Rights and Responsibilities · C1.1 Core Module
Person-centred supports
(1) Each participant can access supports that promote, uphold and respect their legal and human rights. (2) Each participant is enabled to exercise informed choice and control. (3) The provision of supports promotes, upholds and respects individual rights to freedom of expression, self-determination and decision-making.
Quality indicators (3)
- Each participant's legal and human rights are understood and incorporated into everyday practice.
- Communication with each participant about the provision of supports is responsive to their needs and is provided in the language, mode of communication and terms that the participant is most likely to understand.
- Each participant is supported to engage with their support network and chosen community as directed by the participant.
Documents (10)
CORE-POL-01 Rights and Responsibilities Policy and ProcedureCORE-FRM-87 Easy Read Participant HandbookCORE-HBK-01 Staff HandbookCORE-HBK-02 Participant HandbookCORE-FRM-86 Participant Charter of Rights and ResponsibilitiesCORE-GDE-01 Self-Assessment Guide and Sample AnswersCORE-ER-02 Easy Read My RightsCORE-ER-03 Easy Read Making a Complaint- and 2 more
Evidence an auditor may ask for (3)
- Participant information pack
- Participant satisfaction survey results
- Support plan
Rights and Responsibilities · C1.2 Core Module
Individual values and beliefs
Each participant can access supports that respect their culture, diversity, values and beliefs.
Quality indicators (2)
- At the direction of the participant, the culture, diversity, values and beliefs of that participant are identified and sensitively responded to.
- Each participant's right to practice their culture, values and beliefs while accessing supports is supported.
Documents (6)
CORE-POL-02 Individual Values and Beliefs Policy and ProcedureCORE-FRM-64 Staff to Participant Match FormCORE-FRM-75 My Eating and Drinking ProfileCORE-FRM-86 Participant Charter of Rights and ResponsibilitiesCORE-GDE-01 Self-Assessment Guide and Sample AnswersCORE-ER-02 Easy Read My Rights
Evidence an auditor may ask for (1)
- Staff to participant matching records
Rights and Responsibilities · C1.3 Core Module
Privacy and dignity
Each participant can access supports that respect and protect their dignity and right to privacy.
Quality indicators (3)
- Consistent processes and practices are in place that respect and protect the personal privacy and dignity of each participant.
- Each participant is advised of confidentiality policies using the language, mode of communication and terms that the participant is most likely to understand.
- Each participant understands and agrees to what personal information will be collected and why, including recorded material in audio and/or visual format.
Documents (14)
CORE-POL-01 Rights and Responsibilities Policy and ProcedureCORE-POL-03 Privacy and Confidentiality Policy and ProcedureCORE-POL-10 Information Management Policy and ProcedureCORE-POL-25 Personal Support Policy and ProcedureCORE-FRM-87 Easy Read Participant HandbookCORE-HBK-02 Participant HandbookCORE-FRM-58 Participant Intake FormCORE-FRM-61 Participant Consent Form- and 6 more
Evidence an auditor may ask for (6)
- Consent forms and advocate authorities
- Audit participation consent and opt-out records
- Privacy policy and collection notice
- Data breach response plan and log
- Records storage and access controls
- Consent forms
Rights and Responsibilities · C1.4 Core Module
Independence and informed choice
Each participant is supported by the provider to make informed choices, exercise control and maximise their independence in relation to the supports provided.
Quality indicators (5)
- Active decision-making and individual choice is supported for each participant including the timely provision of information using the language, mode of communication and terms that the participant is most likely to understand.
- Each participant's right to the dignity of risk in decision-making is supported. When needed, each participant is supported to make informed choices about the benefits and risks of the options under consideration.
- Each participant's autonomy is respected, including their right to intimacy and sexual expression.
- Each participant has sufficient time to consider and review their options and seek advice if required, at any stage of support provision, including assessment, planning, provision, review and exit.
- Each participant's right to access an advocate (including an independent advocate) of their choosing is supported, as is their right to have the advocate present.
Documents (27)
CORE-POL-01 Rights and Responsibilities Policy and ProcedureCORE-POL-04 Independence and Informed Choice Policy and ProcedureCORE-POL-07 Conflict of Interest Policy and ProcedureCORE-FRM-63 Participant Assessment and Support PlanCORE-FRM-87 Easy Read Participant HandbookCORE-HBK-02 Participant HandbookCORE-FRM-58 Participant Intake FormCORE-FRM-59 Intake Assessment Form- and 19 more
Evidence an auditor may ask for (5)
- Conflict of interest register and declarations
- Consent forms and advocate authorities
- Participant information pack
- Shared living (SIL) house records
- Consent forms
Rights and Responsibilities · C1.5 Core Module
Freedom from violence, abuse, neglect, exploitation or discrimination
Each participant can access supports free from violence, abuse, neglect, exploitation or discrimination.
Quality indicators (3)
- Policies, procedures and practices are in place which actively prevent violence, abuse, neglect, exploitation or discrimination.
- Each participant is provided with information about the use of an advocate (including an independent advocate) and access to an advocate is facilitated where allegations of violence, abuse, neglect, exploitation or discrimination have been made.
- Allegations and incidents of violence, abuse, neglect, exploitation or discrimination, are acted upon, each participant affected is supported and assisted, records are made of any details and outcomes of reviews and investigations (where applicable) and action is taken to prevent similar incidents occurring again.
Documents (9)
CORE-POL-05 Freedom from Violence, Abuse, Neglect, Exploitation and Discrimination Policy and ProcedureCORE-POL-23 Participant Money and Property Policy and ProcedureCORE-HBK-01 Staff HandbookCORE-HBK-02 Participant HandbookCORE-FRM-86 Participant Charter of Rights and ResponsibilitiesCORE-GDE-01 Self-Assessment Guide and Sample AnswersCORE-ER-02 Easy Read My RightsCORE-ER-05 Easy Read Feeling Safe and Speaking Up- and 1 more
Evidence an auditor may ask for (5)
- Staff handbook and Code of Conduct
- Records of worker misconduct allegations and responses
- Behaviour support plans and restrictive practice authorisations
- Child safe practices
- Behaviour support plan and authorisation
Provider Governance and Operational Management · C2.1 Core Module
Governance and operational management
Each participant's support is overseen by robust governance and operational management systems relevant and proportionate to the size and scale of the provider and the scope and complexity of the supports being delivered.
Quality indicators (8)
- Opportunities are provided by the governing body for people with disability to contribute to the governance of the organisation and have input into the development of organisational policy and processes relevant to the provision of supports and the protection of participant rights.
- A defined structure is implemented by the governing body to meet a governing body's financial, legislative, regulatory and contractual responsibilities, and to monitor and respond to quality and safeguarding matters associated with delivering supports to participants.
- The skills and knowledge required for the governing body to govern effectively are identified, and relevant training is undertaken by members of the governing body to address any gaps.
- The governing body ensures that strategic and business planning considers legislative requirements, organisational risks, other requirements related to operating under the NDIS (for example Agency requirements and guidance), participants' and workers' needs and the wider organisational environment.
- The performance of management, including responses to individual issues, is monitored by the governing body to drive continuous improvement in management practices.
- The provider is managed by a suitably qualified and/or experienced persons with clearly defined responsibility, authority and accountability for the provision of supports.
- There is a documented system of delegated responsibility and authority to another suitable person in the absence of a usual position holder in place.
- Perceived and actual conflicts of interest are proactively managed and documented, including through development and maintenance of organisational policies.
Documents (27)
CORE-POL-06 Governance and Operational Management Policy and ProcedureCORE-POL-07 Conflict of Interest Policy and ProcedureCORE-FRM-16 Business PlanCORE-FRM-17 Strategic PlanCORE-FRM-18 Operational PlanCORE-FRM-28 Continuous Improvement PlanCORE-FRM-19 Management Review ReportCORE-FRM-20 Governing Body Meeting Agenda and Minutes- and 19 more
Evidence an auditor may ask for (17)
- ABN and business registration records
- NDIS registration certificate or application reference
- Scope of audit from the NDIS Commission
- Organisational chart
- Key personnel list and suitability declarations
- Governing body meeting minutes
- and 11 more
Provider Governance and Operational Management · C2.2 Core Module
Risk management
Risks to participants, workers and the provider are identified and managed.
Quality indicators (6)
- Risks to the organisation, including risks to participants, financial and work health and safety risks, and risks associated with provision of supports are identified, analysed, prioritised and treated.
- A documented risk management system that effectively manages identified risks is in place, and is relevant and proportionate to the size and scale of the provider and the scope and complexity of supports provided.
- The risk management system covers each of the following: (a) incident management; (b) complaints management and resolution; (c) financial management; (d) governance and operational management; (e) human resource management; (f) information management; (g) work health and safety; (h) emergency and disaster management.
- Where relevant, the risk management system includes measures for the prevention and control of infection and outbreaks.
- Supports and services are provided in a way that is consistent with the risk management system.
- Appropriate insurance is in place, including professional indemnity, public liability and accident insurance.
Documents (17)
CORE-POL-08 Risk Management Policy and ProcedureCORE-POL-21 Safe Environment Policy and ProcedureCORE-POL-22 Infection Prevention and Control Policy and ProcedureCORE-FRM-33 Risk Management PlanCORE-FRM-46 Data Breach Response PlanCORE-FRM-53 Site Emergency and Disaster Management PlanCORE-FRM-55 Infectious Disease Outbreak Management PlanCORE-FRM-56 Business Continuity Plan- and 9 more
Evidence an auditor may ask for (7)
- Public liability insurance certificate of currency
- Professional indemnity insurance certificate of currency
- Workers compensation or personal accident insurance
- Subcontractor and independent contractor agreements
- Risk management plan and risk register
- Hazard reports and WHS consultation records
- and 1 more
Provider Governance and Operational Management · C2.3 Core Module
Quality management
Each participant benefits from a quality management system that is relevant and proportionate to the size and scale of the provider and that promotes continuous improvement of support delivery.
Quality indicators (3)
- A quality management system is maintained that is relevant and proportionate to the size and scale of the provider and the scope and complexity of the supports delivered. The system defines how to meet the requirements of legislation and these standards. The system is reviewed and updated as required to improve support delivery.
- The provider's quality management system has a documented program of internal audits relevant (proportionate) to the size and scale of the provider and the scope and complexity of supports delivered.
- The provider's quality management system supports continuous improvement, using outcomes, risk related data, evidence-informed practice and feedback from participants and workers.
Documents (15)
CORE-POL-06 Governance and Operational Management Policy and ProcedureCORE-POL-09 Quality Management Policy and ProcedureCORE-POL-15 Continuous Improvement Policy and ProcedureCORE-FRM-28 Continuous Improvement PlanCORE-FRM-30 Continuous Improvement FormCORE-FRM-67 Progress NotesCORE-FRM-68 Progress ReportCORE-FRM-69 Participant Satisfaction Survey- and 7 more
Evidence an auditor may ask for (10)
- Completed self-assessment
- Policies and procedures approved and version controlled
- Legal requirements register
- Continuous Improvement Register
- Internal audit program and results
- Management review report
- and 4 more
Provider Governance and Operational Management · C2.4 Core Module
Information management
(1) Management of each participant's information ensures that it is identifiable, accurately recorded, current and confidential. (2) Each participant's information is easily accessible to the participant and appropriately utilised by relevant workers.
Quality indicators (4)
- Each participant's consent is obtained to collect, use and retain their information or to disclose their information (including assessments) to other parties, including details of the purpose of collection, use and disclosure. Each participant is informed in what circumstances the information could be disclosed, including that the information could be provided without their consent if required or authorised by law.
- Each participant is informed of how their information is stored and used, and when and how each participant can access or correct their information, and withdraw or amend their prior consent.
- An information management system is maintained that is relevant and proportionate to the size and scale of the organisation and records each participant's information in an accurate and timely manner.
- Documents are stored with appropriate use, access, transfer, storage, security, retrieval, retention, destruction and disposal processes relevant and proportionate to the scope and complexity of supports delivered.
Documents (14)
CORE-POL-03 Privacy and Confidentiality Policy and ProcedureCORE-POL-10 Information Management Policy and ProcedureCORE-FRM-46 Data Breach Response PlanCORE-FRM-49 Data Backup PlanCORE-FRM-48 Data Breach Assessment ReportCORE-FRM-71 Participant Exit FormCORE-FRM-90 Participant Consent Form - NDIS Audit Participation and Opt-OutCORE-FRM-25 Asset Register- and 6 more
Evidence an auditor may ask for (10)
- Participant list and Service Delivery Register
- Consent forms and advocate authorities
- Audit participation consent and opt-out records
- Privacy policy and collection notice
- Data breach response plan and log
- Records storage and access controls
- and 4 more
Provider Governance and Operational Management · C2.5 Core Module
Complaints management and resolution
(1) Each participant has knowledge of and access to the provider's complaints management and resolution system. (2) Complaints are welcomed, acknowledged, respected and well managed.
Quality indicators (4)
- A complaints management and resolution system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system follows principles of procedural fairness and natural justice and complies with the requirements under the National Disability Insurance Scheme (Complaints Management and Resolution) Rules 2018.
- Each participant is provided with information on how to give feedback or make a complaint, including avenues external to the provider, and their right to access advocates. There is a supportive environment for any person who provides feedback and/or makes complaints.
- Demonstrated continuous improvement in complaints and feedback management by regular review of complaint and feedback policies and procedures, seeking of participant views on the accessibility of the complaints management and resolution system, and incorporation of feedback throughout the provider's organisation.
- All workers are aware of, trained in, and comply with the required procedures in relation to complaints handling.
Documents (13)
CORE-POL-11 Feedback and Complaints Management Policy and ProcedureCORE-FRM-87 Easy Read Participant HandbookCORE-HBK-01 Staff HandbookCORE-HBK-02 Participant HandbookCORE-FRM-40 Complaint Report FormCORE-FRM-69 Participant Satisfaction SurveyCORE-FRM-86 Participant Charter of Rights and ResponsibilitiesCORE-FRM-39 Feedback and Complaints Register- and 5 more
Evidence an auditor may ask for (3)
- Feedback and Complaints Register
- Complaint records and outcome letters
- Incidents and complaints involving the participant
Provider Governance and Operational Management · C2.6 Core Module
Incident management
Each participant is safeguarded by the provider's incident management system, ensuring that incidents are acknowledged, responded to, well managed and learned from.
Quality indicators (4)
- An incident management system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system complies with the requirements under the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.
- Each participant is provided with information on incident management, including how incidents involving the participant have been managed.
- Demonstrated continuous improvement in incident management by regular review of incident management policies and procedures, review of the causes, handling and outcomes of incidents, seeking of participant and worker views, and incorporation of feedback throughout the provider's organisation.
- All workers are aware of, trained in, and comply with the required procedures in relation to incident management.
Documents (10)
CORE-POL-12 Incident Management Policy and ProcedureCORE-HBK-01 Staff HandbookCORE-HBK-02 Participant HandbookCORE-FRM-42 Incident Report FormCORE-FRM-43 Incident Investigation FormCORE-FRM-69 Participant Satisfaction SurveyCORE-FRM-41 Incident RegisterCORE-GDE-01 Self-Assessment Guide and Sample Answers- and 2 more
Evidence an auditor may ask for (4)
- Incident Register
- Incident reports and investigations
- Behaviour support plans and restrictive practice authorisations
- Incidents and complaints involving the participant
Provider Governance and Operational Management · C2.7 Core Module
Human resource management
Each participant's support needs are met by workers who are competent in relation to their role, hold relevant qualifications and have relevant expertise and experience to provide person-centred support.
Quality indicators (10)
- The skills and knowledge required of each position within a provider are identified and documented together with the responsibilities, scope and limitations of each position.
- Records of worker pre-employment checks, qualifications and experience are maintained.
- An orientation and induction process is in place that is completed by workers including completion of the mandatory NDIS worker orientation program.
- A system to identify, plan, facilitate, record and evaluate the effectiveness of training and education for workers is in place to ensure that workers meet the needs of each participant. The system identifies training that is mandatory and includes training in relation to staff obligations under the NDIS Practice Standards and other National Disability Insurance Scheme rules.
- Timely supervision, support and resources are available to workers relevant to the scope and complexity of supports delivered.
- The performance of workers is managed, developed and documented, including through providing feedback and development opportunities.
- Workers with capabilities that are relevant to assisting in the response to an emergency or disaster (such as contingency planning or infection prevention or control) are identified.
- Plans are in place to identify, source and induct a workforce in the event that workforce disruptions occur in an emergency or disaster.
- Infection prevention and control training, including refresher training, is undertaken by all workers involved in providing supports to participants.
- For each worker, the following details are recorded and kept up to date: (a) their contact details; (b) details of their secondary employment (if any).
Documents (31)
CORE-POL-13 Human Resource Management Policy and ProcedureCORE-POL-22 Infection Prevention and Control Policy and ProcedureCORE-FRM-84 Employment ContractCORE-FRM-85 Labour Hire AgreementCORE-HBK-01 Staff HandbookCORE-FRM-03 Position DescriptionCORE-FRM-04 Staff Information FormCORE-FRM-07 Secondary Employment Report- and 23 more
Evidence an auditor may ask for (18)
- Key personnel list and suitability declarations
- Employment contract template and award coverage
- Labour hire agreement
- Subcontractor and independent contractor agreements
- Human Resource Register
- Risk assessed role register and worker screening log
- and 12 more
Provider Governance and Operational Management · C2.8 Core Module
Continuity of supports
Each participant has access to timely and appropriate supports without interruption.
Quality indicators (5)
- Day-to-day operations are managed in an efficient and effective way to avoid disruption and ensure continuity of supports.
- In the event of worker absence or vacancy, a suitably qualified and/or experienced person performs the role.
- Supports are planned with each participant to meet their specific needs and preferences. These needs and preferences are documented and provided to workers prior to commencing work with each participant to ensure the participant's experience is consistent with their expressed preferences.
- Arrangements are in place to ensure support is provided to the participant without interruption throughout the period of their service agreement. These arrangements are relevant and proportionate to the scope and complexity of supports delivered by the provider.
- Alternative arrangements for the continuity of supports for each participant, where changes or interruptions are unavoidable, are: (a) explained and agreed with them; and (b) delivered in a way that is appropriate to their needs, preferences and goals.
Documents (13)
CORE-POL-14 Emergency and Disaster Management Policy and ProcedureCORE-POL-17 Support Planning Policy and ProcedureCORE-POL-19 Responsive Support Provision Policy and ProcedureCORE-POL-20 Transition to or From a Provider Policy and ProcedureCORE-FRM-49 Data Backup PlanCORE-FRM-52 Personal Emergency Management PlanCORE-FRM-53 Site Emergency and Disaster Management PlanCORE-FRM-55 Infectious Disease Outbreak Management Plan- and 5 more
Evidence an auditor may ask for (2)
- Business continuity plan
- Personal emergency management plan
Provider Governance and Operational Management · C2.9 Core Module
Emergency and disaster management
Emergency and disaster management includes planning that: (a) ensures that the risks to the health, safety and wellbeing of participants that may arise in an emergency or disaster are considered and mitigated; and (b) ensures the continuity of supports critical to the health, safety and wellbeing of participants in an emergency or disaster.
Quality indicators (9)
- Measures are in place to enable continuity of supports that are critical to the safety, health and wellbeing of each participant before, during and after an emergency or disaster.
- The measures include planning for each of the following: (a) preparing for, and responding to, the emergency or disaster; (b) making changes to participant supports; (c) adapting, and rapidly responding, to changes to participant supports and to other interruptions; (d) communicating changes to participant supports to workers and to participants and their support networks.
- The governing body develops emergency and disaster management plans (the plans), consults with participants and their support networks about the plans and puts the plans in place.
- The plans explain and guide how the governing body will respond to, and oversee the response to, an emergency or disaster.
- Mechanisms are in place for the governing body to actively test the plans, and adjust them, in the context of a particular kind of emergency or disaster.
- The plans have periodic review points to enable the governing body to respond to the changing nature of an emergency or disaster.
- The governing body regularly reviews the plans, and consults with participants and their support networks about the reviews of the plans.
- The governing body communicates the plans to workers, participants and their support networks.
- Each worker is trained in the implementation of the plans.
Documents (8)
CORE-POL-08 Risk Management Policy and ProcedureCORE-POL-14 Emergency and Disaster Management Policy and ProcedureCORE-FRM-52 Personal Emergency Management PlanCORE-FRM-53 Site Emergency and Disaster Management PlanCORE-FRM-55 Infectious Disease Outbreak Management PlanCORE-FRM-56 Business Continuity PlanCORE-FRM-54 Emergency and Disaster Drill ReportCORE-GDE-01 Self-Assessment Guide and Sample Answers
Evidence an auditor may ask for (3)
- Emergency and disaster management plan
- Emergency drill records
- Personal emergency management plan
Provision of Supports · C3.1 Core Module
Access to supports
Each participant can access the most appropriate supports that meet the participant's needs, goals and preferences.
Quality indicators (3)
- The supports available, and any access / entry criteria (including any associated costs) are clearly defined and documented. This information is communicated to each participant using the language, mode of communication and terms that the participant is most likely to understand.
- Reasonable adjustments to the support delivery environment are made and monitored to ensure it is fit for purpose and each participant's health, privacy, dignity, quality of life and independence is supported.
- Each participant is supported to understand under what circumstances supports can be withdrawn. Access to supports required by the participant will not be withdrawn or denied solely on the basis of a dignity of risk choice that has been made by the participant.
Documents (9)
CORE-POL-16 Access to Supports Policy and ProcedureCORE-FRM-57 Service AgreementCORE-FRM-58 Participant Intake FormCORE-FRM-59 Intake Assessment FormCORE-FRM-60 Referral FormCORE-FRM-61 Participant Consent FormCORE-GDE-01 Self-Assessment Guide and Sample AnswersCORE-ER-04 Easy Read Keeping My Information Private- and 1 more
Evidence an auditor may ask for (3)
- Intake, referral and access records
- Participant information pack
- NDIS plan details and goals
Provision of Supports · C3.2 Core Module
Support planning
(1) Each participant is actively involved in the development of their support plans. (2) Support plans reflect participant needs, requirements, preferences, strengths and goals, and are regularly reviewed.
Quality indicators (10)
- (1) With each participant's consent, work is undertaken with the participant and their support network to enable effective assessment and to develop a support plan. Appropriate information and access is sought from a range of resources to ensure the participant's needs, support requirements, preferences, strengths and goals are included in the assessment and the support plan.
- (2) In collaboration with each participant: (a) risk assessments are regularly undertaken, and documented in their support plans; and (b) appropriate strategies are planned and implemented to treat known risks to them.
- (2A) Risk assessments include the following: (a) consideration of the degree to which participants rely on the provider's services to meet their daily living needs; (b) the extent to which the health and safety of participants would be affected if those services were disrupted.
- (3) Periodic reviews of the effectiveness of risk management strategies are undertaken with each participant to ensure risks are being adequately addressed, and changes are made when required.
- (4) Each support plan is reviewed annually or earlier in collaboration with each participant, according to their changing needs or circumstances. Progress in meeting desired outcomes and goals is assessed, at a frequency relevant and proportionate to risks, the participant's functionality and the participant's wishes.
- (5) Where progress is different from expected outcomes and goals, work is done with the participant to change and update the support plan.
- (6) Each participant's support plan is: (a) provided to them in the language, mode of communication and terms they are most likely to understand; and (b) readily accessible by them and by workers providing supports to them.
- (7) Each participant's support plan is communicated, where appropriate and with their consent, to their support network, other providers and relevant government agencies.
- (8) Each participant's support plan includes arrangements, where required, for proactive support for preventative health measures, including support to access recommended vaccinations, dental check-ups, comprehensive health assessments and allied health services.
- (9) Each participant's support plan: (a) anticipates and incorporates responses to individual, provider and community emergencies and disasters to ensure their safety, health and wellbeing; and (b) is understood by each worker supporting them.
Documents (16)
CORE-POL-17 Support Planning Policy and ProcedureCORE-FRM-63 Participant Assessment and Support PlanCORE-FRM-35 Individual Risk Assessment FormCORE-FRM-59 Intake Assessment FormCORE-FRM-68 Progress ReportCORE-FRM-72 Participant File Audit ChecklistCORE-GDE-01 Self-Assessment Guide and Sample AnswersM1-POL-01 High Intensity Daily Personal Activities Policy and Procedure- and 8 more
Evidence an auditor may ask for (6)
- Support plan template and review schedule
- High intensity support competency evidence
- NDIS plan details and goals
- Support plan
- Risk assessment
- Reviews and progress reports
Provision of Supports · C3.3 Core Module
Service agreements
Each participant has a clear understanding of the supports they have chosen and how the supports will be provided.
Quality indicators (5)
- Collaboration occurs with each participant to develop a service agreement which establishes expectations, explains the supports to be delivered, and specifies any conditions attached to the delivery of supports, including why these conditions are attached.
- Each participant is supported to understand their service agreement and conditions using the language, mode of communication and terms that the participant is most likely to understand.
- Where the service agreement is created in writing, each participant receives a copy of their agreement signed by the participant and the provider. Where this is not practicable, or the participant chooses not to have an agreement, a record is made of the circumstances under which the participant did not receive a copy of their agreement.
- Where the provider delivers supported independent living supports to participants in specialist disability accommodation dwellings, documented arrangements are in place with each participant and each specialist disability accommodation provider. At a minimum, the arrangements should outline the party or parties responsible and their roles (where applicable) for the following matters: (a) How a Participant's concerns about the dwelling will be communicated and addressed; (b) How potential conflicts involving participant(s) will be managed; (c) How changes to participant circumstances and/or support needs will be agreed and communicated; (d) In shared living, how vacancies will be filled, including each participant's right to have their needs, preferences and situation taken into account; and (e) How behaviours of concern which may put tenancies at risk will be managed, if this is a relevant issue for the participant.
- Service agreements set out the arrangements for providing supports to be put in place in the event of an emergency or disaster.
Documents (11)
CORE-POL-18 Service Agreements with Participants Policy and ProcedureCORE-FRM-57 Service AgreementCORE-HBK-02 Participant HandbookCORE-FRM-91 Invoice TemplateCORE-FRM-65 Service Delivery RegisterCORE-FRM-72 Participant File Audit ChecklistCORE-GDE-01 Self-Assessment Guide and Sample AnswersCORE-ER-01 Easy Read Service Agreement- and 3 more
Evidence an auditor may ask for (3)
- Service agreement template and signed agreements
- Price list, invoices and claim reconciliation
- Signed service agreement
Provision of Supports · C3.4 Core Module
Responsive support provision
Each participant can access responsive, timely, competent and appropriate supports to meet their needs, desired outcomes and goals.
Quality indicators (4)
- Supports are provided based on the least intrusive options, in accordance with contemporary evidence-informed practices that meet participant needs and help achieve desired outcomes.
- For each participant (with their consent or direction and as agreed in their service agreement) links are developed and maintained by the provider through collaboration with other providers, including health care and allied health providers, to share their information, manage risks to them and meet their needs.
- Reasonable efforts are made to involve the participant in selecting their workers, including the preferred gender of workers providing personal care supports.
- Where a participant has specific needs which require monitoring and/or daily support, workers are appropriately trained and understand the participant's needs and preferences.
Documents (11)
CORE-POL-19 Responsive Support Provision Policy and ProcedureCORE-POL-24 Mealtime Management Policy and ProcedureCORE-POL-25 Personal Support Policy and ProcedureCORE-POL-26 Medication Management Policy and ProcedureCORE-FRM-63 Participant Assessment and Support PlanCORE-FRM-64 Staff to Participant Match FormCORE-FRM-67 Progress NotesCORE-FRM-68 Progress Report- and 3 more
Evidence an auditor may ask for (5)
- Rosters
- Staff to participant matching records
- Participant list and Service Delivery Register
- Progress notes
- Reviews and progress reports
Provision of Supports · C3.5 Core Module
Transitions to and from a provider
Each participant experiences a planned and coordinated transition to or from the provider.
Quality indicators (3)
- A planned transition to or from the provider is facilitated in collaboration with each participant when possible, and this is documented, communicated and effectively managed.
- Risks associated with each transition to or from the provider are identified, documented and responded to, including risks associated with temporary transitions from the provider to respond to a risk to the participant, such as a health care risk requiring hospitalisation.
- Processes for transitioning to or from the provider (including temporary transitions referred to in subsection (2)) are developed, applied, reviewed and communicated.
Documents (5)
CORE-POL-20 Transition to or From a Provider Policy and ProcedureCORE-FRM-70 Transition To or From a Provider PlanCORE-FRM-71 Participant Exit FormCORE-FRM-72 Participant File Audit ChecklistCORE-GDE-01 Self-Assessment Guide and Sample Answers
Evidence an auditor may ask for (1)
- Transition and exit records
Support Provision Environment · C4.1 Core Module
Safe environment
Each participant can access supports in a safe environment that is appropriate to their needs.
Quality indicators (11)
- (1) Each participant can easily identify workers who provide supports to them.
- (2) Work is undertaken with each participant, and others, in settings where supports are provided (including their home), to ensure a safe support delivery environment for them.
- (3) Where relevant, work is undertaken with other providers (including health care and allied health providers and providers of other services) to identify and manage risks to participants and to correctly interpret their needs and preferences.
- (4) For each participant requiring support with communication, clear arrangements are in place to assist workers who support them to understand their communication needs and the manner in which they express emerging health concerns.
- (5) To avoid delays in treatments for participants: (a) protocols are in place for each participant about how to respond to medical emergencies for them; and (b) each worker providing support to them is trained to respond to such emergencies (including how to distinguish between urgent and non-urgent health situations).
- (6) Systems for escalation are established for each participant in urgent health situations.
- (7) Infection prevention and control standard precautions are implemented throughout all settings in which supports are provided to participants.
- (8) Routine environmental cleaning is conducted of settings in which supports are provided to participants (other than in their homes), particularly of frequently-touched surfaces.
- (9) Each worker is trained, and has refresher training, in infection prevention and control standard precautions including hand hygiene practices, respiratory hygiene and cough etiquette.
- (10) Each worker who provides supports directly to participants is trained, and has refresher training, in the use of PPE.
- (11) PPE is available to each worker, and each participant, who requires it.
Documents (23)
CORE-POL-21 Safe Environment Policy and ProcedureCORE-POL-22 Infection Prevention and Control Policy and ProcedureCORE-POL-24 Mealtime Management Policy and ProcedureCORE-POL-25 Personal Support Policy and ProcedureCORE-POL-26 Medication Management Policy and ProcedureCORE-POL-27 Waste Management Policy and ProcedureCORE-FRM-52 Personal Emergency Management PlanCORE-FRM-53 Site Emergency and Disaster Management Plan- and 15 more
Evidence an auditor may ask for (9)
- Motor vehicle insurance and registration
- Hazard reports and WHS consultation records
- Home and venue risk assessments
- Emergency drill records
- Infection prevention and control evidence
- Premises safety records
- and 3 more
Support Provision Environment · C4.2 Core Module
Participant money and property
Participant money and property is secure and each participant uses their own money and property as they determine.
Quality indicators (3)
- Where the provider has access to a participant's money or other property, processes to ensure that it is managed, protected and accounted for are developed, applied, reviewed and communicated. Participants' money or other property is only used with the consent of the participant and for the purposes intended by the participant.
- If required, each participant is supported to access and spend their own money as the participant determines.
- Participants are not given financial advice or information other than that which would reasonably be required under the participant's plan.
Documents (4)
CORE-POL-23 Participant Money and Property Policy and ProcedureCORE-FRM-71 Participant Exit FormCORE-FRM-66 Participant Money and Property RegisterCORE-GDE-01 Self-Assessment Guide and Sample Answers
Evidence an auditor may ask for (1)
- Participant money and property records
Support Provision Environment · C4.3 Core Module
Medication management
(1) This standard applies to a provider that is responsible for administering medication to participants. (2) Each participant requiring medication is confident that their provider administers, stores and monitors the effects of the participant's medication and works to prevent errors and incidents.
Quality indicators (3)
- Records clearly identify the medication and dosage required by each participant, including all information required to correctly identify the participant and to safely administer the medication.
- All workers responsible for administering medication understand the effects and side-effects of the medication and the steps to take in the event of an incident involving medication.
- All medications are stored safely and securely, can be easily identified and differentiated, and are only accessed by appropriately trained workers.
Documents (10)
CORE-POL-26 Medication Management Policy and ProcedureCORE-FRM-77 Medication Administration RecordCORE-FRM-78 Medication Administration Consent FormCORE-FRM-80 Self-Administration of Medication Assessment ToolCORE-FRM-79 Administration of Medication Evaluation ChecklistCORE-GDE-01 Self-Assessment Guide and Sample AnswersM1-POL-01 High Intensity Daily Personal Activities Policy and ProcedureM1-POL-02 High Intensity Support Area Procedures- and 2 more
Evidence an auditor may ask for (2)
- Medication management records
- Medication chart and consent
Support Provision Environment · C4.4 Core Module
Mealtime management
(1) This standard applies to a provider that is responsible for providing supports to participants who require mealtime management. (2) Each participant requiring mealtime management receives meals that are: (a) nutritious, and of a texture that is appropriate to their individual needs; and (b) appropriately planned, and prepared in an environment and manner that meets their individual needs and preferences; and (c) delivered in a way that is appropriate to their individual needs and ensures that the meals are enjoyable.
Quality indicators (9)
- Providers identify each participant requiring mealtime management.
- Each participant requiring mealtime management has their individual mealtime management needs assessed by appropriately qualified health practitioners, including by practitioners: (a) undertaking comprehensive assessments of their nutrition and swallowing; and (b) assessing their seating and positioning requirements for eating and drinking; and (c) providing mealtime management plans which outline their mealtime management needs, including for swallowing, eating and drinking; and (d) reviewing assessments and plans annually or in accordance with the professional advice of the participant's practitioner, or more frequently if needs change or difficulty is observed.
- With their consent, each participant requiring mealtime management is involved in the assessment and development of their mealtime management plans.
- Each worker responsible for providing mealtime management to participants understands the mealtime management needs of those participants and the steps to take if safety incidents occur during meals, such as coughing or choking on food or fluids.
- Each worker responsible for providing mealtime management to participants is trained in preparing and providing safe meals with participants that would reasonably be expected to be enjoyable and proactively managing emerging and chronic health risks related to mealtime difficulties, including how to seek help to manage such risks.
- Mealtime management plans for participants are available where mealtime management is provided to them and are easily accessible to workers providing mealtime management to them.
- Effective planning is in place to develop menus with each participant requiring mealtime management to support them to: (a) be provided with nutritious meals that would reasonably be expected to be enjoyable, reflecting their preferences, their informed choice and any recommendations by an appropriately qualified health practitioner that are reflected in their mealtime management plan; and (b) if they have chronic health risks (such as swallowing difficulties, diabetes, anaphylaxis, food allergies, obesity or being underweight)-proactively manage those risks.
- Procedures are in place for workers to prepare and provide texture-modified foods and fluids in accordance with mealtime management plans for participants and to check that meals for participants are of the correct texture, as identified in the plans.
- Meals that may be provided to participants requiring mealtime management are stored safely and in accordance with health standards, can be easily identified as meals to be provided to particular participants and can be differentiated from meals not to be provided to particular participants.
Documents (9)
CORE-POL-24 Mealtime Management Policy and ProcedureCORE-FRM-73 Mealtime Management PlanCORE-FRM-75 My Eating and Drinking ProfileCORE-FRM-76 Food DiaryCORE-FRM-74 Nutrition and Swallowing Risk ChecklistCORE-GDE-01 Self-Assessment Guide and Sample AnswersM1-POL-02 High Intensity Support Area ProceduresM1-FRM-02 High Intensity Support Screening and Health Practitioner Assessment Record- and 1 more
Evidence an auditor may ask for (2)
- Mealtime management plans and worker training
- Mealtime management plan
Support Provision Environment · C4.5 Core Module
Waste management
(1) This standard applies to a provider that is required to manage waste, or infectious or hazardous substances. (2) Each participant, each worker and any other person in the support environment is protected from harm as a result of exposure to waste or infectious or hazardous substances generated during the delivery of supports.
Quality indicators (4)
- Policies, procedures and practices are in place for the safe and appropriate storage, handling and disposal of waste and infectious or hazardous substances (including used PPE), and each policy, procedure and practice complies with current legislation and local health district requirements.
- All incidents involving infectious material, body substances or hazardous substances are reported, recorded, investigated and reviewed.
- An emergency plan is in place to respond to clinical waste or hazardous substance management issues and/or accidents. Where the plan is implemented, its effectiveness is evaluated, and revisions are made if required.
- Each worker involved in the management of waste, or infectious or hazardous substances, is trained in the safe and appropriate handling of the waste or substances, including the use of PPE or any other clothing required when handling the waste or substances.
Documents (4)
CORE-POL-27 Waste Management Policy and ProcedureCORE-FRM-81 Waste Management PlanCORE-FRM-82 Waste Management RecordCORE-GDE-01 Self-Assessment Guide and Sample Answers
Evidence an auditor may ask for (1)
- Waste management plan and records
Verification Module · V1 Verification
Risk management
Risks to participants, workers and the provider are identified and managed.
Requirements (5)
- A documented risk management system that effectively manages work health and safety risks is in place, and is relevant and proportionate to the size and scale of the provider and the scope and complexity of supports.
- Appropriate insurance is in place, including professional indemnity, public liability and accident insurance.
- The risk management system includes emergency and disaster planning.
- Risk assessments are regularly undertaken, and include the following: (a) consideration of the degree to which participants rely on the provider's services to meet their daily living needs; (b) the extent to which their health and safety would be affected if those services were disrupted.
- Infection prevention and control standard precautions are implemented throughout all settings.
Documents (13)
CORE-POL-08 Risk Management Policy and ProcedureCORE-POL-14 Emergency and Disaster Management Policy and ProcedureCORE-FRM-33 Risk Management PlanCORE-FRM-35 Individual Risk Assessment FormCORE-FRM-36 Home Risk Assessment FormCORE-FRM-37 External Venue Risk Assessment FormCORE-FRM-38 Hazard Identification ReportCORE-FRM-34 Risk Register- and 5 more
Evidence an auditor may ask for (12)
- Public liability insurance certificate of currency
- Professional indemnity insurance certificate of currency
- Workers compensation or personal accident insurance
- Motor vehicle insurance and registration
- Risk management plan and risk register
- Hazard reports and WHS consultation records
- and 6 more
Verification Module · V2 Verification
Complaints management
(Rules) (1) Each participant has knowledge of and access to the provider's complaints management and resolution system. (2) Complaints are welcomed, acknowledged, respected and well managed. (QI) Each participant has knowledge of and access to the provider's complaints management and resolution system. Complaints made by all parties are welcomed, acknowledged, respected and well-managed.
Requirements (1)
- A complaints management and resolution system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system follows principles of procedural fairness and natural justice and complies with the requirements under the National Disability Insurance Scheme (Complaints Management and Resolution) Rules 2018.
Documents (7)
CORE-POL-11 Feedback and Complaints Management Policy and ProcedureCORE-FRM-40 Complaint Report FormCORE-FRM-39 Feedback and Complaints RegisterCORE-GDE-01 Self-Assessment Guide and Sample AnswersVER-01 Verification Module Policy and Procedure ManualVER-03 Verification Module Evidence ChecklistVER-02 Verification Module Self-Assessment and Evidence Guide
Evidence an auditor may ask for (2)
- Feedback and Complaints Register
- Complaint records and outcome letters
Verification Module · V3 Verification
Incident management
Each participant is safeguarded by the provider's incident management system, ensuring that incidents are acknowledged, responded to, well managed and learned from.
Requirements (1)
- An incident management system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system complies with the requirements under the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.
Documents (8)
CORE-POL-12 Incident Management Policy and ProcedureCORE-FRM-42 Incident Report FormCORE-FRM-43 Incident Investigation FormCORE-FRM-41 Incident RegisterCORE-GDE-01 Self-Assessment Guide and Sample AnswersVER-01 Verification Module Policy and Procedure ManualVER-03 Verification Module Evidence ChecklistVER-02 Verification Module Self-Assessment and Evidence Guide
Evidence an auditor may ask for (3)
- Incident Register
- Incident reports and investigations
- Incidents and complaints involving the participant
Verification Module · V4 Verification
Human resource management
Each participant's support needs are met by workers who are competent in relation to their role, hold relevant qualifications and have relevant expertise and experience to provide person-centred support.
Requirements (5)
- Records of worker identity, right to work, pre-employment checks, qualifications and/ or experience are maintained.
- Workers complete mandatory NDIS orientation module and records of continuing professional development are maintained.
- Each worker is trained, and has refresher training, in infection prevention and control standard precautions including hand hygiene practices, respiratory hygiene and cough etiquette.
- Each worker who provides supports directly to participants is trained, and has refresher training, in the use of PPE.
- PPE is available to each worker, and each participant, who requires it.
Documents (21)
CORE-POL-13 Human Resource Management Policy and ProcedureCORE-FRM-03 Position DescriptionCORE-FRM-04 Staff Information FormCORE-FRM-07 Secondary Employment ReportCORE-FRM-08 Staff Commitment Declaration FormCORE-FRM-10 Training Attendance RecordCORE-FRM-12 Performance Review FormCORE-FRM-13 Skill Assessment Form- and 13 more
Evidence an auditor may ask for (12)
- Employment contract template and award coverage
- Labour hire agreement
- Subcontractor and independent contractor agreements
- Human Resource Register
- Risk assessed role register and worker screening log
- Position descriptions
- and 6 more