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Internal Audit Requirements Tool Revised July 2009

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Internal Audit Requirements Tool Revised July 2009 Powered By Docstoc
					North and West Metropolitan Region
Disability Accommodation Services




Internal Audit Requirements

SUMMARY OF OBSERVATIONS




Internal Audit Requirements – NW – V2 - May 2009   Page 1 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                                                 SUMMARY OF OBSERVATIONS


CONTENTS


LOCATION DETAILS ................................................................................................................................................................................... 3
SSA Staff and Resident Details .................................................................................................................................................................... 5
Industry Standard 2: INDIVIDUAL NEEDS ..................................................................................................................................................... 6
Industry Standard 3: DECISION MAKING AND CHOICE ................................................................................................................................ 42
Industry Standard 4: PRIVACY, DIGNITY AND CONFIDENTIALITY .................................................................................................................. 44
Industry Standard 5: PARTICIPATION AND INTEGRATION ............................................................................................................................ 46
Industry Standard 6: VALUED STATUS ....................................................................................................................................................... 48
Industry Standard 7: COMPLAINTS AND DISPUTES ...................................................................................................................................... 49
Industry Standard 8: SERVICE MANAGEMENT ............................................................................................................................................. 50
Industry Standard 9: FREEDOM FROM ABUSE AND NEGLECT ........................................................................................................................ 62
Staff Training Records .............................................................................................................................................................................. 64




Internal Audit Requirements – NW – V2 - May 2009                                                                                                                                        Page 2 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                      SUMMARY OF OBSERVATIONS


LOCATION DETAILS


Group Home Name

House Address

DAS Area

DAS Area Manager

Domain Manager

House Supervisor

Auditor Names


Date of Review                                         Start           Finish
Follow up of review dates if applicable                Start           Finish


Remedial Notice Completed (if needed)                  Date            Reviewer Sign
Action Plan Developed                                  Date            Reviewer Sign


Date Action Plan to be completed
Date of next cyclic Review


INDUSTRY STANDARD RATING


     Standard                   2                  3           4   5            6      7        8          9
Rating




Internal Audit Requirements – NW – V2 - May 2009                                                       Page 3 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                   SUMMARY OF OBSERVATIONS



Group Home Critical Indicator                      High number of reported incidents within past 12 months

                                                   Low number of reported incidents within past 12 months
Comments:
                                                   Subject to a formal discipline investigation in past 12 months


                                                   Subject to a preliminary discipline investigation in past 12 months


                                                   High challenging behaviour residents


                                                   High support needs residents


                                                   Adverse event


                                                   Staff issues


                                                   Performance management issues in past 12 months


                                                   Complaints by residents


                                                   Grievances lodged within past 12 months


                                                   RCUBs lodged within past 12 months


                                                    Other, please specify e.g. no reported incidents or issues at the SSA,
                                                   reduction in resident behaviours without explanation etc




Internal Audit Requirements – NW – V2 - May 2009                                                                     Page 4 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                   SUMMARY OF OBSERVATIONS


Staff and Resident Details
                                                                        DDSO1
                                                                        DDSO1Q
                                                              Casual
                                                                        DDSO2
Core Roster Staff                                  Present    Ongoing            Residents                          Present
                                                                        DDSO2A
                                                              Fixed
                                                                        DDSO3
                                                              Term
                                                                        DDSO3A

Given Name:            Surname:                    Present:                      1. Given Name:   Surname:          Present:

Given Name:            Surname:                    Present:                      2. Given Name:   Surname:          Present:

Given Name:            Surname:                    Present:                      3. Given Name:   Surname:          Present:

Given Name:            Surname:                    Present:                      4. Given Name:   Surname:          Present:

Given Name:            Surname:                    Present:                      5. Given Name:   Surname:          Present:

Given Name:            Surname:                    Present:                      6. Given Name:   Surname:          Present:

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:

Non-Core Roster Staff

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:

Given Name:            Surname:                    Present:


Internal Audit Requirements – NW – V2 - May 2009                                                                    Page 5 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


Industry Standard 2: INDIVIDUAL NEEDS
Planning and support is tailored, flexible, responsive and appropriate to the individual.
To be completed for EACH RESIDENT (pages 6-11 are followed by 5 copies = 6 residents)

RESIDENT 1: Insert Name -
         Evidence Indicator                        Evidence Type                  Comments   Improvement Opportunities         Rating
         Outcome Measure
2.1      Resident Profile is current and            Process as per policy
         reviewed on an annual basis                Documentation
         and includes:
                                                    Staff Knowledge
          Current photo
                                                    Consumer Feedback
          Alerts
                                                    Observable
          Contacts
          Support requirements
2.1      Staff signatures appear on the             Process as per policy
         Resident Profile verifying they            Documentation
         have read and are familiar with
                                                    Staff Knowledge
         content
                                                    Consumer Feedback
          Includes rostered, contracts and
           regular casuals                          Observable

2.3      Resident Health and Wellbeing             Refer to Individual Resident
         needs are met.                            assessment template below

2.5      Resident Behaviour Support                Refer to Individual Resident
         needs are met.                            assessment template below

2.2      The resident is supported to               Process as per policy
2.4      communicate their needs in the             Documentation
         PCP planning process via
                                                    Staff Knowledge
          Communication tool
                                                    Consumer Feedback
          Case manager
                                                    Observable
          Family
          Advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                         Page 6 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


2.6      The SSA demonstrates the                   Process as per policy
2.7      following principles in practice:          Documentation
          Community Access                         Staff Knowledge
          Inclusion and Participation              Consumer Feedback
          Social Friendship Networks               Observable
          Promotes Physical Activity
2.6      The resident is supported to access        Process as per policy
         and participate in valued
                                                    Documentation
         community activities (of own
         choice)                                    Staff Knowledge
          Activity board                           Consumer Feedback
          Access record                            Observable
          Activity sampling record
          Possesses Companion Card

2.7      Person Centred Plan                        Process as per policy
2.9       The PCP identifies resident goals,       Documentation
           aspirations and cultural identity and
           defines how these are to be met;         Staff Knowledge
           goals, strategies and resources          Consumer Feedback
           required
                                                    Observable
          Where identified as a goal, residents
           participate in meaningful day
           programs, employment or
           volunteering activities
          The resident PCP is current and
           includes relevant parties as
           contributing to the plan.
          Includes family and advocates where
           applicable
          PCP is reviewed annually, as a
           minimum
         Date of last review:

2.7      The progress of PCP goals are              Process as per policy
2.8      reported on and updated each               Documentation
         month.
2.9                                                 Staff Knowledge
          Action plan completed
2.10                                                Consumer Feedback
          Key worker reports completed
                                                    Observable


Internal Audit Requirements – NW – V2 - May 2009                                             Page 7 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


RESIDENT 1: Health and Behaviour Assessment Template
2.3 Health and Wellbeing            Evidence Type       Comments   2.4 Behaviour and Support          Evidence Type        Comments


 A health plan is             Process as per policy               A Behaviour Support          Process as per policy
  documented on current        Documentation                        Plan is in place for each    Documentation
  2007 template and any                                              resident who is the
                               Staff Knowledge                                                   Staff Knowledge
  specific health                                                    subject of restrictive
  management strategies        Consumer Feedback                    interventions due to         Consumer Feedback
  are documented               Observable                           behaviours of concern        Observable
Plan has been reviewed:                                             Behaviour Support Plans
 3 monthly by staff                                                 have been signed off by
                                                                     Authorised Program
 6 monthly by GP
                                                                     Officer (APO)
 Yearly in consultation
                                                                    Data is entered on the
  with significant others
                                                                     Restrictive Intervention
  and health
                                                                     Database System (RIDS)
  professionals, as
                                                                     on a monthly basis
  appropriate
                                                                    As a minimum,
                                                                     Behaviour Support Plans
                                                                     are reviewed annually
 An annual health             Process as per policy               Behaviours of Concern        Process as per policy
  assessment (CHAP) is         Documentation                        correspond with those        Documentation
  completed and                                                      identified in Resident
                               Staff Knowledge                                                   Staff Knowledge
 There is documentation                                             Profile
                               Consumer Feedback                                                 Consumer Feedback
  of any follow up actions
  in health files.             Observable                                                        Observable




 An annual Health Review      Process as per policy               Proactive Strategies         Process as per policy
  (CHAP) has been              Documentation                        identified/included          Documentation
  completed by a GP
                               Staff Knowledge                                                   Staff Knowledge
 Where CHAP is not
                               Consumer Feedback                                                 Consumer Feedback
  evident, a Health Action
  Plan is developed for        Observable                                                        Observable
  each resident




Internal Audit Requirements – NW – V2 - May 2009                                                                              Page 8 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                     SUMMARY OF OBSERVATIONS


 Current client treatment     Process as per policy   Date of last Dr Review:    Restrictive Strategies      Process as per policy   RIDS Date:
  sheet and Doctors            Documentation                                       identified/included         Documentation
  Medication notes
                               Staff Knowledge                                                                 Staff Knowledge
 Dose recording sheets
                               Consumer Feedback                                                               Consumer Feedback
  correspond with client
  treatment                    Observable                                                                      Observable




An Annual Review has           Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
been completed, where          Documentation                                       include use of chemical     Documentation
applicable:                                                                         restraint
                               Staff Knowledge                                                                 Staff Knowledge
 Mental Health /
                               Consumer Feedback                                                               Consumer Feedback
  Psychiatric
                               Observable                                                                      Observable
 Psychologist




 An annual Nutrition and      Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  Swallowing Issues            Documentation                                       include use of              Documentation
  Checklist (NASIC) on                                                              mechanical restraint
                               Staff Knowledge                                                                 Staff Knowledge
  current 2007 format is
  completed and                Consumer Feedback                                                               Consumer Feedback
 Follow up actions            Observable                                                                      Observable
  documented




 The ‘weight monitor’ tool    Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  on desktop of house          Documentation                                       include use of seclusion    Documentation
  computer is used
                               Staff Knowledge                                                                 Staff Knowledge
  monthly
                               Consumer Feedback                                                               Consumer Feedback
                               Observable                                                                      Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                                      Page 9 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                             SUMMARY OF OBSERVATIONS


 Instructions for              Process as per policy    Behaviour Support Plan       Process as per policy     Case Manager
  supporting people who         Documentation             developed in                 Documentation           Date:
  need assistance with                                     consultation with
                                Staff Knowledge                                        Staff Knowledge           BIST.
  meals are clearly                                        relevant / other
  documented                    Consumer Feedback         professional                 Consumer Feedback       Date:
                                Observable                                             Observable                Speech Pathologist.
                                                                                                                 Date:
                                                                                                                   Psychiatrist.
                                                                                                                 Date:
                                                                                                                   GP.
                                                                                                                 Date:
                                                                                                                   Family Member.
                                                                                                                 Date:
                                                                                                                   Other:
                                                                                                                 Date:
(if appropriate)                Process as per policy    Staff are trained and        Process as per policy
 Instructions for              Documentation             inducted in identifying      Documentation
  supporting people who                                    the least restrictive and
                                Staff Knowledge                                        Staff Knowledge
  need assistance with                                     least intrusive support
                                Consumer Feedback                                      Consumer Feedback
  continence issues are
  clearly documented            Observable                                             Observable




 Clear instructions are        Process as per policy    Staff are competent in       Process as per policy
  available for all specific    Documentation             the application of the       Documentation
  health procedures                                        strategies identified in
                                Staff Knowledge                                        Staff Knowledge
 Staff have received                                      the support plan
                                Consumer Feedback                                      Consumer Feedback
  training specific to
  procedure for that            Observable                                             Observable
  resident




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 10 of 64
   North and West Metropolitan Region
   Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


  (if appropriate)                Process as per policy    Staff regularly report on    Process as per policy
   A health plan is              Documentation             the application of the       Documentation
    documented                                               strategies and areas for
                                  Staff Knowledge                                        Staff Knowledge
                                                             review and improvement
   Seizure observation           Consumer Feedback                                      Consumer Feedback
    charts and records are
                                  Observable                                             Observable
    maintained
   Resident profile has
    relevant alerts
(if appropriate)                  Process as per policy
    Instructions for             Documentation
     supporting people who        Staff Knowledge
     need assistance with
                                  Consumer Feedback
     pressure sores are
     clearly documented           Observable

  Hospital admission            Process as per policy   OTHER:                         Process as per policy
    forms (profile and            Documentation                                          Documentation
    contacts) are kept up to
                                  Staff Knowledge                                        Staff Knowledge
    date
                                  Consumer Feedback                                      Consumer Feedback
   With consent form for
    medical / dental              Observable                                             Observable
    procedures


  Detail Health                 List                       Detail Behaviours of          List
  Conditions:                                              Concern:




   Internal Audit Requirements – NW – V2 - May 2009                                                                Page 11 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS




RESIDENT 2: Insert Name -
         Evidence Indicator                        Evidence Type                  Comments   Improvement Opportunities         Rating
         Outcome Measure
2.1      Resident Profile is current and            Process as per policy
         reviewed on an annual basis                Documentation
         and includes:
                                                    Staff Knowledge
          Current photo
                                                    Consumer Feedback
          Alerts
                                                    Observable
          Contacts
          Support requirements


2.2      Staff signatures appear on the             Process as per policy
         Resident Profile verifying they            Documentation
         have read and are familiar with
                                                    Staff Knowledge
         content
                                                    Consumer Feedback
          Includes rostered, contracts and
         regular casuals                            Observable


2.3      Resident Health and Wellbeing             Refer to Individual Resident
         needs are met.                            assessment template below

2.5      Resident Behaviour Support                Refer to Individual Resident
         needs are met.                            assessment template below

2.4      The resident is supported to               Process as per policy
         communicate their needs in the             Documentation
         PCP planning process via
                                                    Staff Knowledge
          Communication tool
                                                    Consumer Feedback
          Case manager
                                                    Observable
          Family
          Advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                         Page 12 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


2.6      The SSA demonstrates the                   Process as per policy
2.7      following principles in practice:          Documentation
          Community Access                         Staff Knowledge
          Inclusion and Participation              Consumer Feedback
          Social Friendship Networks               Observable
          Promotes Physical Activity
2.6      The resident is supported to               Process as per policy
         access and participate in                  Documentation
         valued community activities (of
                                                    Staff Knowledge
         own choice)
                                                    Consumer Feedback
          Activity board
                                                    Observable
          Access record
          Activity sampling record
          Possesses Companion Card
2.7      Person Centred Plan                        Process as per policy
          The PCP identifies resident goals,       Documentation
           aspirations and cultural identity and
           defines how these are to be met;         Staff Knowledge
           goals, strategies and resources          Consumer Feedback
           required
                                                    Observable
          Where identified as a goal, residents
           participate in meaningful day
           programs, employment or
           volunteering activities
          The resident PCP is current and
           includes relevant parties as
           contributing to the plan.
          Includes family and advocates where
           applicable
         Date of review: insert

2.7      The progress of PCP goals are              Process as per policy
2.8      reported on and updated each               Documentation
         month.
2.9                                                 Staff Knowledge
          Action plan completed
2.10                                                Consumer Feedback
          Key worker reports completed
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                             Page 13 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


RESIDENT 2: Health and Behaviour Assessment Template
2.3 Health and Wellbeing            Evidence Type       Comments   2.4 Behaviour and Support          Evidence Type        Comments


 A health plan is             Process as per policy               A Behaviour Support          Process as per policy
  documented on current        Documentation                        Plan is in place for each    Documentation
  2007 template and any                                              resident who is the
                               Staff Knowledge                                                   Staff Knowledge
  specific health                                                    subject of restrictive
  management strategies        Consumer Feedback                    interventions due to         Consumer Feedback
  are documented               Observable                           behaviours of concern        Observable
Plan has been reviewed:                                             Behaviour Support Plans
 3 monthly by staff                                                 have been signed off by
                                                                     Authorised Program
 6 monthly by GP
                                                                     Officer (APO)
 Yearly in consultation
                                                                    Data is entered on the
  with significant others
                                                                     Restrictive Intervention
  and health
                                                                     Database System (RIDS)
  professionals, as
                                                                     on a monthly basis
  appropriate
                                                                    As a minimum,
                                                                     Behaviour Support Plans
                                                                     are reviewed annually
 An annual health             Process as per policy               Behaviours of Concern        Process as per policy
  assessment (CHAP) is         Documentation                        correspond with those        Documentation
  completed and                                                      identified in Resident
                               Staff Knowledge                                                   Staff Knowledge
 There is documentation                                             Profile
                               Consumer Feedback                                                 Consumer Feedback
  of any follow up actions
  in health files.             Observable                                                        Observable




 An annual Health Review      Process as per policy               Proactive Strategies         Process as per policy
  (CHAP) has been              Documentation                        identified/included          Documentation
  completed by a GP
                               Staff Knowledge                                                   Staff Knowledge
 Where CHAP is not
                               Consumer Feedback                                                 Consumer Feedback
  evident, a Health Action
  Plan is developed for        Observable                                                        Observable
  each resident




Internal Audit Requirements – NW – V2 - May 2009                                                                              Page 14 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                     SUMMARY OF OBSERVATIONS


 Current client treatment     Process as per policy   Date of last Dr Review:    Restrictive Strategies      Process as per policy   RIDS Date:
  sheet and Doctors            Documentation                                       identified/included         Documentation
  Medication notes
                               Staff Knowledge                                                                 Staff Knowledge
 Dose recording sheets
                               Consumer Feedback                                                               Consumer Feedback
  correspond with client
  treatment                    Observable                                                                      Observable




An Annual Review has           Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
been completed, where          Documentation                                       include use of chemical     Documentation
applicable:                                                                         restraint
                               Staff Knowledge                                                                 Staff Knowledge
 Mental Health /
                               Consumer Feedback                                                               Consumer Feedback
  Psychiatric
                               Observable                                                                      Observable
 Psychologist




 An annual Nutrition and      Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  Swallowing Issues            Documentation                                       include use of              Documentation
  Checklist (NASIC) on                                                              mechanical restraint
                               Staff Knowledge                                                                 Staff Knowledge
  current 2007 format is
  completed and                Consumer Feedback                                                               Consumer Feedback
 Follow up actions            Observable                                                                      Observable
  documented




 The ‘weight monitor’ tool    Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  on desktop of house          Documentation                                       include use of seclusion    Documentation
  computer is used
                               Staff Knowledge                                                                 Staff Knowledge
  monthly
                               Consumer Feedback                                                               Consumer Feedback
                               Observable                                                                      Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                                      Page 15 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                             SUMMARY OF OBSERVATIONS


 Instructions for              Process as per policy    Behaviour Support Plan       Process as per policy     Case Manager
  supporting people who         Documentation             developed in                 Documentation           Date:
  need assistance with                                     consultation with
                                Staff Knowledge                                        Staff Knowledge           BIST.
  meals are clearly                                        relevant / other
  documented                    Consumer Feedback         professional                 Consumer Feedback       Date:
                                Observable                                             Observable                Speech Pathologist.
                                                                                                                 Date:
                                                                                                                   Psychiatrist.
                                                                                                                 Date:
                                                                                                                   GP.
                                                                                                                 Date:
                                                                                                                   Family Member.
                                                                                                                 Date:
                                                                                                                   Other:
                                                                                                                 Date:
(if appropriate)                Process as per policy    Staff are trained and        Process as per policy
 Instructions for              Documentation             inducted in identifying      Documentation
  supporting people who                                    the least restrictive and
                                Staff Knowledge                                        Staff Knowledge
  need assistance with                                     least intrusive support
                                Consumer Feedback                                      Consumer Feedback
  continence issues are
  clearly documented            Observable                                             Observable




 Clear instructions are        Process as per policy    Staff are competent in       Process as per policy
  available for all specific    Documentation             the application of the       Documentation
  health procedures                                        strategies identified in
                                Staff Knowledge                                        Staff Knowledge
 Staff have received                                      the support plan
                                Consumer Feedback                                      Consumer Feedback
  training specific to
  procedure for that            Observable                                             Observable
  resident




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 16 of 64
   North and West Metropolitan Region
   Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


  (if appropriate)                Process as per policy    Staff regularly report on    Process as per policy
   A health plan is              Documentation             the application of the       Documentation
    documented                                               strategies and areas for
                                  Staff Knowledge                                        Staff Knowledge
                                                             review and improvement
   Seizure observation           Consumer Feedback                                      Consumer Feedback
    charts and records are
                                  Observable                                             Observable
    maintained
   Resident profile has
    relevant alerts
(if appropriate)                  Process as per policy
    Instructions for             Documentation
     supporting people who        Staff Knowledge
     need assistance with
                                  Consumer Feedback
     pressure sores are
     clearly documented           Observable

  Hospital admission            Process as per policy   OTHER:                         Process as per policy
    forms (profile and            Documentation                                          Documentation
    contacts) are kept up to
                                  Staff Knowledge                                        Staff Knowledge
    date
                                  Consumer Feedback                                      Consumer Feedback
   With consent form for
    medical / dental              Observable                                             Observable
    procedures


  Detail Health                 List                       Detail Behaviours of          List
  Conditions:                                              Concern:




   Internal Audit Requirements – NW – V2 - May 2009                                                                Page 17 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


RESIDENT 3: Insert Name -
         Evidence Indicator                        Evidence Type                  Comments   Improvement Opportunities         Rating
         Outcome Measure
2.1      Resident Profile is current and            Process as per policy
         reviewed on an annual basis                Documentation
         and includes:
                                                    Staff Knowledge
          Current photo
                                                    Consumer Feedback
          Alerts
                                                    Observable
          Contacts
          Support requirements


2.2      Staff signatures appear on the             Process as per policy
         Resident Profile verifying they            Documentation
         have read and are familiar with
                                                    Staff Knowledge
         content
                                                    Consumer Feedback
          Includes rostered, contracts and
         regular casuals                            Observable


2.3      Resident Health and Wellbeing             Refer to Individual Resident
         needs are met.                            assessment template below

2.5      Resident Behaviour Support                Refer to Individual Resident
         needs are met.                            assessment template below

2.4      The resident is supported to               Process as per policy
         communicate their needs in the             Documentation
         PCP planning process via
                                                    Staff Knowledge
          Communication tool
                                                    Consumer Feedback
          Case manager
                                                    Observable
          Family
          Advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                         Page 18 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


2.6      The SSA demonstrates the                   Process as per policy
2.7      following principles in practice:          Documentation
          Community Access                         Staff Knowledge
          Inclusion and Participation              Consumer Feedback
          Social Friendship Networks               Observable
          Promotes Physical Activity
2.6      The resident is supported to               Process as per policy
         access and participate in                  Documentation
         valued community activities (of
                                                    Staff Knowledge
         own choice)
                                                    Consumer Feedback
          Activity board
                                                    Observable
          Access record
          Activity sampling record
          Possesses Companion Card
2.7      Person Centred Plan                        Process as per policy
          The PCP identifies resident goals,       Documentation
           aspirations and cultural identity and
           defines how these are to be met;         Staff Knowledge
           goals, strategies and resources          Consumer Feedback
           required
                                                    Observable
          Where identified as a goal, residents
           participate in meaningful day
           programs, employment or
           volunteering activities
          The resident PCP is current and
           includes relevant parties as
           contributing to the plan.
          Includes family and advocates where
           applicable
         Date of review: insert

2.7      The progress of PCP goals are              Process as per policy
2.8      reported on and updated each               Documentation
         month.
2.9                                                 Staff Knowledge
          Action plan completed
2.10                                                Consumer Feedback
          Key worker reports completed
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                             Page 19 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


RESIDENT 3: Health and Behaviour Assessment Template
2.3 Health and Wellbeing            Evidence Type       Comments   2.4 Behaviour and Support          Evidence Type        Comments


 A health plan is             Process as per policy               A Behaviour Support          Process as per policy
  documented on current        Documentation                        Plan is in place for each    Documentation
  2007 template and any                                              resident who is the
                               Staff Knowledge                                                   Staff Knowledge
  specific health                                                    subject of restrictive
  management strategies        Consumer Feedback                    interventions due to         Consumer Feedback
  are documented               Observable                           behaviours of concern        Observable
Plan has been reviewed:                                             Behaviour Support Plans
 3 monthly by staff                                                 have been signed off by
                                                                     Authorised Program
 6 monthly by GP
                                                                     Officer (APO)
 Yearly in consultation
                                                                    Data is entered on the
  with significant others
                                                                     Restrictive Intervention
  and health
                                                                     Database System (RIDS)
  professionals, as
                                                                     on a monthly basis
  appropriate
                                                                    As a minimum,
                                                                     Behaviour Support Plans
                                                                     are reviewed annually
 An annual health             Process as per policy               Behaviours of Concern        Process as per policy
  assessment (CHAP) is         Documentation                        correspond with those        Documentation
  completed and                                                      identified in Resident
                               Staff Knowledge                                                   Staff Knowledge
 There is documentation                                             Profile
                               Consumer Feedback                                                 Consumer Feedback
  of any follow up actions
  in health files.             Observable                                                        Observable




 An annual Health Review      Process as per policy               Proactive Strategies         Process as per policy
  (CHAP) has been              Documentation                        identified/included          Documentation
  completed by a GP
                               Staff Knowledge                                                   Staff Knowledge
 Where CHAP is not
                               Consumer Feedback                                                 Consumer Feedback
  evident, a Health Action
  Plan is developed for        Observable                                                        Observable
  each resident




Internal Audit Requirements – NW – V2 - May 2009                                                                              Page 20 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                     SUMMARY OF OBSERVATIONS


 Current client treatment     Process as per policy   Date of last Dr Review:    Restrictive Strategies      Process as per policy   RIDS Date:
  sheet and Doctors            Documentation                                       identified/included         Documentation
  Medication notes
                               Staff Knowledge                                                                 Staff Knowledge
 Dose recording sheets
                               Consumer Feedback                                                               Consumer Feedback
  correspond with client
  treatment                    Observable                                                                      Observable




An Annual Review has           Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
been completed, where          Documentation                                       include use of chemical     Documentation
applicable:                                                                         restraint
                               Staff Knowledge                                                                 Staff Knowledge
 Mental Health /
                               Consumer Feedback                                                               Consumer Feedback
  Psychiatric
                               Observable                                                                      Observable
 Psychologist




 An annual Nutrition and      Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  Swallowing Issues            Documentation                                       include use of              Documentation
  Checklist (NASIC) on                                                              mechanical restraint
                               Staff Knowledge                                                                 Staff Knowledge
  current 2007 format is
  completed and                Consumer Feedback                                                               Consumer Feedback
 Follow up actions            Observable                                                                      Observable
  documented




 The ‘weight monitor’ tool    Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  on desktop of house          Documentation                                       include use of seclusion    Documentation
  computer is used
                               Staff Knowledge                                                                 Staff Knowledge
  monthly
                               Consumer Feedback                                                               Consumer Feedback
                               Observable                                                                      Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                                      Page 21 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                             SUMMARY OF OBSERVATIONS


 Instructions for              Process as per policy    Behaviour Support Plan       Process as per policy     Case Manager
  supporting people who         Documentation             developed in                 Documentation           Date:
  need assistance with                                     consultation with
                                Staff Knowledge                                        Staff Knowledge           BIST.
  meals are clearly                                        relevant / other
  documented                    Consumer Feedback         professional                 Consumer Feedback       Date:
                                Observable                                             Observable                Speech Pathologist.
                                                                                                                 Date:
                                                                                                                   Psychiatrist.
                                                                                                                 Date:
                                                                                                                   GP.
                                                                                                                 Date:
                                                                                                                   Family Member.
                                                                                                                 Date:
                                                                                                                   Other:
                                                                                                                 Date:
(if appropriate)                Process as per policy    Staff are trained and        Process as per policy
 Instructions for              Documentation             inducted in identifying      Documentation
  supporting people who                                    the least restrictive and
                                Staff Knowledge                                        Staff Knowledge
  need assistance with                                     least intrusive support
                                Consumer Feedback                                      Consumer Feedback
  continence issues are
  clearly documented            Observable                                             Observable




 Clear instructions are        Process as per policy    Staff are competent in       Process as per policy
  available for all specific    Documentation             the application of the       Documentation
  health procedures                                        strategies identified in
                                Staff Knowledge                                        Staff Knowledge
 Staff have received                                      the support plan
                                Consumer Feedback                                      Consumer Feedback
  training specific to
  procedure for that            Observable                                             Observable
  resident




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 22 of 64
   North and West Metropolitan Region
   Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


  (if appropriate)                Process as per policy    Staff regularly report on    Process as per policy
   A health plan is              Documentation             the application of the       Documentation
    documented                                               strategies and areas for
                                  Staff Knowledge                                        Staff Knowledge
                                                             review and improvement
   Seizure observation           Consumer Feedback                                      Consumer Feedback
    charts and records are
                                  Observable                                             Observable
    maintained
   Resident profile has
    relevant alerts
(if appropriate)                  Process as per policy
    Instructions for             Documentation
     supporting people who        Staff Knowledge
     need assistance with
                                  Consumer Feedback
     pressure sores are
     clearly documented           Observable

  Hospital admission            Process as per policy   OTHER:                         Process as per policy
    forms (profile and            Documentation                                          Documentation
    contacts) are kept up to
                                  Staff Knowledge                                        Staff Knowledge
    date
                                  Consumer Feedback                                      Consumer Feedback
   With consent form for
    medical / dental              Observable                                             Observable
    procedures


  Detail Health                 List                       Detail Behaviours of          List
  Conditions:                                              Concern:




   Internal Audit Requirements – NW – V2 - May 2009                                                                Page 23 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


RESIDENT 4: Insert Name -
         Evidence Indicator                        Evidence Type                  Comments   Improvement Opportunities         Rating
         Outcome Measure
2.1      Resident Profile is current and            Process as per policy
         reviewed on an annual basis                Documentation
         and includes:
                                                    Staff Knowledge
          Current photo
                                                    Consumer Feedback
          Alerts
                                                    Observable
          Contacts
          Support requirements


2.2      Staff signatures appear on the             Process as per policy
         Resident Profile verifying they            Documentation
         have read and are familiar with
                                                    Staff Knowledge
         content
                                                    Consumer Feedback
          Includes rostered, contracts and
         regular casuals                            Observable


2.3      Resident Health and Wellbeing             Refer to Individual Resident
         needs are met.                            assessment template below

2.5      Resident Behaviour Support                Refer to Individual Resident
         needs are met.                            assessment template below

2.4      The resident is supported to               Process as per policy
         communicate their needs in the             Documentation
         PCP planning process via
                                                    Staff Knowledge
          Communication tool
                                                    Consumer Feedback
          Case manager
                                                    Observable
          Family
          Advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                         Page 24 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


2.6      The SSA demonstrates the                   Process as per policy
2.7      following principles in practice:          Documentation
          Community Access                         Staff Knowledge
          Inclusion and Participation              Consumer Feedback
          Social Friendship Networks               Observable
          Promotes Physical Activity
2.6      The resident is supported to               Process as per policy
         access and participate in                  Documentation
         valued community activities (of
                                                    Staff Knowledge
         own choice)
                                                    Consumer Feedback
          Activity board
                                                    Observable
          Access record
          Activity sampling record
          Possesses Companion Card
2.7      Person Centred Plan                        Process as per policy
          The PCP identifies resident goals,       Documentation
           aspirations and cultural identity and
           defines how these are to be met;         Staff Knowledge
           goals, strategies and resources          Consumer Feedback
           required
                                                    Observable
          Where identified as a goal, residents
           participate in meaningful day
           programs, employment or
           volunteering activities
          The resident PCP is current and
           includes relevant parties as
           contributing to the plan.
          Includes family and advocates where
           applicable
         Date of review: insert

2.7      The progress of PCP goals are              Process as per policy
2.8      reported on and updated each               Documentation
         month.
2.9                                                 Staff Knowledge
          Action plan completed
2.10                                                Consumer Feedback
          Key worker reports completed
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                             Page 25 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


RESIDENT 4: Health and Behaviour Assessment Template
2.3 Health and Wellbeing            Evidence Type       Comments   2.4 Behaviour and Support          Evidence Type        Comments


 A health plan is             Process as per policy               A Behaviour Support          Process as per policy
  documented on current        Documentation                        Plan is in place for each    Documentation
  2007 template and any                                              resident who is the
                               Staff Knowledge                                                   Staff Knowledge
  specific health                                                    subject of restrictive
  management strategies        Consumer Feedback                    interventions due to         Consumer Feedback
  are documented               Observable                           behaviours of concern        Observable
Plan has been reviewed:                                             Behaviour Support Plans
 3 monthly by staff                                                 have been signed off by
                                                                     Authorised Program
 6 monthly by GP
                                                                     Officer (APO)
 Yearly in consultation
                                                                    Data is entered on the
  with significant others
                                                                     Restrictive Intervention
  and health
                                                                     Database System (RIDS)
  professionals, as
                                                                     on a monthly basis
  appropriate
                                                                    As a minimum,
                                                                     Behaviour Support Plans
                                                                     are reviewed annually
 An annual health             Process as per policy               Behaviours of Concern        Process as per policy
  assessment (CHAP) is         Documentation                        correspond with those        Documentation
  completed and                                                      identified in Resident
                               Staff Knowledge                                                   Staff Knowledge
 There is documentation                                             Profile
                               Consumer Feedback                                                 Consumer Feedback
  of any follow up actions
  in health files.             Observable                                                        Observable




 An annual Health Review      Process as per policy               Proactive Strategies         Process as per policy
  (CHAP) has been              Documentation                        identified/included          Documentation
  completed by a GP
                               Staff Knowledge                                                   Staff Knowledge
 Where CHAP is not
                               Consumer Feedback                                                 Consumer Feedback
  evident, a Health Action
  Plan is developed for        Observable                                                        Observable
  each resident




Internal Audit Requirements – NW – V2 - May 2009                                                                              Page 26 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                     SUMMARY OF OBSERVATIONS


 Current client treatment     Process as per policy   Date of last Dr Review:    Restrictive Strategies      Process as per policy   RIDS Date:
  sheet and Doctors            Documentation                                       identified/included         Documentation
  Medication notes
                               Staff Knowledge                                                                 Staff Knowledge
 Dose recording sheets
                               Consumer Feedback                                                               Consumer Feedback
  correspond with client
  treatment                    Observable                                                                      Observable




An Annual Review has           Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
been completed, where          Documentation                                       include use of chemical     Documentation
applicable:                                                                         restraint
                               Staff Knowledge                                                                 Staff Knowledge
 Mental Health /
                               Consumer Feedback                                                               Consumer Feedback
  Psychiatric
                               Observable                                                                      Observable
 Psychologist




 An annual Nutrition and      Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  Swallowing Issues            Documentation                                       include use of              Documentation
  Checklist (NASIC) on                                                              mechanical restraint
                               Staff Knowledge                                                                 Staff Knowledge
  current 2007 format is
  completed and                Consumer Feedback                                                               Consumer Feedback
 Follow up actions            Observable                                                                      Observable
  documented




 The ‘weight monitor’ tool    Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  on desktop of house          Documentation                                       include use of seclusion    Documentation
  computer is used
                               Staff Knowledge                                                                 Staff Knowledge
  monthly
                               Consumer Feedback                                                               Consumer Feedback
                               Observable                                                                      Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                                      Page 27 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                             SUMMARY OF OBSERVATIONS


 Instructions for              Process as per policy    Behaviour Support Plan       Process as per policy     Case Manager
  supporting people who         Documentation             developed in                 Documentation           Date:
  need assistance with                                     consultation with
                                Staff Knowledge                                        Staff Knowledge           BIST.
  meals are clearly                                        relevant / other
  documented                    Consumer Feedback         professional                 Consumer Feedback       Date:
                                Observable                                             Observable                Speech Pathologist.
                                                                                                                 Date:
                                                                                                                   Psychiatrist.
                                                                                                                 Date:
                                                                                                                   GP.
                                                                                                                 Date:
                                                                                                                   Family Member.
                                                                                                                 Date:
                                                                                                                   Other:
                                                                                                                 Date:
(if appropriate)                Process as per policy    Staff are trained and        Process as per policy
 Instructions for              Documentation             inducted in identifying      Documentation
  supporting people who                                    the least restrictive and
                                Staff Knowledge                                        Staff Knowledge
  need assistance with                                     least intrusive support
                                Consumer Feedback                                      Consumer Feedback
  continence issues are
  clearly documented            Observable                                             Observable




 Clear instructions are        Process as per policy    Staff are competent in       Process as per policy
  available for all specific    Documentation             the application of the       Documentation
  health procedures                                        strategies identified in
                                Staff Knowledge                                        Staff Knowledge
 Staff have received                                      the support plan
                                Consumer Feedback                                      Consumer Feedback
  training specific to
  procedure for that            Observable                                             Observable
  resident




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 28 of 64
   North and West Metropolitan Region
   Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


  (if appropriate)                Process as per policy    Staff regularly report on    Process as per policy
   A health plan is              Documentation             the application of the       Documentation
    documented                                               strategies and areas for
                                  Staff Knowledge                                        Staff Knowledge
                                                             review and improvement
   Seizure observation           Consumer Feedback                                      Consumer Feedback
    charts and records are
                                  Observable                                             Observable
    maintained
   Resident profile has
    relevant alerts
(if appropriate)                  Process as per policy
    Instructions for             Documentation
     supporting people who        Staff Knowledge
     need assistance with
                                  Consumer Feedback
     pressure sores are
     clearly documented           Observable

  Hospital admission            Process as per policy   OTHER:                         Process as per policy
    forms (profile and            Documentation                                          Documentation
    contacts) are kept up to
                                  Staff Knowledge                                        Staff Knowledge
    date
                                  Consumer Feedback                                      Consumer Feedback
   With consent form for
    medical / dental              Observable                                             Observable
    procedures


  Detail Health                 List                       Detail Behaviours of          List
  Conditions:                                              Concern:




   Internal Audit Requirements – NW – V2 - May 2009                                                                Page 29 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


RESIDENT 5: Insert Name -
         Evidence Indicator                        Evidence Type                  Comments   Improvement Opportunities         Rating
         Outcome Measure
2.1      Resident Profile is current and            Process as per policy
         reviewed on an annual basis                Documentation
         and includes:
                                                    Staff Knowledge
          Current photo
                                                    Consumer Feedback
          Alerts
                                                    Observable
          Contacts
          Support requirements


2.2      Staff signatures appear on the             Process as per policy
         Resident Profile verifying they            Documentation
         have read and are familiar with
                                                    Staff Knowledge
         content
                                                    Consumer Feedback
          Includes rostered, contracts and
         regular casuals                            Observable


2.3      Resident Health and Wellbeing             Refer to Individual Resident
         needs are met.                            assessment template below

2.5      Resident Behaviour Support                Refer to Individual Resident
         needs are met.                            assessment template below

2.4      The resident is supported to               Process as per policy
         communicate their needs in the             Documentation
         PCP planning process via
                                                    Staff Knowledge
          Communication tool
                                                    Consumer Feedback
          Case manager
                                                    Observable
          Family
          Advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                         Page 30 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


2.6      The SSA demonstrates the                   Process as per policy
2.7      following principles in practice:          Documentation
          Community Access                         Staff Knowledge
          Inclusion and Participation              Consumer Feedback
          Social Friendship Networks               Observable
          Promotes Physical Activity
2.6      The resident is supported to               Process as per policy
         access and participate in                  Documentation
         valued community activities (of
                                                    Staff Knowledge
         own choice)
                                                    Consumer Feedback
          Activity board
                                                    Observable
          Access record
          Activity sampling record
          Possesses Companion Card
2.7      Person Centred Plan                        Process as per policy
          The PCP identifies resident goals,       Documentation
           aspirations and cultural identity and
           defines how these are to be met;         Staff Knowledge
           goals, strategies and resources          Consumer Feedback
           required
                                                    Observable
          Where identified as a goal, residents
           participate in meaningful day
           programs, employment or
           volunteering activities
          The resident PCP is current and
           includes relevant parties as
           contributing to the plan.
          Includes family and advocates where
           applicable
         Date of review: insert

2.7      The progress of PCP goals are              Process as per policy
2.8      reported on and updated each               Documentation
         month.
2.9                                                 Staff Knowledge
          Action plan completed
2.10                                                Consumer Feedback
          Key worker reports completed
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                             Page 31 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


RESIDENT 5: Health and Behaviour Assessment Template
2.3 Health and Wellbeing            Evidence Type       Comments   2.4 Behaviour and Support          Evidence Type        Comments


 A health plan is             Process as per policy               A Behaviour Support          Process as per policy
  documented on current        Documentation                        Plan is in place for each    Documentation
  2007 template and any                                              resident who is the
                               Staff Knowledge                                                   Staff Knowledge
  specific health                                                    subject of restrictive
  management strategies        Consumer Feedback                    interventions due to         Consumer Feedback
  are documented               Observable                           behaviours of concern        Observable
Plan has been reviewed:                                             Behaviour Support Plans
 3 monthly by staff                                                 have been signed off by
                                                                     Authorised Program
 6 monthly by GP
                                                                     Officer (APO)
 Yearly in consultation
                                                                    Data is entered on the
  with significant others
                                                                     Restrictive Intervention
  and health
                                                                     Database System (RIDS)
  professionals, as
                                                                     on a monthly basis
  appropriate
                                                                    As a minimum,
                                                                     Behaviour Support Plans
                                                                     are reviewed annually
 An annual health             Process as per policy               Behaviours of Concern        Process as per policy
  assessment (CHAP) is         Documentation                        correspond with those        Documentation
  completed and                                                      identified in Resident
                               Staff Knowledge                                                   Staff Knowledge
 There is documentation                                             Profile
                               Consumer Feedback                                                 Consumer Feedback
  of any follow up actions
  in health files.             Observable                                                        Observable




 An annual Health Review      Process as per policy               Proactive Strategies         Process as per policy
  (CHAP) has been              Documentation                        identified/included          Documentation
  completed by a GP
                               Staff Knowledge                                                   Staff Knowledge
 Where CHAP is not
                               Consumer Feedback                                                 Consumer Feedback
  evident, a Health Action
  Plan is developed for        Observable                                                        Observable
  each resident




Internal Audit Requirements – NW – V2 - May 2009                                                                              Page 32 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                     SUMMARY OF OBSERVATIONS


 Current client treatment     Process as per policy   Date of last Dr Review:    Restrictive Strategies      Process as per policy   RIDS Date:
  sheet and Doctors            Documentation                                       identified/included         Documentation
  Medication notes
                               Staff Knowledge                                                                 Staff Knowledge
 Dose recording sheets
                               Consumer Feedback                                                               Consumer Feedback
  correspond with client
  treatment                    Observable                                                                      Observable




An Annual Review has           Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
been completed, where          Documentation                                       include use of chemical     Documentation
applicable:                                                                         restraint
                               Staff Knowledge                                                                 Staff Knowledge
 Mental Health /
                               Consumer Feedback                                                               Consumer Feedback
  Psychiatric
                               Observable                                                                      Observable
 Psychologist




 An annual Nutrition and      Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  Swallowing Issues            Documentation                                       include use of              Documentation
  Checklist (NASIC) on                                                              mechanical restraint
                               Staff Knowledge                                                                 Staff Knowledge
  current 2007 format is
  completed and                Consumer Feedback                                                               Consumer Feedback
 Follow up actions            Observable                                                                      Observable
  documented




 The ‘weight monitor’ tool    Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  on desktop of house          Documentation                                       include use of seclusion    Documentation
  computer is used
                               Staff Knowledge                                                                 Staff Knowledge
  monthly
                               Consumer Feedback                                                               Consumer Feedback
                               Observable                                                                      Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                                      Page 33 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                             SUMMARY OF OBSERVATIONS


 Instructions for              Process as per policy    Behaviour Support Plan       Process as per policy     Case Manager
  supporting people who         Documentation             developed in                 Documentation           Date:
  need assistance with                                     consultation with
                                Staff Knowledge                                        Staff Knowledge           BIST.
  meals are clearly                                        relevant / other
  documented                    Consumer Feedback         professional                 Consumer Feedback       Date:
                                Observable                                             Observable                Speech Pathologist.
                                                                                                                 Date:
                                                                                                                   Psychiatrist.
                                                                                                                 Date:
                                                                                                                   GP.
                                                                                                                 Date:
                                                                                                                   Family Member.
                                                                                                                 Date:
                                                                                                                   Other:
                                                                                                                 Date:
(if appropriate)                Process as per policy    Staff are trained and        Process as per policy
 Instructions for              Documentation             inducted in identifying      Documentation
  supporting people who                                    the least restrictive and
                                Staff Knowledge                                        Staff Knowledge
  need assistance with                                     least intrusive support
                                Consumer Feedback                                      Consumer Feedback
  continence issues are
  clearly documented            Observable                                             Observable




 Clear instructions are        Process as per policy    Staff are competent in       Process as per policy
  available for all specific    Documentation             the application of the       Documentation
  health procedures                                        strategies identified in
                                Staff Knowledge                                        Staff Knowledge
 Staff have received                                      the support plan
                                Consumer Feedback                                      Consumer Feedback
  training specific to
  procedure for that            Observable                                             Observable
  resident




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 34 of 64
   North and West Metropolitan Region
   Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


  (if appropriate)                Process as per policy    Staff regularly report on    Process as per policy
   A health plan is              Documentation             the application of the       Documentation
    documented                                               strategies and areas for
                                  Staff Knowledge                                        Staff Knowledge
                                                             review and improvement
   Seizure observation           Consumer Feedback                                      Consumer Feedback
    charts and records are
                                  Observable                                             Observable
    maintained
   Resident profile has
    relevant alerts
(if appropriate)                  Process as per policy
    Instructions for             Documentation
     supporting people who        Staff Knowledge
     need assistance with
                                  Consumer Feedback
     pressure sores are
     clearly documented           Observable

  Hospital admission            Process as per policy   OTHER:                         Process as per policy
    forms (profile and            Documentation                                          Documentation
    contacts) are kept up to
                                  Staff Knowledge                                        Staff Knowledge
    date
                                  Consumer Feedback                                      Consumer Feedback
   With consent form for
    medical / dental              Observable                                             Observable
    procedures


  Detail Health                 List                       Detail Behaviours of          List
  Conditions:                                              Concern:




   Internal Audit Requirements – NW – V2 - May 2009                                                                Page 35 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


RESIDENT 6: Insert Name -
         Evidence Indicator                        Evidence Type                  Comments   Improvement Opportunities         Rating
         Outcome Measure
2.1      Resident Profile is current and            Process as per policy
         reviewed on an annual basis                Documentation
         and includes:
                                                    Staff Knowledge
          Current photo
                                                    Consumer Feedback
          Alerts
                                                    Observable
          Contacts
          Support requirements


2.2      Staff signatures appear on the             Process as per policy
         Resident Profile verifying they            Documentation
         have read and are familiar with
                                                    Staff Knowledge
         content
                                                    Consumer Feedback
          Includes rostered, contracts and
         regular casuals                            Observable


2.3      Resident Health and Wellbeing             Refer to Individual Resident
         needs are met.                            assessment template below

2.5      Resident Behaviour Support                Refer to Individual Resident
         needs are met.                            assessment template below

2.4      The resident is supported to               Process as per policy
         communicate their needs in the             Documentation
         PCP planning process via
                                                    Staff Knowledge
          Communication tool
                                                    Consumer Feedback
          Case manager
                                                    Observable
          Family
          Advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                         Page 36 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


2.6      The SSA demonstrates the                   Process as per policy
2.7      following principles in practice:          Documentation
          Community Access                         Staff Knowledge
          Inclusion and Participation              Consumer Feedback
          Social Friendship Networks               Observable
          Promotes Physical Activity
2.6      The resident is supported to               Process as per policy
         access and participate in                  Documentation
         valued community activities (of
                                                    Staff Knowledge
         own choice)
                                                    Consumer Feedback
          Activity board
                                                    Observable
          Access record
          Activity sampling record
          Possesses Companion Card
2.7      Person Centred Plan                        Process as per policy
          The PCP identifies resident goals,       Documentation
           aspirations and cultural identity and
           defines how these are to be met;         Staff Knowledge
           goals, strategies and resources          Consumer Feedback
           required
                                                    Observable
          Where identified as a goal, residents
           participate in meaningful day
           programs, employment or
           volunteering activities
          The resident PCP is current and
           includes relevant parties as
           contributing to the plan.
          Includes family and advocates where
           applicable
         Date of review: insert

2.7      The progress of PCP goals are              Process as per policy
2.8      reported on and updated each               Documentation
         month.
2.9                                                 Staff Knowledge
          Action plan completed
2.10                                                Consumer Feedback
          Key worker reports completed
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                             Page 37 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


RESIDENT 6: Health and Behaviour Assessment Template
2.3 Health and Wellbeing            Evidence Type       Comments   2.4 Behaviour and Support          Evidence Type        Comments


 A health plan is             Process as per policy               A Behaviour Support          Process as per policy
  documented on current        Documentation                        Plan is in place for each    Documentation
  2007 template and any                                              resident who is the
                               Staff Knowledge                                                   Staff Knowledge
  specific health                                                    subject of restrictive
  management strategies        Consumer Feedback                    interventions due to         Consumer Feedback
  are documented               Observable                           behaviours of concern        Observable
Plan has been reviewed:                                             Behaviour Support Plans
 3 monthly by staff                                                 have been signed off by
                                                                     Authorised Program
 6 monthly by GP
                                                                     Officer (APO)
 Yearly in consultation
                                                                    Data is entered on the
  with significant others
                                                                     Restrictive Intervention
  and health
                                                                     Database System (RIDS)
  professionals, as
                                                                     on a monthly basis
  appropriate
                                                                    As a minimum,
                                                                     Behaviour Support Plans
                                                                     are reviewed annually
 An annual health             Process as per policy               Behaviours of Concern        Process as per policy
  assessment (CHAP) is         Documentation                        correspond with those        Documentation
  completed and                                                      identified in Resident
                               Staff Knowledge                                                   Staff Knowledge
 There is documentation                                             Profile
                               Consumer Feedback                                                 Consumer Feedback
  of any follow up actions
  in health files.             Observable                                                        Observable




 An annual Health Review      Process as per policy               Proactive Strategies         Process as per policy
  (CHAP) has been              Documentation                        identified/included          Documentation
  completed by a GP
                               Staff Knowledge                                                   Staff Knowledge
 Where CHAP is not
                               Consumer Feedback                                                 Consumer Feedback
  evident, a Health Action
  Plan is developed for        Observable                                                        Observable
  each resident




Internal Audit Requirements – NW – V2 - May 2009                                                                              Page 38 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                                     SUMMARY OF OBSERVATIONS


 Current client treatment     Process as per policy   Date of last Dr Review:    Restrictive Strategies      Process as per policy   RIDS Date:
  sheet and Doctors            Documentation                                       identified/included         Documentation
  Medication notes
                               Staff Knowledge                                                                 Staff Knowledge
 Dose recording sheets
                               Consumer Feedback                                                               Consumer Feedback
  correspond with client
  treatment                    Observable                                                                      Observable




An Annual Review has           Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
been completed, where          Documentation                                       include use of chemical     Documentation
applicable:                                                                         restraint
                               Staff Knowledge                                                                 Staff Knowledge
 Mental Health /
                               Consumer Feedback                                                               Consumer Feedback
  Psychiatric
                               Observable                                                                      Observable
 Psychologist




 An annual Nutrition and      Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  Swallowing Issues            Documentation                                       include use of              Documentation
  Checklist (NASIC) on                                                              mechanical restraint
                               Staff Knowledge                                                                 Staff Knowledge
  current 2007 format is
  completed and                Consumer Feedback                                                               Consumer Feedback
 Follow up actions            Observable                                                                      Observable
  documented




 The ‘weight monitor’ tool    Process as per policy                              Restrictive Strategies      Process as per policy   RIDS Date:
  on desktop of house          Documentation                                       include use of seclusion    Documentation
  computer is used
                               Staff Knowledge                                                                 Staff Knowledge
  monthly
                               Consumer Feedback                                                               Consumer Feedback
                               Observable                                                                      Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                                      Page 39 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                             SUMMARY OF OBSERVATIONS


 Instructions for              Process as per policy    Behaviour Support Plan       Process as per policy     Case Manager
  supporting people who         Documentation             developed in                 Documentation           Date:
  need assistance with                                     consultation with
                                Staff Knowledge                                        Staff Knowledge           BIST.
  meals are clearly                                        relevant / other
  documented                    Consumer Feedback         professional                 Consumer Feedback       Date:
                                Observable                                             Observable                Speech Pathologist.
                                                                                                                 Date:
                                                                                                                   Psychiatrist.
                                                                                                                 Date:
                                                                                                                   GP.
                                                                                                                 Date:
                                                                                                                   Family Member.
                                                                                                                 Date:
                                                                                                                   Other:
                                                                                                                 Date:
(if appropriate)                Process as per policy    Staff are trained and        Process as per policy
 Instructions for              Documentation             inducted in identifying      Documentation
  supporting people who                                    the least restrictive and
                                Staff Knowledge                                        Staff Knowledge
  need assistance with                                     least intrusive support
                                Consumer Feedback                                      Consumer Feedback
  continence issues are
  clearly documented            Observable                                             Observable




 Clear instructions are        Process as per policy    Staff are competent in       Process as per policy
  available for all specific    Documentation             the application of the       Documentation
  health procedures                                        strategies identified in
                                Staff Knowledge                                        Staff Knowledge
 Staff have received                                      the support plan
                                Consumer Feedback                                      Consumer Feedback
  training specific to
  procedure for that            Observable                                             Observable
  resident




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 40 of 64
   North and West Metropolitan Region
   Disability Accommodation Services                                                            SUMMARY OF OBSERVATIONS


  (if appropriate)                Process as per policy    Staff regularly report on    Process as per policy
   A health plan is              Documentation             the application of the       Documentation
    documented                                               strategies and areas for
                                  Staff Knowledge                                        Staff Knowledge
                                                             review and improvement
   Seizure observation           Consumer Feedback                                      Consumer Feedback
    charts and records are
                                  Observable                                             Observable
    maintained
   Resident profile has
    relevant alerts
(if appropriate)                  Process as per policy
    Instructions for             Documentation
     supporting people who        Staff Knowledge
     need assistance with
                                  Consumer Feedback
     pressure sores are
     clearly documented           Observable

  Hospital admission            Process as per policy   OTHER:                         Process as per policy
    forms (profile and            Documentation                                          Documentation
    contacts) are kept up to
                                  Staff Knowledge                                        Staff Knowledge
    date
                                  Consumer Feedback                                      Consumer Feedback
   With consent form for
    medical / dental              Observable                                             Observable
    procedures


  Detail Health                 List                       Detail Behaviours of          List
  Conditions:                                              Concern:




   Internal Audit Requirements – NW – V2 - May 2009                                                                Page 41 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                              SUMMARY OF OBSERVATIONS


Industry Standard 3: DECISION MAKING AND CHOICE
Support options are planned, developed, implemented and reviewed in a manner that is responsive to decisions, choices and
aspirations of individuals.

         Evidence Indicator                        Evidence Type             Comments          Improvement Opportunities        Rating
         Outcome Measure
3.1       Resident key worker assigned             Process as per policy
           and                                      Documentation
          Supports residents with decision         Staff Knowledge
           making and choice
                                                    Consumer Feedback
          FRED poster displayed
                                                    Observable

3.2      Staff members are familiar                 Process as per policy
         with and adhere to their Duty              Documentation
         of Care requirements
                                                    Staff Knowledge
          Duty of Care poster displayed
                                                    Consumer Feedback
          Team meeting agenda item
                                                    Observable
           within last 6 months
3.3      Resident Empowerment                       Process as per policy
          Resident meetings are held               Documentation
          Active support plans and                 Staff Knowledge
           programs are developed                   Consumer Feedback
          Residents are able to access to          Observable
           necessary aids, equipment and
           resources
          Residents are provided
           opportunity to contribute to
           service being provided
          Residents are able to access
           necessary supports to assist
           with decision making and
           choice, for example advocate




Internal Audit Requirements – NW – V2 - May 2009                                                                           Page 42 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


3.3       Residents choose, own and                Process as per policy
           maintain own possessions                 Documentation
          Residents contribute to daily            Staff Knowledge
           and lifestyle routines
                                                    Consumer Feedback
          Residents are engaged in meal
                                                    Observable
           choices


3.3       Communication assessment has             Process as per policy
           been completed for each                  Documentation
           resident with complex
                                                    Staff Knowledge
           communication needs
                                                    Consumer Feedback
                                                    Observable
3.4       Residential Statement is current         Process as per policy
           (accurate content) and                   Documentation
          Provided in a format suitable to         Staff Knowledge
           resident needs
                                                    Consumer Feedback
                                                    Observable
         Date of Issue:


3.4       Family/significant other issued          Process as per policy
           with N&WMR Residential                   Documentation
           Statement and Information
                                                    Staff Knowledge
           Package
                                                    Consumer Feedback
                                                    Observable
         Date of Issue:


3.5      Regular meetings/forums/                   Process as per policy
         communication occurring with               Documentation
         Family/ Significant others
                                                    Staff Knowledge
          Where relevant the wishes of
                                                    Consumer Feedback
           personal networks are
           considered in the decision               Observable
           making process and outcomes
           for residents



Internal Audit Requirements – NW – V2 - May 2009                                             Page 43 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                       SUMMARY OF OBSERVATIONS


Industry Standard 4: PRIVACY, DIGNITY AND CONFIDENTIALITY
Privacy, dignity and confidentially are respected and maintained.

         Evidence Indicator                        Evidence Type             Comments   Improvement Opportunities        Rating
         Outcome Measure
4.2      Information is maintained in               Process as per policy
         accordance with the principals of          Documentation
         the Information Privacy Act and
                                                    Staff Knowledge
         Health Records Act (Vic):
                                                    Consumer Feedback
          Staff aware of privacy principles
                                                    Observable
          Staff demonstrate an
           understanding of privacy and
           confidentiality of information
          Information gathered is related
           to service provision
          Written information is factual,
           non-judgmental, legible, signed
           and dated as required
          Red Pen and white-out is not
           used


4.3      Resident consent forms are                 Process as per policy
         completed where information                Documentation
         is being shared
                                                    Staff Knowledge
          Consent to Share / Release
                                                    Consumer Feedback
           Information
                                                    Observable
          Consent for Publication
          Forms in accessible format




Internal Audit Requirements – NW – V2 - May 2009                                                                    Page 44 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


4.4      N&WMR Standard Folder                      Process as per policy
         System                                     Documentation
          Documents in relevant sections           Staff Knowledge
          Records maintained/completed             Consumer Feedback
          Records accurate/up to                   Observable
           date/signed
          Resident identity secure when
           information is leaving the
           premises
4.5       Residents are provided with              Process as per policy
4.10       information in a format that             Documentation
           facilitates understanding about
                                                    Staff Knowledge
           their rights and responsibilities
           in relation to information               Consumer Feedback
           privacy                                  Observable
4.7       Residents are provided                   Process as per policy
           information sheets, for example          Documentation
           personal privacy; private time;
                                                    Staff Knowledge
           dignity and respect
                                                    Consumer Feedback
          Complaints
                                                    Observable
          Person Centred Plans
          Other Plans Specify:
4.3      Residents                                  Process as per policy
4.6       Have own bedrooms/space                  Documentation
4.8       Access areas as they choose              Staff Knowledge
4.9       Are able to make private calls,          Consumer Feedback
           have private conversations               Observable
         Staff demonstrate
          Staff knock and receive
           permission to enter bedrooms
          Curtains/ Blinds on bedroom
           windows
          Resident dignity and privacy is
           respected




Internal Audit Requirements – NW – V2 - May 2009                                             Page 45 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                              SUMMARY OF OBSERVATIONS


Industry Standard 5: PARTICIPATION AND INTEGRATION
Support options are planned, developed, implemented and reviewed in a manner that builds opportunities for individuals to
participate in the life of the community.

         Evidence Indicator                        Evidence Type             Comments           Improvement Opportunities        Rating
         Outcome Measure
5.1      Residents have a documented                Process as per policy
         schedule that includes                     Documentation
         community participation and
                                                    Staff Knowledge
         integration:
                                                    Consumer Feedback
          Is reported and reviewed at
           monthly team meetings                    Observable
          Reflects opportunities for new
           experiences
          Evidence of Activity Sampling
5.2      Residents are supported to                 Process as per policy
         access ‘local’ community                   Documentation
         services and activities
                                                    Staff Knowledge
          The SSA has a Local Community
                                                    Consumer Feedback
           resource ‘reference’ guide.
                                                    Observable
          LGA AAA/Metro Access contacts
           are displayed and services utilised
           (when considering activity
           planning)
          Staff are aware and residents hold
           a Companion Card, where
           applicable
          Staff are aware and residents are
           members of the Multi Purpose
           Taxi Program, where applicable
          Staff are aware, and where
           appropriate, residents access
           CALD and Indigenous groups and
           activities
          Staff are aware of how to access
           interpreter or translator service



Internal Audit Requirements – NW – V2 - May 2009                                                                            Page 46 of 64
North and West Metropolitan Region
Disability Accommodation Services                                             SUMMARY OF OBSERVATIONS




5.3      Residents                                   Process as per policy
          Contribute to activity planning           Documentation
          Participate in activities that reflect    Staff Knowledge
           personal interest an preferences          Consumer Feedback
          Are provided with a broad range           Observable
           of experiences and options;
           including cultural events,
           festivals, health services, etc.
          Are supported to identify and
           overcome barriers that may
           prevent community participation
           and inclusion
          Are supported to maintain /
           develop community network and
           relationships
          Where resident holidays have
           been arranged, checklists 1-8
           have been completed




Internal Audit Requirements – NW – V2 - May 2009                                              Page 47 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                SUMMARY OF OBSERVATIONS


Industry Standard 6: VALUED STATUS
Support options are planned, developed, implemented and reviewed in a manner that recognises the skills, abilities and potential of
individuals and enables the achievement of valued roles in the community.

         Evidence Indicator                        Evidence Type             Comments            Improvement Opportunities        Rating
         Outcome Measure
6.1       Residents have a Person                   Process as per policy
6.2       Centred Active Support                    Documentation
          schedule that
6.3                                                 Staff Knowledge
          Provides opportunities for
                                                    Consumer Feedback
           personal skill development
                                                    Observable
          Provides opportunities to be
           engaged in their home
          Is based on outcomes from a
           PCAS baseline measurement
          Is reviewed and outcomes
           reported on a monthly basis


6.1       Staff at the SSA:                         Process as per policy
6.2        Have received PCAS training             Documentation
6.3        Are supported to model and              Staff Knowledge
            implement PCAS principals in            Consumer Feedback
            the workplace.
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 48 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                               SUMMARY OF OBSERVATIONS


Industry Standard 7: COMPLAINTS AND DISPUTES
Complaints and disputes are addressed promptly, fairly and respectfully without compromising services to the individual.

         Evidence Indicator                        Evidence Type             Comments            Improvement Opportunities        Rating
         Outcome Measure
7.1       Residents are provided a copy            Process as per policy
7.6        of the Complaints procedure in           Documentation
           an accessible format
                                                    Staff Knowledge
          Information includes how to
                                                    Consumer Feedback
           make a complaint and relevant
           contact details                          Observable

7.2       Complaints procedure is made             Process as per policy
7.4        available to all staff                   Documentation
          Complaints procedure is posted           Staff Knowledge
           where residents and staff can
                                                    Consumer Feedback
           readily access information
                                                    Observable
          Service improvement action has
           been undertaken following a
           complaint and documented in
           quality plan
7.3       Residents are supported to               Process as per policy
7.5        make complaints and have                 Documentation
           issues addressed
                                                    Staff Knowledge
          Residents are encouraged and
                                                    Consumer Feedback
           residents are aware they may
           engage an advocate / support             Observable
           person to assist with complaints
          Information regarding avenues
           for making a complaint is
           provided to residents, family
           members and advocates




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 49 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                       SUMMARY OF OBSERVATIONS


Industry Standard 8: SERVICE MANAGEMENT
Management and governance practice is sound, accountable and consistent with current disability support policy and practice.

         Evidence Indicator                            Evidence Type     Comments                           Improvement Opportunities   Rating
         Outcome Measure
8.1       Refer to Service Management
To       Template below
8.14

Standard 8 Service Management
Industry Standard                                                      Staff Familiar with Policy Content     Comments
                                                                       and Implementation is Evidenced
                                                                       in SSA
8.1 Values
Staff members have access to and are         Process as per policy     Yes    No
aware of:                                    Documentation            Evidence:
 DHS ‘Our Values’ publication               Staff Knowledge
 Code of Conduct for Victorian public       Consumer Feedback
  sector employees
                                             Observable
8.2 Environmental
SSA physical environment is suitable to      Process as per policy     Yes    No
the needs of all individuals                 Documentation            Evidence:
 Common and private space                   Staff Knowledge
 Appropriate equipment and furniture        Consumer Feedback
 Lighting and Ventilation                   Observable
 Physically Accessible


 Residents have access to food that is      Process as per policy     Yes    No
  varied, adequate and consistent with       Documentation            Evidence:
  nutritionally sound principals and
                                             Staff Knowledge
  relevant practitioner
  recommendations                            Consumer Feedback
                                             Observable



Internal Audit Requirements – NW – V2 - May 2009                                                                                   Page 50 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS


8.3 Medication Practice
 Client Treatment Sheet aligns with         Process as per policy    Yes    No
  the Doctor’s Medication Notes              Documentation           Evidence:
 Medication including PRN are written       Staff Knowledge
  up correctly
                                             Consumer Feedback
 All over the counter and non-
                                             Observable
  prescription medication is approved
  by a Doctor, where prescription
  medication is being administered
 Topical non-prescription medications
  administered within authorised
  timeframes and requirements
 PRN /STAT Administration Sheets
  (yellow) are completed correctly and
  in full
 Client Treatment Sheets are
  completed correctly and in full
 Medication review has been                 Process as per policy    Yes    No
  conducted within the last 6 months,        Documentation           Evidence:
  or as directed by the Doctor
                                             Staff Knowledge
                                             Consumer Feedback
                                             Observable


 Tablets and capsules are packed in         Process as per policy    Yes    No
  blister packs and labelled correctly       Documentation           Evidence:
 Medication is stored according to          Staff Knowledge
  manufacturer’s instruction
                                             Consumer Feedback
 Medication is stored in a lockable
                                             Observable
  cabinet
 Refrigerated medication is in a
  lockable container and thermometer
  is used to check temperature weekly
 As required, medication is in original
  container, for example medicine,
  ointment



Internal Audit Requirements – NW – V2 - May 2009                                                     Page 51 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS


 Medication cabinet keys are clearly        Process as per policy    Yes    No
  labelled and stored safely                 Documentation           Evidence:
 Spare set of keys is kept in a secure      Staff Knowledge
  location on site
                                             Consumer Feedback
                                             Observable




 Each staff member who administers          Process as per policy    Yes    No
  medication to the resident has             Documentation           Evidence:
  printed their name and signed their
                                             Staff Knowledge
  initials once on the legend at the
  bottom of the Doctor’s Medication          Consumer Feedback
  Notes                                      Observable
 Only blue or black pen is used to
  record medication administration




 Details about non-prescription             Process as per policy    Yes    No
  medication and PRN administered,           Documentation           Evidence:
  by whom, at what time and for what
                                             Staff Knowledge
  purpose is recorded in the shift
  report and person’s file                   Consumer Feedback
 Where a resident is absent (e.g.           Observable
  holiday) the supervisor marks a line
  through the dates on the Medication
  Administration Record, and an entry
  indicating the absence is made in the
  person’s notes, the shift report and
  diary
 When a medication is ceased, a line
  is marked through the medication on
  the Client Treatment Sheet and
  ‘ceased’ written, and a note made in
  the person’s notes and in the shift
  report and diary


Internal Audit Requirements – NW – V2 - May 2009                                                     Page 52 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS


 At the end of shift, staff check that      Process as per policy    Yes    No
  all medication has been administered       Documentation           Evidence:
  during the shift, and provide
                                             Staff Knowledge
  appropriate handover to incoming
  staff                                      Consumer Feedback
 Any medication leaving the house is        Observable
  noted and signed off in the shift
  report
 Returned medication is noted and
  signed for in the shift report
 Where medication may be
  administered in error or refused, all
  staff are alerted, and an incident
  report is completed and forwarded to
  Manager
 Supervisor is responsible for the
  disposal of medication; has
  documented the return of all
  medication in the resident’s notes
  and the shift report after return to
  the pharmacy.


8.4 Legislation
Staff are aware and have access to:          Process as per policy    Yes    No
 Disability Act 2006                        Documentation           Evidence:
 State Disability Plan                      Staff Knowledge
 Quality Framework                          Consumer Feedback
 Privacy Act                                Observable
 Health Records Act
 Occupational Health and Safety
  legislation, policy, and guidelines




Internal Audit Requirements – NW – V2 - May 2009                                                     Page 53 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS


8.5 Organisation Chart
DAS Organisational Chart                     Process as per policy    Yes    No
accessible to staff:                         Documentation           Evidence:
 Organisational Chart is accessible to      Staff Knowledge
  staff
                                             Consumer Feedback
 Staff awareness of chart / where to
                                             Observable
  locate
8.6 Planning
SSA Quality Plan                             Process as per policy    Yes    No     Please describe consumer activities
Quality plan is maintained:                  Documentation           Evidence:        undertaken:
 Identifies improvement areas to            Staff Knowledge
  meet Disability Service Standard           Consumer Feedback
  indicators
                                             Observable
 Improvement areas have been
  identified through consumer
  assessment activities
8.7 Performance Monitoring and
    Review
 Resident Meetings are held                 Process as per policy    Yes    No
 Family Meetings are held                   Documentation           Evidence:
 Minutes of meetings are maintained         Staff Knowledge
 Key Worker reports completed in full       Consumer Feedback
                                             Observable
8.8 Risk Management
Manual Handling                              Process as per policy    Yes    No
 Yearly manual handling hazard              Documentation           Evidence:
  identification and risk assessments        Staff Knowledge
  have been completed
                                             Consumer Feedback
 Action plans have been developed for
                                             Observable
  identified risks




Internal Audit Requirements – NW – V2 - May 2009                                                              Page 54 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS


Infectious Control                           Process as per policy    Yes    No
 Spill kit is in use and contents up to     Documentation           Evidence:
  date                                       Staff Knowledge
 Staff are aware of spill kit location      Consumer Feedback
 Staff are aware of correct hand            Observable
  washing procedure
 Personal Protective Equipment is
  provided and used correctly by staff,
  for example gloves, aprons, shoe
  covers




Occupational Violence                        Process as per policy    Yes    No
OVRAMAT – occupational violence risk         Documentation           Evidence:
assessment and management tool               Staff Knowledge
 OVRAMAT has been completed for             Consumer Feedback
  new residents
                                             Observable
 Incidents have been reported and
  DINMA completed as required
 Yearly review completed




Hazard Check                                 Process as per policy    Yes    No
 Quarterly Hazard Inspection                Documentation           Evidence:
  Checklist has been completed               Staff Knowledge
 Hazard Inspection Checklists               Consumer Feedback
  evidenced for previous 12 months
                                             Observable




Internal Audit Requirements – NW – V2 - May 2009                                                     Page 55 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                     SUMMARY OF OBSERVATIONS


FIRE                                          Process as per policy    Yes    No
 Weekly fire safety checks are               Documentation           Evidence:
  completed as evidenced in house             Staff Knowledge
  diary
                                              Consumer Feedback
 Evacuation Packs have reflective
                                              Observable
  stripping and are located near the
  primary safety exit, or as required in
  a known secure location, contents
  are up to date, and checked weekly
 Equipment is maintained and
  serviced regularly
 Fire and Emergency Procedure
  Manual is up to date


 Staff have been trained in the use of       Process as per policy    Yes    No
  fire safety equipment                       Documentation           Evidence:
 New and casual staff are provided           Staff Knowledge
  fire and emergency procedures
                                              Consumer Feedback
  orientation to the house
                                              Observable
 Staff have received training to meet
  house specific and resident individual
  needs


Refer to training record last page


Fire evacuations have been completed:         Process as per policy    Yes    No
 Evacuation Drill Record Sheet is            Documentation           Evidence:
  completed                                   Staff Knowledge
 Evacuation Drill Record Sheet               Consumer Feedback
  identifies different staff participating
                                              Observable
  in drills
 Night Drills – twice annually
 Day Drills – four annually




Internal Audit Requirements – NW – V2 - May 2009                                                      Page 56 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS




First Aid                                    Process as per policy    Yes    No
 Staff aware of the location of the         Documentation           Evidence:
  First Aid Kit                              Staff Knowledge
 First Aid Kit has a Contents List          Consumer Feedback
 First Aid Kit is stocked correctly and     Observable
  items within use by dates
 First Aid is checked monthly
 First Aid Kit is taken on outings
 First Aid Kit contents includes
  emergency contact form and
  emergency information for each
  resident
 Current First Aid and CPR manual
  are accessible to staff at the house


Food Safety                                  Process as per policy    Yes    No
 Food Safety Plan is developed              Documentation           Evidence:
                                             Staff Knowledge
                                             Consumer Feedback
                                             Observable




DINMA                                        Process as per policy    Yes    No
 Employee copy of DINMA provided to         Documentation           Evidence:
  employee                                   Staff Knowledge
 DINMA forms are completed                  Consumer Feedback
  correctly
                                             Observable
 White page copy from DINMA
  Records Book are maintained in a
  separate file in a locked cabinet




Internal Audit Requirements – NW – V2 - May 2009                                                     Page 57 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                    SUMMARY OF OBSERVATIONS




Workplace Health and Safety                  Process as per policy    Yes    No
Checks                                       Documentation           Evidence:
 Bi-annual workplace safety                 Staff Knowledge
  inspections have been completed;
                                             Consumer Feedback
  checklist
                                             Observable




8.9 Financial Management
CERS                                         Process as per policy    Yes    No
As a minimum:                                Documentation           Evidence:
 Supervisor has completed CERS              Staff Knowledge
  training                                   Consumer Feedback
 Bi- Annual CERS audit completed            Observable
 CERS Audit Actions have been
  followed up / completed
 Specific resident or house keeping
  purchases that fall outside the
  financial plan are made via special
  purchase process




Internal Audit Requirements – NW – V2 - May 2009                                                     Page 58 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                          SUMMARY OF OBSERVATIONS


8.10 Learning and Development                                         Refer to Staff Training Record for Individual Staff Evidence Assessment
8.10.2 / 8.10.3 / 8.10.6 / 8.10.7 / 8.10.8
Professional Development and                 Process as per policy    Yes     No
  Support / Supervision (PPS)                Documentation           Evidence:
 PDS is developed for each staff            Staff Knowledge
  member and reviewed monthly
                                             Consumer Feedback
 PDS outcomes reflect professional
                                             Observable
  development planning and activities
  for individual staff


 The SSA has a training plan that is        Process as per policy    Yes     No
  reviewed as part of the standard           Documentation           Evidence:
  team meeting
                                             Staff Knowledge
                                             Consumer Feedback
                                             Observable



 Staff have access to a current             Process as per policy    Yes     No
  position description                       Documentation           Evidence:
 Staff are aware of how to access a         Staff Knowledge
  copy of position description
                                             Consumer Feedback
                                             Observable



 Staff have received training to meet       Process as per policy    Yes     No
  house specific and resident individual     Documentation           Evidence:
  needs
                                             Staff Knowledge
                                             Consumer Feedback
Refer to training record last page
                                             Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                                           Page 59 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                        SUMMARY OF OBSERVATIONS


8.12 Policies and Procedures
 Staff have access to Residential               Process as per policy    Yes    No
  Services Manual                                Documentation           Evidence:
 Staff are aware policies and                   Staff Knowledge
  procedures are outlined in the
                                                 Consumer Feedback
  Residential Services Manual
                                                 Observable
 Staff are aware policies, procedures
  and forms are available on the
  intranet
 Policy and procedure education is
  included as team meeting agenda
  item
 Policy and procedure education is
  included as resident meeting agenda
  item
8.13 Feedback Processes
 Please identify and specify feedback
  processes implemented within the
  house
That may monitor
 Difficulty gaining access to services and
  supports
 Experience outcomes that are valued by
  the broader community
 Goals, needs and outcomes are identified
  addressed, supported and achieved
 Receive relevant information in a format
  that is accessible and facilitates
  understanding
 Rights and responsibilities are recognised,
  promoted and protected
 Make decisions and choices in a manner
  that supports the individual to exercise
  maximum control over their lives
 Personal, cultural, communication, and
  health and wellbeing needs and
  preferences are addressed




Internal Audit Requirements – NW – V2 - May 2009                                                         Page 60 of 64
North and West Metropolitan Region
Disability Accommodation Services                  SUMMARY OF OBSERVATIONS


8.14   Participation Service Quality
 Family members
 Carers
 Personal Networks
Are included in processes to monitor
service quality, consumer satisfaction
and outcomes




Internal Audit Requirements – NW – V2 - May 2009                   Page 61 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                SUMMARY OF OBSERVATIONS


Industry Standard 9: FREEDOM FROM ABUSE AND NEGLECT
Supports are provided in safe and healthy environments that support individuals to exercise their legal and human rights.

         Evidence Indicator                        Evidence Type             Comments            Improvement Opportunities        Rating
         Outcome Measure
9.1      The following policies and                 Process as per policy
         legislation are displayed                  Documentation
         and/or readily available for
                                                    Staff Knowledge
         staff and residents
                                                    Consumer Feedback
          Responding to Physical and
           Sexual Assault Policy                    Observable
          Human Rights Charter
          Incident Report Guidelines
9.4      Security and Equipment                     Process as per policy
          Residents are supported to be            Documentation
           involved in risk management              Staff Knowledge
           processes where possible
                                                    Consumer Feedback
          Risk assessments are completed
                                                    Observable
           as required and strategies
           implemented and understood by
           staff and residents
9.6       Responding to Allegations of             Process as per policy
           Physical and Sexual Assault              Documentation
           Instructions is accessible to
                                                    Staff Knowledge
           staff
                                                    Consumer Feedback
          Any allegations have been
           recorded and responded to as             Observable
           per policy

9.7       Staff are aware of the support           Process as per policy
           services available to residents          Documentation
           who have experienced assault
                                                    Staff Knowledge
           abuse or neglect
                                                    Consumer Feedback
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                                                             Page 62 of 64
North and West Metropolitan Region
Disability Accommodation Services                                            SUMMARY OF OBSERVATIONS


9.8       Staff educate residents in               Process as per policy
           understanding how to stay safe           Documentation
          Residents are aware of who               Staff Knowledge
           they may go to you if they feel
                                                    Consumer Feedback
           unsafe
                                                    Observable
9.9       Residents are provided                   Process as per policy
           information on assault, abuse            Documentation
           and neglect in a format that
                                                    Staff Knowledge
           facilitates understanding
                                                    Consumer Feedback
                                                    Observable




Internal Audit Requirements – NW – V2 - May 2009                                             Page 63 of 64
North and West Metropolitan Region
Disability Accommodation Services                                                                               SUMMARY OF OBSERVATIONS


Staff Training Records
Minimum requirement as per skills sets identified in House Profile and identified in PDS.



                      Please identify that staff First Aid and CPR are current
                      Please identify staff training undertaken in the last 12 months and insert date of training
                      Add training topics in blank columns and insert date of training


New Starter      LIST                        House       First Aid      CPR         Fire    CERS    Positive   Person    Epilepsy
Induction                                  Orientation                             Safety          Behaviour   Centred
and                                                                                                 Support     Active
Orientation      STAFF MEMBER NAME
                                                                                                               Support
Fire Safety


Manual
Handling

Communication


OHS


Administration
Medication




Internal Audit Requirements – NW – V2 - May 2009                                                                                    Page 64 of 64

				
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