Guide for CBs by 0Ot0AvJ


									Maintenance Audit Report Writing Guide

This document aims to assist certification bodies in the completion of the
Maintenance Audit Report and Summary and Findings templates.

The Maintenance Audit Report is to provide an overview of the service provider’s
continued quality of service delivery in relation to the Queensland Disability
Service Standards (QDSS) or the Queensland Disability Advocacy Standards

This guide for maintenance report writing has been set up to reflect the
equivalent headings as they appear in the templates.

The report consists of two templates to be used for either the QDSS or QDAS.
The templates, outlined below, contain mandatory headings and can include text
that is designed to be incorporated in the final audit report. Please add additional
text under each heading where appropriate.

Maintenance Audit Report Template
Please select which set of standards (QDSS or QDAS) you have audited against
(where indicated in yellow) through this document, deleting the non applicable

There is a requirement for the Maintenance Audit Report to consist of:
 Confidentiality statement
 Organisational profile
 Executive summary
 Audit team details
 Audit plan

Summary and Findings Template
Please select the applicable template to which set of standards (QDSS or QDAS)
you have audited against.

There is a requirement for the Summary and Findings Template to consist of:
 Rating summary
 Findings of the sampled service standards and indicators
Maintenance Audit Report Template Guidance Notes

Confidentiality Statement

Provide a confidentiality statement for your auditing body, or use the statement
provided in the template.

Organisational Profile

Service provider
 Provide information relating to service provider’s details here i.e. name of
   organisation, incorporation etc.

History and location
 Provide details about the location, DSQ region and service type outlets as
    detailed in the service’s General Service Agreement.

Service type/s
 Provide details about the range of service types delivered as per CSTDA
   NMDS definitions.

Staff profile
 Provide details about staff numbers and occupational profiles.

Service user profile
 Provide de-identified details about the service user profiles.

Number of service users
 Where possible, provide details about the approximate number of service
   users by service type.

Organisation changes
 Provide details about any significant changes to the organisation from
   previous audit report, if applicable.

Executive Summary

An executive summary should ideally cover the following (but not be limited to):

      Details of the services’ strengths and weaknesses as a summary of the
       audit findings
      Summary of audit taken place
      Recommendations of Certifying Body for improvements
      Provide details of any nonconformities found
      Evidence of continuous improvement
      Positive feedback from service users
        An effective approach to service planning, management and evaluation
        Involvement of Board members, management, service users and staff

Maintenance assessment date
Provide date of the current maintenance assessment you are undertaking.

Period of certification
Provide the commencement and expiry dates of the existing period of
certification, over the three year cycle.

Next maintenance, follow up or recertification audit date
Provide details of the next proposed maintenance, follow up or recertification
audit date and include any areas of focus or required improvements to be

In accordance with the rating principles, record where the service has either:
     Maintained certification

        Maintained certification with acknowledged nonconformities:
         -     Specify any nonconformities and timeframes for follow-up.

            Not maintained certification:
         -     Specify major nonconformities and timeframes for follow-up.

Please include:
    the conformity rating number against the number of service standards
      assessed upon completion of the maintenance audit

Audit Team

Provide names of the audit team that have undertaken the audit.

Audit Plan

Document Review
As part of the maintenance cycle the audit team is to undertake a review of
improvement actions through continuous improvement and the closing out of any
prior nonconformities through the review of documents.

Please list the documents that have been reviewed in this section of the audit

The evidence that may be gathered can include:

       reviewing the continuous improvement plan and progress of planned
       effectiveness of the service’s management review system
    addressing of any non conformities previously identified, as stated in the
     continuous improvement plan and previous audit report
    observations of activities and the surrounding work environment and
    reviewing documentation of various kinds such as policies, objectives, plans,
     procedures, standards, instructions, licences and permits, specification,
     contracts and orders
    records such as minutes of meetings, audit reports, records of monitoring
     programs and the results of measurements
    data summaries, analyses and performance indicators
    results and information on internal auditing programs and on procedures of
     control of these programs
    reviewing service users plans
    interviews with service users/supports, management and staff

Multi-site service provider sample
The multi-site sampling method for the service provider is to be set out in this
section. Please provide detailed information relating to the number of service
type outlets and how the multi-site sampling was applied.

Service user sample
Annex 3 of Procedure 28 details the approach to be taken for service user
sampling. It acknowledges the diversity of the sector and states that the service
provider and the certification body must agree on the size of the sample and the
approach to be used for each service.

   Please provide details on how the sample approach was formulated
   Provide details on the approach and size of sample.
   If applicable, provide information on why 50% of the individual interview
    sample was not achievable.

Sample approach of standards
DSQ has introduced an integrated framework for quality that includes three
conceptual domains. These domains cover the following respective functions:

The QDSS or the QDAS are applied to the integrated framework in the following

                 Domain                  Function                  Standards
                Individual        Direct service delivery          1, 2, 5, 6
                  Rights             Human and legal               3, 4, 7, 9
               Organisation       Management and staff               8, 10

Each maintenance audit requires certification bodies to assess as a minimum a
disability standard derived from each of the conceptual domains.

Please list the standards from each of the conceptual domains that have been
sampled in this section.
The outcome of this approach is to ensure a broad range of standards are
assessed over the three-year certification cycle whilst still allowing flexibility for
certification bodies. Maintenance audits shall at a minimum, ensure:

       minimum of one disability standard from each domain is chosen to be
        assessed in full (minimum sample size of three standards in total)
       within the chosen sample no disability standard shall be assessed more
        than once over the two annual maintenance audits
       in the presence of existing non-conforming standards they shall not
        constitute part of the chosen sample
       other selected disability standards can be assessed at the discretion of the
        certification body

To view the complete JAS ANZ Policy 07/07 “Implementation of changes in
Maintenance audit procedures for bodies auditing and certifying disability support
services in Queensland (DSSQ)” please refer to the JAS ANZ web site:

ATSU Activities
As outlined in Procedure 28 (G.2.2.11) the audit-trained service user team
member shall actively participate in the following audit activities with the other
team members and this involvement shall be traceable via reports or other
documents on the certification body's files.

       ATSU Activities undertaken
        Participation in the development of the audit plan
        Participation in the planning and preparing the methods of service
         user/support participation in the audit
        Participation in interviews of service user/supports to collect evidence
         with respect to QDSS and QDAS
        Participation in reviewing service user/support files
        Participation in following up on issues with service user/supports
        Contribution to the review audit evidence prior to presentation of audit
         findings to service provider
        Contribution to the written report prior to submission to the service
        Provide support in understanding appropriate language required for the
         audit and the service provider’s particular social and cultural

The Rating Scale for Audit Findings

In this section of the template please use the text provided or if you wish to add
alternative text please ensure the rating scale is outlined with definitions of each
rating and the rules for finding more than two nonconformities are explained.
Summary and Findings Template Guidance Notes

Rating Summary Template

Provide a summary of the ratings for each sampled service standard indicator
and the overall rating for all related service standards that are sampled. Please
also indicate Yes/No to any observations made.

Service Standards and Indicators Template

Definitions for each section of the template:
 If applicable, provide a summary of your observations on aspects of the
   service’s system, processes and/or practices in the template. They may
   include strengths and evidence of good practice.

Observations / Improvements:
 If applicable, provide a summary of details to identify areas for improvement.

Observations are provided as guidance on areas for potential system
deficiencies or system improvement, and should be actioned where appropriate.

Isolated or incidental deficiencies identified in observations may indicate that
specific aspects of the system need to be reviewed to prevent problems
occurring in the future.

Close-out of Nonconformities:
 If applicable, provide details where a service standard indicator or standard
   has been previously rated as nonconformity with evidence supporting the

Current Nonconformity Evidence
 If applicable, provide details of where a service standard indicator has been
  rated as a major nonconformity or nonconformity with evidence supporting the

Required Actions / Conditions
 If applicable, provide details where a service standard indicator has been
  rated as a major nonconformity or nonconformity, the required
  conditions/actions for follow-up are stated.

Recommended Rating:
 Record the recommend the rating for the service standard indicator (0, 1 or

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