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					SAMPLE TEMPLATES FOR THE QUEENSLAND DISABILITY SERVICE STANDARDS
These sample templates have been provided as examples only. Service providers are under no obligation to adopt any of these samples. They are intended as a guide only, and providers choosing to adopt one (or more) should consider modifying the template (with additions or deletions) so that it accurately reflects their practices/service type.

Template title 1 Continuous Quality Improvement Register Action Minutes Format for Meetings Referrals Register

Relevance for Queensland Disability Service Standard and service standard indicators 2 3 4 5 6 7 8 9 8.1, 8.2, 9.5 8.3, 8.4, 8.5 8.3, 8.4, 8.5

10

Priority Rating Scale Risk Analysis Likelihood Matrix Document Control Register Quality Monitoring & Auditing Schedule Complaints Register Policy Format

1.1, 1.2, 1.3, 1.4, 1.5 1.1, 1.2, 1.3 3.4, 3.5 8.2 8.3 2,1, 2.2, 2.3, 2.4, 2.5, .26 1.1 – 1.5 2.1 – 2.6 3.1 – 3.5 4.1 – 4.6 5.1 – 5.3 6.1 – 6.3 7.5, 7.6 8.1, 8.2, 8.3, 8.4, 8.5 8.1 – 8.5 9.5 10.4 9.3

7.1, 7.5, 7.6 7.1 – 7.6

9.1 – 9.5

10.1-10.4

Template Title 1 Preferred Suppliers Register Staff Professional Development Log Assessment Information Checklist Staff Induction Checklist Assets Register Recruitment and Selection Checklist Applicant Short-listing Matrix Interview Scoring Grid Staff Performance Appraisal & Professional Development Record Code of Conduct Nomination of Support Person/Advocate Form Guidelines for Advocates Personalised Plan format Personalised Plan Review Schedule

Relevance for Queensland Disability Service Standard and service standard indicators 2 3 4 5 6 7 8 9 2.2 4.4 7.1 8.4, 8.5 9.1

10

10.4 1.1, 1.2, 1.4, 1.5 1.1, 1.2 2.1 – 2.6 3.3, 3.4 4.3, 4.4, 4.5 4.1, 4.5

7.6

8.1, 8.2 8.1 8.1, 8.2 8.1, 8.2 8.1, 8.2 8.1, 8.2

10.2, 10.3

1.4 1.4

2.3 2.3 2.1 – 2.6 2.5

3.4 3.3 3.3 3.3

4.2 4.4 4.4

5.3 5.2 5.2

6.1

8.1 7.4 7.4

9.1

9.2

Continuous Quality Improvement Register
The following entries provide an example of how this template may be used. Note that this is a summary only of improvements undertaken, and will not contain all the detail you may have in your Continuous Improvement Plan. Should your monitoring activities find your improvement activity was unsuccessful, and another strategy is planned, allocate another CQI ID# to the new activity, and record that number in the Closure column to enable your PDCA Cycle to be evidenced. As a commitment to continuous improvement is a requirement across the Queensland Disability Service Standards, the CQI Register can be used to evidence practice against all standards but it is of particular relevance in evidencing service standard indicators 8.1, 8.2, 8.3, 8.4, 8.5, 9.5.

CQI ID#
CQI 01

Date
30/5/04

Source
Service user assessment

Issue
Opportunities for service user input into policy development Dissatisfaction with staff member Audit of 15/6/04 identified that access to fire emergency exit door was blocked by stored equipment

Improvement activity/s
Establish a monthly representative service user forum, comprised of individuals nominated by service users. Review staff allocation rosters and replace the member allocated to that service user. Clear impediments to emergency exits. Review fire safety requirements at team meeting of 20/6/04. To be reassessed during next WH&S audit.

Closure
Date of first forum meeting Date of new roster Date of satisfactory audit

CQI 02 CQI 02

5/6/04 18/6/04

Complaint WH&S Committee

Action Minutes Format for Meetings
This format for recording minutes of meetings ensures that decisions made are recorded in a way that facilitates follow-up in Matters arising from the previous minutes. It may have applicability to a wide range of service standard indicators, wherever issues relating to service performance or improvement are raised for discussion during a meeting (e.g. a workplace health and safety issue, a complaint, staff compliance with a documented procedure, promoting opportunities for service users). Where an issue is raised requiring an improvement activity, it should then be transferred to your Continuous Improvement Plan, and when closed out, entered in the CQI Register. Tasks not completed by the due date are referred to the following meeting, under the same identification number (ID#), until it is closed out. This template is of particular relevance in evidencing service standard indicators 8.3, 8.4, 8.5.
Name of meeting Date/time Names of those present Apologies received Acceptance of minutes of last meeting Matters arising

ID #

Issue

Action to be taken

Person responsible

Date for reporting back

Task completed

Correspondence in/out Presentation and tabling of reports

New business ID # Issue

Action to be taken

Person responsible

Date for reporting back

Referrals Register
This register will enable you to evidence the consistency and fairness of your entry and exit procedures, decisions on relative need, nondiscriminatory access, and referrals made to alternative services. This template is of particular relevance in evidencing service standard indicators 1.1, 1.2, 1.3, 1.4, 1.5.

Date of referral

Service user name/contact details

Nominated support person contact details

Date of assessment

Priority entry rating

Date of entry

Referrals made

Outcome of referrals

Priority Rating Scale
In order to demonstrate compliance with the intent of the Queensland Disability Service Standard 1: Service access, you will need to have a mechanism in place to assess relative need and prioritisation of service access. Some kind of rating scale should therefore be included in your initial assessment, to guide your determination of relative need. This sample template is provided to give an indication of how relative needs can be rated from the assessment process. It is anticipated that service providers will develop their own Priority Rating Scale to suit their practice/service type. A priority rating scale will assist you to evidence your practice against service standard indicators 1.1, 1.2, 1.3.

Service user details
Service user name:……………………………………………………… Address: ………………………………………………………………… Date of birth (dd/mm/yyyy): ……./……/……………….. Nominated advocate/support person: ……………………………….. Date of assessment: ………………………………………… Contact telephone number: ………………………………… Sex: (please circle): M F

Contact telephone number: …………………………………

Relative needs rating calculations
1. Self-Care Functional Assessment 0 = Able to complete a task independently 1 = Able to complete a task with supervision/minor assistance 2 = Requires major assistance by 1 or 2 people and/or use of aids to complete the task 3 = Completely dependent on others to complete the task

t Transfer total score from assessment records.

Self-care functional assessment total score ÷ number of functional areas assessed =
2. Behavioural Assessment 0 = Does not require monitoring 1 = Requires monitoring but not regular supervision 2 = Requires monitoring and regular supervision 3 = Requires constant supervision

__________

Transfer total score from assessment records. Behavioural assessment total score ÷ number of behavioural elements assessed = 3. Cognitive Assessment __________

0 = No cognitive impairment 1 = Can follow verbal/written instructions 2 = Requires supervision/assistance to follow verbal/written instruction 3 = Unable to follow verbal/written instruction

Transfer total score from assessment records. Cognitive assessment total score ÷ number of cognitive functions assessed = _________

4. Social Assessment

0 = Has a wide range of family and personal/social relationships 1 = Friendships made or maintained with some difficulty 2 = Very small social circle and limited opportunity for expanding it 3 = Socially isolated and alone a large part of the time

Transfer total score from assessment records Social assessment total score ÷ number of criteria assessed = _________

5. Carer Profile (e.g. parent, support person) 0 = 1= 2= 3=

Transfer total score from assessment records Carer’s profile total score ÷ number of determinants of health and wellbeing _________

Relative needs rating: (Add all total assessment scores together) =

_________

Divide answer by number of assessment fields (in this example, x 5). This will give you an answer in the range of 0–3. Priority rating scale A rating of 3 A rating of 2–3 A rating of 1–2 A rating of 0–1 = Extremely urgent = Urgent = Accept as soon as a place is available = Not urgent — may go on waiting list or be referred to alternative services.

Risk Analysis Likelihood Matrix
This matrix enables you to analyse the potential risk of an activity/event. By considering both the probability of an incident, and its likely consequence should it occur, you are able to allocate a risk rating, ranging from extreme to low. Where the risk is extreme or high, immediate action should be taken to mitigate the risk. Where the risk is medium or low, decisions would need to be made about whether you are prepared to accept the risk, or initiate a strategy to reduce or eliminate it. This tool has application for service standard indicators 3.4, 3.5, 8.2, 9.3.

Risk Analysis Likelihood Matrix
Risk Ratings: Extreme; High; Medium; Low
Catastrophic; = Extreme = High = Medium = Low Almost Certain;
The event is expected to occur i n most circumstances. Death, toxic release off-site with detrimental effect, high fi nancial loss

Major;
Extensi ve injuries, loss of production capability, off-site release with no detrimental effects, major fi nancial loss

Moderate;
Medical treatment required, on-site release contained with outside assistance, high fi nancial loss

Minor;
First aid treatment, onsite release immediately contained, medium financial loss

Insignificant;
No injuries, low financial fi nancial loss

Likely;
The event will probably occur in most circumstances

Moderate;
The event should occur at some time

Unlikely;
The event should occur at some time

Rare;
The event may occur only i n exceptional circumstances

The matrix above indicates the following: Extreme risk results when there is a catastrophic event (death, toxic release off-site with detrimental effect, high financial risk) that is almost certain to happen (the event is expected to occur in most instances). Extreme risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that is likely to happen (the event will probably occur in most instances).

Extreme risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) that is almost certain to happen (the event is expected to occur in most instances). High risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that has a moderate likelihood of happening (the event should occur at some time). High risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that is unlikely to happen (the event should occur at some time). High risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) that is likely to happen (the event will probably occur in most instances). High risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) and there is a moderate likelihood of it happening (the event should occur at some time). High risk results when there is a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) that is almost certain to happen (the event is expected to occur in most instances). High risk when there is a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) that is likely to happen (the event will probably occur in most instances). Medium risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that is would be rare to happen (the event may occur only in exceptional circumstances) Medium risk results when there is a major (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) event that is unlikely to happen (the event should occur at some time). Medium risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) that would be rare to happen (the event may occur only in exceptional circumstances). Medium risk results when a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) and there is a moderate likelihood of it happening (the event should occur at some time).

Medium risk results when a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) event that is unlikely to happen (the event should occur at some time). Medium risk results when a minor event (first aid treatment, on-site release immediately contained, medium financial loss) that is almost certain to happen (the event is expected to occur in most instances). Medium risk results when a minor event (first aid treatment, on-site release immediately contained, medium financial loss) that is likely to happen (the event will probably occur in most instances). Medium risk results when a minor event (first aid treatment, on-site release immediately contained, medium financial loss) and there is a moderate likelihood of it happening (the event should occur at some time). Low risk results when there is a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) that would be rare to happen (the event may occur only in exceptional circumstances). Low risk results when there is a minor event (first aid treatment, on-site release immediately contained, medium financial loss) event that is unlikely to happen (the event should occur at some time). Low risk results when there is a minor event (first aid treatment, on-site release immediately contained, medium financial loss) that would be rare to happen (the event may occur only in exceptional circumstances). Low risk results when there is an insignificant event (no injuries, low financial loss) that is almost certain to happen (the event is expected to occur in most instances). Low risk results when there is an insignificant event (no injuries, low financial loss) that is likely to happen (the event will probably occur in most instances). Low risk results when there is an insignificant event (no injuries, low financial loss) and there is a moderate likelihood of it happening (the event should occur at some time). Low risk results when there is an insignificant event (no injuries, low financial loss) that is unlikely to happen (the event should occur at some time).

Low risk results when there is an insignificant event (no injuries, low financial loss) that would be rare to happen (the event may occur only in exceptional circumstances).

Document Control Register
A Document Control Register enables you to control your mission-critical documents to ensure obsolete documents are removed from circulation, and access and distribution of documents is controlled. A good strategy for effective information management is to include in the footer of each document its electronic file path, the document control number, and the date of issue. You will need to establish and communicate to stakeholders your coding system, for example a prefix allocated to classify document types (P prefix for a policy; F prefix for a controlled form etc.). This register can be used to evidence practice against service standard indicator 8.3.

ID # Policies, forms etc.

Document title Name of document

Access Any security access codes required, or specify limited access

Electronic file pathway File location

Date last reviewed Should be consistent with date in document footer

Archived Location of archived documents

Disposal method Disposal method, e.g. shredding

Quality Monitoring and Auditing Schedule
Establishing a planned annual schedule will enable you to evidence your commitment to quality control and ongoing quality improvement. Include all the major monitoring activities that require the planning and allocation of resources, some examples of which are included in the template sample. As a commitment to continuous improvement is a requirement across the Queensland Disability Service Standards, the Quality Monitoring Schedule can be used to evidence practice against all standards. It is of particular relevance in evidencing service standard indicators 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 7.5, 7.6, 8.1, 8.2, 8.3, 8.4, 8.5, 9.5, 10.4.

Review subject Planning e.g. Strategic Plan Document review e.g. review of all policies and procedures for continuing applicability Controlled documents e.g. Document Control Register

Process Annual management/staff planning day

Who Committee and Staff Committee and staff Administrative staff

When Month due/date

Review for effectiveness and currency and re-endorse during annual planning Currency updating and review of dates of re-endorsement in footers of all mission-critical documents, following document review Performance appraisal process Contract review of requirements and performance Review of Assets Register and updating of warranty details and depreciation Audit of maintenance schedules for continuing effectiveness

Month due/date Month due/date (one week after document review)

Performance e.g. staff performance reviews Suppliers e.g. quality monitoring of suppliers Assets management monitoring e.g. assets management and maintenance

CEO/Manager CEO/Manager Manager & treasurer

Month due/date Month due/date Month due/date (prior to AGM) Month due/date

Records e.g. client records system Service quality/improvement e.g. Staff Satisfaction/retention rates/levels Service user satisfaction

Random survey of 10% of client records against policystipulated content requirements, clarity of entries, security, currency/archiving procedures a) Staff Satisfaction survey b) Review of retention rates/reasons for leaving for CQI planning a) Survey of service users to assess awareness of their rights, satisfaction levels, and suggestions for improvements. b) Service user service assessment process a) Review of CQI Register, Quality Improvement Plan and minutes of meetings to ensure actions have been recorded b) Service user planning forums c) Self-assessment against the QDSS Review Complaints Register for patterns/trends emerging, and actions taken for continuous improvement a) Standing agenda item for management meetings for review of accidents/incidents b) Internal environmental safety compliance audits against documented procedures c) Fire safety environmental audits and inspection of equipment d) Electrical equipment checking and tagging a) Preparation and submission of reports against service agreement requirements b) Annual acquittals and financial reporting to funding bodies

Manager Manager

Month due/date

CEO/Manager

Month due/date

Program Managers

Month due/date

Continuous improvement

CEO/Manager

Month due/date

Complaints Workplace Health and Safety e.g. staff/service user safety and regulatory compliance

CEO/Manager Management WH&S officer Fire Department WH&S CEO/Manager CEO/Manager

Month due/date Month due/date Month due/date Month due/date Month due/date Month due/date Month due/date

Accountabilities/reporting e.g. reporting to funding bodies etc.

Complaints Register
Establishment of a Complaints Register enables providers to monitor their internal processes to ensure complaints and concerns raised are addressed in accordance with the principles of natural justice. Where a significant issue/concern is raised through informal channels (i.e. is not a formally documented complaint) an entry should still be made in the register, in order for you to evidence your practice. Where the action you take for resolution leads to a continuous improvement activity (e.g. a change in a policy or procedure), this should be noted in Action taken column with reference to the allocated CQI ID #. This register can be used to evidence practice against service standard indicators 7.1, 7.5, 7.6.

Complainant’s name

Contact Details

Date complaint received

Issue/ concern raised

Action taken

Date action taken

Date of resolution/ closure

Date of feedback

Policy Format
This sample template provides an example of a policy format. Policies may be used to evidence practice against all standards, as they establish the parameters and procedural guidelines for your practices. Use the service standard indicators as a guide for policy content for each standard.
Policy Number (as entered in Document Control Register): POLICY TITLE (N.B. Enter electronic file path and date of endorsement/currency in the document footer and in the Document Control Register) POLICY STATEMENT The policy statement/purpose provides the direction and rationale. SCOPE The scope may need to be specified to clarify applicability (e.g. are any program areas exempted from any clauses, where specific criteria may apply for their service type — otherwise, delete this heading). PRINCIPLES Explicit values which drive this policy. May link to organisational values, constitutional objects, or principles of practice etc. REFERENCES Identify regulatory or situational references (e.g. QDSS, strategic plan, cross-referenced policies, legislation/regulations, Australian standards). ATTACHMENTS Controlled forms mentioned in the procedures, which form part of this policy. Delete if not applicable. PROCEDURAL FRAMEWORK 1. 1.1 Heading Sub-heading if more than one element to this procedure

i.

Identification of clauses under this heading

Preferred Suppliers Register
This sample template is a tool for ensuring sustainable practice, providing confidence that ,should a key person leave, the new incumbent in the position will have access to information on the suppliers currently used by the organisation, and any issues relating to quality that may have required attention in the past. Where performance of a supplier is unsatisfactory, and a decision is made to cease using their products/services, record this information in the Action taken column, but do not delete the entry. A new supplier‘s details may be entered for that product/service type, with the date of transfer to the new supplier entered in the Quality monitoring/comments column. Some examples have been included in the sample template below. Depending on your entries, this template may have relevance for evidencing practice against service standard indicators 2.2, 4.4, 7.1, 8.4, 8.5, 9.2.

Product/service Tradespeople (electrician, plumber, etc.) Contracted/brokered agencies Insurance broker Consultants Auditor Solicitor Courier service etc. Office equipment/furnishings Telephone system Internet provider Stationers Vehicle fleet suppliers

Supplier

Contact details

Quality monitoring/ comments

Action taken

IT support IT equipment Advocacy agencies etc. etc.

Staff Professional Development Log
This sample template enables you to monitor the equitable distribution of professional development resources across the staff team, and to demonstrate the opportunities you have provided to enhance each individual‘s skills, knowledge and competencies. While in-service education activities may be included, it is more common to document only externally accessed programs/conferences, as training provided by the organisation would be evidenced on an annual in-service training calendar. Choose what is most appropriate for you when deciding whether to use the log for internal as well as external staff development. This template will assist you to evidence practice against service standard indicator 10.4.

Each staff member is responsible for maintaining and updating his/her own professional development log. One copy may be kept by the employee for his or her curriculum vitae, and one copy is to be retained by the Executive Director in the personnel file. If the training completed has been at the cost of the staff member, note ―AOE‖ (At Own Expense) in the ―Cost‖ column. If the training program has been attended in the staff member‘s own time, note ―IOT‖ (In Own Time) in the ―Hours‖ column when recording the hours involved.

NAME: POSITION TITLE: DATE COMMENCED:

Date

Course/conference attended

Hours

Cost

Assessment Information Checklist
Having a checklist of information provided to service users and/or their supports at the time of initial assessment is one way that you can demonstrate what information is routinely provided. Inviting the service user/support to sign the form verifies their receipt of this information. This template will assist you to evidence practice against service standard indicators 1.1, 1.2, 1.4, 1.5, 2.1, 2.2, 2.3, 2.4, 2.5, 3.3, 3.4, 4.3, 4.4, 4.5, 6.2, 7.1, 7.3, 8.3, 9.2.
I have explained the following information to: …………………………………………….……………………… Signed by assessment officer: …………………………………………………………………………………….                Eligibility criteria for entry to the service, and procedures for prioritising access Service user‘s right to access a support person of their choice to assist them when entering or exiting a service, and in developing their personalised plan How the service works with the service user to develop a personalised plan to assist them to achieve their goals, and in what format the copy of the plan will be provided to the service user What support will be provided, how the support will be delivered, and how frequently the personalised plan will be reviewed What information and support can be offered to assist service users to access an independent support person of their choice Procedures for minimising risks to the service user without unduly limiting their choices The service user‘s rights in relation to privacy and confidentiality of personal information, and how they may access information held about them Procedures for release of personal information to another party and the requirement for informed consent for release What assistance can be provided for the development and maintenance of the service user‘s skills The processes for raising a complaint or concern, and the service‘s policies for resolving issues causing service-use dissatisfaction How the service user can participate in decision-making processes to assist the service to improve Date: ……………………………



How the service user can be assisted to exercise his/her human rights

The above information has been explained to me. Signed by service user/support person: ………………………………………………………………………. Date: ……………………………..

Staff Induction Checklist
Having a checklist of information provided to new staff members during their induction enables you to demonstrate the content of your induction program and that information essential to performance management is consistently provided. Inviting the incumbent in the position to sign the form verifies his/her receipt and understanding of this information. This template will assist you to evidence practice against service standard indicators 1.1, 1.2, 4.1, 4.5, 7.6, 8.1, .8.2, 10.2, 10.3.

Personal information
Contract of employment Position description Performance monitoring/appraisal processes Code of ethics (accepted and signed) Confidentiality agreement (accepted and signed) Allocation of IT access code Terms and conditions of employment/Award conditions Documented essential practice guidelines Review of organisational policies and documented procedures Quality monitoring and continuous improvement systems The organisation‘s mission, vision and values Service user participation in service management

Workplace Health and Safety Instruction in safe work practice Duty of care Fire safety procedures Standard operating procedures Time sheets Leave requests/Entitlements Training records/Entitlements Mandatory training Premises security Use of vehicles Schedule of staff meetings Internal communication mechanisms Service delivery Service eligibility criteria for service users, and processes for assessing prioritisation of need Principles of operation in supporting service users Rights of service users and their nominated supports Service delivery orientation period completed under supervision (―buddy‖ or supervisor) I confirm I have completed my formal induction process and have understood my responsibilities in relation to the information provided

Signed: …………………………………………

Dated: ……………

Assets Register
An Assets Register is an inventory record of your physical assets. It can be used as part of your equipment maintenance procedures to check warranties that may still be in force, and also for end-of-year financial accounting and asset depreciation. It should be updated when you acquire any major purchase, and annually just prior to the annual general meeting.

This template will assist you to evidence practice against service standard indicator 8.1.

Register number

Description of property

Date acquired

Price Paid

Warranty period

Serial number

Date of disposal

Amount received

Depreciation rate

Recruitment and Selection Checklist
This sample template provides a guide for service providers to verify procedural application of good practice guidelines in recruiting and selecting staff. It will assist you to evidence practice against service standard indicators 10.1, 10.2.

Process

Who is responsible

Date task due for completion

Check box

Human resource planning and analysis of skills/competencies required Develop job specification of skills/competencies/knowledge required Develop position description that articulates duties to be undertaken Identify the key selection criteria from the core competencies required for the position Place advertisement, which includes the date for close of applications, and telephone contact for provision of an applicants‘ information pack Distribute applicants‘ information pack to those who inquire regarding the position. The pack should include clear instructions regarding addressing the key selection criteria in applications submitted. Close application period Establish an interview panel Train the panel in interview techniques, EEO principles, ‗Merit‘ principles, awareness of ‗familiarity bias‘ (the tendency to favour candidates who are similar to the panel member), awareness of ‗primacy and recency‘ effect (tendency to forget responses from candidates interviewed first when comparing candidates‘ responses to questions) Evaluate applications according to the key selection criteria, using a scoring matrix Short-list the candidates Develop structured interview questions from the key selection criteria, and note your expected responses

Weight key selection criteria to acknowledge the relative importance of each predictor Notify short-listed candidates and arrange interview appointments Notify unsuccessful candidates in writing Conduct structured interviews with short-listed candidates using standard questions and a scoring grid Panel members to compare their ratings/scores, and make a decision on the successful applicant Telephone referees, and verify qualifications Notify successful candidate of offer of appointment, and confirm date appointment will take effect and date of commencement of induction Notify unsuccessful candidates in writing

Applicant Short-listing Matrix
This sample template provides a guide for evaluating and short-listing applicants for a position, based on their responses to the key selection criteria (KSC). Each panel member would allocate a score based on the ratings scale in the appropriate cell for that key selection criterion. The total score should then be calculated. (Add or delete columns according to the number of key selection criteria you are assessing candidates‘ against.) It will assist you to evidence practice against service standard indicators 10.1, 10.2.
NAME OF APPLICANT: ………………………………………………………………………………… POSITION APPLIED FOR: ……………………………………………………………………………. Ratings scale Exceptional High level Above requirements Meets requirements Meets some requirements Limited 10 9 8 7 6 5 4 3 2 1 KSC1 KSC2 KSC3 KSC4 KSC5 DATE: ……..……………………………………… PANEL MEMBER: ………………………………… KSC6 KSC7 KSC8

Does not meet requirements 0 TOTAL SCORE: …………………………………….. COMMENTS: ………………………………………………………………………………………………………………………………………………………

Interview Scoring Grid
Using an Interview Scoring Grid enables all members of the interview panel to make independent decisions, based on the merit of each candidate‘s response to questions related to the key selection criteria (KSC). Once the panel has decided whether any selection criteria are to be weighted (to acknowledge their relative importance), they allocate a ‗raw score‘ out of a possible 10 (based on the rating scale). This score is then multiplied by the weighting given to determine the total score against each KSC. It will assist you to evidence practice against service standard indicators 10.1, 10.2.

Name of applicant: ……………………………………………………………… Position applied for: …………………………………………………………. Key selection criteria KSC 1 – Weighting = KSC 2 – Weighting = KSC 3 – Weighting = KSC 4 – Weighting = KSC 5 – Weighting = KSC 6 – Weighting = Raw score Total

Date of interview: ……………………………………. Name of panel member: ……………………………... Comments

RATING SCALE: 10 Exceptional

8–9 High level

6–7 Above Meets

5

3–4 Meets some

2–1 Limited

0 Does not meet

requirements SCORES: Application:

requirements

requirements

requirements

Interview:

Referee check:

TOTAL SCORE:

Staff Performance Appraisal and Professional Development Record
Staff may sometimes feel threatened by performance appraisal processes, and it is therefore beneficial to adopt a system for performance review that focuses on opportunities for further professional development. Staff members can complete this sample template themselves, identifying the skills, knowledge and abilities they need to undertake their duties proficiently, and rating themselves on their present level of competence against each area (using the √ box). Where they feel further knowledge would be of benefit, they identify professional development goals. This is then discussed with the supervisor, necessary amendments jointly negotiated, and timelines established for the goals to be achieved over the next twelve months. Once educational goals have been met, a date is entered in the Targets met column by the supervisor and staff member, and a joint assessment made of the new competency level. It will assist you to evidence practice against service standard indicators 10.1, 10.2.

Assessment codes NC = Not competent C = Competent HC = Highly competent

Duties from position description

Skills, knowledge and competencies needed

NC

C

HC

Goals

Targets met

NC

C

HC

Code of Conduct
Ideally, an organisation‘s Code of Conduct will be developed collaboratively by management and staff, and reflect the core values held by the organisation. Both management and staff should then be invited to sign it, and a copy held in each individual‘s personnel file. Where a Code of Conduct has already been established, it should be an essential component of the induction process for both staff and management committee members. This template sample is intended only as a starting point for discussion within your organisation. A thoughtful and well-designed Code of Conduct will assist you to evidence practice against service standard indicators 3.4, 4.2, 5.3, 6.1, 8.1, 9.2.
It is expected that all members of ………………………..…………………. will conduct themselves at all times in accordance with our Code of Conduct. Our Code of Conduct encapsulates the professional ethics and behaviours expected of both management and staff. The signing of the Code to confirm acceptance of the responsibilities it entails is a prerequisite of employment and/or nomination to the management committee. Name: ……………………………………………………………………………….… I accept and agree to adhere to the following Code of Conduct. I will:            demonstrate a commitment in my work and relationships to principles of social justice demonstrate through my behaviours and actions a commitment to non-discrimination empower disadvantaged individuals in their choice and decision making through provision of information and support support service users to exercise their legal and human rights apply the least restrictive alternative principle in the provision of services to service users continually develop my skills to enhance individual and organisational performance contribute within my capacity to the organisation‘s continuous improvement philosophy and practice treat all service users at all times with dignity and respect maintain privacy and confidentiality obligations to service users and to the organisation undertake my responsibilities and operate within a client-centred framework promote the principles of community participation and integration for people with disabilities Position: ……………………………………………………

  

promote the ability of people with a disability to fulfill valued roles in the community refrain from soliciting or personally accepting gifts or gratuities from service users refrain from any practices, either direct or implied, which may be construed as sexual harassment. Signature: …………………………………………………….

Date: ……………………………………………………………………………………

Nomination of Support Person/Advocate Form
It is recommended this form be included in each service user‘s file, and be reviewed with the service user/support person each time the personalised plan is reviewed, to ensure ongoing currency of the support person/advocate of their choice. Service users may choose to nominate an informal support person and an independent formal or informal advocate, as the roles are distinctly different. In this case two forms would be completed. This sample template will assist you to evidence your practice against service standard indicators 1.4, 2.3, 3.3, 4.4, 5.2, 7.4.

Our service users may have the support person of their choice accompany them through any procedures or negotiations with our service. Parents or legal representatives are accepted as service user support people without the need for completion of this form. This form is to be used when a service user chooses to nominate an informal support person (friend or significant other) or an individual or organisation to advocate on their behalf, or change their nominated support person/advocate. The intention is to ensure clarity between the service and the nominated individual/agency about their role. A support person acts to support the service user in his or her negotiations with our service. This may include interpreting, providing assistance with communication, and/or advising on the service user‘s needs. An advocate speaks on behalf of the service user, to ensure their best interests are represented. A service user may choose to have both an informal support person and an advocate, depending on the circumstances concerned. When completing the form, please strike out the term that does not apply. If both an informal support person and an advocate are being nominated, please complete a form for each. I, ………………………………………………………. nominate ………………………………………………to act as my support person/advocate,
(Name of service user)

effective from …………………………………………..
(insert date)

His/her contact details are: ……………..………………………………………………………. Date: ……………………………………….

Signed: …………………………………………………
(Signature of service user/legal representative)

I, ………………………………………
(Name of service user)

wish to change my nominated support person/advocate. Effective from …………………………………..
(insert date)

I would like my interests to be represented by ……………………………………………………………….…., whose contact details are:
(Name of support person/advocate) …………………………………………………………………………………………………………………………………………………………………………………………………………………

Signed: ………………………………………………..
(Signature of service user/legal representative)

Date: ………………………………………

Guidelines for Advocates
As service user advocates undertake a specialised role in representing the service user‘s interests, it may be helpful to present nominated advocates with guidelines to provide confidence that he/she is aware of the responsibilities inherent in this role. This sample template will assist you evidence your practice against service standard indicators 1.4, 2.3, 3.3, 4.4, 5.2, 7.4, 9.2.

Who can be an advocate? Advocacy is the process of standing alongside an individual who is disadvantaged, and speaking out on their behalf in a way that represents the best interests of that person. If a service user of our agency has asked you to be their advocate, this means they would like you to act on their behalf. You may be a family member or friend of the person, or a member of an advocacy service. Service users and prospective advocates should be aware that interpreters cannot be used as advocates, as they have a distinct role to play in interpreting communication between two or more parties. Responsibilities as a service user advocate Being an advocate may mean your attendance or involvement could be required during assessments and reviews of the service user‘s personalised plan, or should the service user want a representative to communicate or negotiate with us on his/her behalf regarding access to their personal information; lodging a complaint; or any issue related to our service performance . We ask our service users to complete a ―Notification of Support Person/Advocate Form‖ when they wish to appoint or change their advocate. Service users are free to change their advocates whenever they wish, however, whenever a change occurs another nomination form is to be completed. Definitions Advocate Informal Advocate Systems Advocate An advocate is a person who, with explicit authority, represents another persons interests. A friend or family member who is nominated by a service user as their personal advocate. An organisation or professional advocate who can act for a disadvantaged individual or group of individuals in an institutional setting. A nominated advocate whose role has legal status, for example holding an Enduring Power of Attorney.

Legal Advocate

The role of an advocate explained Advocacy may involve speaking, acting or writing on behalf of an individual (or group) who has limited ability to exercise his/her rights. Advocacy is a mechanism to facilitate service user rights, and you may be requested to support the service user in exercising his/her rights, for example the right:  to privacy and confidentiality  to respect and dignity  to quality services  to information to inform decision making  to choice and control  to resolution of complaints  to non-discrimination, and  to protection of legal and human rights and freedom from abuse and neglect. Advocacy differs from mediation and negotiation. Mediation and negotiation processes aim to reach a mutually acceptable outcome between the parties. The role of the advocate is not impartial, as he or she has an obligation to operate entirely from the perspective of the service user in negotiating an outcome. Advocacy is concerned with genuine major needs, and aims to protect the interests and promote the welfare of the service user. The advocacy perspective is specialised and quite distinct from the service provider perspective. As advocates and advocacy organisations often stand in contradiction to the system in terms of attitudes towards people in need and beliefs regarding how best to serve them, effective advocates strive for independence and minimise conflict of interest. It is therefore inappropriate that interpreters accept the advocacy role, as their interpreting responsibility does not permit the necessary independence required of an advocate. Advocacy may involve a degree of conflict with service providers and other authorities and therefore may be costly in terms of emotional stress and other demands. Checklist for advocates As an advocate of a service user we ask you to be aware of the following and to ensure that:  the service user has given written authority for you to act on his/her behalf  you inform us that you are acting as the service user's advocate  you always act in the best interests of the service user  the service user is aware of any issues and developments in relation to. services they receive and which you, as their advocate, may be involved in  the service user is kept informed of any developments in relation to the issue/s where you are representing their interests, and that any decisions will be made by the service user  you encourage the service user to provide feedback to you about the services they are receiving

   

you advise the service about any changes in service user circumstances and any concerns about changing service user needs you are prepared to relinquish the role of advocate should the service user wish this you avoid representing them in circumstances where there may be a conflict of interest, and you do not act as an interpreter for the service user while acting in an advocacy role. Thank you for acting as an advocate for our service user.

Personalised Plan Format
It is anticipated that all service providers will already have a personalised plan format in place. However, for recently established services a sample template may be useful. The personalised plan template will assist you to evidence your practice against service standard indicators 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 3.3.

Individual Program Plan
for ………………………………………………………………… For the period ............................................................... Service name:………………………………………………………….. Nominated advocate/support person: ……………………………….. Review date for individual program plan:……………………………… Copy of plan provided to service user/support person: ………………
(enter date)

Support worker: ………….…………………………………………………. Plan developed in consultation with: ……………………………………….. Plan authorised by: ……………………………………………………..……..
(Signature of service user/nominated support person)

Preferred format: ………………………………...……………………………

Identified skills/knowledge/attributes: …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………

Health and wellbeing needs: ……………………………………………………………………………………………………………………………………………. Behavioural support needs: ……………………………………………………………………………………………………………………………………….. Physical support needs/aids: ……………………………………………………………………………………………………………………………………… Psycho-social support needs: …………………………………………………………………………………………………………………………………….. Communication needs: ……………………………………………………………………………………………………………………………………………... Cultural needs: ……………………………………………………………………………………………………………………………………………………….. Who will provide the required support: ………………………………………………… At what time: ………………………………………………………………………….. For what length of time: ………………………………… Under what conditions: …………………………………..

What risks are involved in implementing the plan ………………………………………………………………………………………………………………. How will risks be managed …………………………………………………………………………………………………………………………………………

Service user‘s vision statement ………………………………………………………………………………………………………………………………………………………………………… Long-term goals: 1. ……………………………………………………………………………………………………………………………………………………………………… 2. ………………………………………………………………………………………………………………………………………………………..……………… 3. ………………………………………………………………………………………………………………………………………………………………………. 4. ………………………………………………………………………………………………………………………………………………………………………..

Short-term goals: 1.1 ………………………………………………………………………………. 1.2 …………………………………………………………………………… 2.1 ………………………………………………………………………………. 2.2 …………………………………………………………………………… 3.1 ……………………………………………………………………………….. 3.2 …………………………………………………………………………… 4.1 ………………………………………………………………………………. 4.2 …………………………………………………………………………..

RESPONSES: The service will address progression towards achieving these goals in the following manner: Long-term goals: 1. Measuring device: ….…………………………………………………………………………………………………………………………………… 2. Measuring device: ………………………………………………………………………………………………………………………………………. 3. Measuring device: ………………………………………………………………………………………………………………………………………. 4. Measuring device: ………………………………………………………………………………………………………………………………………

Program content details for: ………………………………………………………………………………………………………………………………………. Date/s: …………………………………………………………………………. Days: ……………………………………………………………………………..

Start time

Finish time

Means of transport (if transportation time)

Voucher required? Yes/No Yes/No

ACTIVITY

VENUE Address, telephone number and contact name MUST BE INCLUDED

Task analysis? Yes/No Yes/No

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Support Strategies:

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Items required by service user for activities are: …………………………..……………………………………………………………………………………… Support worker hours allocated: …………. Brokered hours allocated: ……..…. Informal support hours negotiated: ………... Total hours: ……. Goals focused by today‘s activities (e.g. 1.1, 4.2, etc): ……………………………………..…………………………………………………………………

Personalised Plan Review Schedule
While personalised plans will include the anticipated review schedule, it may be useful for the individual responsible to have a schedule planned for the service users who he/she is supporting. This sample template will assist you to evidence your practice against service standard indicator 2.5.

Service user’s name

Date of last plan review

Date next quarterly review due

Appointment made with service user/support/s

Goal attainment reviewed and new activities planned


				
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