDIS in Queensland. These include:

adhering to the safeguards set out in the Disability Services Act 2006 (DSA) and other Queensland state legislation such as:- criminal history screening requirements outlined in the DSA 2006 and regulation- working with children check requirements outlined in the Working with Children (Risk

Management and Screening) Act 2000 and regulation


mailto:[email protected]

http://www.communities.qld.gov.au/hsqf

- positive behaviour support and requirements for the use of restrictive practices as specified in the DSA 2006

Developing, implementing and acting in accordance with the DCCSDS policy for Preventing and Responding to the Abuse, Neglect and Exploitation of People with Disability

Developing and implementing a complaints management framework that is aligned with the Australian/New Zealand Standard Guidelines for Complaint Management in Organizations (AS/NZS 10002:2014)

Developing and implementing a risk management framework that is aligned with ISO 31000.

A number of developmental requirements are also identified. These allow service providers to focus their efforts and resources for future development. Implementation of development actions does not need to be fully demonstrated at the initial self-assessment – this can occur over time.

Submission formThe Submission Form includes key information identifying the service provider and associated details such as the address, contact details and so on. Please ensure all information in this form is fully completed.

The submission from also includes a Declaration. When signed the declaration is a formal statement that the information contained in the self-assessment is accurate. This includes any plans for improvement action.

Further informationFor further information contact:

HSQF TeamDepartment of Communities, Child Safety and Disability Services

Telephone: 1800 034 022 or 07 3247 3072Email: [email protected]


Version 2.3 – December 2017

Human Services Quality Standards - Self-Assessment

For providers registering with the National Disability Insurance

Scheme (NDIS) in Queensland

Self-Assessment Submission FormPlease complete the following details, to be submitted with the self-assessment to the Department of Communities Child Safety and Disability Services (DCCSDS) at [email protected].

Provider name(legal entity)

Provider trading name (where applicable)

Australian Business No (ABN)

NDIS Provider Registration No

Head Office physical address

Provider legal entity status (e.g. Sole Trader, Partnership, Australian Private Company, Incorporated Association)

NDIS Registration group(s)– Section 4 NDIS Guide to Suitability

(Please check all relevant boxes)

☐ Development Life Skills (01117) ☐ Daily Personal Activities (0107) ☐ High Intensity Daily Personal Activities (0104) ☐ Daily Tasks/Shared Living (0115) ☐ Participate Community (0125) ☐ Group/Centre Activities (0136) ☐ Plan Management (0127) ☐ Life Stage, Transition (0106)

NDIS Professional Registration group(s)

Section 5 NDIS Guide to Suitability

(Please check all relevant boxes and include evidence of membership with relevant professional association as per requirements of Section 8 Guide to Suitability)

☐ Behaviour Support (0110) ☐ Early Intervention for early childhood (0118) ☐ Support Coordination (0132) ☐ Therapeutic Supports (0128)

NDIS participant focus

(Please check all relevant boxes)

☐ Children and young people under 18 years

☐ Adults over 18 years

Geographic location for delivery of registration groups

Accountable officer(refer to Declaration below)

Name

Position

Email

Phone contact

Person who completed the self-assessment

Name

Position


Date self-assessment completed

DeclarationAs the Accountable and Authorised Officer for (insert Provider Name), I certify that as at (insert date) (insert Provider Name) has developed, and will fully implement, the policies, procedures and management systems detailed in this self-assessment in accordance with the requirements of the Human Services Quality Standards. The Governing Body has reviewed this self-assessment and obtained assurance from the Accountable Officer that these policies, procedures and management systems have been developed and will be implemented.

Signed: ……………………………………….………………………………. Date: ……………………………………….

Name: ……………………………………………………..................... Position: ………………………………….

Witness: …………………………………………..………………………… Date: ……………………………………….

Privacy NoticeThe Department of Communities, Child Safety and Disability Services is collecting your personal information to assess the completeness of this self-assessment against the Human Services Quality Standards as required for registration to provide prescribed disability services for the NDIS in Queensland. The Department will handle your personal information in accordance with the Information Privacy Act 2009.


Self-assessment workbook


Reference Indicator details Core or

Developmental

Requirements(Safeguard requirements

to be addressed in the indicator)

Evidence available (Yes or

No)

Provider evidence(What is, or is intended to be

in place, to meet this indicator)

Improvement action(As required)

Required by date

Standard 1

Governance and management

Expected Outcomes: Sound governance and management systems that maximise outcomes for stakeholders

Context: The organisation maintains accountability to stakeholders through the implementation and maintenance of sound governance and management systems. These systems should reflect the size and structure of the organisation and contribute to maximising outcomes for people using services.

1.1 The organisation has accountable and transparent governance arrangements that ensure compliance with relevant legislation, regulations and contractual arrangements.

Core

Processes or systems are in place for ensuring compliance with financial, legislative, regulatory and contractual responsibilities relevant to the provider’s operations.

Defined structure and process for monitoring and responding to quality and safety matters associated with delivering supports to Participants.

Documented business or organisational structure/plan (appropriate to the size of the provider and the types of supports or services to be provided) that identifies key decision makers, roles and relationships, and delegated authorities.

Evidence examples

Policies, procedures or other documentation that support good governance e.g. constitution, terms of reference, or equivalent guiding documents that articulate processes of how the governing body/company/sole trader operates, including meeting and reporting arrangements, conflict of interest policy/procedure, Code of Conduct

Processes for maintaining legislative compliance e.g. regulatory compliance processes, external audits/reviews, advisory services & professional or industry specific memberships


Reference Indicator details Core or

Developmental




No)




Required by date

1.2 The organisation ensures that members of the governing body possess and maintain the knowledge, skills and experience required to fulfil their roles.

Core

Members of the governing body* has access to learning and development opportunities relevant to their role and function.

(*Note: For providers without a governing body this requirement can be interpreted to include learning and development relevant to provision of supports and services to NDIS participants)

Evidence examples

Records of orientation, induction or training provided, attendance at professional development training/workshops

Processes for identifying and addressing any gaps in skills or knowledge or experience

1.3 The organisation develops and implements a vision, purpose statement, values, objectives and strategies for service delivery that reflect contemporary practice.

Core

The purpose and values of the provider are documented and communicated to stakeholders

Evidence examples

Processes to establish plans, objectives & strategies required to deliver services. These may include: strategic plan, business or operational plan, vision and values statement, client charter, Code of Conduct

Processes for measuring performance against established plans

Continued…


Reference Indicator details

Core or Development

al

Requirements(Safeguard requirements to be

addressed in the indicator)


No)




Required by date

1.4 The organisation’s management systems are clearly defined, documented, monitored and (where appropriate) communicated including finance, assets and risk.

Core

Evidence of a risk management framework that addresses the core elements of ISO 31000.

This should include: processes for identifying, assessing and managing risk, including: organisational; financial; occupational; as well as risks associated with provision of supports to participants.

Note: This framework should be proportionate to the provider’s size, structure and types of supports provided

Evidence examples

Documented risk management plans including risk assessments relating to support activities for NDIS participants, financial and asset management, occupational health & safety, building/equipment maintenance plan, business continuity plan, emergency/disaster management & recovery plans

Financial management systems which support effective management, accountability, control & ongoing viability (e.g. documentation of financial controls & delegations, insurances, budgeting & purchasing processes, payroll processes)

Processes for delegating authority & responsibilities throughout the organisation & for establishing, recording, communicating & reviewing delegated authority

Processes for reporting adverse events including notification to the correct authority where required e.g. incident reporting


Core (C) or Development

al (D)

Requirements(Safeguard requirements to

be addressed in the indicator)


No)

Provider evidence(What is, or is intended to be in place, to meet this

indicator)


Required by date

1.5 Mechanisms for Development A continuous improvement


continuous improvement are demonstrated in organisational management and service delivery processes.

al

plan that includes (at a minimum): the improvement

identified the action to be taken person responsible for

actioning date of completion and

implementation review date.

Evidence examples

Documented continuous quality improvement plan Improvement processes connected to: feedback, complaints and

appeals processes; records of incidents for people using services; workplace injuries/hazard reporting systems

Processes for the governing body to regularly review the effectiveness of its own processes and structure in providing good governance to the organisation

1.6 The organisation encourages and promotes processes for participation by people using services and other relevant stakeholders in governance and management processes.

Developmental

Participants, their nominated representatives and/or advocates are offered opportunities to participate in review and improvement activities

Evidence examples

Strategies & processes that support participation by people using services & other stakeholders

Strategies for supporting people using services to submit feedback on service management or governance processes e.g. surveys, feedback forms &/or member groups

Representation of people using services on the organisation’s board

Continued…

Referenc Indicator details Core (C) or Requirements Evidence Provider evidence Improvement action Required


e Developmental (D)

(Safeguard requirements to be addressed in the

indicator)

available (Yes or

No)

(What is, or is intended to be in place, to meet this

indicator)(As required) by date

1.7 The organisation has effective information management systems that maintain appropriate controls of privacy and confidentiality for stakeholders.

Core

Processes are in place for ensuring the confidentiality and privacy of personal information of participants and other stakeholders

Processes are in place for aligning information management systems and operational processes with privacy legislation and relevant privacy principles.

Evidence examples

Policies & procedures addressing information management, privacy & confidentiality requirements, management of consents, retrieval, archiving and disposal of records, & records management generally

Privacy Policy & processes that align with the Australian Privacy Principles

Privacy statement is included on all forms or electronic platforms used to collect personal information

Electronic storage systems have appropriate security mechanisms (including ensuring the security, privacy & confidentiality of information supported by cloud based technology such as web portals & portable electronic devices such as iPad and laptops, smartphones and USB drives)

Processes for maintaining physical security, including access to building(s), rooms & filing cabinets

Where electronic monitoring is in use (e.g. in accommodation sites), documented processes to guide its usage, storage and retrieval of images & obtaining informed consent from people using services & other relevant stakeholders

Records &/or feedback from participants (family members or carers) or other stakeholders confirm the effectiveness of privacy & confidentiality controls, as appropriate to the supports provided




al (D)




No)




Required by date

Standard 2

Service access

Expected Outcomes: Sound eligibility, entry and exit processes facilitate access to services on the basis of relative need and available resources.

Context: The organisation makes their services available to their target group in fair, transparent and non-discriminatory ways and people seeking access to services are prioritised and responded to.

2.1 Where the organisation has responsibility for eligibility, entry and exit processes, these are consistently applied based on relative need, available resources and the purpose of the service.

Developmental

Processes are in place for ensuring that participants seeking to access supports are treated in a fair, equitable and non-discriminatory way.

Evidence examples

Eligibility criteria, priority of access & waiting list policy & procedures are developed within the context of the Anti-Discrimination Act 1991 (Queensland) and/or Disability Discrimination Act 1992 (Commonwealth)

2.2 The organisation has processes to communicate, interact effectively and respond to the individuals’ decision to access and/or exit services.

Core

Access and entry criteria (including associated costs) are clearly defined and communicated to participants in a manner and format the person is most likely to understand.

Evidence examples

Welcome kit for participants, family members and carers (available in different formats) is provided on entry to the service or initial engagement with provider

2.3 Where an organisation is unable to provide services to a person, due to ineligibility or lack of capacity, there are processes in place to refer the person to an appropriate alternative service.

Developmental

Information available to participants on the process for leaving the service includes alternative service options and referral points

Evidence examples

Procedures describe the information that will be provided to people on leaving the service & this includes information on alternative service options & referral points




al (D)




No)




Required by date

Standard 3

Responding to individual need

Expected Outcomes: The assessed needs of the individual are being appropriately addressed and responded to within resource capability.

Context: The organisation provides appropriate services that are identified/assessed, planned, monitored, reviewed and delivered in collaboration with the person using the service, their representative and/or relevant stakeholders. The organisation uses referral pathways and partnerships to promote integrated service.

3.1 The organisation uses flexible and inclusive methods to identify the individual strengths, needs, goals and aspirations of people using services.

Developmental

Processes are in place demonstrating a person-centred approach to provision of supports

Staff/key personnel are provided with training on how to use a strengths-based approach to identifying needs and life goals

Records show how feedback is sought from participants on the most appropriate ways to collaboratively work together to identify strengths, needs and life goals

Participant support plans show that the wellbeing of the person is taken into consideration through individualised planning and review

Evidence examples

Processes are in place for: Assessing & recording individual/s’ needs, strengths, goals and

aspirations Including & ensuring the active involvement of the individual/s in

planning Promoting a belief in the ability of people with disability to fulfil valued

roles in the community (e.g. through promoting skills development and lifelong learning)

Informing people using services about changes to service provision


Continued...



al (D)




No)

Provider evidence(What is, or is intended to be in place, to meet this

indicator)


Required by date

3.2 The organisation formulates service delivery that respects and values the individual (e.g. identity, gender, sexuality, culture, age and religious beliefs).

Core

Core guiding documents and/or purpose statements describe how the provider responds to diversity, at both an organisational and individual participant level.

Where supports are provided to Aboriginal and Torres Strait Islander people, processes are in place to support a culturally informed assessment process and for addressing cultural strengths, risks and needs in the provision of supports.

Developmental

Policy outlining the provider’s commitment to supporting diversity is available.

Staff participate in relevant training regarding diversity, cultural competency and can describe implications of recognising and facilitating diversity in the provision of supports to participants

Evidence examples

Processes for allocating a suitable person/s working for the provider to deliver the most appropriate service

Cultural competency Processes for promoting opportunities for people using services to

fulfil valued community roles




al (D)



Evidence

available (Yes or No)

Provider evidence(What is, or is intended to be in

place, to meet this indicator)


Required by date

3.3 The organisation has processes to ensure that services delivered to individual(s) are monitored, reviewed and reassessed in a timely manner. Core

Documented process/procedure that describes: how the participant

(and/or their nominated representative) consent to, and are involved in review planning

how individualised planning, and review, is centred on the strengths, needs and goals of participants

assessment and needs identification processes.

Developmental

Support staff/key personnel can describe how they facilitate the involvement of participants in making decisions relating to their individual goals

Staff/key personnel can describe how they review individual goals with participants and significant others, where relevant and/or as directed by the participant.

There are review records demonstrating how participants have progressed in achieving their goals, and that goal plans are modified where necessary so that goals remain relevant to the person

Feedback from participants confirms that their goals and aspirations have been considered during the review process


Evidence examples

Processes are in place for: Providing support in order to meet the changing needs, strengths, goals

& aspirations of people accessing supports Planning, delivering, monitoring & reassessing the supports provided to

an individual/s.



al (D)



Evidence





Required by date

3.4 The organisation has partnerships and collaborates to enable it to effectively work with community support networks, other organisations and government agencies as relevant and appropriate.

Developmental

Records demonstrating collaboration with other services and/or professionals relevant to participant support needs.

Documented arrangements for working in partnership with other providers, agencies and community members to support participants to actively participate in their community.

Evidence examples

Processes for supporting people using services to take part in the community

Processes for referring people using services to other agencies where relevant to their needs/goals and aspirations

3.5 The organisation has a range of strategies to ensure communication and decision-making by the individual is respected and reflected in goals set by the person using services and in plans to achieve service delivery outcomes.

Developmental

Records show that feedback is sought from participants on the most appropriate ways to work together to identify strengths, needs and goals

Participant files include evidence of participants being provided with their individual plan in a manner and format the person is most likely to understand

Where an external party has been involved in planning, delivery of supports, and or review, there is documentary evidence of this involvement

Evidence examples

Processes & documentation for providing information in different ways to suit a range of communication needs




al (D)



Evidence





Required by date

Standard 4

Safety, wellbeing and rights

Expected Outcomes: The safety, wellbeing and human and legal rights of people using services are protected and promoted.

Context: The organisation upholds the legal and human rights of people using services. This includes people’s right to receive services that protect and promote their safety and wellbeing, participation and choice.

4.1 The organisation provides services in a manner that upholds people’s human and legal rights.

Core

Core guiding document that outlines how supports will be planned and delivered in a manner that supports the human and legal rights of people with disability.

Policies and processes are in place for ensuring that supports are provided in the least restrictive way.

Policy and operational procedures are in place to ensure legislative compliance (under the Disability Services Act 2006) for services provided for positive behaviour support and the delivery of services involving the use of restrictive practices, including: a copy of the Model

Statement is available on participant’s file

conducting a multidisciplinary functional assessment and developing a positive behaviour support plan (PBSP) or a respite/ community access plan

monthly reporting to the department of the use of restrictive practices in accordance with the


4.1 cont.Disability Services Regulation 2017

obtaining relevant consents and approvals for the use of the restrictive practice as detailed in the PBSP (note - the model PBSP will evidence these requirements such as dates of approval)

using reports from the department’s Online Data Collection (ODC) system (e.g. Client Record of restrictive practices usage report) to monitor and review the implementation and outcomes of the PBSP with the view to improving quality of life and reducing use of restrictive practices

professional staff who conduct multidisciplinary functional assessments and develop PBSPs be appropriately qualified and experienced as per the Act (relevant to NDIS Professional Registration Group Specialist Positive Behaviour Support).

Evidence examples

A Code of Conduct or Charter of Rights Policies & operational procedures for ensuring that services are

provided in the least restrictive way possible & uphold the rights of people with a disability

Current Positive Behaviour Support plan with record of consents & approval including evidence of the Model Statement being provided

Examples of appropriately skilled or qualified persons such as behaviour analysts, medical practitioners, psychologist, psychiatrists, speech & language pathologies, occupational therapists, registered nurses, social workers

Examples of appropriately skilled/qualified person has significant practice in conducting & implementing functional assessments &


development of PBSPs to a high standard Pamphlets/welcome kits providing information to service users about

their rights & responsibilities




al (D)




No)




Required by date

4.2 The organisation proactively prevents, identifies and responds to risks to the safety and wellbeing of people using services.

Core

Policies and processes are in place for preventing, identifying and responding to risks to the safety (including the prevention of all forms of harm, abuse and neglect) and wellbeing of participants.

Processes are in place for ensuring accessible and safe environments with due regard to legislative requirements* as relevant to the types of supports to be provided.

*Relevant requirements may include, fire safety, pool safety, electrical safety, maintenance and management of equipment and buildings, medication management, infection control

Policy, procedures and/or processes for criminal history screening.

These include as relevant to the provider: (1) ensuring compliance with requirements of the Disability Services Act 2006 (i.e. yellow card system for working with adults with disability), including:




al (D)




No)




Required by date

4.2 cont.

ensuring that all relevant persons engaged by the provider undergo criminal history screening

managing and tracking the status of screening applications

implementing a Risk Management Strategy which complies with legislative requirements.

(2) Where the provider is in the scope of the Blue Card system under the Working with Children (Risk Management and Screening) Act 2000, policies and procedures are in place for ensuring child safe practices and compliance with legislative requirements, including: ensuring that all relevant

persons engaged by the provider undergo criminal history screening

managing and tracking the status of screening applications

implementing child and youth risk management strategies that address the 8 minimum requirements set out in the Regulation.

Evidence examples

Incident management policy & procedures, registers and reports Processes & registers for ensuring that criminal history screening

requirements for all persons working in or for the organisation including volunteers are monitored and met (e.g. Blue Card register/Yellow Card register)

Processes that minimise & promptly respond to challenging behaviours or threats against other people using the service or people working in the organisation




al (D)




No)




Required by date

Policies/procedures/registers for ensuring that medication is managed safely & correctly (e.g. security, storage and disposal of medications, authorisation & administration of medications, processes for monitoring correctness of medications against medication records, monitoring and review of medication errors)

Records of preventative and corrective actions to protect the safety & wellbeing of people using services

Continued...




al (D)



Evidence

available (Yes or

No)




Required by date

4.3 The organisation has processes for reporting and responding to potential or actual harm, abuse and/or neglect that may occur for people using services.

Core Policies and processes consistent with the DCCSDS policy for Preventing and Responding to the Abuse, Neglect and Exploitation of People with a Disability are in place, including: promoting a culture of no

retribution ensuring there are systems

to identify and respond to abuse, neglect or exploitation

ensuring timely, adequate and appropriate responses to incidents.

Policies and processes are in place for reporting and responding to incidents and adverse events including potential, suspected, alleged or actual harm, abuse and/or neglect of participants.

Processes are established to ensure that all people working in or for the provider (including volunteers) are aware of: what constitutes, harm,

abuse, neglect and exploitation; and how to respond in a manner that is consistent with any legislative requirements

how to record and report allegations or incidents, including reporting of harm


4.3 cont.

through internal processes and to any external agencies (e.g. QPS, Child Safety), as appropriate

their responsibilities to support people, or make referrals to appropriate supports

the importance of responding to allegations of harm in a manner that observes the principles of natural justice, and for all parties to be supported during the investigation of an allegation of harm.

Note: Providers should respond as relevant to their size and structure.

Evidence examples

Incident management policy & procedures, registers and reports Records of correspondence with guardians/custodians regarding

incidents Records demonstrating the organisation’s response to incidents involving

the use of restrictive or prohibited practices Records of reporting to external agencies where harm has been

identified or suspected (e.g. the Queensland Police Service) Action plans which outline strategies to prevent future risk Records of staff training on: what constitutes harm, abuse, neglect &

exploitation; how to respond to actual or suspected instances; & how to respond to, record & report allegations

Continued...




al (D)



Evidence





Required by date

4.4 People using services are enabled to access appropriate supports and advocacy.

Developmental

Participants are provided with information on independent advocacy services and are supported to access an advocate to promote their rights, interests and wellbeing

Evidence examples

Welcome kits including details of relevant advocacy & support services Contact details for support/advocacy bodies are displayed in areas that

are frequently accessed by people using services Case records demonstrate how the provider has supported people using

services to access independent advocacy and support services (e.g. Community Visitors, advocates)

Policies outlining the requirement for people using services to be provided with relevant information & contact details

Where applicable, processes to link people using services with Aboriginal and Torres Strait Islander services, ethno-specific or multi-cultural services (including language or specialist services) in order to support people exercise their legal and human rights

4.5 The organisation has processes that demonstrate the right of the individual to participate and make choices about the services received.

Developmental

Processes are in place for ensuring that information is provided in appropriate formats (based on the individual’s preferences for the communication method) to enable people to participate and make choices about the supports and services they receive.

Evidence examples

Welcome/ induction packs contain information regarding service user’s rights to participate & make choices about services

Documented strategies for identifying & addressing barriers to service user participation are available

There are processes for supporting flexibility in service delivery options which reflect the changing needs, aspiration & choices of people using services


Reference

Indicator details


al (D)




No)




Required by date

Standard 5

Feedback, complaints and appeals

Expected Outcomes: Effective feedback, complaints and appeals processes that lead to improvements in service delivery.

Context: The organisation listens to people and takes on feedback as a source of ideas for improving services and other activities. It includes the way the organisation responds to complaints from people using services and their right to have complaints fairly assessed and acted upon.

5.1 The organisation has fair, accessible and accountable feedback, complaints and appeals processes.

Core

The provider has a complaints management framework that is aligned with Australian/New Zealand Standard Guidelines for Complaint Management in Organizations (AS/NZS 10002:2014).

Evidence examples

Processes for managing, resolving complaints & tracking complaints are developed that include all of the following: A definition or explanation of what constitutes a complaint How the complaint can be made, including formal and informal avenues

for making complaints, including anonymously Timeframes & steps for responding to a complaint Avenues for escalating a complaint How complaints are recorded A method for tracking complaints How the organisation will respect people’s right to privacy &

confidentiality in managing complaints How the stakeholders will be advised of the outcome of the complaint How feedback, complaints & appeals are reported to the governance

body or to the delegated authority How complaints are submitted to funding bodies where required Mechanisms to ensure complaints are responded to & dealt with in a

timely manner Review processes to identify & address any systematic barriers to

complaints, appeals & feedback mechanisms Processes are in place to ensure that people are not disadvantaged as a

result of making complaints




al (D)

Requirements(Safeguard

requirements to be addressed in the

indicator)

Evidence available

(Yes or No)




Required by date

5.2 The organisation effectively communicates feedback, complaints and appeals processes to people using services and other relevant stakeholders.

Developmental

There are records demonstrating that the provider communicates the results of feedback (including complaints) to participants and/or significant others

Participants and/or nominated representatives are involved in the review of feedback.

Evidence examples

Processes are in place that maximise access to information about complaints, disputes & feedback processes for all people accessing services including those from diverse stakeholder groups (culture, age etc.)

Welcome kit/induction pack information informing people using services of the organisation’s complaint mechanisms & feedback processes

Complaints information is made available in areas that are frequently accessed by people using services

5.3 People using services and other relevant stakeholders are informed of and enabled to access any external avenues or appropriate supports for feedback, complaints or appeals processes and assisted to understand how they access them.

Developmental

Policy/procedures or process for ensuring that participants are made aware of their right to access an external complaints agency and independent advocacy/support agency as appropriate, and are informed how to do so

Policy/procedure or process for ensuring that participants are appropriately supported to: provide feedback; make a complaint; or appeal to external avenues should they




al (D)

Requirements(Safeguard

requirements to be addressed in the

indicator)

Evidence available

(Yes or No)




Required by date

5.3 cont. choose to do so

Evidence examples

Policy and/or procedure that describes how people will be supported to provide feedback, make a complaint, or appeal to an external body

Welcome kit and or induction pack containing contact information to relevant external feedback, complaint, & appeal bodies

Procedure for engaging an independent mediator where complaints & appeals remain unresolved

Process for ensuring external feedback, complaints & appeals mechanisms are made available in areas that are frequently accessed by people who access the service & significant others.

Continued...




al (D)



Evidence available

(Yes or No)




Required by date

5.4 The organisation demonstrates that feedback, complaints and appeals processes lead to improvements within the service and that outcomes are communicated to relevant stakeholders.

Core

There is a welcome/Induction pack for participants that includes information about how the provider will use feedback and complaints information.

Developmental

There is a Complaints Register that includes actions recommended and documents times taken to complete the complaints process

Evidence examples

There is: A policy & or procedure that addresses how feedback, complaints and

appeals will inform service delivery and planning A Quality Improvement Plan and associated action plans Systems for managing feedback, complaints and appeals Meeting agenda templates with relevant standing agenda items regarding

feedback, complaints, appeals & continuous quality improvement

Continued...




al (D)




No)




Required by date

Standard 6

Human resourcesExpected Outcomes: Effective human resource management systems, including recruitment, induction and supervisory processes, result in quality service provision.Context: The organisation has human resource management systems that ensure people working in services (including volunteers) are recruited appropriately and are suitable for their roles within the organisation. Once appointed, people working in the organisation have access to support, supervision, opportunities for training and development and grievance processes.

6.1 The organisation has human resource management systems that are consistent with regulatory requirements, industrial relations legislation, work health and safety legislation and relevant agreements or awards. Core

Management processes (proportionate to the size of the provider and types of supports provided) are in place – these include, but are not limited to: Workforce planning Learning and

development Code of conduct Emergency

procedures Performance

planning and management

Recruitment, selection and retention processes

Position descriptions Grievance

procedures Use of phones &

information technology

Note: Providers should respond as relevant to their size and structure.

Evidence examples

Policies & procedures for Human Resource Management are in place including: non-discriminatory human resource practices; application of equal employment opportunity principles; elimination of bullying & harassment; consistent application of awards, collective agreements or contracts; safe work practices; safe work environment

Evidence of health & safety training relevant to a staff member’s role Meeting/training records regarding safe work practices & safe work

environment (e.g. records of safety and quality committee meeting agenda HSQF Self-assessment workbook - For providers registering with the NDIS in Queensland Version 2.3 December 2017

34

and minutes) Policy/procedures for ensuing staff safety (e.g. when working with people

with challenging behaviours)



al (D)




No)




Required by date

6.2 The organisation has transparent and accountable recruitment and selection processes that ensure people working in the organisation possess knowledge, skills and experience required to fulfil their roles.

Developmental

Written policies and procedures guide recruitment and selection, induction and ethical conduct for all staff, management, governing bodies and volunteers, including position descriptions that outline required skills and knowledge (e.g. up to date records of qualifications and legal requirements, such as police clearances and mandatory criminal history screening)

Note: Providers should respond as relevant to their size and structure. d

Evidence examples

Examples of evidence: Policy & procedures for workforce planning, recruitment & selection

processes Duty statements or position descriptions for all roles Records of the advertising/promotion of available positions Evidence that staff qualifications have been checked & are current & that

they have the skills & experience necessary to fulfil their role Professional registration &/or other credentialing requirements for

specialist roles are outlined within position descriptions & a process is in place to ensure that staff maintain these requirements

Continued...




al (D)




No)




Required by date

6.3 The organisation provides people working in the organisation with induction, training and development opportunities relevant to their roles.

Core

Policy and process for ensuring compliance with the DCCSDS policy on Preventing and Responding to the Abuse, Neglect and Exploitation of People with Disability, including ensuring that staff/volunteers: are aware of, trained

in, policies on preventing and responding to the abuse, neglect and exploitation

are trained to recognise and prevent/minimise the occurrence or recurrence of abuse, neglect and exploitation

are trained in early intervention approaches where potential or actual abuse, neglect or exploitation of people using services is identified.

Note: Providers should respond as relevant to their size and structure

Evidence examples

Policies or procedures addressing induction, training and development of people working in or for the organisation

Records of induction processes showing that the organisation has addressed all mandatory requirements & the knowledge necessary to fulfil a role within the organisation

Written strategies/policies that support & promote the retention of staff


and/or volunteers



al (D)



Evidence





Required by date

6.4 The organisation provides ongoing support, supervision, feedback and fair disciplinary processes for people working in the organisation.

Developmental

Policy and associated procedures and processes for the provision of supervision, reflective practice, or similar feedback process.

Note: Providers should respond as relevant to their size and structure..

Evidence examples

Policy &/or procedures outlining the organisation’s approach to supporting staff/volunteers, providing supervision, feedback & commitment to fair disciplinary processes.

Records of performance management processes6.5 The organisation

ensures that people working in the organisation have access to fair and effective systems for dealing with grievances and disputes.

Developmental

Policy, procedure and process which addresses the management of grievances and disputes raised by people working in and for the organisation

Note: Providers should respond as relevant to their size and structure..

Evidence examples

Policies or procedures which outline how the organisation manages staff/volunteer grievances & disputes

Staff induction kit containing information regarding the organisation’s dispute resolution procedure & how staff can raise grievances


hsqf ndis service provider self-assessment workbook web viewexamples of appropriately skilled ......

Documents