DRC: Complaints Management

Now that the Disability Royal Commission (DRC) has released its final report, we will be publishing some blog posts on a number of the report’s key themes.  

Our posts are intended to help providers understand the changes to the disability system that the DRC is recommending, so that they can consider whether they need to adjust or improve how they provide services.  It is also a great time for providers to  review their policies and procedures. Note that the Australian Government has not yet accepted the recommendations of the DRC, so they are subject to change further down the track.

This first post is about complaints management, and how providers can get on the front foot to ensure complaints processes are what they should be.

Complaints management principles

Recommendation 11.5 suggests that states and territories develop specific guidelines to help organisations implement complaint handling systems which are accessible and responsive to people with disability.

The DRC outlined ten core principles which the guidelines should reflect, which are:

  • creating a rights-focused complaints culture;
  • encouraging people with disability and others to speak up;
  • making adjustments to enable participation;
  • supporting the person with disability, their family and others in complaint processes;
  • respecting complexity, diversity and cultural difference;
  • providing clear information about how to complain, and multiple pathways to complain;
  • working respectfully and effectively alongside police;
  • conducting safe and inclusive investigations, that are trauma-informed;
  • providing tailored outcomes and redress; and
  • using complaints data to drive continuous improvement in service provision and complaint handling.

Barriers and accessibility in complaints and feedback

One of the key concerns outlined by the DRC was the lack of accessibility in complaints systems. They raised a series of concerns related to things such as:

  • inaccessible policies and processes,
  • a lack of options for raising concerns,
  • potential victimisation, and
  • fear of not being believed or treated or taken seriously, among other things.

To ensure that your organisation’s complaints management does not create barriers, regularly review your policies and procedures and check that they are in line with (and promote) the principles of natural justice.

It is also important to ensure that policies are well communicated and can be easily understood.  For example, adopting an Easy English complaints policies which addresses the communication needs of participants can assist in making your complaint handling processes easier to understand. 

Strengthening complaints systems

The Executive Summary of the DRC report contains recommendations for measures which NDIS Providers can implement to strengthen their existing complaints management systems, including the following:

  • Creating a dedicated complaints management team or individual
    This team or individual should be separate from those delivering services. Their primary role is to increase the engagement with participants and their support networks to ensure that complaints are addressed appropriately.
  • Prioritising complaints based on risk
    This involves assessing each complaint separately to determine its severity, and using a triage system to address complaints which have the most potential risk to participants.
  • Establishing lines of communication
    A common theme from the DRC’s investigation of complaints systems is confusion arising from lack of communication. This includes participants not knowing whom to contact, as well as not feeling comfortable to speak up.
  • Record keeping
    Strong record keeping practices, including documenting the conclusion and resolution of complaints, are central to good complaints management.
  • Organisational culture
    Developing a culture that encourages and welcomes feedback is essential to complaints management, and will help inform continuous improvement activities.

Responding to complaints

The DRC stressed the importance of adequately responding to complaints and concerns. Providers should acknowledge the complaint when it is made, and actively involve participants and their families in the investigation and resolution of a complaint.

Poor communication between service providers and participants can result in feelings of distrust and anxiety.

To address this, providers should communicate regularly with participants about the progress of their complaint and ensure that participants are aware of their rights in relation to complaints.

How we can help

We have a number of resources to help providers with complaints management:

  • Policy: Complaints Management
  • Info: Complaints Management
  • Policy: Complaints (Easy English)
  • Policy: Child Safe Complaints Management
  • Template: Complaints Register
  • Template: Complaints Information for Clients
  • Template: Complaint Process Tracking Form
  • Template: Complaint Submission Form
  • Template: Complaint Response Letter

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Preparing for new Aged Care Provider Governance requirements

On December 1, 2023, further changes to the Aged Care Act regarding provider governance will come into effect. The changes aim to strengthen the governance and leadership of aged care providers, while increasing the levels of accountability and transparency of aged care governing bodies. The culture and values of a provider are set at the top levels of the organisation, meaning that an effective and strong governance system is integral to the success of the organisation in practice.  

 Broadly speaking, the new requirements align with: 

  • Standards 6, 7, & 8 of the Aged Care Quality Standards; and, for those looking ahead,  
  • Standards 2 & 5 of the Strengthened Aged Care Quality Standards Pilot Draft.

Who has to comply?

Approved providers of residential, home and flexible aged care services must comply with the provider governance requirements, including providers involved in short-term, multi-purpose and transition care. Providers who became approved on or after 1 December 2022 will already be subject to these requirements, and any provider approved prior to this date must ensure compliance from 1 December 2023 

Providers operating under grant agreements such as the Commonwealth Home Support Programme (CHSP) or National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP) are not required to comply with the provider governance changes. However, they should consider whether aspects of these requirements could be implemented in their organisation as best practice governance.  

What are some of the key requirements?

Who’s on the governing body?

There are new requirements about the skills and qualifications of governing body members, designed to ensure that governing bodies have a strong mix of experience and expertise to drive the right culture and governance systems across the whole organisation. The key requirements are: 

  • The right mix of skills, experience and expertise: Providers should appoint board members who can challenge and analyse how the organisation operates, hold management to account, and who have skills and experience that are relevant to the services their organisation provides.  
  • Experience in clinical care: At least one member of the governing body must now have experience in providing clinical care, in order to provide insights and perspectives of their experience. The input they provide will be important guidance in making decisions about the clinical care operations of the organisation. The type of clinical experience required is not specified, as it will differ amongst providers, but it should be relevant to the care and services provided.  For example, if a large proportion of the clinical care provided to older people involves physiotherapy, it would be good practice to have a person with physiotherapy experience as a Board member.
  • Majority of independent non-executives: A majority of the governing body members must now be independent non-executive members. This change is designed to reduce conflicts of interest for those serving on boards, and ensure that decisions are made objectively and in the best interests of care recipients. There is no prescribed definition of “independent non-executive members”, so whether a person is independent or not will be a matter for each organisation to determine. Organisations should consider whether each candidate for Board membership is able to perform their duties independently, without the influence or conflict of any outside or personal interests. Some examples of people who would not be independent would include:
    • Paid staff members of the organisation; and
    • Owners of the organisation, including shareholders and employees of parent or holding companies.

Some providers don’t need to meet the governing body requirements

If a provider is one of the following, they are exempt from these requirements: 

  • Approved providers that are a state, territory or local government authority; 
  • Providers who have fewer than 5 members in their governing body and provide care to fewer than 40 care recipients; and 
  • Approved providers that are Aboriginal Community Controlled Organisations (ACCOs). 

If these circumstances change, the organisation will be required to comply, for example if they begin to provide services to 40 or more care recipients.  

Additionally, providers who cannot meet the governing body requirements may apply to the Commission for a determination, but this should only be attempted after exhausting all possible avenues for meeting the requirements, and is not designed to be a permanent exemption from compliance. In particular, providers in rural or remote areas might face greater difficulties in finding suitable members to serve on their governing bodies, although this is not an automatic justification for exemption. Organisations should use alternative attempts to facilitate compliance, such as online meeting software or networking with other providers in similar situations to find candidates, before making an application.  

Advisory body requirements

The new changes set out various requirements for advisory bodies, specifically a quality care advisory body and a consumer advisory body. Advisory bodies are groups that assist governing bodies by providing advice and information about specific issues. They are separate from the governing body and don’t have the responsibilities of a governing body. 

The quality care advisory body

This advisory body is designed to support the governing body with their decision-making and continuous improvement, by identifying and reporting on any issues of concern relating to the quality of the care provided by the organisation.  

The quality care advisory body must provide a written report to the governing body at least every 6 months, and can also provide feedback at any other time.  The report will be based on the quality care advisory body’s review of a range of performance indicators, including: 

  • Feedback and complaints about the quality of care; 
  • Any regulatory action taken, or performance reports provided, by the Commission; 
  • The organisation’s progress against its continuous improvement plan; 
  • Information about staffing arrangements; 
  • Any reportable incidents; and 
  • Feedback and details about the quality of food provided (for residential aged care providers). 

The governing body must provide a written response to feedback and reports from the quality care advisory body, in which it responds to the issues identified and sets our proposed actions to address those issues. 

Organisations don’t need to create a new body for this purpose if an existing body or group meets all the requirements and performs the same functions. Membership of the quality care advisory body must include:  

  • a member of the organisation’s key personnel (ideally not someone who is on the governing body) who has experience providing aged care;  
  • a staff member who is directly involved in providing aged care or clinical care services; and  
  • a member representing the interests of older people/care recipients (for example, a care recipient, family member, carer or representative).  

It is recommended that the chairperson of the quality care advisory body is independent, and not an executive of the organisation. 

The consumer advisory body

At least once every 12 months, organisations must make a written offer to older people to establish a consumer advisory body, and invite them to join it (or to join an existing consumer advisory body, if one or more already exist).  It is not mandatory to actually have a consumer advisory body, however it is mandatory to make the annual offer in writing to establish one. 

This body provides the governing body feedback, concerns and suggestions from the consumer perspective, highlighting areas of focus that the governing body may otherwise miss, and helping to incorporate the views and wishes of consumers into how services should be designed and improved . Issues, concerns and feedback a consumer advisory body provides must be considered by the governing body in their decision-making and continuous improvement processes, and a written report must be provided to the consumer advisory body explaining how their feedback has been considered. 

Additional provider governance changes

  • Governing bodies need to make sure their staff have appropriate skills, qualifications and experience to fulfil their roles when delivering aged care services, including providing staff withy professional and skill development opportunities; and  
  • Organisations that are a wholly-owned subsidiary of another body corporate (known as a holding company) which is not an approved provider must ensure their constitution requires company directors to act in the best interest of older people rather than prioritising the interests of their holding company. 

Commission resources

The Aged Care Quality and Safety Commission has created several fact sheets on provider governance changes: 

They have also published responses to common questions about the new governing body requirements, which could be a good place to start if you have further questions about how the governing body requirements and determination process work.  

BNG resources

We’ve created 5 new templates and revised some of our existing policy documents to help providers with their new governance requirements: 

  • Template: Consumer Advisory Body Terms of Reference 
  • Template: Invitation to join Consumer Advisory Body 
  • Template: Written response to Consumer Advisory Body Report 
  • Template: Quality Care Advisory Body Terms of Reference 
  • Template: Written response to Quality Care Report 
  • Policy: Provider Governance (Aged Care) 

These new resources join our existing package of provider governance resources that we released in late 2022, which includes: 

  • Policy: Key Personnel 
  • Template: Key Personnel Suitability Checklist 
  • Template: Key Personnel Declaration and Undertaking 
  • Template: Governing Body Requirements Checklist 

We also have a whole range of aged care self-assessment modules in SPP including for: 

  • The current Aged Care Quality Standards 
  • The Strengthened Aged Care Quality Standards Pilot Draft 
  • Clinical Governance 
  • The Aged Care Prudential Standards 
  • The Aged Care Code of Conduct 
  • Provider Governance Reforms 

Ensure you're ready for provider governance reform.

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Changes to nutrition in aged care are coming… are you ready?

The Royal Commission’s Recommendation

One of the major changes coming to Aged Care is the strengthening of the Aged Care Quality Standards based on the findings and recommendations of the Aged Care Royal Commission. A key area of focus of the Royal Commission was the nutrition, hydration and dining experience of residents in aged care.

The Royal Commission recommended:

imposing appropriate requirements to meet resident nutritional needs and ensure meals are desirable to eat, having regard to a person’s preferences and religious and cultural considerations. 

New requirements

Following the review of the Quality Standards, the Pilot Draft of the Revised Quality Standards now contains Standard 6: Food and Nutrition. This is a completely new standard, which will apply only to residential aged care services.

Standard 6’s expectation statement for older people is: 

I receive plenty of food and drinks that I enjoy. Food and drinks are nutritious, appetising and safe, and meet my needs and preferences. The dining experience is enjoyable, includes variety and supports a sense of belonging. 

Standard 6 notes that access to nutritionally adequate food is a fundamental human right, and draws attention to the fact that food, drink and the dining experience can greatly impact a person’s wellbeing. The Standard sets out a number of new concepts for aged care providers, including new or enhanced actions and requirements to: 

  • Partner with older people on how to create an enjoyable food drinks and dining experience;  
  • Monitor and continuously improve food services in accordance with the feedback of older people;  
  • Regularly assess the nutritional and dining needs of each older person;  
  • Review menus in partnership with both older people and health professionals;  
  • Promote choice about what, when, where and how older people eat and drink;  
  • Offer and enable access to snacks and drinks at all times;  
  • Ensure sufficient workers are available to assist in the dining experience;  
  • Ensure that the dining experience promotes belonging and enjoyment; and 
  • Offer older people the opportunity to share food and drinks with their visitors.  

New resources from the Commission

The Commission has recently released some new resources to help providers better understand the importance of choice in food and drink in aged care, as well as the dining experienceThe full list of the Commission’s resources includes information for providers, staff and consumers, and can be found here. Some of the key new resources are:

How SPP can help

To assist providers get up to speed with the new food and nutrition requirements that will be in Standard 6, we’ve recently summarised all necessary information into a helpful information sheet. We have also incorporated the new and enhanced actions and requirements of Standard 6 into our comprehensive policy document.  

  • Info: Nutrition, Meals and Hydration 
  • Policy: Nutrition, Meals and Hydration (Aged Care) 

Other resources for service providers

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Latest from the Disability Royal Commission

The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (the DRC) is set to deliver its final report by 29 September 2023. Ahead of the final report, we’ve been tracking some of the common themes that have emerged from the latest Public Hearings, to identify likely recommendations that we might see in the final report.

Public Hearing 32 examined violence, abuse, neglect and exploitation of people with disability, and the role that provider policies and procedures play in safeguarding participants. Public Hearing 32 was the final time in the DRC’s process that service providers were examined, so it is a useful insight into the recommendations for providers that we might see in the final report.

There are some common themes throughout the Counsel Assisting submissions to Public Hearing 32 for which we have developed resources. Our resources will help providers to get on the front foot in terms of best practice service delivery.

Safeguarding

Preventing and responding to violence, abuse, neglect and exploitation of people with disability is not a new concept for NDIS providers, however Counsel Assisting submissions to the DRC identified a number of processes which should be implemented by providers to ensure that the rights of participants are upheld, including:

  • implementing proper recruitment, training and oversight processes to ensure that all workers understand and uphold the core rights of participants. This includes exercises such as conducting reference checks and querying gaps in employment history; and
  • implementing appropriate redress processes, including the important step of making apologies when redress is required.

Trauma–Informed Care

Public Hearing 32 introduced the concept of trauma-informed care to the disability sector, particularly in the context of cultural safety for Aboriginal and Torres Strait Islander participants. Providers should incorporate principles of trauma-informed care into all aspects of the organisation, recognising that everyone may have a history of trauma, and that everyone’s responses to trauma and needs arising from trauma will be different.

Establishing effective trauma-informed care procedures contributes both to a safer care environment for participants, and to care that is person-centred and tailored to the unique needs of each participant.

Supported Decision-Making

Supported decision-making is another area that has been closely examined by the DRC. Understanding each participant’s will and preferences was highlighted as central to supporting the decision-making process. Organisations should presume that every adult participant has the ability to make decisions that are directed by their will and preferences, unless there is evidence otherwise.  Organisations should implement processes to seek to understand and document each participant’s will and preferences, and then ensure that they and their families are actively involved in all decisions.

While it was not explicitly called for in the Counsel Assisting submissions, a clear emerging principle in this area is that substitute decision-making should be a last resort only.  An organisation’s supported decision-making processes should prioritise supported decision-making in partnership with the participant, and only utilise substitute decision-makers as a last resort, when someone is unable to assist in making a decision, or does not want to make a decision.

Human Rights & Dignity

Clearly understanding and protecting all participants’ human rights is an issue which has been consistently raised by Counsel Assisting submissions, and the DRC more broadly. Enshrining each participant’s human rights in policies and procedures is a core governance concept for NDIS Providers. The DRC has pointed out that, whilst providers should have a human rights policy, it is essential to ensure that the processes outlined in the policy are clearly communicated to, and understood by, all workers so that they are consistently implemented and followed in practice, throughout the organisation.

Co-design

Co-design was also a common theme throughout Public Hearing 32. There are some guiding principles of co-design which providers should follow, including:

  • Representation in the design process, particularly including people with lived experience and diverse cultural representation;
  • Effective leadership and acceptance of change;
  • Education and training for staff;
  • Empowering staff to make change;
  • Communication and information sharing to draw on the experiences and expertise of other providers; and
  • Monitoring, evaluation and continuous improvement.

For more information about co-design, see our blog post on the topic.

How we can help

We have developed and updated several resources to help you implement processes to address the above common themes. These resources include:

  • Policy: Safeguarding (Responding to Abuse);
  • Info: Safeguarding (Responding to Abuse);
  • Policy: Supported Decision-Making and Dignity of Risk (NDIS);
  • Policy: Supported Decision-Making and Dignity of Risk;
  • Policy: Trauma-Informed Care;
  • Policy: Trauma-Informed Care (Disability); and
  • Policy: Trauma-Informed Care (Child Safe).

We are also in the process of developing resources for:

  • Human rights and dignity of risk; and
  • Inclusive co-design.

Towards better practice!

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Victorian social services framework- what’s changing? 

Currently, Victorian social service providers are required to comply with multiple different sets of regulations depending on the services they offer. Ensuring compliance with overlapping registration, reporting and regulatory requirements overburdens these organisations, in some cases requiring duplicate reporting or conflicting requirements between different frameworks.

In order to streamline the various social services frameworks, the Victorian Department of Families, Fairness and Housing recently released a Consultation Draft of the Social Services Regulations 2023. They are designed to provide a single cohesive regulatory framework for all registered social service providers in Victoria. The new framework aims to both increase efficiency of the social service system by simplifying registration and reporting requirements for providers, and improve the safety of Victorian consumers who engage with the social service system. 

When is the new Victorian social services framework coming into effect?

Following the conclusion of the consultation period on July 16 2023, the final version of the regulations is expected to be published in late 2023, with the scheme commencing on July 1 2024.

Who will it apply to?

There are approximately 700 providers operating in Victoria that will be covered by the scheme, including providers of: 

  • child protection services and secure welfare services delivered by the department; 
  • community-based child and family services,  
  • out of-home care services for children and young people;  
  • disability support services; 
  • family violence services, including services for perpetrators;  
  • sexual assault services; 
  • homelessness services; and 
  • supported residential services. 

What are the main features of the new framework?

As a comprehensive scheme, the framework will encompass multiple stages of regulatory compliance, from establishing the requirements for providers, to monitoring compliance. Some of the key features of the framework include: 

  • The Victorian Social Services Standards; 
  • The establishment and appointment of a new, independent Social Services Regulator; 
  • A Worker and Carer Exclusion Scheme; and 
  • Mandatory registration requirements for organisations providing services within the scope of the scheme.

A brief explanation of each of these features is below, however more in-depth information is also available on the Department’s website.

The Standards

The new Victorian Social Services Standards are the core requirements that registered service providers will need to comply with. The six Standards are: 

  1. Safe service delivery  
  2. Service user agency and dignity  
  3. Safe service environment 
  4. Feedback and complaints  
  5. Accountable organisational governance 
  6. Safe workforce 

The Standards are available to view on Page 56 of the Draft Social Services Regulations, for providers looking for more specific details on each requirement.  We’ve also summarised them in a document that you can access after you log in to SPP.  

The Regulator

The new Social Services Regulator replaces the existing Human Services Regulator and will be appointed in the second half of 2023. They will be granted monitoring and enforcement powers to aid their response to any risks of harm in service provision and will be actively involved in checking workers and carers’ suitability against the Exclusion Scheme. 

The Worker and Carer Exclusion Scheme

The Worker and Carer Exclusion Scheme will replace the Victorian Carer Register and act as a safeguard against risks of harm for service users.  Providers wishing to employ workers or carers will need to request the regulator to check each individual against the database to ensure that they do not pose a risk of harm before they are employed.  

Registration

Service organisations within the scope of the framework must be registered to confirm the suitability of the organisation itself and its key personnel to provide services to its users. Suitability matters include: 

  • Criminal history;  
  • A history of fraud;  
  • Findings of misconduct; 
  • Whether registration to provide a social service has been revoked, or has had any conditions/sanctions/restrictions placed on it; and  
  • Whether the person/business has been insolvent. 

Registration will also assess a provider’s arrangements, such as their governance structures, insurance and financial capacity, and determine whether the provider and its key personnel have sufficient qualifications, skills and experience to deliver safe and quality services to its users. 

SPP and the new Victorian Social Services Standards

To help you understand all of the requirements and intended outcomes of the new draft Social Services Standards, we’ve built a new self-assessment module in SPP. Of course, if there are any changes made to the final form of the Standards later this year, we will update our module for those changes. 

And for providers who have been using our existing self-assessment module to follow the current Human Services Standards, we have a mapped self-assessment in the new Standards, so that you can quickly compare the two sets of standards and identify any additional areas of work required.

Are you ready for the new Victorian Social Services Framework?

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Sexual harassment and discrimination… what you need to know

Several legislative changes have come into effect recently, resulting in new protections against workplace sexual harassment and discrimination. Both the Fair Work Act and Sex Discrimination Act have received updates 

The updates impose a duty on employers to take proactive and meaningful action towards the elimination of workplace sexual harassment and discrimination.

The Fair Work Act

The most important changes to the Fair Work Act include:  

  • Specific definitions of sexual harassment and the meaning of sexually harassed at work;  
  • Clarification of the meaning of a ‘worker’;  
  • Inclusion of sexual harassment as a valid reason for dismissal; and 
  • New powers of the Fair Work Commission to grant orders to stop sexual harassment. 

The Sex Discrimination Act

Some of the key changes that have been introduced to the Sex Discrimination Act include: 

  • Prohibition of conduct that results in a hostile workplace environment based on gender; and 
  • New investigatory and compliance powers of the Australian Human Rights Commission (commencing December 2023 to allow employers time to ensure compliance).  

These legislative updates require employers to take steps to prevent sexual harassment and discrimination in the workplace before it occurs, rather than responding to incidents when they occur. 

For more information about the new legislative changes, see this summary from the Fair Work Ombudsman.

How we can help

To help you stay across these changes, we have revised two of our resources relating to discrimination and workplace conduct to reflect the updated definitions and expanded processes relating to sexual harassment and gender-based discrimination in the workplace.

The two updated resources are:

  • Policy: Harassment and Bullying; and  
  • Policy: EEO, Equity and Diversity.

You can find the updated resources in our Reading Room under the ‘workplace relations‘ -> ‘human resources‘ subtopics. 

Ready to improve workplace protections?

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What makes a good Quality Management system?

Managing and continuously improving quality is the core business of every service provider. Quality management is the action you take to make sure that you always provide the best possible service to your clients. It involves:

  • Evaluating your services to ensure they align with performance indicators contained in relevant standards;
  • Listening to clients, workers and other stakeholders, and valuing their feedback;
  • Understanding what is working well;
  • Identifying where improvements are needed; and
  • Taking action in order to best meet the needs of clients, workers and other stakeholders.

All major sets of Standards require organisations to have effective quality management and continuous improvement systems in place.

The quality improvement process

Quality improvement is not a singular action. It requires a cycle of continuous improvement, in which you are reviewing your systems, services and processes to evaluate whether you are providing the best possible service to each client. 

This cycle is commonly known as the ‘Plan/Do/Check/Act’ cycle and follows four key stages.

Plan:

The planning stage involves evaluating the current state of your organisation and identifying where improvements can be made. In this phase, you should reflect on how you are delivering the services you are providing, your organisation’s compliance with relevant Standards, and feedback and complaints received to determine areas for improvement. Any incidents and near misses that have occurred should also inform your evaluation. The results of this evaluation should be used to plan ways that your service provision can improve, set goals and identify actions to put the plan into practice.

Do:

The next step of the quality improvement cycle is to action your planned changes. This could involve implementing improvements in stages, or testing variations of a planned change to determine the best solution in practice. Relevant stakeholders should be informed of the changes, and what that could mean for them. Adequate resources should be allocated for the purpose of executing the changes successfully, whether that involves extra funding, increased staffing, or more time. It is important that you document the decisions made during this stage, as this data will be used in the next stage of the process.

Check:

During the checking stage, you should be analysing both qualitative and quantitative results from the changes, to determine whether they are achieving the expected outcomes and resulting in better services. Feedback from stakeholders should be sought on their experiences with the changes, as well as any comments they have on further improvements. You should consider reflective questions during this stage to aid evaluation, such as:

  • Are the improvements delivering the outcomes as we intended?
  • What were the major gaps in our service delivery from our planning process, and have we addressed these gaps?
  • Are there any unforeseen outcomes from the changes?
  • Are there further improvements we can make, or can we make the process more efficient?

Act:

In this part of the cycle you should decide whether or not to implement the changes based on your evaluation. If the evaluation results demonstrate the changes were not successful, you should revert back to the planning stage to repeat the process and determine a new plan that is based on learnings from the unsuccessful trial.

If the results do show improvements meeting or exceeding your established goals, you should implement the changes and incorporate them into your regular service delivery. You should inform all stakeholders of the changes, including the differences between the old and new procedures, and ensure that all workers are trained in the new processes. Make sure you also update your policy and procedure documents where appropriate, to reflect the changes you’ve implemented.

Feedback, Complaints, Incidents and Near Misses

One of the most important ways you can gather information about the services you provide is through the information you receive from stakeholders, including workers, clients and their support people. Efficient and accessible feedback and complaints mechanisms ensure that those who are impacted can easily communicate their opinions and experiences with the service. In particular, if there is a lived experience disconnect between your clients and decision-makers in your organisation (for example services for children or young people), feedback is an important way to broaden perspectives in the quality management process.

In addition, encouraging clients to work in collaboration with your organisation to tailor services to their unique needs allows you to both provide the best possible service to your clients , as well as meet wider standards obligations. The requirements in many sets of standards include partnering with clients and providing culturally competent services for each individual. Meeting these standards requirements is part of consistently providing the best possible service to your clients and ensuring quality care.

So, what does a good quality management system look like?

An effective quality management system underpins your organisation’s approach to service delivery, and provides the framework for how you deliver quality and safe services for each individual.  Quality management should be incorporated as a core facet of the service and be explained clearly in your quality management policies and procedures, as well as policies on related areas.

Your quality management system should:

  • Be founded on core policies and procedures that are communicated and understood across your organisation, so that your approach and processes are transparent to everyone, set clear expectations and responsibilities for workers and the organisation, and are consistently followed;
  • Be supported by other, related policies and procedures covering areas such as:
    • risk management;
    • compliance monitoring;
    • complaints management; and
    • incident reporting
  • Be integrated with your Standards compliance status;
  • Allocate responsibilities to team members for identified improvements; and
  • Be easy to manage, and provide you with up-to-date reports on compliance, improvements identified and how you are tracking towards achieving them.

In conclusion, having a good quality management system is important for organisations to ensure they are providing the best possible services for their clients as well as fulfilling their standards obligations.

Improving your quality management system with SPP

SPP has a wide variety of information sheets and templates available to help you reach your quality management goals, from a template quality improvement register and quality improvement plan to a sample quality management and continuous quality improvement policy. We also have a “Towards Best Practice” self-assessment module on Continuous Improvement.

In addition, we have a range of resources on related topics like risk, complaints, and incidents support the delivery of quality service. 

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Cultural diversity and cultural competence in service delivery

The Australian population is incredibly diverse and multicultural. With this diversity comes the challenge of ensuring that all individuals, regardless of their cultural background, have equal access to services and support. 

Organisations providing services to the public must be prepared to respond to the diverse and individual needs of each client and ensure that the organisation and its staff are culturally competent.  

What is cultural competence?

A culturally competent organisation: 

  • understands and responds to the unique needs of individuals from diverse cultural backgrounds; and 
  • improves feelings of cultural safety for clients and staff, making them feel that their background, values, identity and needs are respected and valued for the diversity they bring to society and to the organisation.  

When a client feels culturally safe, they feel as if the organisation cares about them as an individual, and that they are seen as a person, not simply part of a homogenous group. Meeting someone’s cultural needs can indicate that an organisation will take care to meet a person’s other unique needs.

And what is cultural diversity?

Cultural diversity encompasses many forms or aspects of identity, including:

  • Cultural identity
  • Ethnic identity
  • Nationality
  • Class
  • Education
  • Language
  • Religion
  • Spiritual views
  • Gender
  • Sexuality
  • Political orientation
  • Age

Each one of these factors will contribute to a person’s identity, how they see the world and their needs when receiving services. 

It is important to note that a ‘one-size-fits-all’ approach to cultural competence will not adequately address the needs of clients, as multiple aspects of their identities intersect to create unique strengths and vulnerabilities. 

Organisations must therefore prioritise a flexible and adaptable approach to service delivery, and ensure staff are able to respond effectively and appropriately to the varying and individual needs of each client.

Strategies for cultural competence

1. Culturally diverse staff

Having a diverse workforce allows an organisation to have broad perspectives of how different actions may impact on people from varying cultural backgrounds and provide insight into changes to improve the cultural safety of clients. Having staff available who share their cultural background can help clients feel that their cultural identity and needs will be respected and valued during their time engaging with the service. In addition, a diverse workforce helps staff improve their cross-cultural communication skills, which can then flow on to better communication outcomes for clients.

2. Ongoing reflection on services

Cultural competence is not a singular action. As the diversity of the organisation’s clients and staff changes, the organisation must constantly reflect on the services it provides and whether they are appropriate for the current demographics. To improve their cultural competence, especially where client demographics have changed, it may be appropriate to partner or consult with local cultural or community groups to ensure the service meets cultural needs.

3. Client involvement in service delivery

The unique experiences of each client means that what they need from a service may be equally as unique. Allowing clients input into aspects of their experience with your organisation allows them to receive a service that is appropriate for them, improving their sense of cultural safety and their perception of the service. In residential services, this is especially important in making the service feel like a ‘home’ for residents.

Cultural diversity and compliance

Cultural diversity is increasingly being incorporated into quality standards for services. This means organisations must be culturally competent and have strategies for engaging with diverse clients in order to meet their standards obligations. 

All of the major national and state/territory standards have cultural diversity requirementsHere are just a few, by way of example only: 

  • Aged Care Quality Standards

  • Australian Service Excellence Standards

  • Human Services Quality Framework (Qld)

  • Human Services Standards (Vic)

  • National Safety and Quality Health Standards (and a number of aligned standards)

  • National Principles for Child Safe Organisations

  • NDIS Practice Standards

  • RACGP Standards

Self-assessments for all of the above standards are available for providers in SPP. 

BNG and Cultural Diversity

We’ve recently updated some of our cultural diversity and cultural competence resources to better assist service providers with their cultural competence.  

  • Good Practice Guide: Cultural Competence 
  • Info: Cultural Diversity 
  • Policy: Diversity and Cultural Inclusion

Other resources for service providers

Aged Care Diversity Framework action plans four action plans to assist aged care providers when engaging with diverse clients, Aboriginal and Torres Strait Islander clients, CALD clients and LGBTI clients. All four action plans are available as self-assessments on SPP. 

The Centre for Cultural Diversity in Ageing has developed the Inclusive Service Standards and accompanying supportive resources to assist aged care providers in the development and delivery of inclusive services to all clientsSPP also provides a self-assessment for the Inclusive Service Standards. 

Ready for cultural change?

Sign up for a free trial of SPP for resources to help your organisation’s cultural competence.

Psychosocial hazards and psychological safety in the workplace

Potential risks to physical safety in the workplace are often easy to identify. However, potential psychological hazards aren’t always as easy to spot, yet can cause just as much harm to a person who is impacted by them.

As an employer, you have a duty to protect your employees from risks to their health, including psychological health. It’s important to note that every jurisdiction has different laws and regulations about psychological safety. Your obligations as an employer will be shaped by the rules that apply to you, however much of the guidance available is useful for employers as best practice even where it is not mandatory.

What are psychosocial hazards?

A psychosocial hazard is a hazard that arises from, or relates to, 

  • the design or management of work, 
  • a work environment, 
  • plant at a workplace, or 
  • workplace interactions and behaviours 

and has the potential to cause psychological harm or injury (Work Health and Safety Regulations 2011 (Cth) section 55A).

Depending on the nature of the workplace, some psychosocial hazards may always be present, while others may temporarily arise due to some change in working conditions. For example, the risk of emotional trauma connected to the loss of a patient in aged care is high and ever-present due to the nature of the work, whereas a psychosocial hazard connected to working increased hours due to staff shortages because of illness is likely to be temporary in nature. In many cases, one or more hazards will interact, and the effects compound to create a greater risk of harm.

Types of psychosocial hazard

There are three broad categories of psychosocial hazards that employers must manage: 

  1. The working environment – includes hazards such as working in high risk areas, working in remote or isolated areas or working unusual shift patterns. 
  2. The work itself – does the work require unusually high or low levels of mental load, does the work involve exposure to traumatic events or material, and is the workload unreasonably high? 
  3. Interpersonal conflicts  including between staff, poor management of the workforce, or mistreatment of staff by consumers. 

Personal issues faced by staff outside the working environment may compound their risk of psychological harm. While employers can’t control these hazards, they may be able to work with staff to ensure that the workplace does not contribute to the staff member’s risk of psychological injury.  

Appendix A of the model Code of Practice – Managing psychosocial hazards at work 2022 (Cth) provides a detailed example list of common psychosocial hazards, and potential control measures for each.

What is the current legislative status?

Most states and territories have implemented the model Work Health and Safety laws. As of April 1 2023, some jurisdictions have updated their Work Health and Safety Regulations and introduced a Code of Practice to specifically cover psychological safety and psychosocial hazards. Victoria’s psychological safety falls under its Occupational Health and Safety Act, and reforms are currently underway to better incorporate psychological safety into the existing occupational health and safety regulations.

See the below table for a brief summary of the psychological safety legislative requirements per jurisdiction, or refer to Safe Work Australia for more detailed information. 

What do I have to do to manage psychosocial hazards?

In all jurisdictions, employers have a duty to ensure the health and safety of their workers where “reasonably practicable”. This includes considering: 

  • whether the hazard was reasonably foreseeable; 
  • the potential severity of the harm that could occur; 
  • whether the organisation or its management knew or should have known about the hazard; 
  • whether there are any available and suitable methods of controlling the risk from the hazard; and
  • the cost of managing the risk. 

Other benefits of good psychological safety

In addition to making sure you’re meeting your legal obligations, good management of psychosocial risks can flow on to benefit the organisation. 

Demonstrating care for the wellbeing of employees and making work a mentally healthy place can boost staff retention rates, while staff who aren’t affected by psychological injury are less likely to require time off work, leading to more predictable and consistent rostering.  

Checking in with the workforce about psychological health can aid the organisation in understanding the challenges and difficulties staff are facing, while reviewing policies and processes for psychological safety can lead to operational changes improving service delivery.  

How SPP can help

We’ve updated these resources for you, which are available in SPP’s Reading Room: 

  • Info Sheet: Psychological Safety in the Workplace
  • Policy: Psychological Safety for Staff

Ready to improve psychological safety?

Sign up to SPP and see how our resources can help you become a psychologically safe workplace!