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Residential Care Performance Audit ProgramDepartment of Health and Human Services

Document title

Residential Care Performance Audit ProgramDepartment of Health and Human Services

Residential Care Performance Audit Program

To receive this publication in an accessible format phone 03 9096 8768 using the National Relay Service 13 36 77 if required, or email the Compliance and Quality Unit <c&[email protected]>.

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, Department of Health and Human Services, August 2018.

Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people. Indigenous is retained when it is part of the title of a report, program or quotation.

ISBN 978-1-76069-523-1 (pdf/online/MS word)

Available at http://providers.dhhs.vic.gov.au/program-requirements-out-home-care-services


mailto:c%[email protected]

Contents

Introduction............................................................................................................................................... 1

Background............................................................................................................................................ 1

Purpose.................................................................................................................................................. 1

Program requirements for residential care in Victoria..........................................................................2

Human Services Standards..................................................................................................................... 3

Residential care performance audits......................................................................................................4

Roles and responsibilities....................................................................................................................... 5

Residential care providers...................................................................................................................... 5

Operational Performance and Quality.....................................................................................................5

Authorised Officers................................................................................................................................. 5

Department divisional staff..................................................................................................................... 5

House ratings............................................................................................................................................ 6

Audit methodology and scope................................................................................................................7

Methodology........................................................................................................................................... 7

Sampling method.................................................................................................................................... 7

Duration of audits................................................................................................................................... 7

Audit preparation.................................................................................................................................... 7

Rating audit findings............................................................................................................................... 8

Audit report............................................................................................................................................. 8

Review requests..................................................................................................................................... 9

Action plan.............................................................................................................................................. 9

Residential care audit criteria and evidence considerations..............................................................10

Section 1: Case, cultural and care planning.........................................................................................10

Section 2: Managing challenging behaviours.......................................................................................11

Section 3: Responding to adverse events including those categorised as critical incidents.................12

Section 4: Health.................................................................................................................................. 13

Section 5: Environmental safety...........................................................................................................14

Section 6: Operational and human resources.......................................................................................15

Residential care audit rating system....................................................................................................18

Appendix 1: Residential care – client file audit tool............................................................................21

Appendix 2: Residential care – staff file audit tool..............................................................................25

Appendix 3: Site/unit audit tool.............................................................................................................28

Property and fire safety.........................................................................................................................29

General observations............................................................................................................................ 30

Policies................................................................................................................................................. 30

Fire evacuation training........................................................................................................................ 31


Staff supervision................................................................................................................................... 31

Staff interview questions.......................................................................................................................32

Unit-level debrief/exit notes.................................................................................................................. 37

Head office exit notes........................................................................................................................... 37


Introduction

Background The Human Services Standards (the Standards) apply to community service organisations (CSOs) that deliver direct client contact human services activities (children, youth and families, disability services, homelessness services, family violence and sexual assault services). Compliance with the Standards and Program requirements for residential care services in Victoria (October 2016) and Program requirements for the delivery of therapeutic residential care in Victoria (October 2016) (‘program requirements’) is required as a condition of the Service Agreement with the Department of Health and Human Services (the department) and/or registration under the Disability Act 2006 and the Children, Youth and Families Act 2005.

In January 2015 unannounced audits of CSOs were introduced as part of a ministerial initiative designed to monitor the health, safety and wellbeing of children and young people in residential out-of-home care placements. The audits may include discussions with young people, in-person observations, interviews with staff and an examination of documentation. These audits complement the existing certification process, which requires external reviews every three years and one mid-term review in the cycle by a department-endorsed Independent Review Body (IRB) against the Standards.

A department-led program of compliance and quality audits against the program requirements commenced in March 2015. The audits of residential care providers focus on assessing each CSO’s compliance with key program requirements. The audit team sits within the Compliance and Quality Unit, Operational Performance and Quality Branch, Children, Families, Disability and Operations Division.

All operational residential care houses1 have now been audited at least once under the house rating system. A review of the residential care audit program was completed in early 2018, in consultation with sector representatives, to identify areas for improvement. Based on this feedback, the residential care audit criteria and methodology have been refined.

PurposeThe purpose of this document is to describe the refined audit methodology by which house ratings will now be applied. The methodology remains structured, objective and consistent.

In conducting the audits, the Operational Performance and Quality Branch aims to improve the outcomes for children living in residential care services. The audits achieve this by:

ensuring that CSOs comply with key criteria set out in the program requirements2

ensuring that funded CSOs deliver quality services that meet the Standards, focusing on the safety and wellbeing of children

moving CSOs beyond minimum compliance through continuous improvement.

To ensure these aims are achieved, the audit team will demonstrate a commitment to carrying out the compliance audits in a transparent, consultative and consistent manner.

1 This may exclude newly established contingency units that commence on a short-term capacity and are not noted in the Client Relationship Information System (CRIS) extract being utilised by Operational Performance and Quality.2 Therapeutically funded units are also assessed against key criteria within the Program requirements for the delivery of therapeutic residential care in Victoria (October 2016).

Residential Care Performance Audit Program Page 1

Program requirements for residential care in Victoria

The department is responsible for planning, managing, funding and delivering housing and community services for Victorians.

The department funds a range of community-based child and family services to promote the safety, stability and development of children and their families, and to build the capacity and resilience of children, families and communities.

Together with its service partners, the department is responsible for assisting children and families who need support or protection, including:

children subject to, or at risk of, harm, abuse and neglect Aboriginal children subject to, or at risk of, harm, abuse or neglect children who need support to remain with their family families that need support to ensure an appropriate, safe and stable developmental environment for

their children.

The program requirements are the prerequisites for providing quality services for children in residential care throughout the state. These requirements are designed to be used, where relevant, in conjunction with the program requirements for the delivery of therapeutic residential care.

The program requirements are statements of what CSOs providing residential care services must do to meet service expectations. In line with the Children, Youth and Families Act, the program requirements describe what CSOs need to do to provide services in a manner that is in the best interests of the child or young person.3 In general, the requirements do not outline how to provide services. This information can be sourced from the range of program guidelines and other documents referenced in the program requirements. CSOs also have their own operational and procedural documentation to describe how the program requirements are implemented within that CSO.

3 Section 1.7 of the Children, Youth and Families Act


Human Services Standards

On 1 July 2012, the Department of Human Services Standards were implemented. These standards replaced three sets of standards that had been in use prior to that time (Standards for Disability Services in Victoria, Victorian Registration Standards for Community Service CSOs and Homelessness Assistance Service Standards). Now known as the ‘Human Services Standards’, the Standards apply to human services activities that involve direct client contact. The Standards represent a single set of service quality standards for department-funded and/or registered service providers and department-managed services. The Standards comprise the department’s four service quality standards and the governance and management standards of a department-endorsed IRB.

The Standards comprise:

Empowerment: People’s rights are promoted and upheld. Access and engagement: People’s right to access transparent, equitable and integrated services is

promoted and upheld. Wellbeing: People’s right to wellbeing and safety is promoted and upheld. Participation: People’s right to choice, decision making and to actively participate as a valued member

of their community is promoted and upheld. Governance and management: As determined by the department’s endorsed IRBs.

CSOs that are funded to provide direct client services are required to meet the Standards as an essential term of their Service Agreement. Those CSOs registered under the Children, Youth and Families Act, and the Disability Act, are obliged to meet the Standards set by the Minister under those Acts. The Standards also apply to a limited number of services delivered by the department including disability, residential and case management services. Details regarding the policy obligations of the Standards can be found in the Human Services Standards policy <https://providers.dhhs.vic.gov.au/human-services-standards-policy-word>.


https://providers.dhhs.vic.gov.au/human-services-standards-policy-word

Residential care performance audits

The department operates a program of compliance and quality audits focusing on client safety and the wellbeing of children in out-of-home care that supplements the existing accreditation model. The residential care audits are conducted against the applicable program requirements.4

Senior Compliance and Quality Officers from within the Operational, Performance and Quality Branch conduct the audits. The audits review unit-level performance against the program requirements using a consistent methodology and include:

speaking to staff and clients observing the physical environment, practice and staff–client interaction reviewing documents and files.

Examples of the types of evidence that may be requested during an audit are in the program requirements and in the ‘Residential care audit criteria and evidence considerations’ section of this document.

Auditors will:

speak with staff and clients – being aware that client participation is voluntary at all times be respectful of the fact they are in clients’ homes and endeavour to be unobtrusive have police checks, Working with Children Checks and carry authorised officer identification.

Any documentation obtained or copied will be managed in line with the department’s confidentiality procedures.

Any identified risk to clients will be raised with the CSO for their immediate attention and promptly reported to the Compliance and Quality Unit Manager.

A written report is provided to the CSO following the audit. The report details evidence assessed during the audit, identifying any areas of non-compliance against the program requirements. Where non-compliance is identified the CSO will be requested to submit an action plan detailing corrective actions to be taken once they receive the final report.

4 Therapeutically funded residential units are also assessed against the Program requirements for the delivery of therapeutic residential care in Victoria October 2016.


Roles and responsibilities

Residential care providersThe CSO is responsible for delivering service to clients in accordance with the program requirements and Standards. CSOs are obliged to prepare and maintain documentation that will serve as evidence of their compliance with their obligations. CSOs are also required to give the department and its auditor’s access to all information reasonably required to confirm compliance with the program requirements.

Following receipt of the final report, the CSO must develop an action plan to address all areas of non-compliance. The action plan must be submitted to the Compliance and Quality Unit, Operational Performance and Quality Branch within 10 business days of receiving the final report.

Operational Performance and QualityOperational Performance and Quality Branch is responsible for coordinating and completing residential care audits against the program requirements. The branch’s responsibilities include: developing the audit report; distributing the final report to CSOs and divisional staff; and distributing the action plan to divisional staff. The audit report and action plan are also uploaded to the department’s Service Agreement Management System.

Authorised OfficersSenior Compliance and Quality Officers within the Operational, Performance and Quality Branch conduct the audits. The auditors are authorised delegates of the Secretary to the department under the Children, Youth and Families Act, s. 17 and Authorised Officers under s. 194.

Specifically, as delegates of the Secretary under the Children Youth and Families Act, the auditors may at any time visit any community service:

(a) to make any examinations or inspections that appear to be necessary regarding the management of the community service; and

(b) to inspect any part of the premises of that community service; and

(c) to see any child who is receiving services from the community service; and

(d) to make inquiries relating to the care of children in that community service; and

(e) to inspect any document or record relating to the child or that is required to be kept under [the] Act or the regulations.

Department divisional staffThe final report is distributed to the CSO, the Divisional Deputy Secretary and other applicable divisional staff. The action plan is distributed to divisional staff. Divisional staff may choose to support a CSO to implement its action plan; however, the responsibility to develop and implement the plan remains with the CSO.


House ratings

A number of CSOs deliver residential care services across Victoria. The house rating system was introduced to assist the department and CSOs to monitor performance at each service delivery site. All operational residential care houses have now been audited at least once under the house rating system.

The house rating system also allows CSOs to clearly identify houses where there is a high level of performance against the Standards and program requirements from those where significant work may be required to meet the Standards and program requirements.

The starting point for audits of each house is 100 per cent compliance. Where areas of non-compliance are identified, points are deducted. The scoring and house rating system is outlined in the section entitled Residential care audit rating system.


Audit methodology and scope

MethodologyThe residential care audits involve a minimum of two Senior Compliance and Quality Officers attending the CSOs’ residential units and management offices to assess performance against the Standards and program requirements. The audits support safe and suitable residential care placements. This includes speaking with staff, making observations and examining key documentation such as:

client and staff files (hard copy or electronic) key policies and procedures information given to new staff and clients induction and orientation materials given to new staff.

Unit staff are interviewed regarding key policies and procedures, client care and operation of the unit.

Auditors will also assess each CSO’s compliance with key departmental policy and guidelines (for example, the Client Incident Management System).

Initial audit findings are discussed with the CSO as they emerge and a summary of findings is provided to management at an exit meeting prior to the end of the audit.

Sampling methodThe audit sampling method applies to each residential unit visited. This consists of auditing:

the files of all children and young people currently living in the unit a sample of staff files from the unit’s roster, including labour hire agency staff (capped at 10 staff).

A copy of the previous week’s staff roster is requested at the time of the audit. The program requirements for staff to be audited will include recruitment and safety screening processes (police checks and Working with Children Checks), reference checks, induction, supervision and training.

The review of staff files is conducted at an office location confirmed by the CSO.

Duration of audits The duration of the residential care performance audits may vary depending on the location and number of units being visited, the number of clients living in each unit and the location of the office to be visited.

The audit of a residential unit normally requires up to three days to complete. This includes the site visit and reviews of relevant staff files and any other records held at the CSO’s head office. Additional time may be required depending on the availability of information and any outstanding issues requiring follow-up.

Audit preparationCSOs receive notification of the audit seven business days before the proposed start date in writing via an email from the director of Operational Performance and Quality.

The audit notification letter requests that the CSO confirms within two business days:

that the site addresses to be visited are correct the names of the young people in residence a contact person for the duration of the audit.


The lead auditor will communicate with the CSO’s nominated contact to confirm the audit details including current clients, anticipated arrival and departure times and to answer any questions regarding the audit process.

Where appropriate the lead auditor will also call the CSO’s nominated contact before entering each unit on the day of the audit to confirm the visit can proceed.

Rating audit findingsEach residential care unit is assessed for its level of compliance with the audit criteria drawn from the program requirements relevant to its classification – for example, as a ‘therapeutic service’.

Audit findings against each criterion are rated as ‘compliant’ (C), ‘non-compliant’ (NC) or ‘not applicable’ (NA) against the program requirements, as set out in the site, client and staff file audit tools. Criteria rated as ‘compliant’ may or may not include comments in the audit report.

All units start the audit with 100 per cent compliance. Where areas of non-compliance are identified, points are deducted. The total score achieved is converted to a percentage and awarded a rating (level 1–4). Level 1 is the lowest rating (significantly underperforming) and level 4 is the highest rating (very good).

Where a residential unit meets all audited program requirements, it will be rated as 100 per cent compliant. Weighted scores are divided across client and staff program requirements.

CSOs receive feedback on provisional ratings during the audit. Where feedback is provided on criteria provisionally rated ‘non-compliant’ and the CSO believes it can provide evidence to support compliance that is not immediately accessible, auditors should advise that this will be considered if it is submitted within three business days of the audit. However, it is important to note that any additional evidence submitted must exist at the time of the audit. That is, action taken after the audit to address identified non-compliance will not result in any change to the initial findings/ratings.

Audit criteria and weighted scores are included in the ‘Residential care audit rating system’ section of this document.

Audit reportThe Compliance and Quality unit generates the audit report as per the following timeframes:

Requirement Timeframe

Draft report sent to CSO 15 business days following the audit

Right of reply period 10 business days from receiving the draft report

No appeals within timeframe Draft report finalised and sent to CSO. A copy is sent to the relevant operational division of the department.

CSO appeals audit finding Where a request for review is lodged and accepted the report findings will be reviewed and changes made where the evidence satisfies the requirements.Where additional evidence does not satisfy the program requirement the decision is communicated to the CSO and the report finalised.Note: Any additional evidence submitted must have existed at the time of the audit. That is, evidence developed post audit to address identified non-compliance cannot be accepted and will not result in any change to the initial findings/ratings.

Action plan submitted to Compliance and Quality Unit 10 business days from receiving the final report


Review requests

A review is a reassessment of the rating findings for one or more areas audited within the initial audit report. CSOs may request a review of an audit finding within 10 business days of receiving the initial audit report. The request for a review must be on factual grounds rather than opinion. Evidence must be submitted to support a review request.

If the CSO does not request a review within this timeframe, the report will be finalised and distributed to the relevant departmental contacts.

Action planWhere non-compliances are identified, the CSO must submit an action plan addressing the outstanding issues. While there is no set proforma for action plans, the CSO should, at a minimum, include the non-compliances identified, actions to address these and dates by which actions will be completed. Actions should focus on addressing the non-compliance issue at the system level.


Residential care audit criteria and evidence considerations

Section 1: Case, cultural and care planning

Program requirement (PR) Evidence requirements

Essential Information Records Essential Information Record (EIR) commenced within two weeks of placement with the CSO. The EIR is kept up to date.

Care and placement plan(s) or care and transition plan(s)

Care and Placement Plan or 15+ Care and Transition plan (as applicable) developed within two weeks of the placement beginning.

Assessment and progress record(s)

Assessment and Progress Record completed for clients who have been in care or six months or longer and at least annually thereafter. For clients under five years of age, this record must be completed every six months.

Responding to cultural needsClients from an Aboriginal background

Clients from an Aboriginal background are supported to maintain and develop their Aboriginal identity. Staff can demonstrate knowledge of local cultural supports in place such as local Aboriginal healthcare clinics, Elders,

mentors, youth groups and support from the Victorian Aboriginal Child Care Agency. Evidence of clients being provided opportunities to engage in cultural activities. For example:

- case plans and cultural support plans

- culturally appropriate books and toys

- links to Aboriginal services where possible.

Supporting children to have safe and appropriate contacts with family and friends

Staff are aware of and can articulate the safe contact procedure, including what to do where a child or young person has contact with a person who has been identified as unsafe (for example, report to care team, case manager or senior manager).

Evidence in the client file that staff ensure access visits are approved by the department/case manager. Evidence in the client file that children and young people are supported to establish or re-establish relationships with family,

extended family and other significant people. Evidence in the client file of follow-up/consultation with the care team or case manager or senior staff member where

contacts are deemed unsafe.

Engagement in education, training or employment

Each young person is engaged in education, training or employment. If disengaged, there is documented evidence of a plan to commence education and/or that the CSO has been in active

communication with the care team regarding each client’s educational needs. Note that attendance at school in Victoria is compulsory for young people aged between six and 17 years.



Referral to Springboard (for 16–18 year olds if not engaged and on an interim accommodation order, family reunification order or care by Secretary order) or evidence that the issue has been raised with a manager or case manager.

Section 2: Managing challenging behaviours


Therapeutic assessment reports and plans (designated therapeutic units only)

A therapeutic specialist is involved in assessing and developing treatment plans for the child or young person. The client file includes a Therapeutic Assessment Report (completed within six weeks of the current placement

commencing) and plan (where applicable).

Behaviour management plans

Can also be referred to as a risk management plan, crisis management plan, positive behaviour plan, safety plan or absconding plan

Behaviour management plans (behaviour plans may not be required for every child or young person) are in place where complex or risk-taking behaviours have been identified. Plans reflect the current behaviours/needs of the individual client and include strategies to assist staff in managing these.

The appropriate plan has a date when it was last reviewed and a follow-up review date. Behaviour management plans and/or risk assessments in use from a previous placement will be compliant as long as they

are reflective of the young person’s current complex needs or risk-taking behaviours. Staff can describe how they respond to disruptive/challenging behaviour in line with each young person’s behaviour

management plan.

Sexualised behaviour Staff are aware of clients who display sexualised behaviour. Staff can describe actions to manage client’s sexualised behaviour, in line with the client’s plan. If no client in the unit is identified as displaying sexualised behaviour no score is deducted.

Substance abuse All young people in the unit with substance abuse issues have been referred to a drug and alcohol treatment service. Substance abuse issues and strategies are discussed and coordinated at care team meetings. Day-to-day items that could be used as inhalants can be securely stored in the unit (where required).

Restrictive practice Where restrictive practices are in place there is a documented rationale that is regularly reviewed. The restrictive practice is endorsed by the appropriate senior manager.


Section 3: Responding to adverse events including those categorised as critical incidents


Client incidents Staff are familiar and comply with the departmental incident reporting requirements. Staff can describe when a client incident should be reported (an event or circumstance that occurred during service

delivery that resulted in harm or has the potential to harm), including how they assess harm or potential harm. A management representative checks the incident report and signs off before submission. Staff can talk through the last incident they reported and this is in line with the Client Information Management System

(CIMS) policy and procedure. Any serious events recorded in the unit communication book or day notes are reported and managed as per the CSO’s

incident reporting requirements (‘serious event’ refers to a client action that led to or placed self or others at risk of harm).

Absent/missing young people from the unit

The unit is following the departmental CIMS process. The response to absent/missing persons is consistent with CSO’s procedure. Staff use a risk assessment approach to support their decision making when considering when to report young people

missing. This may include consideration of:- the age and development of the client

- whether a client’s whereabouts are known

- whether there is a concern for the client’s or others’ safety and welfare

- any previous history of the client missing or absconding

- the drug and mental health status of the client

- the degree of contact with the client while they are missing.

Sexual exploitation Staff are aware of clients in their care who are at risk of sexual exploitation. Staff can describe what triggers/indicators they would look for that might indicate a young person is at risk of sexual

exploitation. Staff can describe steps they would take if they thought a young person was at risk of sexual exploitation, in line with the

CSO’s guidelines. Where a young person has been identified as at risk, staff can describe the strategies in place to address the risks of

sexual exploitation, in line with the young person’s behaviour support plan.


Section 4: Health


Health needs are met The unit complies with prescribed timeframes or requirements for conducting initial health assessments and attending to identified healthcare needs:- clients’ medical health needs (including general medical, dental, optical, auditory) are identified by a medical

practitioner as soon as practical or within three months of entering the CSO’s care for the first time (or for the first time during the current period of involvement)

- mental health and/or other specialist needs are identified and met.

Where a client is entering from another placement and it cannot be confirmed that a health assessment has occurred, another assessment will be required.

Refusals of young people to attend appointments must be documented to evidence the rationale for not completing a health assessment.

Specific details of any ongoing treatment required are documented in each client’s care and placement plan. Medical records are maintained including relevant health assessments/treatment and prescribed medication administration. There is evidence of annual medical and dental checks on file.

Medication management There is a policy and procedure to support safe management of medication (request a copy). Staff can demonstrate an understanding of and ability to access the policy and procedure. Medication is securely stored in a secure location. All medication sighted is within the expiry date. Medication is accurately administered and recorded. Medication is disposed of correctly. Incorrectly administered/missed medication or client refusal of medication is documented.

Sexuality education The unit is compliant with delivering sexuality education to clients, in line with the CSO’s policies and procedures. The CSO has a sexuality education policy (request copy). Staff are aware of and can access the policy. Staff can describe ways to support young people with their sexual health, in line with the CSO’s policy (consider age-

appropriate information/support regarding puberty, sexuality/sexual preference, safe sex and contraception, medical issues).


Section 5: Environmental safety


Property safety The unit is in good repair and in a reasonably clean condition. Staff understand their responsibilities in relation to reporting and actioning identified issues. Any property damage that poses a potential threat to the safety and wellbeing of children or staff is rectified immediately

(such as exposed wires, broken windows/doors).Emergency management Evacuation plans are displayed and current and reflect the current floor plan. The Evac Pack has appropriate contents including current client details

(h ttps://providers.dhhs.vic.gov.au/sites/dhhsproviders/files/2017-07/Evacuation-pack-contents-checklist-FRMU.doc ) A first aid kit is accessible to staff and the contents are regularly checked.Infection control A spill kit is in place and regularly checked. A sharps container is available, where required. Food is appropriately and hygienically stored.General Electrical leads are not in the way and are intact (cords are not trip hazards, no exposed wires, etc.). Chemicals are stored securely. Safety data sheets are available. Knives are stored securely and counted where a need is identified. Aerosols/razors are stored securely where a need is identified. Unit vehicles are registered. Where staff use their own vehicles to transport clients, the CSO has a process to ensure these

vehicles are registered. Vehicle keys are stored securely. Keys are stored within an area where clients are unable to easily access them.

Fire safety There is evidence of extinguishers and fire blanket six-monthly tagging and testing (last 12 months). A weekly fire safety checklist is completed (audit will check last two months). Fire drills are conducted and recorded as per program requirements (staff have participated in at least one fire drill in the

past 12 months). Designated exits are unobstructed. Doors/windows can be easily opened in the event of fire (where windows have locks, the keys are accessible in the event



of an emergency). Smoke detectors/alarms are present and illuminated (green light). Safety plans are in place where there is known fire-lighting behaviour(s). Smoking is not occurring inside the unit. Lighters/matches are stored safely, where there is known fire-lighting behaviours. There is a receptacle for safe disposal of butts outside the unit. A bushfire safety plan is in place where applicable (where a unit is located in a Victorian Fire Risk Register – Bushfire

(VFRR-B) area or assessed a being at high bushfire risk or their weather district is subject to a Code Red declaration).- Bushfire survival plans must include a relocation plan and be completed and updated annually for residential facilities

assessed as being at high bushfire risk.

Overnight safety plan The unit is compliant with the program requirement for every unit to have an overnight safety plan in place. The overnight safety plan is current and signed off by the department.5

5 From 1 October 2016, every residential care home in Victoria will be required to have an overnight safety plan to ensure a rapid response of additional staff when required, including the safe return of young people overnight.


Section 6: Operational and human resources


Safe recruitment There is evidence that staff including casual/hired staff, volunteers and students currently working in the unit have:- current Employee (E) Working with Children Check

- three-yearly police checks

- disclosable offences are reported/managed in line with departmental policy (where a category A offence has occurred, evidence of written approval on file from the director of Professional Practice and the Division Deputy Secretary. In all other cases a process of determining the applicant’s suitability for employment and discussion with relevant departmental area director is clearly documented)

- minimum two reference checks completed

- interview notes

- disqualified carer check prior to the staff member commencing.

A process is in place to identify where a staff member has lived overseas for 12 months or more in the past 10 years. Where this is confirmed, an international police check is conducted.

CSOs must run a disqualified carer check and register all residential staff (including labour hire agency staff) on the Electronic Carer Register as out-of-home carers.

Staff training Staff are provided with regular training and professional development opportunities relevant to their role (training completed on file, CSO staff training calendar).

CSOs maintain records of all staff detailing academic qualifications and relevant work experience. CSOs will have an induction training program for new residential carers. There is evidence that residential carers undergo training in the areas of:

- occupational health and safety

- fire and evacuation management

- infection control

- culturally sensitive caring

- Certificate IV in Child, Youth and Family Intervention (residential and out-of-home care).

The following mandatory units for the Certificate IV in Child, Youth and Family Intervention (residential and out-of-home Care) are to be completed:- CHCMHS007 – Work effective in trauma informed care



- CHCPRT009 – Provide primary residential care

- CHCCS009 – Facilitate responsible behaviour.

In addition, for therapeutic residential staff:- CHCPRT010 – Trauma unit

- or previously completed ‘With Care’ foundation training.

Workers who have completed the two (trauma) units CHCMHS007 and CHCPRT010 are considered to have met the two-day With Care foundation training requirements as outlined in the Program requirements for the delivery of therapeutic residential care in Victoria.

Staff supervision Staff records show that supervision is occurring in line with the frequency stated in the CSO’s policy and procedure (includes labour hire staff).

Complaints Information is readily available to children and young people about their rights and responsibilities. Staff demonstrate knowledge of the CSO’s complaints policy and procedure and its application at the house level.

Evidence may include:- coverage of complaints or feedback processes in a ‘welcome pack’ or similar for children and young people entering

residential care and their families- information about complaints or feedback processes visible around the house (for example, a brochure, charts on

display)- guidance on accessing information via the internet (which children and young people have access to)

- alternative/informal feedback processes such as weekly house meetings or direct approaches to staff.

Staff are able to articulate how they support young people to seek a resolution to their complaints. Staff are aware of young people’s right to access external support avenues when making a complaint (the child or young

person making the complaint should always be advised of their option to take their complaint to an external oversight body at any stage of the complaints process including the Victorian Ombudsman and/or Disability Services Commissioner).

For head office/regional office Follow up with head office/supervisor where a complaint has been made or an issue has been identified in the day

book/communication book and no complaint has been reported. What is their process for overseeing complaints? For example:

- complaints register

- reporting and analysis of themes



- evidence of changes that have resulted from complaints.


Residential care audit rating system

Each residential care unit is assessed for its level of compliance with the audit criteria drawn from the Program requirements for residential care in Victoria (October 2016). Therapeutically funded residential care units are also assessed against the Program requirements for the delivery of therapeutic residential care in Victoria (October 2016).

Audit findings against each criterion are rated as ‘compliant’ (C), ‘non-compliant’ (NC) or ‘not applicable’ (NA) against the program requirements. Criteria rated as ‘compliant’ may or may not be accompanied by a comment.

All units start the audit with the premise of 100 percent compliance. Areas of non-compliance identified will reduce the premise of 100 per cent compliance as points are deducted. The total score achieved is converted to a percentage and awarded a rating (level 1–4).

Where a residential unit meets all audited program requirements it will be rated as 100 per cent compliant. Weighted scores are divided across client and staff program requirements as shown in the table below.

Program requirement Component weighting Scoring Percentage of

compliance

Case, cultural and care planning 19 /19

Managing challenging behaviours 16 /16

Responding to adverse events including critical incidents

15 /15

Health 11 /11

Environmental safety 12 /12

Operational and human resources 27 /27

Total 100 /1006 /100%

The total percentage of compliance is awarded the following ratings:

Total percentage of compliance Rating Level Star rating

85–100% compliance Very good 47 Four stars

60–84% compliance Good 3 Three stars

30–59% compliance Requires significant improvement 2 Two stars

0–29% compliance Significantly under performing 1 One star

6 Total points of 96 if not a therapeutic unit and a reduction of one point if labour hire staff are not used.7 Non-compliance with any asterisked (*) audit criterion automatically precludes the CSO from achieving a level 4 or ‘very good’ rating.


Section 1: Case, cultural and care planning

Program requirement Weighting Scoring

Essential Information Records 3

Care and placement plans/15+ transition plans 3

Assessment and progress records 3

Responding to cultural needs 2

Supporting children to have safe and appropriate contacts with family and friends

4

Engagement in education training or employment 4

Subtotal 19

Section 2: Managing challenging behaviours


Therapeutic assessment plans and reports8 4 or N/A

Behaviour management plans 4

Restrictive practice 4

Sexualised behaviour 2

Substance abuse 2

Subtotal 16

Section 3: Responding to adverse events including client incidents


Client incidents 5

Absent/missing young people 5

Sexual exploitation 5

Subtotal 15

Section 4: Health


Initial health checks complete 3

Annual checks 1

Medical history 1

Medication administration 4

Sexual health education 2

Subtotal 11

8 Where the unit is not therapeutically funded this criterion is not applicable (NA). Residential Care Performance Audit Program Page 20

Section 5: Environmental safety


Property/safety issues 5

Fire safety 5

Overnight safety plan 2

Subtotal 12

Section 6: Operational and human resources


Disqualified carer checks/carer registration 4

Police checks 4

Working with Children Checks 4

Interview notes 1

Reference checks 1

Labour hire staff completed9 1 or N/A

Staff training 4

Staff supervision 4

Client complaints 4

Subtotal 27

Total 100

Note: Where a unit has scores deducted for not meeting requirements for disqualified carer check/carer registration, police checks or Working with Children Checks, this automatically precludes them from achieving a level 4 rating.

9 Where the unit does not use labour hire staff this criterion is not applicable (NA).Residential Care Performance Audit Program Page 21

Appendix 1: Residential care – client file audit tool

This audit tool is based on Program requirements for residential care in Victoria: October 2016. Its format has been amended here for information purposes only and is not intended to be used by auditors.

Client 1 name:

Residential unit:

Date of birth:

CSO intake date:

Case managed by:

Court order:

Referral document date:

Client 2 name:

Residential unit:

Date of birth:

CSO intake date:

Case managed by:

Court order:

Referral document date:

Case, cultural and care planning

Criterion Client 1 Client 2

Essential Information Record (EIR)10 Yes No NA Overdue Yes No NA Overdue

10 CSOs will commence recording in the EIR within two weeks of the placement. The EIR will be kept up to date by the CSO as part of the ongoing information gathering, care planning and review processes undertaken with the care team.



Date(s): Date(s):

Care and placement plan (CPP)11 Yes No NA OverdueDate(s):

Yes No NA OverdueDate(s):

15+ Care and transition plan (15+ CTP) Yes No NA OverdueDate(s):


Assessment and progress record (APR)12 Yes No NA OverdueDate(s):


Engagement in education13 School/program:Attendance:Other:

School/program:Attendance:Other:

Health needs


Children entering care for the first time (or for the first time during the current period of involvement) will undergo a comprehensive health assessment by a medical practitioner ASAP or within three months of entering care.

If a child is entering from another placement, the CSO confirms the last date on which the child received a health assessment and arranges any assessment and treatment required.

MedicalYes No NA OverdueDate(s):


DentalYes No NA OverdueDate(s):


OpticalYes No NA OverdueDate(s):

OpticalYes No NA OverdueDate(s):

11 CSOs will develop a CPP (for a child under 15 years) or 15+ CTP (for a young person aged 15 years or older) in conjunction with the care team as soon as possible, and within two weeks of the placement.12 An APR must be completed for every child who has been in care for six months or longer and at least annually thereafter. For children under five years, this record must be completed every six months. 13 There must be evidence that the young person is engaged, not just enrolled. If between 16 and 18 years old and not engaged in education, training or employment, look for evidence that the young person has a Springboard referral (statutory orders only).



AuditoryYes No NA OverdueDate(s):

AuditoryYes No NA OverdueDate(s):

Annual health check14 MedicalYes No NA OverdueDate(s):




Evidence of specialist and/or mental health assessments and ongoing treatment where a need is identified

Yes No NA Yes No NA

Medical records maintained such as health assessments and treatments, ongoing and prescribed medication administration

Yes No NA Yes No NA

Managing challenging behaviours


Therapeutic assessment plans and reports15 Yes No NA OverdueDate(s):


Behaviour/safety plans reflect current behaviours and needs16 Yes No NADate:

Yes No NADate:

14 Or evidence of appointments been made within this timeframe15 Where the unit is not therapeutically funded this criterion is not applicable (NA). Therapeutic assessments within the TRC program should be completed within six weeks.16 Where applicable includes issues relating to sexualised behaviour, substance abuse, absconding and/or sexual exploitation


Responding to adverse events including client incidents


All details from a client incident are clearly documented in the client file

Yes No NAComments:

Yes No NAComments:

Additional notes


Appendix 2: Residential care – staff file audit tool This tool has been adapted from DHHS Human Services Standards: Staff, volunteer and carer file audit tool (November 2016). Its format has been amended here for information purposes only and is not intended to be used by auditors.

Residential unit:

Audit date:

Staff member 1 name:

Date started with CSO:

Date started at unit:

Labour hire staff? Yes No

Staff member 2 name:

Date started with CSO:

Date started at unit:

Labour hire staff? Yes No

Staff recruitment

Criterion Staff member 1 Staff member 2

Initial police check dated within past three years Yes NoExpiry date:

Yes NoExpiry date:

Three-year renewal completed Yes No NAExpiry date:

Yes No NAExpiry date:

Disclosable offence17 Yes No Yes No

17 If a person’s national police history includes a Category A offence, the individual should not be engaged in any client contact role without the written approval of the director of the Office of Professional Practice and the Divisional Deputy Secretary. In all other cases, the relevant manager in the funded/registered organisation will manage the assessment process to determine the applicant's suitability for



Number: Number:

Written sign off from the department to proceed Yes No NADate:

Yes No NADate:

International police record check18 Yes No NA Yes No NA

‘Employee (E)’ Working with Children Check Yes No NAExpiry date:

Yes No NAExpiry date:

Disqualified carer check Yes No NA Yes No NA

Staff member added to carer register Yes NoDate:

Yes NoDate:

Referee checks × 2 Yes No Yes No

Interview notes Yes No Yes No

Orientation and induction completed19 Yes No Yes No

Labour hire staff – additional requirements


Attachment 3 (completed checklist)20 Yes No Yes No

Attachment 4 (signed undertaking)21 Yes No Yes No

employment or placement (refer to Appendix 5 Safety screening assessment instructions and form) and discussion occurs with the relevant departmental area director.18 Required for applicants who have spent 12 months or more overseas during the past 10 years – completed by the relevant overseas police force.19 For labour hire staff, evidence of completed labour hire services procedures: Attachment 5: CSO action checklist – management of contract worker [refer to section 2.5 of the department’s Labour hire procedures: Engaging labour hire agency residential care staff in out of home care (June 2015)]20 Attachment 3 is the ‘Labour hire agency checklist – placement of contract worker’ template.21 Attachment 4 is the ‘Confidentiality and privacy undertaking of contract worker’ template.


Staff training


Training in fire and evacuation management Yes No Yes No

Training in occupational health and safety Yes No Yes No

Training in infection control Yes No Yes No

Training in culturally sensitive caring Yes No Yes No

Certificate IV in Child, Youth and Family Intervention (residential and out-of-home care)22 The following mandatory units are to be completed:

Yes NoStatus: Enrolled

Completed

Yes NoStatus: Enrolled

Completed

CHCMHS007 – Work effective in trauma informed care Yes No Yes No

CHCPRT009 – Provide primary residential care Yes No Yes No

CHCCS009 – Facilitate responsible behaviour Yes No Yes No

In addition, for therapeutic residential staff:23 NA NA

CHCPRT010 – Trauma unit Yes No Yes No

or previously completed ‘With Care’ foundation training Yes No Yes No

22 Minimum qualification requirements from 30 June 2018 for all residential care unit staff, which includes the three mandatory units of competency listed above. Staff employed as at 28 March 2018 must have completed the training by 30 June 2018. Staff employed after 28 March must have begun the mandatory units of competency by 30 June 2018 and completed the training within three months. 23 Therapeutic residential care: Workers who have completed the two (trauma) units CHCMHS007 and CHCPRT010 are considered to have met the two-day ‘With Care’ foundation training requirements as outlined in the Program requirements for the delivery of therapeutic residential care in Victoria.


Appendix 3: Site/unit audit tool

Residential unit address

Date(s) of audit

AuditorsAuditor 1 (lead):Auditor 2:

Audit duration

Staff on duty (name and role)

Are any clients on a voluntary placement? Yes No

Is this a therapeutic unit? Yes No

Is this a contingency unit? Yes No

Number of bedrooms

Number of funded placements

Is the unit in scope for stand up staffing?24 Yes No

Overnight safety plan current and signed off by the department25

Yes No

24 All units with four or more beds that receive RP3 funding must have stand-up staff (PR 2.3.9). This applies irrespective of whether a placement is vacant at the time. 25 From 1 October 2016, every residential care home in Victoria will be required to have an overnight safety plan to ensure a rapid response of additional staff when required, including the safe return of young people overnight.


Property and fire safety

Fire safety

Evidence requirement Yes No NA

Extinguishers and fire blanket evidence of six-monthly tagging and testing (check last 12 months only)

Weekly fire safety checklist is completed (check last two months only)

Fire drills are conducted and recorded as per program requirements26

Designated exits are unobstructed

Doors/windows can be easily opened in the event of fire (keys are accessible where key locks are fitted)

Smoke detectors/alarms are intact and illuminated (green light)

Safety plans are in place where there is known fire-lighting behaviour(s)

Smoking is not occurring inside the unit

Lighters/matches are stored safely, where applicable27

There is a receptacle for safe disposal of butts outside the unit

A bushfire safety plan is in place where applicable28

Any property damage that poses a potential threat to the safety and wellbeing of young people or staff is rectified immediately

Property/safety issues


Evacuation plans are displayed and current

The Evac Pack is checked by staff to ensure correct contents

A first aid kit is accessible and staff regularly check to ensure it contains appropriate and in-date contents

A spill kit is in place and checked by staff to ensure appropriate contents

A sharps container is available

Food is appropriately and hygienically stored

Electrical leads are not in the way and are intact

Chemicals are stored securely

Safety data sheets are available

Knives are stored securely and counted where a need is identified

Aerosols/razors are stored securely where a need is identified

Vehicle keys are stored securely

26 Check fire evacuation records for staff in the selected sample only and record evidence in section 5: Fire evacuation training.27 Where there is known fire-lighting behaviour28 Units in high-risk bushfire areas are identified at pre-audit stage. Bushfire plan needs to reflect current bushfire period (for example, 2018–19).



Record unit vehicle number plates:29

Comments:Note: Photo evidence is required where property/safety or fire issues are identified.

General observationsAppropriate interactions between staff and children/young people observed Yes No NA

Restrictive practices30 are in place Yes No

Any restrictive practice has a documented rationale, is time limited, with a scheduled review date

Yes No NA

Details:

PoliciesStaff are able to access requested policies or procedures (request copies)

Staff supervision Yes No

Sexuality education Yes No

Client complaints Yes No

Medication management Yes No

Fire training/evacuation Yes No

Substance abuse Yes No

For head office Vehicle policy Yes No

29 At head office obtain evidence of vehicle details to ensure vehicles are registered and serviced, including where staff use their own vehicles to transport clients.30 Clients should have free access to linen, food, cutlery, games room/toys and laundry.


Fire evacuation trainingFire drills are conducted and recorded as per program requirements (all staff must participate in at least one fire evacuation exercise every 12 months).31

Staff member Date of last fire evacuation exercise

Staff supervision

Is staff supervision occurred in line with CSO policy?32 Yes No

Staff member Dates of supervision in the past six months

31 Check for staff in the selected sample only.32 Check records for staff in the selected sample only.


Staff interview questions

Cultural planning


Are there any children/young people who identify as Aboriginal or Torres Strait Islander living at the unit?

Staff demonstrate knowledge of local cultural supports in place such as local Aboriginal healthcare clinics, Elders, mentors, youth groups, support from the Victorian Aboriginal Child Care Agency

Aboriginal children/young people are given opportunities to participate in cultural activities

Are there children/young people from a culturally diverse background living at the unit?

Staff can describe how they support young people from other cultural backgrounds to maintain and develop their cultural identity

Staff can describe how they would provide a culturally inclusive environment

Comments:

Contact with family and friends


Staff can articulate safe contact procedures

Staff can describe how they advocate for clients to have safe contact with family

Staff ensure access visits are approved by the department/case manager

Comments:


Health needs


Staff can describe how they support young people in relation to their sexual health

A range of age-appropriate sexual health information and supports are made available to young people

Staff can describe how they assist young people to access support in relation to substance abuse, including inhalant, alcohol and other drug use

Staff are aware of clients who have substance abuse issuesIf yes: Are staff aware if a referral has been made to a drug and alcohol service?

Comments:

Challenging behaviours


Staff can talk about the challenging behaviours of each child/young person and how these are managed

Staff are aware of children/young people in the unit who display sexualised behaviour

Staff can describe how they work with children/young people who display sexualised behaviour

Can staff describe how they would identify issues of sexual exploitation

Staff are aware of children/young people in the unit who are at risk of sexual exploitation

Staff can describe how they support children/young people at risk of sexual exploitation, including requirements for reporting

Where a young person has been identified as at risk, staff can describe the strategies in place to address the risks of sexual exploitation, in line with each client’s planExamples:

Awareness of sexual exploitation information template Informing and engaging with local Victoria Police Awareness of legal responses (serving the perpetrator or person

of interest with a harbouring or loitering notice)



Comments:

Therapeutic specialist


Staff demonstrate understanding of the role of a therapeutic specialist

Is a therapeutic specialist involved in developing and assessing treatment plans for the child or young person?

Comments:

Incident reporting


Staff can talk through the last incident they reported

Staff can describe when a CIMS client incident report is required (for example, incidents that happen at a service, during service delivery, that involve or impact significantly on clients. Major versus non-major impact)

Comments:

Note: When reviewing day notes or a communication book, check to see if all incidents have been reported as required. Check the last three months.


Missing and absent client/young people


Staff are aware of what to do if children/young people go missing to ensure their safety, in line with policy and procedure

Staff use a risk assessment methodology to support decision making when considering when to report young people missing (refer to behaviour management plan or discussion with staff)

Prompts:

Age and developmental stage of the client Whether the client’s whereabouts are known Whether there is concern for the client’s or others’ safety and

welfare Any previous history of the client missing or absconding Drug and mental health status of the client Degree of contact with the client while they are missing

Staff can describe their reporting obligations for an absent/missing person

Comments:

Complaints


Staff can access the CSO complaints policy and procedure (request copy)

Staff demonstrate knowledge of the CSO complaints policy and procedure33

Staff are able to articulate how they support young people and/or their families to seek a resolution to their complaints

Staff are aware of young people’s right to external advocacy

Staff can describe how young people and their families receive information about the CSO’s complaints process

Staff can talk through a recent complaint to resolution/closure

33 Appropriate to their role and position.Residential Care Performance Audit Program Page 36


Comments:

Note: Ask staff to talk about a recent complaint and how it was managed.

Medication


There is a policy and procedure to support safe management of medication

Staff can speak to and access the policy and procedure

All medication sighted is within the expiry date

Medication administered is accurately recorded

Medication is disposed of correctly

Comments:


Unit-level debrief/exit notes

Feedback provided to unit staff

Feedback from unit staff to auditors

[Provide the opportunity for unit staff to comment on the process and findings, including any disagreement with findings, requests for clarification]

Head office exit notes

Feedback provided to head office


Urgent or safety issues raised/action required

Feedback from head office to auditors

Note: At the end of the meeting, the lead auditor explains that the findings discussed are preliminary only until all evidence is analysed and the report is prepared. On returning to the office the lead auditor is required to send an email to the key contact confirming any additional evidence requested to assist in confirming compliance.


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