quality evaluation report

Disability Services Commission: Quality System Quality Evaluation Report

Quality Evaluation Report Version 1:0, April 2015

Assessment against the National Standards for Disability Services Disability sector organisation: Disability Services Commission Service point name: WA NDIS My Way Lower South West Outlet name(s): • Busselton

• Margaret River Director General: Dr Ron Chalmers Final report date: 4 June 2015 Evaluation team: Cheryl Lewis and Penny Blackburne *This report was prepared by a member of the Panel Contract of Team Leaders and Evaluators. The Panel Contract is managed by the Disability Services Commission. Further information Please contact the Quality and Evaluation team. Contact details: Quality and Evaluation Disability Services Commission, 146 - 160 Colin Street, West Perth WA 6005 Phone: 9426 9200 [email protected]

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Contents Part A: Executive summary ..................................................................................................................... 3

Introduction .......................................................................................................................................... 3 Summary of findings ............................................................................................................................ 5

Part B: The Standards ............................................................................................................................. 7 Standard 1: Rights ............................................................................................................................... 8 Standard 2: Participation and inclusion ........................................................................................... 11 Standard 3: Individual outcomes ....................................................................................................... 14 Standard 4: Feedback and complaints .............................................................................................. 18 Standard 5: Service access ............................................................................................................... 20 Standard 6: Service management ..................................................................................................... 22

Appendix 1: Definitions .......................................................................................................................... 26 Disclaimer .............................................................................................................................................. 28 Acknowledgments The Evaluator(s) extend thanks to individuals, families, carers, management and staff for the assistance they provided throughout the evaluation visit.

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Part A: Executive summary Introduction This report describes the findings of the evaluator(s) who visited WA NDIS My Way Lower South West during March and April 2015 and completed an assessment of feedback from individuals with disability, their families and carers, staff and management; and the service’s compliance against the National Standards for Disability Services. A preliminary meeting was held on 9 March 2015 in Bridgetown and 10 March 2015 in Busselton. An exit meeting was held on 4 June 2015. The organisation uses the term individual/person to refer to people with disability who access the services. Note: Under the Carer’s Recognition Act 2004, a carer refers to a person who provides care or assistance to another person who is frail, has a disability, a chronic illness or a mental illness, without payment apart from a pension, benefit or allowance. Service profile Service description The services provided The WA NDIS My Way Lower South West trial provides

ongoing support to people with disability, their family and carers to enhance wellbeing, promote choice and control, support participation in the community and continued learning. Planning focuses on natural networks, community supports and local connections wherever possible. Plans are individualised and may change over time as the person’s needs and goals change.

The resources The My Way Lower South West team includes: 1 x Regional Director 2 x Area Managers 1x Allied Health Consultant 1 x Technical Officer 17 x My Way Coordinators across three offices: Busselton, Manjimup and Margaret River. Administration is provided in the Busselton office and the Commission’s head office in West Perth.

The people using services The Commission’s second quarterly report to the Commonwealth Government, December 2014, identified 623 people eligible for supports and services; of those, 595 had a completed WA NDIS My Way plan. People accessing supports have an intellectual, cognitive, neurological, sensory or physical impairment, or a combination of these impairments. These figures also include 44 people with a psychosocial disability.

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Quality Evaluation assessment against the Standards The following scale has been used to measure performance against each National Standard

Met Feedback, observed and written evidence clearly demonstrates that the service provider meets the requirements

Not met Feedback, observed and written evidence clearly demonstrates that the service provider does not meet the requirements

Based on the information provided by individuals, their families, friends, carers, advocates, staff and management; and through documentation and observations made by the Evaluation team, this organisation’s performance has been assessed as: Assessment against the Standards Standard Assessment Standard 1: Rights Met Standard 2: Participation and inclusion Met Standard 3: Individual outcomes Met Standard 4: Feedback and complaints Met Standard 5: Service access Met Standard 6: Service management Met

Consultation Statistics Number of visits to group homes n/a Number of individuals with disability present in group homes during visits n/a Number of visits to private homes 1 Number of interviews with individuals with disability 4 Number of interviews with family members / friends / carers / advocates 8 Number of telephone interviews or emails with individuals with disability 7 Number of telephone interviews or emails with family members / friends / carers / advocates

12

Number of individual files / plans reviewed 16 Number of complaints reviewed nil Number of staff meetings attended nil Number of staff consulted 9 Number of external stakeholders consulted 6

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Summary of findings Please refer to Appendix 1: Definitions Good Practices (GP) If/where noted during a Quality Evaluation, GPs refer to exemplary contemporary practices that demonstrate how services support people to achieve better individual outcomes. Examples of GP inform the Commission’s Board and enhance sector development. The following includes up to two (2) brief example/s of GPs implemented. Person-centred practice/s • One My Way Coordinator gives newly referred

people a ‘little show pack’ that provides information about local resources that may be useful for that person and their family before the Plan is established.

• The obvious time and effort put in by My Way Coordinators to develop a positive relationship with individuals and families.

Business practice/s Other good practices noted

• The overwhelmingly favourable feedback from individuals and families about the services they are receiving and the changes these have made in their lives.

Required Actions (RA) If/where noted during a Quality Evaluation, RAs focus on the minimum satisfactory level of service and refer to action necessary to address matters that have serious implications for the safety, wellbeing and dignity of people with disability. They may also relate to legal requirements and duty of care issues as reflected in all the National Standards for Disability Services. RAs are a major gap in meeting Standards. No Standard RA statement Compliance

date 1. No Required Actions were identified Service Improvement (SI) If/where noted during a Quality Evaluation, SIs identify actions to enhance practices in addressing outcomes for people with disability and enhancing compliance with the National Standards for Disability Services. While still a gap in meeting Standards, SIs are less major; and are required to be reported on in the annual self-assessment. No Standard SI statement 1. 3 Clearly articulate to individuals and families the priority and

processes for plans to be reviewed. 2. 1,2,3 Systematically collect and share information of available

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community resources between My Way Coordinators and make it available to service users in accessible formats. Inform people of funded and unfunded options.

3. 3 Procedures for measuring and recording progress towards meeting goals to be consolidated in the central system.

4. 6 An emergency evacuation plan is established for all offices, the plan is practised and records are kept of the trials.

Other matters (OM) If/where noted during a Quality Evaluation, OMs refer to identified matters that are not within the scope of a Required Action/s or Service Improvement/s – and therefore, do not have reporting requirements. These matters are highlighted as continuous improvement activities and may be noted in future Quality Evaluations. The following includes up to four (4) brief example/s of OMs noted. No Standard OM statement 1. 1,2 People new to the program stated they were not always able to

articulate their needs, know what to ask for or know how to negotiate with service providers. In the early stages of the program people would benefit from assistance in this area.

2. 6 There were a few file notes that included judgements of a personal nature, it is suggested that My Way Coordinators be reminded of the need to write objective records.

3. 6 Internal communication needs to be improved to ensure all staff are kept updated about changes and new policies and procedures.

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Part B: The Standards In this section, the Standards are assessed against compliance requirements and qualitative elements. A brief comment is provided regarding the Standard. There are six National Standards that apply to disability service providers. 1. Rights: The service promotes individual rights to freedom of expression, self-

determination and decision-making and actively prevents abuse, harm, neglect and violence.

2. Participation and inclusion: The service works with individuals and families,

friends and carers to promote opportunities for meaningful participation and active inclusion in society.

3. Individual outcomes: Services and supports are assessed, planned, delivered

and reviewed to build on individual strengths that enable individuals to reach their goals.

4. Feedback and complaints: Regular feedback is sought and used to inform

individual and organisation-wide service reviews and improvement. 5. Service access: The service manages access, commencement and leaving a

service in a transparent, fair, equal and responsive way. 6. Service management: The service has effective and accountable service

management and leadership to maximise outcomes for individuals. Further information about the National Standards and the Commission’s Quality System can be access on the website: http://www.disability.wa.gov.au/disability-service-providers-/for-disability-service-providers/quality-system

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http://www.disability.wa.gov.au/disability-service-providers-/for-disability-service-providers/quality-system

http://www.disability.wa.gov.au/disability-service-providers-/for-disability-service-providers/quality-system


Standard 1: Rights

The intent of this Standard is to promote ethical, respectful and safe service delivery that meets legislative requirements and achieves positive outcomes for people with disability. This Standard has a focus on particular rights including: freedom of expression, decision-making and choice; freedom from restriction; freedom from abuse, neglect, harm, exploitation and discrimination; privacy and confidentiality.

Compliance This section relates to the policy component of the Standards and indicates where policies and procedures are in place for the service point. • (P) proposed: yet to be developed • (E) existing: currently in place • (R) under review: in place and scheduled for review • (NA) not applicable: not relevant P E R NA The service point has the following policies and / or procedures for:

• treating individuals with dignity and respect x • promoting and supporting individuals’ freedom of

expression and decision-making and choice

x

• recognising, preventing, responding to and reporting abuse, neglect, exploitation and other serious incidents

x

• safeguarding individuals’ rights x • providing contemporary, evidence-based support strategies

with minimal restrictions

x

• maintaining individuals’ privacy and confidentiality x Qualitative information This section relates to evidence gathered to assist in the assessment of practices related to compliance for this Standard. Feedback from individuals with disability, their families, friends, carers and advocates • Every individual and family member consulted stated they were always treated

with dignity and respect. They all felt they took the lead role, with assistance from the My Way Coordinator, in determining what was to be included in their plan. There was strong ownership by individuals and families of their plan. Nobody felt pressured by their coordinator to agree to anything they did not want.

• One person expressed her thoughts in writing and read them to the evaluator. She said, “I have been given the right as an individual to make my own decisions and have been given the right to have choice and control of my own life. I have been continually treated with dignity and respect. I like that my mum/carer has been given the opportunity to participate in developing my plan, because mum has been my carer/advocate and has supported me for many years.”

• Another family member commented they were, “Overjoyed at the way things were working.” However, this same family expressed concern that there was no real sense of ‘permanence’ now that plans would be reviewed every 12 months.

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• People felt respected and valued when the coordinator knew about their disability and devalued when they sensed they did not. For example one person said how satisfied and confident they were when the My Way Coordinator shared that he/she had a family member with a similar condition. Another person commented their My Way Coordinator did not appear to understand their psychosocial disability; the impact this had on their life and on the way supports need to be delivered.

• A few people spoke about lack of contact from their My Way Coordinators – one person with an unfunded program had not been contacted for seven months; this person said he/she would appreciate contact as it would provide a small level of support. A number of others felt a phone call to just ‘check-in’ would be useful.

• All people spoken to recognised the very high work pressure on My Way Coordinators and understood that this would limit contact, but felt that a quick follow up phone call once every three months would be welcome.

• All persons asked said they were confident the privacy and confidentiality of their information was maintained.

• A number of families believed that greater access to activities occurring as a result of their plan in the wider community was in fact a safeguard for their family member.

• People who do not self-manage felt they had less choice and control as they must select services only from endorsed service providers. Management advises shared management arrangements can be negotiated with service providers to increase the choice of support arrangements.

Staff and management knowledge • Staff spoken to display a sound knowledge of the people they are working with.

Examples of individual stories and achievements gained were discussed. • Individuals and their families were spoken of with respect. All staff demonstrated

concern for the privacy and confidentiality of information. • Individuals who receive funding are able to make choices as to how this funding

will be managed. For example they are able to self-manage the funds, contract with a disability service provider to manage and control the funding or choose a combination of the two.

• My Way Coordinators stated that choice belongs to the person. They know how much funding they have been allocated and have the control and are able to choose their preferred provider.

• One family sat around the table with six service providers to discuss their options and support requirements.

Observations • Individuals and families spoke of the very good relationships they had with their

My Way Coordinator. When talking to individuals/families and staff the mutual respect one had for the other was very evident.

• During discussions with staff, the privacy of individuals and families was paramount.

• There was a greater than average interest demonstrated by individuals and their families to participate in the evaluation, gauged by willingness to participate in telephone interviews and the number of people who attended the service users’ focus group. This is an indication of their level of involvement in the program and

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their relationships with the My Way Coordinators. • The office in one area is colourfully decorated with large art works that have been

commissioned from a local art group with inclusive membership and the reception area had a small stand promoting an artist’s work.

Critical documents, systems and processes • Evaluators were able to sight internal documents that presented a significant,

clearly articulated framework to ensure risks and opportunities are identified in all life areas, for example, education, employment, social communication and mobility. Assessment of the level of risk may include interface with mainstream services such as police or child protection services.

Assessment against the Standard General statement Feedback from individuals and families

was very positive. Individuals were always treated with dignity and respect and were empowered to make choices important to them.

Standard 1: Rights Met

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Standard 2: Participation and inclusion The intent of this Standard is to promote the connection of people with disability with their family, friends and chosen communities. It requires services to work collaboratively with individuals to enable their genuine participation and inclusion, and that the individual’s valued role needs to be one of their own choosing. Compliance This section relates to the policy component of the Standards and indicates where policies and procedures are in place for the service point. • (P) proposed: yet to be developed • (E) existing: currently in place • (R) under review: in place and scheduled for review • (NA) not applicable: not relevant P E R NA The service point has the following policies and / or procedures for:

• promoting and supporting participation and inclusion x • respecting Aboriginal and Torres Strait Islander culture, and

promoting Aboriginal and Torres Strait Islander peoples’ cultural and community connection

x

Qualitative information This section relates to evidence gathered to assist in the assessment of practices related to compliance for this Standard. Feedback from individuals with disability, their families, friends, carers and advocates • Individuals and families commented on the range of community activities they or

their family member were involved in. “He is doing more independent stuff then he ever has before.”

• Families discussed their family member’s involvement in volunteer work, better exercise opportunities (eg a walk to the beach), increased independence achieved through doing their own banking, shopping and paying bills.

• For many individuals and families WA NDIS My Way had opened opportunities for participation in the community that they had not been able to access before. Examples included karate, massage and piano lessons.

• One mother described her daughter as gaining so much in confidence that in some areas support has been scaled back, as she is now doing many things in the community on her own, stating that the program has, “Made a huge difference to her life.”

• People said they expect their My Way Coordinators to have a sound knowledge of local resources. Most said their My Way Coordinator had good local knowledge, but a few thought they knew more about what was available than their coordinator.

• One parent said of their My Way Coordinator, that “[Name] talks about things, he/she doesn’t just give web sites.” People valued My Way Coordinators who made suggestions, looked outside the box for solutions and used their initiative.

• People wanted the opportunity ‘to try before they buy’. Before committing to a

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service provider they would like an opportunity to experience what that organisation could provide. Possibly the My Way Coordinator could advocate for this and be more involved in the connections with disability service providers, especially for people who have not accessed community services before. See OM 1

Staff and management knowledge • One staff member described how one gentleman was able now to leave the

nursing home where he is a resident, to go out into the community for coffee or lunch, or simply go for a drive. “He is doing some of the things he always wanted to do.”

• An example of participation and inclusion was recently reported in the WA Disability Update Summer Edition and referred to by staff. The person concerned had limited social contacts due to life-long communication difficulties. After identifying goals and strategies he was supported to communicate with people in his local community. Now he independently takes part in indoor bowls, table tennis and tai chi at Busselton’s Senior Citizens Centre, participates in a Busselton volunteers program, goes fishing and is developing his passion for photography. A natural support network is developing and the person is reaching his goals and looking forward to more opportunities in 2015.

• The My Way Coordinators refer people to organisations and services for funded and unfunded activities. People are provided with a list from which to choose the organisations they will approach. People who self-manage their funding can use any service provider/organisation they choose, but those who do not self-manage must select services from endorsed providers; staff felt these individuals may have less choice available. It must be noted that the number of endorsed providers is growing exponentially and this will assist people who do not self-manage.

• One My Way Coordinator described little show packs that she takes to newly referred people. This pack has information about a range of local services that may meet the needs of the individual and their family. Information is relevant to the life stage of the person newly referred, for example for a mother with a newly diagnosed child with a disability, information is included about Noah’s Toy Library, the Regional Health and Therapy team, a local play café and sensory room, companion card for travel and information about the regional fuel card.

• My Way Coordinators have their own areas of interest and have developed their own bank of resources. There is not a mechanism whereby these resources can be shared easily. See SI 2

Observations • There are a number of information brochures from disability service providers and

the Commission in the reception area of the local offices. • ‘Service Guide Lower South West’ is a large document available in the reception

area and provided to people selecting service providers. Critical documents, systems and processes • The Service Guide details the services provided by endorsed service providers in

the Lower South West, each page has a service description, pricing information and contact details. This is an excellent resource developed by WA NDIS My Way to help people select services. This document is also available on the Commission’s web site.

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• In the Commission’s second Quarterly Report to the Commonwealth Government, Measure 113: Community capacity building activities undertaken by NGOs within the period, there is reference to initiatives funded by the National Disability Insurance Agency Sector Development Fund to build community capacity. As a result the Commission has funded four projects one of which will expand the range of individual service options provided by disability service organisations, and mental health organisations. Although commenced this project is yet to be completed.

Assessment against the Standard General statement Individuals and families gave numerous

examples of the very positive difference My Way Coordinators had made to their connection and inclusion in their local communities.

Standard 2: Participation and inclusion

Met

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Standard 3: Individual outcomes The intent of this Standard is to promote person-centred approaches to service delivery where individuals lead and direct their services and supports. Services and supports are expected to be tailored to an individual’s strengths and needs, and deliver positive outcomes. This Standard recognises the role of families, friends, carers and/or advocates in service planning, delivery and review. Compliance This section relates to the policy component of the Standards and indicates where policies and procedures are in place for the service point. • (P) proposed: yet to be developed • (E) existing: currently in place • (R) under review: in place and scheduled for review • (NA) not applicable: not relevant P E R NA The service point has the following policies and / or procedures for:

• person-centered individual service planning, delivery and review

x

• respecting and responding to individual diversity x • respecting culturally and linguistically diverse cultures and

promoting people’s cultural and community connection

x

Qualitative information This section relates to evidence gathered to assist in the assessment of practices related to compliance for this Standard. Feedback from individuals with disability, their families, friends, carers and advocates • A number of individuals/families made comment that it was difficult to arrange for a

review of their plan outside the 12-month process. One person said, “They [My Way Coordinators] are very reluctant to change a plan unless it is critical.” Documentation supplied by the service, indicates the order for prioritising existing plans. Families felt that the high work load being experienced by My Way Coordinators meant non critical plans would simply have to wait. Some individuals felt ‘locked in’ to their plan. It is understood that some people have started with a six-month plan which may provide greater flexibility and responsiveness. See SI 1

• Most people had somebody else (parent, spouse or friend) present when their plan was being formulated (at least for some of the planning meetings, if not all). This is in part a good safeguard for the individual when decisions around goals and strategies are made.

• Many families commented on the difficulty in finding and keeping ‘good’ staff. One family commented that funding spent on training was wasted when staff did not stay.

• A number of families commented on the lack of skilled workers in the community. For them it was one thing to have a plan and funding to support it, but having to find appropriate support workers was proving an issue. They questioned if WA

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NDIS My Way could do more to help identify appropriate support workers, perhaps supporting some sort of register.

• One mother believed the system of self-management was more complex than it needed to be citing systems used by Family and Community Services as less administratively onerous.

• A number of people felt more information could be provided on what services and supports were available in their local community. See SI 2

• One mother suggested the idea of developing a ‘Mother’s group’ and an internet site to assist new families and possibly even to look at sharing support workers.

• Many individuals commented on the planning process and what a positive experience it had been. “The My Way Coordinator working with you has been great.”

• Although efforts are made to ensure My Way Coordinators adopt the same approach to planning (supervision and comparability meetings) some individuals believed that Coordinators were not consistent in what was ‘allowed’ in a plan.

• One person commented, “I have chosen a support service and part self-managed plan. The self-management involves my health and wellbeing, which has empowered me and given me confidence and motivation, which had previously been lacking.”

• One person said when asked about planning and his/her part in it, “The title says it all: ‘My Way’”. This person spoke of being listened to and of having more freedom and flexibility in what he/she does. The person added, “It makes you feel good about yourself.”

• One person said it was a very long period between being referred in March 2014, starting a Plan in October and actually starting a program in January 2015.

Staff and management knowledge • My Way Coordinators all discussed the planning process and spoke of the person

centred approach and individualised plans. • After a person has been deemed eligible for services the file is allocated to a My

Way Coordinator and that person makes contact and begins to establish the plan. Three months is allowed for this to be achieved. One My Way Coordinator said sometimes this is insufficient time, as the process of completing the Assessment Tool is lengthy; the form is 44 pages, and time needs to be taken to establish rapport and gather the information to complete the Assessment. Unless this is done to a high standard the plan will not be of a good quality and vital points may be overlooked.

• Staff commented that people who cannot self-manage their funding are disadvantaged in that they are only able to use endorsed service providers. There are currently approximately 35 endorsed service providers in the WA NDIS My Way Lower South West area.

• People who are able to self-manage their funds can access a wider range of services in the community.

Observations • Although unable to verify from plans made available through head office,

evaluators were assured all plans were signed and that funding would not be allocated unless this was the case. Families also confirmed they had signed copies of their plans.

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• Reviews were not able to be cited via the centralised system. My Way Coordinators advised of the format and process of reviews and of the level of detail recorded against individual goals and whether or not these had been met. Again, this was unable to be verified.

Critical documents, systems and processes • Evidence viewed in the plans endorsed the individual approach to planning. Each

plan is unique and linked to the individual’s needs and life goals. • The recording of review processes was seen as inadequate on the central system

and evaluators were unable to ascertain a rating of the individual’s progress against each documented goal. See SI 3

Individual plan assessment This section relates to people with individualised funding (where plans are completed by organisations / Local Area Coordinators / My Way Coordinators) Desktop assessment • A total of 16 plans were reviewed and 100 per cent (100%) met basic qualitative

and outcomes criteria Plans consider and document individual choices • Plans were easy to read and well-structured including: personal details; vision –

how I would like life to be; current situation – my/our story; life goals and plan goals; funding summary and sign-off. They documented individual goals and choices based on the circumstances of each person.

Plans record decisions regarding the individual’s supports and funding arrangement, with determination of safeguards as appropriate • Plans clearly identify the goals, agreed strategies for achieving the goals, who is

responsible and any funding involved. The need for safeguards is considered. Plans include monitoring, reviewing and following up individual progress against goals and outcomes • At least six of the plans had been reviewed but evaluators were not able to

determine any evidence of progress towards meeting the documented goals. Documentation discussed new goals and some continued ones, so assumptions were made about progress. My Way Coordinators advised there was detailed documentation kept on individual files but this was not made available to evaluators.

Stated outcomes reflect the wishes of people using services and the extent to which they feel they have choice and control • Most individuals/families stated at interview that they, with assistance from their

My Way Coordinator, determined what they wanted included in their plans and the process for achieving this.

Statement about individuals’ satisfaction with the supports provided to facilitate achievement of goals • Individuals were generally very satisfied with the support and assistance provided

to help them achieve identified goals. Possibly more information could be made available about the depth and level of services/supports available.

Assessment against the Standard General statement Plans were clearly documented and

individually focused. There was evidence of a

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person centred approach with individuals taking the lead role in determining the types of supports and services necessary.

Standard 3: Individual outcomes Met

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Standard 4: Feedback and complaints The intent of this Standard is to ensure that positive and negative feedback, complaints and disputes are effectively handled and seen as opportunities for improvement. Services should provide a range of opportunities to seek feedback, recognising that people need to feel safe to provide feedback and have access to advocates and independent support. Compliance This section relates to the policy component of the Standards and indicates where policies and procedures are in place for the service point. • (P) proposed: yet to be developed • (E) existing: currently in place • (R) under review: in place and scheduled for review • (NA) not applicable: not relevant P E R NA The service point has the following policies and / or procedures for:

• encouraging and managing feedback, complaints and dispute resolution

x

Qualitative information This section relates to evidence gathered to assist in the assessment of practices related to compliance for this Standard. Feedback from individuals with disability, their families, friends, carers and advocates • Some people said they had been asked recently to participate in the Commission’s

Consumer Survey or they had attended a forum about the service provided by WA NDIS My Way.

• People said they had received a package of information about policies and procedures when they first started and some said they retained that information.

• No one referred to this information when asked what they would do if they had a concern or complaint. They all said they would talk to their My Way Coordinator or their service provider.

Staff and management knowledge • Staff said they try to address problems before they escalate to bigger issues. To

date no major complaints have been made. • Staff stated they are given a copy of relevant policies and procedures and advised

via email of any proposed changes. They are given the opportunity to comment on or suggest changes.

Observations • Stakeholders (disability service providers) external to WA NDIS My Way were

contacted to provide feedback on the program. Most felt that although there had been initial ‘teething’ problems these had been identified and worked through systematically.

• Most felt they were now viewed as valued partners in the program and their

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expertise and experience was valued by management and My Way Coordinators alike. They welcomed this environment of ‘partnership’.

• For the majority, relationships with My Way Coordinators were beneficially mutual, but this was not always the case. There was the possibility of relationships (between service providers and My Way Coordinators) to be personality driven.

• All felt that attempts to have plans reviewed earlier than the 12-month period was exceptionally difficult and this was causing issues for some people.

• All hoped that lessons learnt from the implementation of the program in the Lower South West would be built on for future sites.

Critical documents, systems and processes • A WA NDIS My Way Forum was held in February 2015: About 60 people attended

the session aimed at individuals, families and carers. Another session focused on disability service providers in the Lower South West trial site, with approximately 80 people attending. The main objectives of the forum were to gather feedback related to people’s experiences, what is working well and identifying opportunities for improvement.

• ‘Reviewing and appealing decisions’ fact sheet provides information about people’s rights to request a review and what action can be taken if the person is not happy with the review outcome. External avenues for complaint are listed. There is a very brief reference to the use of advocates and how to access an advocate. The fact sheet refers people to their My Way Coordinator or the Area Manager if they want to appoint an advocate. This fact sheet is available in the reception area of the local offices and also on the Commission’s web site.

• Complaints, reviews and appeals are reported in the Commission’s Quarterly Report to the Commonwealth Government and the data is available on the Commission’s web site. There were no reportable complaints or appeals or reviews against decisions about eligibility, funding (reasonable/necessary), self-management of funding, extension of grace period, review of plans, and application of compensation from 1 July to 31 December 2014. The report also states the 100 per cent (100%) of plans were completed on time.

Assessment against the Standard General statement Individuals and families were generally very

positive about the WA NDIS My Way trial and enjoyed a positive relationship with their My Way Coordinator. No complaints have been registered to date. Individuals, families and staff are given the opportunity to provide feedback on the program and possible improvements.

Standard 4: Feedback and complaints

Met

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Standard 5: Service access The intent of this Standard is to ensure that access to services and supports are fair and transparent and that individuals understand criteria and processes regarding access to, and use of, a service or support. This includes clear explanations when a service or support is not available and referral to alternative service options. Compliance This section relates to the policy component of the Standards and indicates where policies and procedures are in place for the service point. • (P) proposed: yet to be developed • (E) existing: currently in place • (R) under review: in place and scheduled for review • (NA) not applicable: not relevant P E R NA The service point has the following policies and / or procedures for:

• promoting and supporting fair and transparent service access

x

Qualitative information This section relates to evidence gathered to assist in the assessment of practices related to compliance for this Standard. Feedback from individuals with disability, their families, friends, carers and advocates • Some individuals and disability service providers commented that initially access

to the program was a bit confusing. Particularly for people who had been receiving funding for some time through an endorsed service provider and were then switched to WA NDIS My Way.

• Those new to WA NDIS My Way also found it confusing initially but are now very satisfied with the achievements made.

• Most people spoken to are very satisfied with the transparency of funding and the control they now have to make decisions.

• Some individuals thought My Way Coordinators were not always consistent with what could be included in a plan.

• A number of individuals said, “You have to understand the program in order to be able to use it,” and felt they did not have this knowledge.

• While one person said accessing the WA NDIS My Way program had taken a very long time most said access was easy and fast.

Staff and management knowledge • Evaluators were advised of an intensive awareness campaign undertaken in the

region initially in an effort to target people who might be eligible for the program. Observations • n/a Critical documents, systems and processes • A range of fact sheets about WA NDIS My Way are available to the public in the

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local offices and also on the Commission’s web site, such as, ‘Am I eligible?’ • The Commission’s website also includes other information and individual stories to

educate people about WA NDIS My Way. Complete ONLY for Local Area Coordination / My Way Level of coordinator knowledge and exploration of the choices and opportunities available for individuals in the community • My Way Coordinators have individual areas of interest and they bring this together

with their wide ranging work experiences to their positions. • There seems to be a variation in the amount of knowledge My Way Coordinators

have about choices and opportunities available for individuals in the community. One My Way Coordinator said there is no longer time to share resource information and that people tended to keep information to themselves. However those people who share the open office space area did talk of sharing information. See SI 2

Level of coordinator support for individuals to access services and supports identified in their plans • There seemed to be a variation in how much support people receive to access

services. Some people described situations where the My Way Coordinators assisted them to access services and advocated on their behalf. Others felt that after the development of the plan they were pretty much left on their own.

Assessment against the Standard General statement Initial confusion seems to have been

overcome with the efforts made by My Way Coordinators. Mechanisms to collect and disseminate available information need to be consolidated.

Standard 5: Service access Met

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Standard 6: Service management The intent of this Standard is to ensure that services are accountable and have sound governance that will enable services and supports to be delivered in a safe environment by appropriately qualified and supervised staff. It also requires services to promote a culture of continuous improvement as a basis for quality service delivery. Compliance This section relates to the policy component of the Standards and indicates where policies and procedures are in place for the service point. • (P) proposed: yet to be developed • (E) existing: currently in place • (R) under review: in place and scheduled for review • (NA) not applicable: not relevant P E R NA The service point has the following policies and / or procedures for:

• human resource management (ie recruitment, selection and induction; code of conduct; accountable and ethical decision-making; and performance management)

x

• employment records that are current and maintained (ie Police Clearances and Working with Children Checks )

x

• individuals’ records that are current and maintained (ie individual plans, services received, demographics, etc)

x

• work health and safety x • maintaining a safe environment (ie fire and evacuation) x • administration of medication x • risk management x • financial management x • promoting opportunities for the involvement of people with

disability, families, carers and advocates in service and support planning, delivery and review

x

• training, monitoring and reviewing staff knowledge and implementation of policies, procedures and practices

x

All policies and procedures relating to the National Standards 1-6 for the service point are:

• dated x • include a review date x • where appropriate, developed in consultation with

individuals, family, friends, carers, advocates

x

• where relevant, available to potential and current individuals, family, friends, carers, advocates

x

• made available in customised accessible formats, including languages other than English, as required

x

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Operating a safe service This section relates to the operational component of the Standards and indicates where practices are in place for the service point. • (M) met: practices demonstrate the requirements have been

met • (NM) not met: practices demonstrate the requirements have

not been met • (NA) not applicable: this practice is not relevant M NM NA The status of the following practices for the service point is assessed as:

• The service provider conducts National Police checks for Board members, staff, volunteers and contractors prior to commencement.

x

• National Police checks are regularly updated for Board members, staff, volunteers and contractors.

x

• The service knows what to do if an unsatisfactory National Police check is received from a Board member, staff member, volunteer or contractor.

x

• Board members, staff, volunteers and contractors have Working with Children clearances as appropriate.

x

• The service has an emergency evacuation plan. x • The service regularly practices its emergency evacuation

plan. x

• The service keeps records of evacuation trials. x • The administration of medication occurs as detailed in the

policies and procedures instructions. x

• The buildings are maintained in a condition that does not pose a risk to staff and service users.

x

• Regular work health safety audits are undertaken to identify and address potential safety hazards.

x

• A risk register is kept which monitors risks associated with workplace, travel, and individuals’ home environment, as applicable.

x

• There is a current record of staff training in the implementation of policies, procedures and practices.

x

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Qualitative information This section relates to evidence gathered to assist in the assessment of practices related to compliance for this Standard. Feedback from individuals with disability, their families, friends, carers and advocates • People were all clear about their funding and how it was managed. There was no

confusion between the funding options: self-managed (managed by the individual or their representative) and organisation managed (managed by a preferred disability service provider, this may include shared management arrangements where the individual works with the service provider to manage the funding together).

• Everybody understood they were part of a new program (WA NDIS My Way) and they were pleased to be involved.

Staff and management knowledge • My Way Coordinators and Area Managers stated that all staff received core

training although this did not always happen as early as required. Staff have access to an on-line Induction program.

• My Way Coordinators were able to identify any training they required and this was scheduled as soon as possible. Management advised core training is most useful when My Way Coordinators have had the opportunity to be in position for three months or more.

• Staff felt the local induction of new My Way Coordinators was not done systematically and this did put pressure on other staff.

• Area Managers stated the allocation of caseloads to new staff was handled strategically.

• A number of staff spoken with had not looked at the National Standards although all knew there were standards in place. (It is understood that these have now been displayed in all offices.)

• My Way Coordinators in Busselton were not aware the quality evaluation was taking place; one coordinator said she had been informed that the evaluation was to be conducted at some time in the future but was unaware that it had commenced. This had led to some embarrassment as the people using the services knew and had asked questions about the evaluation. No staff attended the preliminary meetings. Management advised all staff were made aware of the evaluation via email and team meetings; there was possibly some confusion due to multiple evaluations happening at the same time.

• Staff spoke of regular supervisory meetings with their line managers and of team meetings. However four My Way Coordinators said poor communication was an issue in the office, they explained it was hard to keep up with changes and sometimes information about changes was not distributed to everybody. One said, “Not everybody has the same information; things are changing so quickly, it’s hard to know who to ask.” Recently short ‘stand-up’ meetings have been commenced to address this issue. See OM 3

• Everybody said there was a good team spirit and managers were always accessible and provided formal and informal support to the My Way Coordinators. The Area Manager for the Manjimup office is in the office one day a week to support staff.

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Assessment against the Standard General statement Sound governance practices were evident in

the main. Supervision and training of staff was appropriate. Individuals and families should be encouraged to contribute to the development of policies and the continuous improvement cycle.

Standard 6: Service management Met

• Some commented that resource sharing was not easy as everybody was so busy with their workloads; new staff would benefit from more formal mentoring as learning the role was very complex.

• Problems with the data recording system (My Way LADS) were referred to as adding to the difficulties of performing their role.

Observations • There was no display of the National Standards for Disability Services evident in

the Busselton office. • Security plans for each office were cited but no evidence was available on

evacuation trials conducted and recorded. Management advised that, “Evacuation procedures are practised on a random basis across all three offices (at least every 12 months). These should be recorded and placed on file; however, it appears that this may not be the case.” See SI 4

• The Busselton office is very cramped for office space; they have recently assumed space immediately next door and are planning a move to larger premises later in the year. Refurbishing is also happening in the Manjimup office.

• The new office premises will provide a welcome to people who want to drop in to speak with their My Way Coordinator or to obtain information; currently space is at a premium and rooms previously used as meeting spaces are occupied by staff.

Critical documents, systems and processes • Not all policy documents are easy to access as a number are broad overarching

policies of the Commission. • Operational policies are readily accessible, mainly on-line.

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Disability Services Commission: Quality System

Quality Evaluation Report

Appendix 1: Definitions Good Practices (GP) Descriptors GPs refer to exemplary contemporary practices that demonstrate how services support people to achieve better individual outcomes. Examples of GPs inform the Commission’s Board and enhance sector development.

• The organisation has a sound governance structure with written statements of their vision/mission, sound policies and procedures in place, a strategic plan; and evidence supports their ownership and compliance.

• The organisation has managed and reported on financial and human resources activities well.

• Continuous improvement is embedded within the organisation and demonstrates a planned approach to self-evaluation that is flexible and responsive to changing priorities.

• The organisation demonstrates strong public accountability (websites, publications, public disclosure).

Required Actions (RA) RAs focus on the minimum satisfactory level of service and refer to action necessary to address matters that have serious implications for the rights, safety, wellbeing and dignity of people with disability. They may also relate to legal requirements and duty-of-care issues as reflected in all the National Standards for Disability Services. RAs are a major gap in meeting Standards.

• There is a total breakdown of a system or procedure governed by applicable Standards.

• There is a total absence of a requirement being addressed by the provider. • There is a failure to comply with the requirements of the Standards. • There are serious implications for individuals (‘felony-like’; relating to individual

rights, safety, wellbeing and dignity; legal requirements; duty of care issues). • The major gap represents a high risk to individuals. • Experience and judgement indicate there is a likely failure to assure quality services. • A number of small or long-standing gaps in the Standards are related to the same

requirement. Service Improvement (SI) SIs identify actions to enhance practices in addressing outcomes for people with disability and enhancing compliance with the National

• A minor gap in meeting the Standards or related procedure is evident. • There is a weakness in the system, not the absence of a system. • Human error is evident.

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Standards for Disability Services. While still a gap in meeting Standards, SIs are less major.

• The gap affects the service, but is not unsafe (‘misdemeanour-like’). • There is minimal risk to individuals. • Experience and judgement indicate a reduction in the quality of services. • A single observed lapse or isolated incident is evident, but does not impact the

whole. • There is sound ongoing intent to address the issue, but it is not yet fully resolved.

Other matters (OM) OMs refer to identified matters that are not within the scope of Required Action/s or Service Improvement/s and therefore do not have reporting requirements. These matters are highlighted as continuous improvement activities and may be noted in future Quality Evaluations.

• Matters for consideration may not represent a gap in meeting the Standards, but may enhance the quality of services provided or result in better individual outcomes.

• A lack of financial and/or human resources to enhance services and foster a positive attitude is evident.

• There are opportunities to improve communication mechanisms for: organisational change; contact with individuals, families and carers; response timeframes; and/or alternative communication methods.

• There are opportunities to improve systems, processes and databases (eg data not current) to improve work efficiency.

• There are opportunities to present a balanced and collaborative approach with key stakeholders in decision-making and operational matters.

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Disclaimer The quality evaluation assessment is necessarily limited by the following:

• The methodology used for the evaluation has been designed to enable a reasonable degree of assessment in all the circumstances.

• The assessment involves a reliance on multiple sources of evidence, including

observations, feedback and some written records. The accuracy of written records cannot always be completely verified.

• The assessment will often involve a determination as to which of two or more

versions of the same facts put to the evaluator(s) is correct under circumstances, where this issue cannot be determined with absolute certainty.

• The assessment will involve the evaluator(s) raising issues with a sample of

individuals with disability, their family members, carers, friends, advocates and other relevant stakeholders. On some occasions, information gathered from a sample will not reflect the circumstances applying over the whole group.

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quality evaluation report

Documents