Core Module - Section 2

Provider Governance and Operational Management

Section 2: Provider Governance and Operational Management
TopicPolicy and Procedure
2.1 Governance and Operational Management

● Corporate Governance Policy and Procedure

● Conflict of Interest Policy and Procedure

● Work Health Safety and Environmental Management Policy and Procedure

● Manual Handling Policy and Procedure

● Continuous Improvement Policy and Procedure

2.2 Risk Management● Risk Management Policy and Procedure
2.3 Quality Management● Quality Management Policy and Procedure

2.4 Information Management

(see ‘3.2 Support Planning’)

● Information Management Policy and Procedure

● Consent Policy and Procedure

2.5 Complaints and Feedback Management● Complaints and Feedback Policy and Procedure
2.6 Incident Management● Reportable Incident, Accident and Emergency Policy and Procedure
2.7 Human Resource Management

● Human Resource Management Policy and Procedure

● Delegation of Responsibility and Authority Policy and Procedure

2.8 Continuity of Supports

● Continuity of Supports Policy and Procedure

● Telehealth Policy

● Disaster Management Policy and Procedure

● Business Continuity Policy and Procedure

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2.1 Governance and Operational Management
Corporate Governance Policy and Procedure1.0 Purpose

Corporate governance is a performance driver of our company. Governance refers to the framework of rules, relationships, systems and processes by which an enterprise is directed, controlled and held to account and through which authority is exercised and maintained.

The Elevate Support Care is committed to providing a high-quality service to participants and maintaining business practices that demonstrate high standards of corporate governance. The purpose of this policy is to:

  • ensure the organisation’s business operates in accordance with legal, regulatory and company standards
  • establish a framework for corporate governance that promotes transparency and safeguards against individual’s unethical or unlawful practice
  • outline control measures that govern the internal and external actions of managers, staff, contractors or any person who is conducting business with Elevate Support

2.0 Scope

Principal accountability and approaches to corporate governance include:

  • fulfilling our duty to all Elevate Support Care’s stakeholders, including participants, participants representatives, advocates, staff, contractors and any person conducting business with our organisation
  • providing services of value to our participants
  • providing meaningful employment for our staff
  • contributing to the welfare of the

3.0 Company details

3.1 Elevate Support Care business details

Business nameElevate Support Care
Date registered[Date Registered]
Domain name[insert website address]
Licences and permits

NDIS Registered Service Provider

[add any other licences or permits]

Products/services[Registration Groups]
Premises[insert premise address]
Are these premises rented or owned?[insert premise type]
  • Insurance
Workers compensation[Insert Insurance Company]
Public liability insurance[Insert Insurance Company]
Professional indemnity[Insert Insurance Company]

3.3 Business focus

3.3.1 Commitment to quality

Elevate Support Care is committed to providing high-quality services to its participants in a supportive environment. This commitment is in line with National Disability Insurance Service requirements.

Elevate Support Care will use information from the management of continuous improvement, complaints and feedback, incidents, work health and safety, information feedback and risk management to adjust our policies and practices so that we meet participant and community requirements.

Elevate Support Care will seek feedback from participants and the community to ensure that we are meeting their requirements and to provide high quality, responsive service. Information and feedback gained through surveys and consultation with community and stakeholders will be collated and forwarded to management to review and make recommendations about any adjustments to policies and practices as required. Managerial meetings will document discussions and outcomes, and this data will be fed back into our continuous improvement cycle.

3.3.2 Target group

There are two (2) target groups within the community in which we work:

  1. Participants: Individuals with special needs who require
  2. Service providers: Disability services organisations who seek support for their
3.3.3 Services provided

Elevate Support Care provides the following support services for participants with a disability:

  • [Registration Groups].

3.4 Management and reporting structure

All reporting is based on the management structure as outlined in the organisation chart.

3.5 Key personnel

The following staff are employed/contracted by our organisation:

  • [KeyPersonnel Name]

We also engage specialist consultants and contractors to support business functions and assist with a range of participant support services.

Knowledge, skills and experiences of all partners and key personnel, who influence the company, are reviewed to ascertain if additional training is required to address any identified gaps.

  • [KeyPersonnel Name] [Experience]

3.6 Performance planning and review

The planning and review process are included in the Human Resource Management Policy and Procedure. Elevate Support Care will monitor and review the performance of employees on an annual basis to:

  • determine staff member performance matches the current role description
  • evaluate if the staff member‟s performance is meeting the needs of the participants
  • establish additional training to meet changes in contemporary practices
  • provide support to staff to meet the required level of supports
  • match skills and knowledge to the target

3.6.1 Business planning and review

3.7 Conflict of interest

All key personnel and staff must inform Elevate Support Care’s management regarding any situation in which they will derive personal benefit from actions or decisions made in their official capacity. The person concerned must complete a Conflict of Interest Declaration.

4.0 Procedure

4.1 Corporate governance principles

Elevate Support Care will be governed to ensure the best interests of all stakeholders and to remain viable and productive. Our corporate governance principles include, but are not limited to, the following:

  • services are regularly monitored, reviewed and improved
  • risk management reviews are conducted regularly
  • continuous improvement strategies are undertaken and implemented
  • implementation of necessary reviews and audits of all systems, policies and procedures
  • planning processes incorporate community engagement
  • effective management of human resource requirements, so all services meet the requirements of the participant and community
  • additional training and supervision will be provided to our workers, as needed
  • contractual obligations are to always be met
  • effective management and implementation of appropriate financial and funding

4.2 Financial management

The Elevate Support Care will undertake all requirements linked to NDIS contractual arrangements and other business practices.

An Asset Register will be maintained with a list of all current assets, allowing for additional purchases as required. Building and property will be reviewed to ensure that premises meet the current requirements of our business. If additional sites are required, then an analysis of costing will be undertaken.

4.2.1 Business financial management – roles and tasks
  • Financial roles and responsibilities are determined by Elevate Support
  • An accountant will be used to complete the required financial compliance and
  • Financial decisions are the responsibility of Elevate Support
4.2.2 Business financial management practices

The following practices apply to financial management, including the recording of business earnings and documentation of the company as a legitimate enterprise with a clear revenue stream and records of deductible business expenses.

Documentation and organisation of information regarding company transactions will be used to facilitate financial management for tax purposes. Bank accounts

All bank accounts are maintained, and separate bank accounts are always used for business and private purposes.

For monies withdrawn from any bank account, whether by EFT or other online payment method, approvals are required by the Director to authorise each payment.

Each payment made must be supported by invoice, receipt or other appropriate documentation, and the authorisations must be attached to this documentation before payment.

Any variations to banking arrangements can be made or varied by the Director who will delegate the responsibility for updating the financial system or bank account register with the new information. Credit cards

The business credit card can only be used for travel, authorised entertainment and purchases of small value expenses or equipment up to the value of $ 500.

No cash advances are to be taken using the business credit card unless authorised by the Director.

Where a business credit card is lost or stolen, then the owner of this card is to notify the Director who is responsible for notifying the issuing agency and ensuring the card is cancelled.

The use of the business credit card is not to be used for personal expenses.

All holders of business credit cards are required to attach all receipts for payments made on the credit card. Upon completion and authorisation of the monthly expense statement, these documents are to be forwarded to the Director for payment of the credit card statement.

All business credit cards are to be returned to the business when the person is requested to by the Director or where they cease employment with the business. Budget

Elevate Support Care develops an annual budget with the support of a financial adviser. The budget will include:

  • time frames
  • fixed costs – salaries, rent, insurances and any other known costs
  • variable costs – utilities, cost of materials, staff wages
  • income – over the budget Books of accounts

Elevate Support Care is responsible for maintaining accounts, assisting the financial adviser in the preparation of the annual budget and for preparing monthly, quarterly and annual financial reports.

Elevate Support Care or their delegate is responsible for processing all receipts and payments. Issuing petty cash

Petty cash is approved by the Director. Each payment made must be supported by invoice, receipt or other appropriate documentation and the authorisations must be attached to this documentation before payment before any cash is taken from the petty cash float. Only up to $50 can be disbursed at any one time.

Once the petty cash is spent, a receipt or invoice should be attached to the voucher and returned to petty cash with any balance of money unspent.

Petty cash float is to be reconciled with a delegated staff member. Income

All money received is deposited in our bank account. All monies received are receipted and recorded in the electronic financial system. Unallocated direct deposits of more than one week will be investigated fully to determine the source of deposit. Where the source cannot be identified, the deposit will be allocated to a separate bank account until the source is recovered.

Income is matched against invoices to determine when payments have been received and when additional actions are required. Payments

All payments (except petty cash) are made by electronic transfer. Payments must be accompanied by an invoice and matched against services or equipment received before authorisation. Payments are authorised by the Director. Recurrent payments

Recurrent payments, wherever possible, are made electronically. All recurring payments must be approved by the Director who will delegate the arrangement for the payment to be authorised by the bank.

The Director or their delegate is responsible for carrying out the following duties regarding payment stop on a payment:

  • ensuring the payment has not already been made
  • getting authorisation to activate the stop payment using appropriate forms from the bank
  • ensuring the bank receives the notification of the stop payment notice
  • receiving confirmation of action from the bank of the stop payment
  • ensuring the details of the stop payment are Supplier accounts

When purchases are charged to the accounts of established suppliers, the account will be paid in full, upon receipt of the statement or invoice, within the required terms of payment. Asset register

The Asset Register will list the assets owned by Elevate Support Care. It will contain pertinent details about each fixed asset to track the value and physical location. The register will show the quantity and value of items such as office equipment, motor vehicles, furniture, computers, communications systems and equipment. Reconciliations and ATO reports

The following reconciliations and Australian Taxation Office (ATO) reports are completed at the end of each month:

  • Bank‟s accounts are reconciled against bank statements.
  • The Instalment Activity Statement is completed and forwarded to the

The following reconciliations and ATO reports are completed at the end of each quarter:

  • The Business Activity Statement (BAS) is completed and forwarded to the
  • Superannuation Guarantee contributions are reconciled, and payments

The following reconciliations and ATO reports are completed at the end of each year:

  • Books of accounts are balanced and closed
  • Wages are reconciled, and Payment Summaries are completed and forwarded to the employee and the
  • Audit reports are Audit

Annual acquittal statements and audited financial reports will be forwarded, as per contractual requirements, to the relevant government bodies. An annual audit is undertaken each year by a qualified external auditor. Participant – payments and pricing (NDIS)
  • Elevate Support Care must adhere to the NDIS Price Guide or any other agency pricing arrangements and guidelines as in force from time to
  • Elevate Support Care must declare relevant prices, any notice periods or cancellation terms to participants before delivering a service. Participants are not bound to engage the services of Elevate Support Care once our prices have been
  • Elevate Support Care can make a payment request once that support is delivered or
  • No other charges can be added to the cost of the support, including credit card surcharges, or any additional fees including any „gap‟ fees, late payment fees or cancellation These requirements apply to all Elevate Support Care participants whether the participant self-manages their funds or a plan manager or the agency manages it.
  • A claim for payment is to be submitted within a reasonable time, and no later than sixty (60) days from the end of the service booking, to the participant or the
  • Elevate Support Care will not charge cancellation fees except when provided explicitly in the NDIS Price
  • Elevate Support Care and participants (except for those that are self- managing) cannot contract out of the Price
  • Where there are any inconsistencies between the Service Agreement and the NDIS Price Guide, the NDIS Price Guide
  • As required, Elevate Support Care will obtain a quote for services which the participant is required to approve before the commencement of the

4.3 Monitoring, evaluation and reporting

Elevate Support Care exhibits a continuous improvement culture to facilitate the development of its services and processes; we seek stakeholder input and review immediately upon receipt.

All Elevate Support Care‟s policies are reviewed annually and consider the input from all stakeholders. Policy reviews also consider any changes in legislation and the results attained through monitoring and evaluation practices.

4.4 Strategic plan

The planning process involves:

Planning activityNotesWhen

● Review plan to determine future

services or products required for NDIS participants and their families.

● Review against the vision of creating a unique cultural environment, community environment with genuine care and support, focusing locally, developing staff.

● Review of the current political climate and its influence on business practices and forward planning.

● Organisation’s performance, including risk and continuous improvement.

● Undertake situational analysis as per risks and continuous improvement.

Every three



● Set goals for business and participants

and stakeholders.

● Create a framework that may include:

○ development of participants

○ professional staff development

○ improvement of services

○ safety and security for all.

● Problem identification and problem resolution processes to identify key organisational challenges, goals, strategies, timeframes, persons responsible and evaluation methods.

● Consultation is undertaken with the community, and community priorities are considered in line with the organisation’s vision and mission.

● Use evaluations to adjust planning – political, social, financial continuous improvement recommendations are to be fed back into the plan.

● Ensure that any planning and future planning matches our mission of creating a unique cultural environment, community environment with genuine care and support, focusing locally, developing staff.

Every three



● The plan is developed by Elevate

Support Care.

● Feedback obtained from stakeholders including community members, employees, participants, advocates and networks.

● Using feedback to improve services and develop new services based on the needs of the community and individuals.

Every three


Approval● Plan approved.

Every three



● The details of the plan are shared with

staff and other stakeholders (as relevant).


● Achievements against the plan are

reviewed monthly.

● Elevate Support Care documents achievements and timeframes completed within the plan.


4.5 Risk management

Elevate Support Care will review risks and ensure that they are either eliminated or reduced. Possible potential risks are identified below:



with NDIS


Internal review of policies,

procedures, financial structures and staff training.


Provide high-quality service that

encourages loyalty.

Key personnel riskLikelyHigh

Identify and train a support

person in managing and implementing business needs.

4.6 Marketing

4.6.1 Target markets
  • Legal
  • Plan
  • Small organisations who are seeking reliable support for their participant/s.
4.6.2 Marketing strategy
  • Contact local networks and communities to provide information about the services we
  • Work with the community and other coordinating participant services; advise details of services provided and associated
  • Incorporate community languages into all marketing collateral and on our
  • Provide a single point of contact for enquiries (someone who can provide clear, relevant and accurate information).

5.0 Related documents

  • Asset Register
  • Conflict of Interest Declaration
  • Conflict of Interest Register
  • Continuous Improvement Policy and Procedure
  • Business Plan
  • Participant Handbook
  • Quality Management Policy and Procedure
  • Reportable Incident, Accident and Emergency Policy and Procedure
  • Risk Management Policy and Procedure
  • Offer of Employment Letter
  • Staff Handbook
  • Staff Orientation Checklist
  • Strategy Plan
  • Service Agreement
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house

6.0 References

  • NDIS Practice Standards and Quality Indicators 2020
  • Disability Discrimination Action 1992 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)

Conflict of Interest Policy and Procedure

1.0 Purpose

Elevate Support Care is committed to ensuring that actions and decisions taken at all levels in the organisation are informed, objective and fair. A conflict of interest may affect the way a person acts, the choices they make, or the way they vote on group decisions.

Elevate Support Care will proactively manage any perceived and actual conflicts of interest through the development and maintenance of organisational policies. This management will ensure that corporate and ethical values do not impede the participants right to choose and control their supports and services.

Identified conflicts of interest require action to be undertaken to ensure that personal or individual interests do not impact on the organisation’s services, activities or decisions.

2.0 Scope

All management, staff and contractors must act in the interests of the organisation and notify the organisation when any conflicts clash with other interests or commitments.

3.0 Policy

Declaration and management of conflicts of interest are required explicitly by the Director, as part of their legal responsibilities as the controlling member of the organisation.

This policy requires management and staff to disclose any outside interests that conflict with the interests of the organisation. The Director must act impartially, and without prejudice, and not accept gifts or benefits that would influence any decision relating to Elevate Support Care. Examples may include:

  • close personal friends or family members involved in decisions about employment, discipline or dismissal, service allocation, or awarding of contracts
  • individuals, or their close friends or family members, who are gaining financially or gaining some other form of advantage
  • an individual engaged by another organisation offering services that are in a competitive relationship with Elevate Support Care (the individual may have access to commercially sensitive)
  • information, plans or financial information which conflict with Elevate Support Care
  • prior agreements or allegiances that are binding an individual to other individuals or agencies, requiring them to act in the interests of another party or to take a position on an issue that will conflict with Elevate Support

4.0 Procedure

4.1 Registration of known conflicts of interest

A Conflict of Interest Register will be maintained, and management and staff will be asked to declare:

  • potential or actual conflicts of interest that exist when a person joins the organisation
  • conflicts of interest that arise during their involvement with the organisation, which will be recorded in the register maintained by the Director or their

All potential and actual conflicts will be recorded in the register to provide sight of the identified and declared conflicts.

All management and staff are required to declare any potential or actual conflicts of interest that become evident during their involvement with the organisation. Management must disclose potential conflicts before the commencement of any meeting.

All management and staff must speak with the Director when a conflict becomes apparent and provide formal notification in writing to the Director of the conflict.

4.2 Management of conflicts of interest

Where a conflict of interest is declared or identified by a staff member:

  • the immediate supervisor and the Director will assess the conflict
  • if a conflict of interest exists (or there is a perception that a conflict exists) the staff member may be asked to:
    • contribute to the discussion but abstain from voting or taking part in a decision on the matter
    • observe but not take part in the discussion or decision-making
    • leave the meeting during the discussion and before a decision has been

4.3 Staff involvement in external activities

Elevate Support Care encourages and supports staff to become involved in community activities and volunteer work in their personal lives. However, the staff member may undertake volunteer or professional roles outside the organisation that may give rise to a conflict of interest, or a perception of conflict, e.g. staff undertaking consultancy work for member organisations or government agencies.

As a result, Elevate Support Care expects that all staff members declare their involvement in external work-related activities to allow for discussion and management of the potential conflicts of interest with the Director. Staff members who undertake other (new) work outside of the organisation need to inform the Director.

4.4 Contractors

All contracts with external consultants engaged by the organisation will include a Conflict of Interest Declaration confirming that no conflict of interest exists.

5.0 Related documents

  • Code of Conduct
  • Conflict of Interest Declaration
  • Conflict of Interest Register
  • Privacy and Confidentiality Agreement

6.0 References

  • NDIS Act 2013 (Commonwealth)
  • NDIS Practice Standards and Quality Indicators 2020
  • Privacy Act 1988 (Commonwealth)
  • Australian Privacy Principles(Commonwealth)

Work Health Safety and Environmental Management Policy and Procedure

1.0 Purpose

Work Health and Safety (WHS) regulations place an obligation on decision-makers of the service to take reasonable steps to gain an understanding of the hazards and risks associated with working and support activities, and to allocate appropriate resources and processes, to eliminate or minimise these risks to health and safety.

These legal requirements extend to eliminating risks to staff members, participants, subcontractors, and volunteers whenever it is practical; if it is not feasible to eliminate all risks, then they will be minimised wherever possible.

2.0 Scope

Staff members, participants, volunteers and sub-contractors are also obligated to protect their own and other people‟s health and safety. Their responsibilities also extend to identifying hazards and risks, managing work health and safety risks and applying appropriate treatments. They should also consult with other people, including supervisors or management, about these risks.

3.0 Policy

Elevate Support Care aims to promote and maintain the highest degree of physical, mental and social wellbeing of all individuals in the workplace. The organisation will comply with all relevant federal and state legislation to ensure a safe workplace. All personnel have a responsibility to ensure a safe workplace by implementing safe systems of work.

Elevate Support Care will provide the resources required to comply with relevant acts and regulations associated with workplace health and safety to ensure that the organisation‟s workplaces are safe and without health risk.

Elevate Support Care will undertake regular reviews and take steps to enhance workplace health and safety on a continuous improvement basis.

3.1 Statement of injury management and return to work

Elevate Support Care is committed to:

  • establishing and reviewing the return to work program, that is consistent with the injury management program, to ensure injured workers return to work in a timely and safe manner
  • managing all claims and the return to work of employees injured in the workplace
  • establishing individualised injury management plans according to legislative requirements, as outlined in the policy and procedures
  • consulting with employees and other stakeholders on health and safety issues
  • complying with relevant work health and safety legislation and regulations and other associated legislation
  • providing and maintaining equipment and appropriate personal protective equipment for the safety of our employees
  • providing employees with information, training and supervision, as necessary, to enable them to work in a safe manner and without risks to health
  • documenting, investigating and reviewing incidents
  • displaying, documenting and distributing this Work Health Safety and Environmental Management Policy and Procedure and all other associated documentation in the workplace, including the return to work program
  • maintaining the required insurance cover
  • appointing a designated person to manage all claims for workers‟ compensation, occupational rehabilitation and return to work programs
  • outlining the roles and responsibilities of all relevant parties in the return to work process
  • regularly reviewing workers compensation

3.2 Environmental management

Management will endeavour to minimise our environmental impact in the following areas:

  • reduction of waste generated
  • unnecessary energy

Elevate Support Care will actively take part in:

  • identifying waste streams and options for effective waste management
  • reviewing purchasing behaviour, g. buy recycled materials; reduce waste; use less harmful/volatile chemicals
  • improving storage, g. reduce the quantity of waste and spills, reduce odours by keeping containers closed
  • conserving energy, g. install eco-friendly lights, turn lights off when not needed, purchase energy-efficient emergency equipment and use greener fuel sources
  • conserving water, g. install water-saving accessories, repair leaks
  • preserving waterways, g. mark and protect storm-water drains
  • creating an emergency plan and spill response
  • improving education and awareness
  • notifying relevant authorities in the event of a major environmental

3.3 Incident management

Incident management is an integral element of the Elevate Support Care’s planning processes. All stakeholders are encouraged to raise any concerns regarding risk, incidents or safety. Support delivery issues, and their contributing factors, are identified and utilised as Elevate Support Care‟s performance measures:

  • Elevate Support Care management is ultimately accountable for incident management throughout our service and support
  • Our organisation reinforces our accountability by using governance structures including policy, performance management and delegations; and defines the acceptable level of risk for the

The Director is responsible for:

  • overseeing the incident management system including monitoring, reviewing and reporting on its effectiveness
  • managing, reviewing and implementing the contingency disaster plan, including establishing and maintaining all service agreements
  • implementing incident management processes
  • advising results and analysis of incident investigations
  • evaluating and documenting actual and potential risks with a formal risk assessment
  • ensuring all staff within Elevate Support Care have a responsibility to identify and engage in the minimisation of risks that may exist in service delivery.

Figure 1. Incident management process

3.3.1 Responding and reporting obligations
  • Elevate Support Care has a responsive risk management hazard, incident and accident reporting system in
  • All incidents, of any nature, are a matter of concern and, as such, should be recorded using incident and hazard
  • All notifiable incidents are to be reported to state WorkCover authorities and the NDIS Commission through the portal, as per regulatory
  • Details of incidents will be documented through the incident management
3.3.2 Documentation
  • All information is gathered with due regard to privacy and confidentiality, recorded comprehensively and stored
  • The incident report is for the use of the Director only, as it will contain identifying Minimum information required includes a description of the event, damage, injuries, reporting requirements, parties/persons involved and recommendations. Reportable Incidents documentation will be held for seven (7) years. Where children are involved, records will be kept until the child turns 25 years of age.
  • When discussing the incident findings and recommendations in a meeting, care must be taken not to minute any identifying
3.3.3 Evaluation and feedback
  • Staff involved in the incident will be advised of the findings and recommendations of the incident
  • Information will be reported through the meeting
  • Elevate Support Care may trend incidents, accidents and critical
  • Reviews of policy, procedure and equipment may occur because of an incident or
3.3.4 Support for stakeholders
  • Any staff member, participant or visitor involved in, or affected by, an incident is offered

3.4 Manual handling

  • Elevate Support Care has a Manual Handling Policy and Procedure, and all staff are instructed in this procedure at induction and as
  • Maintenance of the participants‟ independence by encouraging mobility is a
  • The manual handling needs of participants are assessed and documented on entry to Elevate Support
  • Manual handling is a component of the education and training
  • Staff members are instructed on the correct manual handling and lifting
  • All staff members are assessed on their manual handling techniques during induction and then
  • All manual handling injuries and incidents are reviewed, risk assessments are conducted, and then strategies implemented to control
  • Risk identification, assessment and control are carried out in consultation with
  • Incidents, accidents and hazards, identified from manual handling activities, are reported through the communication meeting and other associated meetings, as deemed by management as
  • Appropriate equipment is provided so manual handling activities can be safely
  • Personal manual handling equipment such as „slide sheets‟ are maintained according to infection control
  • The Director will ensure that the general layout of the workplace is conducive to the safe handling of participants and the safe use of

3.5 Work health and safety consultation

Elevate Support Care will establish and maintain systems for work health and safety consultation to enable staff to contribute to the decision-making process regarding matters that affect their health, safety and welfare at work. The intended outcomes of this policy include:

  • prevention of risk of injury to workers and others
  • consultation with workers regarding the risk management process
  • reduction of social and financial costs of work health and safety hazards
  • establishment and maintenance of safe systems of work
  • regulatory compliance maintenance
  • prompt consultation on work health and safety matters, taking into consideration the level of risk involved in any specific issue
  • training is updated according to current work health and safety regulatory requirements and made available to
3.5.1 Nature of consultation

The purpose of the work health and safety consultation with staff is to:

  • share health and safety information
  • provide a reasonable opportunity to:
    • express their views
    • raise work health and safety issues
    • contribute to the decision-making process
  • consider the opinions of staff members
  • promptly inform staff of any future
3.5.2 When a consultation is required

Consultation is required when:

  • identifying and assessing risks to health and safety
  • deciding ways to eliminate or minimise those risks
  • deciding on the adequacy of facilities for worker welfare
  • proposing changes that may affect the health and safety of
3.5.3 Work health and safety resolution
  • Staff are to be consulted on proposed changes to the work environment, equipment, policies, protocols and procedures that may affect their health and
  • Information on hazards, work health and safety activities, and achievements will be disseminated to staff through staff meetings, memos or
  • A staff member may approach the Director to bring forward issues in the
  • The Director will attempt to resolve the issue
  • Elevate Support Care will always make a reasonable effort to achieve a timely, final and effective resolution of work health and safety

Work-related problems, concerns or complaints concerning work health and safety will be managed in accordance with our Human Resource Management Policy and Procedure.

Only after reasonable efforts have been made to resolve the issue can the parties seek the assistance of an appropriate workplace health and safety inspector. This right arises whether all, some or only one of the parties have made reasonable efforts to have the work health and safety issue resolved, this means that a party‟s unwillingness to resolve the issue would not prevent an inspector being called in.

The inspector‟s role is to assist in resolving the issue which could involve the inspector providing advice or recommendations or exercising any of their compliance powers, e.g. issuing a notice.

Even if an inspector has been requested to assist in resolving a work health and safety issue, the rights of a worker to cease unsafe work remain under the Work Health and Safety Act 2011 model.

When an issue is resolved, the details of the issue and the resolution will be set out in writing to the satisfaction of all the parties, as soon as reasonably practicable:

  • Worker/s affected by the issue will be informed of the details of the agreement between the
  • A copy of the agreement to the resolution of an issue may be forwarded by any of the parties involved or Elevate Support Care that represents the

3.6 Workplace incidents

Elevate Support Care will:

  • hold current workers‟ compensation insurance policy that covers all workers
  • notify a worker of any workplace incidents, as per legislative requirements
  • make suitable duties available to injured workers
  • maintain a record of wages according to regulatory requirements
  • maintain a register of workplace-related injuries and illnesses
  • forward any workers’ compensation payments to injured workers
  • avoid dismissing an injured worker because of their injury, within six months of the injury or illness occurring, and the injured worker‟s incapacity to work
  • maintain a register of acceptable modified duties
  • prepare an offer of modified duties in writing and provide these to the injured worker and healthcare practitioner
  • educate staff about the causes of the injury and subsequent risk
  • keep associated records as required
  • ensure all staff are aware of responsibilities and rights concerning return to work through training and education
  • manage disputes according to regulatory
3.6.1 Notification of injuries
  • The Director will be notified of all injuries, as soon as
  • All injuries are to be
  • The workers‟ compensation agent will be notified of any injuries within 48
  • Workers will be notified immediately of any serious incidents involving a fatality or a serious injury or
3.6.2 Recovery
  • The Director will ensure that the injured worker receives appropriate first aid and medical treatment as soon as
  • The injured worker must nominate a treating doctor who will be responsible for the medical management of the injury and assist in planning a return to
3.6.3 Return to work

The Director will:

  • arrange a suitable person to explain the return to work process and the injury management plan to the injured worker
  • ensure the injured worker‟s right to the confidentiality of medical information
  • ensure no information will be used to discriminate against the injured worker
  • provide mechanisms to communicate across cultures including ethnicity, gender and age
  • ensure all return to work plans are completed within the legal time frames
  • prepare the return to work plans based on the advice of the staff member‟s own treating health practitioner/doctor and the workplace rehabilitation provider
  • follow the relevant legislation and the agreed consultation procedures
  • create availability of suitable work where possible, when a staff member’s injury does not allow a return to immediate pre-injury duties (these suitable duties shall be made available temporarily)
  • maintain contact and communication with an injured staff member during the period of incapacity and absence from work
  • ensure the confidentiality of the injured staff member‟s information and rec

3.7 Work health and safety management program

The work health and safety management program consists of a set of activities, policies and procedures that are updated, as required, which relate to all aspects of work health and safety, including:

  • work health and safety training and education
  • work design, workplace design and standard/safe work procedures
  • emergency procedures
  • provision of work health and safety equipment, services and facilities
  • workplace inspections and evaluations
  • reporting, recording and reviewing incidents, accidents, injuries and illnesses
  • hazard identification activities
  • equipment assessment procedures and practices
  • participant risk assessment procedures and practices
  • staff risk assessment procedures and practices
  • provide information on work health and safety to staff, participants and their families
  • implement safe manual handling procedures and safe work

3.8 Education/training

Within seven days of commencing employment, each new employee will be provided instruction regarding:

  • identification and minimisation of hazards in/around a participant‟s home and in the workplace
  • procedures to be followed in the event of an

Every staff member will receive emergency training at least annually. Education/training will always be conducted by appropriately authorised and skilled personnel.

3.9 Hazard identification and risk management

Management actively encourages the reporting of hazards and promotes a positive and timely response; staff and contractors are informed of the mechanism for hazard identification. On identification and reporting of a hazard, staff members and subcontractors will:

  • take immediate action to minimise the hazard(s), where possible
  • report immediately to the person in charge when the action is beyond role limitations, and the hazard poses a high risk
  • record the hazard according to the organisation‟s hazard reporting

Identified hazards are reported and reviewed using Elevate Support Care‟s continuous improvement and risk management processes (see the Risk Management Policy and Procedure and the Continuous Improvement Policy and Procedure).

3.10 Risk management

Elevate Support Care considers risk management to be fundamental to good management practice. Effective management of risks will provide an essential contribution to the achievement of Elevate Support Care‟s strategic and operational objectives and goals. Risk management must be an integral part of Elevate Support Care‟s decision-making and must be incorporated within the strategic and operational planning processes, at all levels, across Elevate Support Care.

Elevate Support Care will maintain strategic and operational risk management plans. Management is committed to ensuring all staff are provided with adequate guidance and training on the principles of risk management and their responsibilities so they can implement risk management effectively.

Elevate Support Care will regularly review and monitor the implementation and effectiveness of the risk management process, including the development of an appropriate risk management culture across our organisation.

4.0 Definitions


Bullying can be defined as “unreasonable and inappropriate

workplace behaviour that may intimidate, offend, degrade, insult or humiliate an employee (or another person), in front of others and which can include physical or psychological behaviours.”

Clinical risk management

Clinical risk management is an approach to improving quality of

care which places special emphasis on identifying circumstances which put participants at risk of harm, and then acting to prevent, control or accept those risks. The aim is to improve the quality of care for participants and to reduce the costs of risks for care providers.

Dangerous goods

Those substances that give rise to an immediate physical effect,

such as fire, explosion, vapour release and are defined as such under Work Health Safety legislation.

Dangerous incident

A dangerous incident means an incident in relation to a workplace

that exposes a worker or any other person to a serious risk to a person’s health or safety emanating from immediate or imminent exposure to:

(a) an uncontrolled escape, spillage or leakage of a substance

(b) an uncontrolled implosion, explosion or fire

(c) an uncontrolled escape of gas or steam

(d) an uncontrolled escape of a pressurised substance

(e) electric shock

(f) the fall or release from a height of any plant, substance or thing

(g) the collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations

(h) the collapse or partial collapse of a structure

(i) the collapse or failure of an excavation or of any shoring supporting an excavation

(j) the inrush of water, mud or gas in workings, in an underground excavation or tunnel

(k) the interruption of the main system of ventilation in an underground excavation or tunnel

(l) any other event prescribed by the regulations but does not include an incident of a prescribed kind.

Due diligence

Where a PCBU (person conducting a business or undertaking)

has a health and safety duty, an officer of the PCBU is required to exercise „due diligence‟ to ensure the PCBU meets that duty.

Due diligence means taking a reasonable step to:

● gain and update knowledge of WHS matters

● understand the nature of the business, undertaking‟s operations and the general hazards and risks involved

● ensure the PCBU has appropriate resources for eliminating/minimising risks, and that these resources are used

● ensure the PCBU has processes for receiving, reviewing and responding to information about incidents, hazards and risks

● ensure the PCBU implements processes for complying with their duties, such as:

○ consultation

○ provision of training and instruction

○ reporting of notifiable incidents.


Components of the earth, including:

● land, air and water

● any layer of the atmosphere

● any organic or inorganic matter and any living organism

● human-made or modified structures and areas and includes interacting natural ecosystems.

HazardSomething with the potential to cause injury, illness or disease.
Hazardous substances

Those substances which can cause detrimental health effects,

such as damage to respiratory tract, skin, eyes (including carcinogens) and are defined as such under WHS legislation.

Health and Safety Representative (HSR)

The person elected by members of a work group within the PCBU,

or across several businesses (e.g. multiple workplaces) to represent that workgroup during consultation on work health and safety issues.

Health and Safety Committee (HSC)A PCBU must establish an HSC where requested to do so by the HSR, or a minimum of 5 or more workers at the workplace or at the PCBUs own initiative. The HSR can be a member of the HSC if they consent.

Incidents can be either an event that has occurred, or a „near

miss‟, and include all complications of care, accidents and side effects, a common feature being that incidents are either potentially or harmful.

Notifiable incident

A notifiable incident is defined as:

● death of a person

● serious injury or illness of a person

● dangerous incident

● abuse or neglect of a person

● unlawful sexual or physical contact or assault of a person

● sexual misconduct committed against, or in the presence of, a person.

● unauthorised use of a restrictive practice in relation to a person.

Person conducting a business or undertaking (PCBU)

A person or entity that conducts the business or undertaking alone

or with others whether, or not, the business or undertaking is conducted for profit or gain.

Officer of the PCBU

A person who makes, or participates in making, decisions that

affect the whole, or a substantial part, of the business or undertaking.

Personal protective equipment (PPE)

Personal protective equipment (PPE) is defined as safety clothing

or equipment for specified circumstances or areas, where the nature of the work involved or the conditions under which people are working, requires wearing or use for personal protection to minimise risk.

Reasonably practicable

Taking all steps, a duty holder was reasonably able to, considering

the cost of eliminating or minimising the risk, and whether this cost far exceeds the level of reduction of risk.


The chance of something happening that will have an impact upon

the services Elevate Support Care provides. Measured in terms of likelihood and consequences.

Risk analysis (Incident)

Seriousness of the event‟s consequences and its likelihood or

frequency of occurring again which provides a Category Code (CAT), generating a numerical rating which guides appropriate action.

Risk identification

Data sources that assist identification of risk include Coroners

reports, clinical indicators, variance analysis, incident reporting, complaints and other feedback.

Risk register

All levels of Elevate Support Care are responsible for the continual

monitoring of the strategic risk profile. A risk register identifies major risks for Elevate Support Care, including an indication if existing controls or management systems are in place to manage that risk.

Risk treatment

Risk can be avoided, controlled, retained or eliminated. Two major

approaches to control risk are reducing risk before it arises (in essence, proactive system design, e.g. Work Health Safety Risk Management Site for Safe Work Method Statement, equipment maintenance) or reducing the risk after the problem arises (countermeasures or barriers such as increased training).

Safety Data Sheet (SDS)

Information containing data regarding the properties and effects of

a substance that must be provided by the manufacturer, supplier or importer of the hazardous substance/dangerous goods. SDS must be current – within five years of the issue date and meet specific legislated format requirements.

Serious injury or illness

Serious injury or illness of a person means an injury or illness

requiring the person to have:

(a) immediate treatment as an in-patient in a hospital

(b) immediate treatment for:

(i) the amputation of any part of his or her body

(ii) a serious head injury

(iii) a serious eye injury

(iv) a serious burn

(v) the separation of his or her skin from an underlying tissue

(vi) a spinal injury

(vii) the loss of a bodily function

(viii) serious lacerations

(c) medical treatment within 48-hours of exposure to a substance, and any other injury or illness prescribed by the regulations but does not include an illness or injury of a prescribed kind.


Anyone who is carrying out work, in any capacity, for a PCBU

including direct employees, contractors and subcontractors and their employees, labour-hire employees engaged in working in the business or undertaking, outworkers, apprentices, trainees and students on work experience and volunteers.

Work group

A work group is the group of people represented by the HSR.

This could be a specific department, shift (e.g. day/night shift), location or type of worker. Work groups are determined by negotiation between the PCBU and workers (and their representative if required).

Work health and safety

The main objective of the model Work Health and Safety Act is to

provide for a balanced and nationally consistent framework to secure the health and safety of workers and workplaces’.


A workplace is a place where work is carried out for a business

or undertaking and includes any place where a worker goes, or is likely to be, while at work.

  • Related documents
  • Complaints and Feedback Form
  • Anonymous Complaints and Feedback Form
  • Complaints Register
  • Continuous Improvement Policy and Procedure
  • Emergency Plan
  • Emergency Plan – Waste
  • Hazard Report Form
  • Incident Investigation Form Final Report
  • Incident Report
  • Incident Register
  • Position Descriptions
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house
  • Return to work program documents
  • Risk Management Policy and Procedure

6.0 References

  • NDIS (Quality and Safeguards Commission) 2018
  • Safe Work Australia National Code of Practice
  • Work Health and Safety Act 2011 (Commonwealth)

Manual Handling Policy and Procedure

1.0 Purpose

Most work roles involve performing some type of manual task using the body to move or hold objects, people or animals. Manual tasks cover a wide range of activities including stacking shelves, cleaning, gardening, moving people and entering data into a computer.

Manual handling relates to any activity that requires effort to undertake, e.g. lifting, lowering, pushing, pulling, supporting, carrying and the moving of loads by hand or by bodily force. Some manual tasks are hazardous and may cause musculoskeletal disorders (MSD). These are the most common workplace injuries across Australia.

The Work Health and Safety Act 2011 and the Work Health and Safety Regulations provide a framework for safeguarding the health, safety and welfare for those who participate in manual handling activities in the workplace.

This document is provided as a guide for staff workers to follow to ensure the implementation of safe manual handling practices. All workers are responsible for following the steps detailed in this procedure for any manual handling activity. The procedure should be read in conjunction with the Work Health Safety and Environmental Management Policy and Procedure.

2.0 Scope

2.1 Organisation

Elevate Support Care has a responsibility for ensuring that manual handling practices are current, and that best practice information is provided to staff workers regarding managing the risk of musculoskeletal injuries associated with hazardous manual tasks. Elevate Support Care takes all reasonable steps to use appropriate resources and processes to eliminate or minimise risks in our organisation caused by hazardous manual tasks.

2.2 Staff workers

Staff workers and participants have a duty to take reasonable care for their health and safety and to not adversely affect the health and safety of others. Staff workers must comply with any reasonable instructions, as far as they are able, and must also cooperate with any reasonable health and safety policies or procedures that they have been provided by Elevate Support Care to mitigate risk.

3.0 Definitions

Manual handling

Any activity that involves lifting, pushing, pulling, carrying,

moving, holding or restraining. It also includes sustained and awkward postures or repetitive movements.

Hazardous manual task

A task requiring a person to lift, lower, push, pull, carry or

otherwise move, hold or restrain any person, animal or thing involving one or more of the following:

● repetitive or sustained force

● a high or sudden force

● repetitive movement

● sustained or awkward posture

● exposure to vibration.

These hazards directly stress the body and may lead to an injury.

Musculoskeletal disorder


An MSD may include:

● sprains and strains of muscles, ligaments and tendons

● back injuries, including damage to the muscles, tendons, ligaments, spinal discs, nerves, joints and bones

● joint and bone injuries or degeneration, including injuries to the shoulder, elbow, wrist, hip, knee, ankle, hands and feet

● nerve injuries or compression (e.g. carpal tunnel syndrome)

● muscular and vascular disorders as a result of hand- arm vibration

● soft tissue injuries including hernias

● chronic pain.

An MSD can occur in two ways, including:

● gradual wear and tear to joints, ligaments, muscles and intervertebral discs caused by repeated or continuous use of the same body parts, including static body positions

● sudden damage caused by strenuous activity, or unexpected movements such as when loads being handled move or change position suddenly.

● Injuries can also occur due to a combination of the above mechanisms.


Any place where work is carried out for a business and

includes any place where a worker goes, or is likely to be, while at work, including a participant’s home.

  • Policy

Elevate Support Care will manage risks to health and safety relating to a musculoskeletal disorder associated with hazardous manual tasks by following the recommendations of the SafeWork Australia‟s Hazardous Manual Tasks Code of Practices.

A Work Health and Safety Officer, delegated by the Director, will manage risks to:

  • identify and assess reasonably foreseeable hazards that could give rise to manual handling risk
  • eliminate the risk, as far as is reasonably practicable
  • minimise the risk, as far as is reasonably practicable, by implementing control measures (e.g. use of appropriate mechanical aids, the provision of training, support and communication with all who may be exposed to the risks and hazards)
  • maintain the implemented control measure, so it remains effective
  • review, and if necessary, revise risk control measures to maintain a work environment that is without risks to health and safety, as far as

Elevate Support Care will ensure it provides:

  • appropriate equipment and related training that promotes safe manual handling practices
  • education specific to manual handling on an annual basis to guarantee staff knowledge is up to date and in line with the current safe work standards
  • induction training and instruction to workers that are suitable and adequate for their work role incorporating:
  • the nature of the work carried out
  • the nature of the risks associated with the work at the time of the information, training and instruction
  • control measures implemented
  • review and monitor the manual handling practices of employees who directly and actively participate in the delivery of care to participants
  • assessment of participants for manual handling risks and where risks are identified ensure these are documented in their clinical record, as well as procedures/practices to be carried out to reduce the risk (to be undertaken upon initial assessment of the client and in the home risk assessment procedures)
  • support for consultative and collaborative improvement processes regarding safe manual handling
  • annual reviews of the individual participant that include the assessment of equipment or processes relating to manual handling to ensure that these are still valid
  • carry out reassessment immediately if there are changes in the participant’s condition that may alter the work environment concerning manual handling
  • investigate all incidents and accidents which result in physical or musculoskeletal injury to employees
  • review risk assessments and systems of work in light of any incidents
  • report all incidents and complete the Incident Investigation Form as soon as

Our staff will ensure they take personal responsibility for reducing the potential risk of injury to themselves, participants and others, by:

  • understanding the principles of manual handling and being able to identify potential hazardous risks
  • familiarising themselves with the Safe Work Australia Hazardous Manual Tasks Code of Practice
  • consistently using safe work practices when undertaking any manual handling activity, following the manufacturer’s operational instructions on the use of equipment and procedures documented in the participant’s notes relating to specific manual handling
    • adhering to our organisation’s policies and procedures relating to manual handling as outlined in this policy and the following

5.0 Procedure

5.1 Managing manual handling risks

All new staff undertake work health and safety training and are provided with relevant documentation at their induction/orientation. The Staff Orientation Checklist records this.

New staff workers will be assessed for their competency in manual handling on their initial buddy shift/s and any later shift observations.

All staff will be provided annual refresher training in manual handling relevant to their role, as per mandatory training outlined in the Staff Development Policy and Procedure.

5.2 Participant care procedures

Participant assessment, planning and ongoing revision will include:

  • an initial assessment of manual handling risks and appropriate control strategies, documented in the Participant Initial Assessment Form
  • notes of manual handling risks in the Risk Assessment Form
  • ongoing assessment of manual handling risks and strategies annually or as

5.3 Continuous improvement procedures

The Quality and Risk Committee will:

  • ensure all musculoskeletal injuries are investigated
  • review policies and procedures in the light of such incidents
  • enter review and outcomes in the Incident Register and Continuous Improvement Register
  • periodically review all employee incidents to identify any patterns related to musculoskeletal injuries and manual

5.4 Employee procedures

Employees are expected to:

  • take part in all training and assessment provided concerning manual handling
  • adhere to manual handling policies and procedures
  • consult with all key persons to reduce manual handling risks, e. participant, family, carer, management and allied health professionals.
  • use and operate equipment following manufacturer instructions and only for its intended
  • report to the Director as soon as possible any:
  • potential hazards and faulty equipment (e.g. commode chair difficult to manoeuvre, malfunctioning hoist batteries, frayed/worn slings, harnesses and broken buckles)
  • incident/accident, injury or dangerous occurrence relating to manual handling
  • changes in the participant’s condition and environment that may increase the risk of injury from manual handling
  • Risk management process for manual tasks

What is the manual task?

● Using the body to lift, lower, push, pull, carry or otherwise move, hold or restrain any person, animal or thing.

Is the manual task hazardous?


Application of


– repetitive

– sustained

– high

– sudden


– sustained

– awkward


– repetitive

Exposure to



What is the risk of MSD?

● How often and how long are specific postures, movements or forces performed or held?

● What is the duration of the task?

● Does the task involve high or sudden force?

● Does the task involve vibration?

What is the source of risk?


Work area design

and layout

Systems of work

Nature, size,

weight and

number of persons, animals or things handled

Work environment

Is the task necessary?

● Can the source of risk (work area layout, environment, etc.) be changed?

● Can mechanical aids be used to perform the task?

● What training is needed to support the control measures?


Conduct a review:

● when the control measure is no longer effective

● before a change at the workplace that is likely to give rise to a new or different health and safety risk that the control measure may not effectively control.

● if the new hazard or risk is identified.

● if results of consultation indicate that a review is necessary

● if a health and safety representative at the workplace requests a review.


6.0 Related documents

  • Incident Report
  • Incident Investigation Form
  • Incident Investigation Form Final Report
  • Incident Register
  • Continuous Improvement Register
  • Continuous Improvement Plan
  • Staff Orientation Checklist
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house
  • Risk Assessment Form
  • Risk Register
  • Risk Management Plan
  • Hazard Report Form
  • Human Resource Management Policy and Procedure
  • Work Health Safety and Environmental Management Policy and Procedure

7.0 References

  • Work Health and Safety Act 2011 (Commonwealth)
  • Work Health and Safety Regulations 2019 (Commonwealth)
  • SafeWork Australia – Hazardous Manual Tasks Code of Practices

Continuous Improvement Policy and Procedure

1.0 Purpose

Elevate Support Care is committed to continuous service improvement. Continuous improvement requires a deliberate and sustained effort and a learning culture. It is results- driven with a focus not only on strengthening service delivery but also on individual outcomes.

This policy supports Elevate Support Care to apply the National Disability Insurance Service Practice Standards and Quality Indicators.

Elevate Support Care actively pursues and demonstrates continuous improvement in all aspects of business operations.

2.0 Scope

All staff, whether permanent or casual, contractors, volunteers or business partners, are responsible for monitoring how well Elevate Support Care services and supports are functioning.

3.0 Definitions

Continuous improvement

A formal, cyclical series of steps that are designed to

improve processes that lead to better outcomes for participants and other stakeholders.

The steps usually include matters such as identifying opportunities for improvement, collecting data, analysing data, deciding on a new approach based on the data analysis, developing and implementing changes and evaluating the effectiveness of the changes.

Internal auditing

An independent, objective assurance and consulting

activity designed to add value and improve the organisation‟s operations. It helps the organisation to accomplish its objectives by bringing a systematic and disciplined approach to evaluate and improve the effectiveness of its quality management system.

Corrective action

An action, or a plan, created by management to

address a non-conformance.

Performance measures

Performance measures (or „indicators‟) how

outcomes or results are evaluated. They are the measures of how well the service provider is carrying out its work and achieving its aims.

They are expressed as numbers rather than as descriptions. They can tell a service provider:

● how much it has done (numbers of people using a service, numbers of activities provided)

● how well it has done something (levels of satisfaction by numbers of people, timeliness or efficiency of activities)

● the effect it has had (outcomes for numbers of people receiving service, changes in social well-being or social policy)

● sound corporate governance

● the financial health of the organisation

● participant satisfaction levels

● achievement of positive outcomes for participants

● level of staff morale

● provide a positive profile for the service provider among stakeholders.

  • Policy

This policy guides the design and delivery of services and ensures Elevate Support Care maintains high standards, improves systems and processes, adapts to changing needs and demonstrates organisational improvement.

4.1 Continuous improvement process

The basis of Elevate Support Care’s quality system is a cycle of self-improvement that follows a basic model involving planning, acting and checking to improve and standardise our processes. This model is used at a whole of organisation level to determine, measure, analyse and improve performance. At a process level, this approach involves:

  • identifying problems or improvement opportunities, then investigating and determining the root cause
  • developing and implementing an action plan, listing tasks, setting target dates, nominating responsibility and tracking progress through continuous management
  • checking that the improvement has led to growth through performance measures and identifying any new or additional measures needed
  • standardising improvements made through policies or other

4.2 Principles

  • All services, processes and procedures undertaken are the best they can
  • Services are regularly reviewed and measured for quality and
  • All staff and participants are encouraged to provide feedback on how to improve service
  • The participants are to be involved in all decision-making processes that affect
  • Participants, family and advocates can provide valuable insights about the effectiveness of services, highlight any gaps or issues that arise and provide ideas for improvements and
  • A learning culture of quality within the organisation ensures all people, regardless of their role, contribute to service quality and quality
  • Planning, resource allocation, risk management and reporting are critical for continuous improvement and are part of an integrated approach that supports Elevate Support Care’s mission and
  • Elevate Support Care is committed to innovation, high quality, continuous improvement, contemporary best practice and effectiveness in the provision of supports to people with

Diagram 1. Continuous Improvement Cycle Process

4.3 Measurements of quality

Elevate Support Care uses survey and audit results to measure outcomes required under the NDIS Practice Standards and Quality Indicators, in addition to other legislative requirements.

4.4 Sources of data for continuous improvement

4.4.1 Changes in legislation/regulation and best practice

Elevate Support Care’s management is informed of regulative and legislative changes via structured access to government, industry and association information channels and through attendance at industry conferences, networking events and ongoing training/education. Information of this type is used to improve practices and approaches in our operations and services, including the implementation of service improvements.

Policies and procedures will be reviewed on an ongoing basis to ensure compliance with legislation. Version control will occur to ensure current documents are available to staff and participants.

4.4.2 Feedback and evaluation of data

Elevate Support Care will conduct formal surveys annually, at a minimum, to obtain opinions and feedback from participants as well as from their families and advocates, where possible.

Such feedback will assist Elevate Support Care to accurately assess the quality of services and to make any improvements necessary.

Elevate Support Care will collate the feedback from its surveys and advise participants of any proposed improvements to service delivery. Surveys and focus groups may also be targeted to review specific aspects of performance, e.g. information provision or ensuring participants are involved in their planning and decision-making.

Staff surveys will be conducted on an annual basis. These will be used to measure morale, understanding of Elevate Support Care‟s policies and procedures, operating environment satisfaction, roles within the organisation, training and information needs and our commitment to our values. Feedback analysis is incorporated into a Continuous Improvement Plan.

4.4.3 Internal/external audits

Elevate Support Care will conduct periodic internal audits to determine whether the quality management system conforms to the requirements of the relevant quality standards. The internal audits will check all processes and documents to ensure that the quality management system has been effectively implemented and maintained.

Internal and external audits will be designed to ensure that legislation, industry standards, and operational processes are correctly understood and implemented as per organisational policy (see Appendix 1: Internal review and external audit schedule).

Data obtained from audits will be stored and used to ensure corrective actions are recorded, verified and closed out. The data collected from internal audits and corrective actions will be integrated into the continuous quality improvement system.

4.4.4 Complaint management

All complaints will be investigated to determine the root causes and required improvements. Improvements will be tracking progress through management systems (meetings and reports) to capture and evaluate corrective actions.

All staff will be responsible for promoting the development of a positive complaint handling culture. Management will review complaints every six months (at least) to ensure that the complaint handling process is in accordance with our policy and procedures.

The Director or their delegate will annually review the entire complaint handling system to ensure changes to policy and practice are implemented when necessary. The complaint data will be analysed to determine if there are any trends or patterns of on-going concern; such analysis will be incorporated into the continuous improvement system and corporate governance.

4.4.5 Incident reporting

The Director, or their delegate will be responsible for reviewing incidents, including incidents recorded under the Incident Register. This register allows for the collation and analysis of

data from incident reports for the determination of issues, trends or patterns of on-going concern; such analysis will be linked to the continuous improvement system.

4.4.6 Unsolicited feedback

Every participant and staff member has the right (and are encouraged) to provide feedback and suggestions that they believe can lead to improvements in the overall operation of Elevate Support Care. They may use the Complaints and Feedback Form to put their thoughts and ideas in writing to the Director. Alternatively, feedback can be provided via email or phone.

All suggestions will be fully considered, and appropriate improvements implemented, wherever possible. This feedback information is linked to our corporate governance to instigate changes in policies and procedures so we can improve practices on an ongoing basis.

4.5 Communication of improvements

An outline of any improvements is provided via:

  • staff meetings
  • emails
  • subcontractor meetings
  • updated policies and

4.6 Monitoring continuous improvement processes and systems

As part of our audit program, continuous improvement processes and systems are regularly audited. All staff, participants and other stakeholders are encouraged to provide ongoing feedback on any issues and areas where improvements are possible.

Continuous improvement should include feedback from participants and stakeholders to ensure that Elevate Support Care meets the needs of the community in which it functions.

Continuous improvement ideas and strategies will be used to inform our corporate governance. Document and version control measures are to be documented in the Document Control Register. New documents are distributed as outlined in this document.

5.0 Related documents

  • Complaints and Feedback Form
  • Complaint Register
  • Hazard Report Form
  • Internal Audit Schedule
  • Internal Audit NDIS Policy Review Form
  • Board Meeting Agenda and Minutes
  • Position Descriptions
  • Risk Assessment Form
  • Risk Indemnity Form
  • Risk Register
  • Risk Management Plan
  • Service Agreement
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house
  • Business Plan and Strategy Plan
  • Maintenance of current registrations and insurances
  • Documentation including meetings and memos
  • Complaints and Feedback Policy and Procedure
  • Risk Management Policy and Procedure
  • Reportable Incident, Accident and Emergency Policy and Procedure
  • Continuous Improvement Policy and Procedure
  • Corporate Governance Policy and Procedure

6.0 References

  • Disability Services Act 1986 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)
  • Disability Discrimination Act 1992 (Commonwealth)
  • NDIS Practice Standards and Quality Indicators 2020

Appendix 1: Internal review and external audit schedule

Audit FocusTechniqueResponsibilityReview Schedule

Policies and


● Evaluate effectiveness

and currency (practices match policy)

● Merge, develop or repeal policies and procedures

● Address non- conformances

● A delegate staff member to review, adjust and train staff in new practices and policies


or delegated officer

Three-year cycle

or when legislation changes.

High-risk policies – annually (all Governance)

Strategic and

Operational Plans

● Management planning


● Update of business plan


or delegated officer


Data Protection


● Internal privacy audits

● Non-conformances to be forward to Director to actioning


NDIS Audit

Certification or Surveillance

● Review previous report

● Inform participants and staff

● Policy matches practice

● Rectifications allocated to relevant staff and used as training and improvement


NDIS Approved External Auditor

Three-year cycle

(Annual surveillance and renewal audits)

Service Delivery

● Preparation and

submission of reports required under any contractual arrangements

● Errors or non- conformances will be actioned to ensure compliance


or delegated officer

As per contractual



● Preparation of annual


● Review current legislative requirements (NDIS,

Tenancy, general business)

● Non-compliances – Director to manage


or delegated officer

Annually following

the end of the financial year

(if relevant)


Financial year reporting:

• quarterly

• end of Financial Year


or delegated officer

Quarterly (March, June,

September and December)

Annually (July)



● Review Assets Register

● Update warranty and depreciation details

● Building and assets review

● Audit maintenance schedules for continuing value and usefulness


or delegated officer




● Review of risk

management and risk treatment plans

● Review continuous improvement register for sign-offs and actions

● Action non-actioned items in Continuous Improvement Register


or delegated officer


● Review Complaints


● Review Continuous Improvement Register for sign-offs and actions

● Action non-actioned items in Continuous Improvement Register


or delegated officer




● Review current Continuous

Improvement Plan, Incident Register, Risk

Management Plans and Complaints Register for trends and plan of action.

● Action non-actioned items in Continuous Improvement Register

Director or

delegated officer

Incident Review

● Incident Register review for

risk identification linked to continuous improvement

● Action non-actioned items in Continuous Improvement Register


or delegated officer


Operational and

Environmental Safety

● Building safety reviews

● Internal and external inspections incorporating physical & digital access audits

● Check all aspects of building for safety, privacy and security

● Actions undertake to rectify non-conformances


or delegated officer


Work Health

Safety Requirements

● Safety compliance audits

against documented work procedures, e.g. fire safety, electrical equipment, participant safety

● Actions undertake to rectify non-conformances by a delegated officer




Provision of


Participant surveys review

● service satisfaction

● staff satisfaction

● rights upheld

● Improvement ideas Action review outcomes


or delegated officer



Resource Management

● Staff performance


● Staff satisfaction surveys and analysis for improvements

● analyse input for trends

● Action trends to improve outcomes for staff

Director or




or suppliers

● Review supplier contract

details, performance, costs and service quality

● Adjust suppliers and contractors if not meeting requirements


or delegated officer


Personnel File


● KPIs reviewed to ensure

meets current job role

● Adjust job descriptions

● Training records current

● Review of relevant registrations and currency

Director or





● Random file selection for

accuracy and compliance

● Check privacy and confidentiality requirements

● Ensure passwords systems are current

● Advice management if any issues

Director or



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Risk Management Policy and Procedure

1.0 Purpose

Elevate Support Care is actively working to identify, address and monitor potential risks to promote a safe environment for participants, staff and visitors and to maintain adequate and viable business operations to:

  • support effective decision-making that is guided by our mission and vision
  • ensure a consistent and effective approach to risk management
  • formalise our commitment to the principles of risk management and incorporating these into all areas of the business
  • foster and encourage a risk-aware culture, where risk management is understood to be a positive attribute of decision-making, rather than a corrective measure
  • align the planning, quality and risk management systems and integration into all areas of our operations
  • implement robust corporate governance practices to manage risk while allowing innovation and

2.0 Scope

Risk management is built into all areas of our operations, including service delivery and corporate governance. Risk management is the responsibility of all staff members and all areas of the organisation. It is the responsibility of the Director to carry out risk management analyses for the organisation and to take appropriate measures.

3.0 Policy

Elevate Support Care recognises the importance of managing risk and ensuring that all stakeholders are aware of their role in identifying, analysing, evaluating, treating, monitoring and communicating risk in a systematic risk management approach.

Elevate Support Care understands the organisation may be at risk when:

  • a well-functioning governance structure is not in place
  • management plans, policies and processes are inadequate
  • staff member roles and responsibilities are unclear
  • participants are not required to sign consent forms or waivers
  • equipment and facilities are not safe for the intended use
  • implementation of a comprehensive risk management plan has not
  • finances are managed inappropriately resulting in inadequate financial sustainability and cash flow
  • insurance is inadequate or inappropriate
  • operations are not evaluated

4.0 Definition


The possibility of something occurring that will have

an impact on the service‟s objectives. Often risks involve constraints, failures, obstacles and losses that may arise in the future.

Risk is measured in terms of consequences, and if the risk will have a positive or negative impact.

  • Procedure

5.1 Identification

Figure 1. Risk identification process

Our organisation implements processes to effectively manage risk, such as:

  • analysing hazard data
  • conducting risk assessments including environmental and equipment assessments
  • reviewing incident/accident information
  • seeking staff, participant and visitor feedback/complaints
  • maintenance of log items
  • ongoing review of all policies and procedures
  • seeking input from staff during staff meetings
  • incorporating appropriate strategies identified during planning days, g. strategic and operational planning sessions
  • incorporating new information obtained via education and training into the business
  • conducting financial audits
  • conducting internal and external

5.2 Planning

Elevate Support Care has established and maintained a Risk Management Plan. The plan identifies and addresses:

  • Risks to Elevate Support Care Including loss of funding, inability to deliver funded outcomes within budget, embezzlement of funds, lack of suitably qualified staff, extended staff illness, damage to reputation and relationships, changes in compliance requirements and eligibility, decisions by the Director and loss of data due to natural
  • Risks to staff – Including lack of suitably qualified staff, extended staff illness, staff member injury due to WHS risks, changes in training and education compliance requirements, impacts of natural disasters and
  • Risks to participants – Including environmental, fire, falls, transport, staff working in a participant‟s home, changes in the consistency of performance of activities, interruptions to service delivery and exit plans (transitioning services to another service provider).

The Risk Management Plan includes:

  • details of the risk
  • the date the risk was identified
  • risk rating and the possible consequence/s of the risk
  • actions required to eliminate, mitigate or control the risk
  • review dates, new controls and changes to existing

The Director reviews the Risk Management Plan every two (2) months, or more frequently as required, in response to information received via work health and safety reviews, audits and continuous improvement systems.

Figure 2: Risk management process

5.3 Managing risks

5.3.1 Controls

Controls are strategies used to manage risk. Identified risks are balanced against the cost and inconvenience of the control to the organisation before implementation. Controls used by Elevate Support Care to manage risks include:

  • implementation of a Strategic Plan
  • implementation of a Risk Management Plan
  • thorough staff orientation, education and training
  • implementation of new processes identified during a risk assessment
  • effective internal and external information systems, including meetings and memos
  • strict adherence to policies, procedures and work instructions by all staff
  • the utilisation of position descriptions
  • ongoing capital maintenance and setting appropriate equipment budgets and plans
  • maintaining all current registrations and
Risk matrix

Risk Control Process used to remove or minimise associated risks.

5.3.2 Improvement committee

Members of the improvement committee are representatives of our workforce. The committee’s function is to identify risks through the review of information (see ‘5.0 Procedure’ and ‘5.1 Identification’). The committee meets every quarter.

Separate to the committee review, all risks will be reviewed independently by Elevate Support Care‟s Director.

Where risks are ongoing, they will be included in the Risk Management Plan and Continuous Improvement Plan. It is the Director‟s role to ensure all actions required to manage identified risks are undertaken within the nominated time frames.

5.3.3 Hazard identification

Where a hazard or potential hazard is identified, a staff worker must complete in detail a Hazard Report Form and provide this, on the same working day, to the Director.

When consequences of hazards are assessed as high or extreme, a staff member must contact Elevate Support Care to inform the Director immediately, or as soon as it is safe to do so. The Director will take steps to address extreme or high hazards immediately.

Detailed documentation of action taken must be included in the Hazard Report Form and Risk Assessment Form and, where required, on the Continuous Improvement Plan. All Hazard Report Forms are provided to the Elevate Support Care Improvement Committee for review.

5.3.4 Monitoring

Risk management processes and systems are audited regularly as part of the audit program.

5.3.5 Reporting

Elevate Support Care will use the data gained from the risk management process to inform decisions and plans to improve practices continuously. The analysis will be conducted to assist changes in services, policies and procedures. The analysis will include, but is not limited to:

  • complaints and feedback
  • financial risk
  • staffing issues
  • participant satisfaction
  • risks to participants and staff
  • amendments to legal or compliance requirements
  • training and
  • Consequence Rating Table
Insignifican tMinorModerateMajorExtreme
The participant

Less than

first aid injury or a

brief emotional disturbance

First aid injury

or emotional disturbance impacting more than two days but does not require treatment.

Substantial injury

resulting in medical treatment.

Temporary impairment or development/exacerba tion of mental illness requiring treatment

Some cases of abuse/ neglect of the person


injury causing permanent impairment.

Severe, long- lasting or significant exacerbation of mental illness requiring long- term treatment.

Significant faults are allowing significant abuse/neglect of people receiving support.


death of a person.

Systemic faults

allowing widespread abuse or neglect of a participant.

Support Worker and others

Nil or minor

first aid

injury or a brief emotional disturbance

First aid injury


psychological injury impacting more than two days but does not require treatment.

Substantial injury

resulting in medical treatment.

Temporary impairment or development or exacerbation of psychological injury requiring treatment.


injury causing permanent impairment.

Severe, long- lasting, or

significant, exacerbation of mental illness requiring long- term treatment.



  • Related documents
  • Emergency Plan
  • Emergency Plan – Waste
  • Complaints and Feedback Policy and Procedure
  • Complaint and Feedback Form
  • Anonymous Complaint and Feedback Form
  • Complaint Register
  • Continuous Improvement Policy and Procedure
  • Hazard Report Form
  • Risk Assessment Form
  • Risk Indemnity Form
  • Risk Management Plan
  • Risk Register
  • Continuous Improvement Plan
  • Continuous Improvement Register
  • Documentation, including meeting minutes, agendas and memos
  • Position Descriptions
  • Capital maintenance and equipment budgets and plans
  • Maintenance of current registrations and insurances
  • References
  • NDIS Practice Standards and Quality Indicators 2020
  • Privacy Act 1988 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)
  • Disability Services Act 1986 (Commonwealth)

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2.3 Quality ManagementQuality Management Policy and Procedure

1.0 Purpose

The quality management system has been established to provide focus and direction within Elevate Support Care to have a positive impact on operational effectiveness, resulting in a high-quality service. The policy is developed to ensure:

  • alignment of people and resources with our mission and vision
  • alignment of planning, quality and risk management systems and the integration of these systems into all areas of operations
  • fostering collaboration and exchange of ‘best practice’ information with all stakeholders to allow us to conduct critical self-evaluation
  • providing a whole-of-service approach, reflecting our governance and organisational structure which outlines responsibilities and accountabilities
  • continuous

2.0 Scope

The Quality Management Policy and Procedure supports the development of a culture in which all staff assume responsibility for quality work performances while engaging with high performing management at all levels and within areas of the organisation.

It is the responsibility of the Director to oversee the quality management system and to implement appropriate strategies. It is the responsibility of staff members engaged in service delivery to follow our quality management policies.

3.0 Policy

Elevate Support Care recognises the importance of implementing and maintaining a quality system (outlined below is an overview of our system). The quality management system is

designed to support our service delivery and ensure that all services meet the requirements of the NDIS Quality Standards and Practice Indicators 2020. Elevate Support Care’s quality management system includes:

  • using data gained from complaints/feedback to improve services and procedures (see Complaints and Feedback Policy and Procedure)
  • managing the continuous improvement system to determine areas of improvement, including input from:
    • Complaints and Feedback Policy and Procedure
    • Risk Management Policy and Procedure
    • Reportable Incident, Accident and Emergency Policy and Procedure
    • Continuous Improvement Policy and
  • incorporating all relevant improvements identified in the Continuous Improvement Register into management and corporate governance processes
  • highlighting risks through the Risk Management Policy and Procedure to reduce hazards and improve practices
  • managing human resources; including training staff on how to deliver quality support to meet the individual needs of participants
  • providing participants access to quality services and allowing them to have input via complaints and feedback
  • devising and implementing an internal audit schedule to ensure our organisation continues to:
    • review legislation that directly affects service provision
    • audit and review policies and procedures to meet NDIS Standards, Rules and Guidelines using the Internal Audit NDIS Policy Review
  • delivering services that meet best-practice standards; including evidence-based, person-centred support plans designed for individual participants
  • reviewing policies and procedures, in conjunction with our feedback strategies, to allow for quality management of all

4.0 Quality plan

4.1 Monitoring the quality plan

  • Elevate Support Care will hold regular managerial meetings with relevant stakeholders (may include, but not limited to, managerial staff, staff representative, accountant or bookkeeper, community members).
  • Monitoring strategies include a review of the following data:
  1. Participant‟s
  2. Environmental
  3. Working with participant‟s risks (work health safety).
  4. Feedback from participants, staff and
  5. Complaints from participants, staff and
  6. Incidents (both non-reportable and reportable).
  7. Accident
  8. Compliance changes (including legal).
  9. Human resources (requirements, vacancies, potential adjustments).
  10. Financial (NDIS income, outgoings).
  11. Technology
  12. Continuous Improvement Register (new and ongoing).
  13. Building maintenance and safety
    • Managerial meetings will use an agenda which will include the following items:
  14. Financial report
  15. Director‟s report
  16. Ratification of executive decisions
  17. Funding and compliance
  18. Organisational risk management
  19. Continuous Improvement
  20. Complaints, compliments, concerns
  21. Human Resources (issues, people, planning)
  22. Work health safety risk management
  23. Information management
  24. Incidents (if applicable)
  25. General business

4.2 Review

  1. Management meetings and input from various sources are used to determine any adjustment to the:
  • strategic or business plans
  • policies and procedures
  • current
  1. Review the Continuous Improvement Register to:
    • sign off actions
    • reallocate responsibilities, if

4.3 Update

After monitoring and reviewing current information, the Director or their delegate will:

  • ensure that staff are trained in new practices
  • record training in staff files
  • adjust policies and procedures and implement versioning control
  • inform participants of

5.0 Related documents

  • Complaints and Feedback Form
  • Complaint Register
  • Hazard Report Form
  • Internal Audit Schedule
  • Internal Audit NDIS Policy Review Form
  • Board Meeting Agenda and Minutes
  • Position Descriptions
  • Risk Assessment Form
  • Risk Indemnity Form
  • Risk Register
  • Risk Management Plan
  • Service Agreement
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house
  • Business Plan and Strategy Plan
  • Maintenance of current registrations and insurances
  • Documentation including meetings and memos
  • Complaints and Feedback Policy and Procedure
  • Risk Management Policy and Procedure
  • Reportable Incident, Accident and Emergency Policy and Procedure
  • Continuous Improvement Policy and Procedure
  • Corporate Governance Policy and Procedure

6.0 References

  • NDIS (Quality and Safeguards) Commission 2018
  • NDIS Practice Standards and Quality Indicators 2020
  • NDIS Act 2013 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)
  • Disability Services Act 1986 (Commonwealth)

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2.4 Information ManagementInformation Management Policy and Procedure

1.0 Purpose

Elevate Support Care actively works towards implementing and operating effective communication processes and information management systems. We strive to maintain all information systems and practices in accordance with legislative, regulatory compliance and organisational standards.

2.0 Scope

It is the policy of Elevate Support Care that all participants, staff, volunteers and contractors will have records established upon entry to the service and maintained while actively engaging with Elevate Support Care.

3.0 Policy

  • Elevate Support Care will maintain effective information management systems that keep appropriate controls of privacy and confidentiality for
  • Elevate Support Care’s policies and procedures are stored as read-only documents in the Policies and Procedures folder on the shared
  • Elevate Support Care is responsible for maintaining the currency of this information with assistance from the Director and other staff members, as
  • The involvement of all staff members is encouraged to ensure Elevate Support Care’s policies and procedures reflect best practice and to foster ownership and familiarity with the
  • A copy of each form used by our organisation is maintained in the shared drive in the sub-folder titled
  • All staff can access the policies and procedures at Elevate Support Care’s office in a paper-based or electronic
  • Policies and procedures are reviewed every three (3) years at a minimum, or as
  • All superseded policies and procedures are deleted from Elevate Support Care’s Policy and Procedure folder and electronically archived by the Director or a

4.0 Procedure

4.1 Elevate Support Care information management system

4.1.1 Participant documentation procedure
  • Confidentiality of participant records is
  • All Elevate Support Care staff and volunteers responsible for providing, directing or coordinating participant support must document their
  • Participant files will provide accurate information regarding their services and support and will contain, but is not limited to:
    • participant personal details
    • referral information
    • assessments
    • support plans and goals
    • participant reviews
    • details regarding service
  • Original participant documentation is stored in the participant’s central
  • Information relating to a participant’s ongoing situation, including changes to their situation (e.g. increased confusion, deteriorating health, increased risk) is to be documented in the participant’s
  • All Elevate Support Care staff who are required to document the activities relating to support of participants will be appropriately trained in documentation and record-
  • Individuals are not permitted to document on behalf of another
  • Participant records will be audited regularly to ensure documentation is thorough, appropriate and of high
  • Participant records will be stored in a safe and secure location with access available to authorised persons
  • Agreements with brokerage agencies will include a requirement for brokerage workers to document their activities
  • Staff must ensure that all relevant information about the progress of, or support provided to a participant, is entered into that person‟s file notes in a factual, accurate, complete and timely
  • Staff members must only use information collected from a participant for the purpose for which it has been
  • Participants should be advised that data which has been collected, but which does not identify any participant, may be used by the organisation for service promotion, planning or
  • Participants, family and advocates have a right to access any of their personal information that has been collected. Staff workers will support such persons to access their personal information as
4.1.2 Entering Elevate Support Care’s service

Upon a participant entering our service, all initial information will be collected using Elevate Support Care’s Participant Intake form. Only personal information necessary to assess and manage the participant‟s support needs will be collected.

The Elevate Support Care’s Assessment Report will be used to document the participant’s assessment information.

Elevate Support Care’s Director will work with the participant, their advocate/s and any other family or service providers/individuals to develop and document a participant support plan; this will be documented using Elevate Support Care’s Support Plan.

A participant file will be created to act as the central repository of all participant’s service information and interactions. A unique identifier will be assigned to each participant for documentation and record-keeping purposes.

The participant’s file will only contain material relevant to the management of services or support needs, including, but not limited to:

  • copy of the signed agreement
  • assessments
  • support plan
  • participant intake form
  • communication notes
  • privacy statement
  • complaint
4.1.3 Ongoing documentation procedures

Elevate Support Care‟s ongoing documentation procedures include:

  • maintaining participant information in the electronic participant management system, in accordance with system practices
  • documenting participant information and service activities only on Elevate Support Care’s approved forms or tools
  • ensuring other service agencies and health professionals involved with the care or support of Elevate Support Care’s participant, provide adequate documentation of their activities and the participant’s wellbeing or

The type of detailed information documented includes:

  • outcomes of all ongoing participants assessments and reassessments
  • changes or redevelopment of a participant’s support plan, including revised goals or preferences
  • critical incidents or significant changes in the participant’s health or wellbeing
  • conversations, in person or via telephone, with a participant, family members, their representative or advocate
  • conversations regarding the participant, with any other providers, agencies, health/medical professionals, family members or other individuals with interest in the participant
  • activities associated with the participant’s admission and exit, including
4.1.4 Setting up and maintaining files for participants

Once a personal file for a participant is established, staff must maintain that file to ensure that all information is accurate, up-to-date and complete:

  • Relevant staff must document, in the participant‟s file, significant issues and events that arise during their work with the participants, as the events and problems
  • As information in the personal file becomes non-current (information that no longer has any bearing on the services provided to the participant) staff will establish an archival file and progressively cull non-current information into that file for secure
  • The Director must regularly audit the files of participants to ensure that:
    • files are up-to-date
    • forms are being used appropriately
    • non-current information is being culled and stored in the archival file
    • progress/file notes are factual, accurate, complete and in chronological
  • When a participant leaves the service, their personal and archival files will be stored in a secure place such as a locked area or password-protected folder on a computer under the control of Elevate Support
4.1.5 Participant file formats
  • The files of participants will be established and maintained in the following format:
  • The file will consist of a standard manila folder, or another similar folder, or held in a secure electronic format with password
  • The forms must be based on the current formats approved by Elevate Support
  • Archival files may be in the form of lever-arch folders or archive boxes and multiple in number as
  • If files are held in an electronic format, the forms/domains and formats must similarly be
  • For ease of access, materials in the archival file should be listed chronologically with each page numbered in order and groups of similar
4.1.6 Security of files and participant information
  • All current hard copy files for participants must be kept in a secure area, such as a lockable filing cabinet at the service, ensuring only authorised personnel can gain access to a participant’s personal
  • Authorised personnel include Elevate Support Care’s staff members who are employed to provide support to the If files cannot be stored at the

service, then alternative arrangements will need to be made by the participant and the Director to ensure confidentiality and security.

  • All electronic files must be password protected to ensure confidentiality and
  • If stored at the service, current files of participants can only be taken from the service by relevant staff members from Elevate Support Care to provide the participant’s information or access to another service, such as a
  • Non-current files should not be removed from the service unless:
    • they are being moved to a more secure archival storage unit
    • permission has been sought from the Director to do
  • Faxing of information about participants should only be considered in exceptional circumstances (e.g. when time constraints prohibit the use of standard security services and only when the receiver of the fax can guarantee the security of the information).
  • Staff must not undertake any of the following actions without the express approval of the Director:
    • photocopying any confidential document, form or record
    • copying any confidential or financial computer data to any other computer, USB or storage system such as Google
  • Conveying any confidential data to any unauthorised staff member or to any other person/s.
4.1.7 Transporting a participant’s hard copy files

If, for any reason, the hard copy files of a participant need to be transported from one location to another (e.g. from their usual site to a doctor) the files must be carried in a locked document container (e.g. a briefcase or attaché case). Elevate Support Care will provide the staff worker with a locked case, as required.

4.1.8 Communication/file notes for participants
  • Communication/file notes for participants must include the following components:
    • the date the entry is made
    • the time when the entry is being made
    • the time when the event occurred
    • nature of the event in a factual, accurate, complete and timely manner
  • signature of the person making the entry
  • the surname of the person making the entry (printed in brackets)
  • person‟s position of employment.
  • Staff must ensure that all relevant information about the participant is entered into the person‟s file notes in a factual, accurate, complete and timely manner.
  • The file notes for each participant should be written when a significant event occurs or to record the type of support provided while working with a participant. The definition of a significant event will vary, from person to person and should be determined in consultation with the Director and should relate to the support required by the person-centred
  • It is required that staff workers make an entry in the file notes on each workday, even when the person‟s day has gone according to plan and without the occurrence of unusual or extraordinary
  • All entries made into file notes should be placed on the next available line. Under no circumstances should blank spaces be left on the file notes
  • All file note entries made by a staff worker, on behalf of another staff member (e.g. dictating over the phone) must be signed by the person dictating the notes on their next It is the responsibility of that person to check the entry for accuracy and, if required, note any corrections that need to be made on the next line available.
  • Whenever required, the participants should be made aware of what has been recorded in their progress/file
4.1.9 Working from home

Staff who are required to work from home must sign the Privacy and Confidentiality Agreement. The security requirements for working from home include:

  • only the staff member can access any documents both written and electronic
  • the computer must have a firewall to protect information
  • all information that is linked to the server must be uploaded at the end of the
  • start and finish times are to be recorded and sent to the supervisor
  • report current work status at least
4.1.10 Access to participants files
  • Participants/guardians are provided access to their records on request. The Director should approve and control the way participants access their files to ensure the security of other non-related information is
  • Access to a participant’s file is the direct responsibility of the When access is requested by anyone, other than staff employed by Elevate Support Care it will only be granted when the Director is satisfied the policies and procedures of Elevate Support Care have been followed and access to the file is in the best interest of the participant. Such access will only be granted when the appropriate person has given consent.
  • All participants files are the property of Elevate Support Care and, although a participant and their guardian can access the file, it cannot be taken by a participant or guardian; or be transferred to any service external to Elevate Support Care without permission of the
  • Copies of files that are legitimately released for any reason shall be recorded on an appropriate letter, which shall be signed as a receipt by the service recipient or their legal guardian. The proper procedure for releasing information about a participant to persons or services that are external to Elevate Support Care is outlined in our Consent Policy and
  • Any students on placement at Elevate Support Care may only access files with the consent of the participant or their guardian. Students will be required to provide a written undertaking that they will always maintain confidentiality and only use non- identifying This agreement is to specify what information is to be used for and advise that any written compositions containing information are to be provided to the Director for approval before dissemination.

4.2 Staff records

Staff files are kept in a filing cabinet in the Director‟s office and are available only to the Director. The filing cabinet is locked when the office is unattended.

4.3 Minutes of meetings

Minutes of meetings are maintained on the shared drive.

4.4 Other administrative information

Individual staff members are responsible for organising and maintaining the filing of general information following their position descriptions.

Administrative information including funding information, financial information and general filing is maintained in the filing cabinets in the Director‟s office. The cabinets are locked out of hours or when the office is unattended for a lengthy period.

4.5 Electronic information management

4.5.1 Data storage
  • All data is stored in the shared drive of the
  • The Director is the only person who can add new data folders to the shared drive of the
4.5.2 Backup
  • All computer data (including emails) is backed up every night to a remote
  • Periodic testing of backed-up data is undertaken to check the reliability of the
4.5.3 External programs

No programs, external data or utilities are installed onto any workstation without the permission of the Director.

4.5.4 Log-in credentials

Log-in credentials are assigned by the Director or their delegate.

4.5.5 Email
  • Staff should send and receive a minimal number of personal
  • All emails are filed in the appropriate folders set up by the
  • Pornographic, sex-related or spam email received is to be deleted Under no circumstances are staff allowed to open or respond to spam emails.
4.5.6 Internet access
  • Internet access is restricted to work-related
  • Internet access reports are maintained on the server and are regularly reviewed by the
  • Under no circumstances are staff allowed to access pornographic or sex-related
4.5.7 IT Support
  • Our organisation maintains an ongoing IT support
  • If staff experience problems with a program, computer, or any other piece of IT equipment, they can, in the first instance, contact the
  • If necessary, the Director will arrange for the IT consultant/s to
4.5.8 Social media
  • Our organisation is aware that social media, e.g. social networking sites such as Facebook, Twitter or similar, video and photo-sharing sites, blogs, forums, discussion boards and websites, promote communication and information
  • Staff are required to ensure the privacy and confidentiality of the organisation‟s information and the privacy and confidentiality of the participant and their
  • Staff must not access inappropriate information or share any information related to their work through social media
  • All staff are required to seek clarification from the Director, if in doubt as to the appropriateness of sharing any information related to their work on social media

4.6 Monitoring information management processes and systems

As part of our audit program, we regularly audit information management processes and systems. Staff, participants and other stakeholders are encouraged to provide ongoing feedback on issues and areas where improvements are possible.

4.7 Archival and storage

All records, after their active period, must be kept in the archive files for an additional time. Regulatory, statutory, legislative requirements determine the retention period, or as defined by Elevate Support Care as a best practice (refer to Attachment 1: Disposal and archiving of documents).

Archived records must be identified and stored in a way that allows for easy access and retrieval when required. Archived records, in hard copy, must be stored in an environment which minimises deterioration and damage, i.e. not exposed to direct sunlight, moisture, extremes of temperature, pests, dust and fire hazards.

4.8 Destruction of records

The following procedures apply for the destruction of records:

  • Junk mail and instructional post-it notes may be placed in recycling bins or other bins as
  • All other records or documents requiring destruction are to be:
    • shredded and then placed in recycling bins
    • sent off-site to be securely pulped
    • deleted from the

5.0 Related documents

  • All electronic and hard copy documentation
  • Complaints Register
  • Complaints and Feedback Form
  • Anonymous Complaints and Feedback Form
  • Consent Policy and Procedure
  • Service Agreement
  • Privacy Statement – Website
  • Participant Intake Form
  • Participant Information Consent Form
  • Participant Support Plan

6.0 References

  • Disability Discrimination Action 1992 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)
  • NDIS Practice Standards and Quality Indicators 2020

Attachment 1: Disposal and archiving of documents

Function or ActivityDescription


disposal action


Aboriginal and

Torres Strait Island participant information

Documents relating to

Aboriginal health

Standard operational documents


7 years after the person‟s

last contact

with the


Business information


Address Telephone number

Compliance notices

Financial records

7 yearsOffice
Internal audits

Audit schedule

Audit questions Audit reports

2 yearsOffice
Participant records


Address Telephone number Emergency contact Application

Complaints about the non-delivery of services

Incident Records Complaint Records BSP Records

Service Agreement

7 years

If the

participant is a child, records must be stored until the child turns 25 years of age.

Contracts/leasesProperties7 yearsOffice
Corrective action financial

Corrective action

Requests Audits Budgets Receipts Cheques

Petty cash documents Other financial records

2 years

7 years



Management review

Minutes of meetings

Agendas Monthly reports

2 years

Held on PCs


to the type of meeting

Consent Policy and Procedure

1.0 Purpose

Elevate Support Care must gain consent from the participant before sharing any information with family, advocates, other providers and government bodies.

Children under the age of eighteen (18) will need consent from their family/advocate/guardian to share information with other providers and government bodies. It is the responsibility of all staff to inform participants about their rights regarding the provision of consent.

2.0 Scope

All efforts should be made to obtain consent. When there are language or communication barriers, staff members will ensure that all reasonable efforts have been made to overcome these, using available communication skills and technology, interpreters, relatives/carers and friends.

Relatives may be consulted about the best ways to communicate or may be requested to assist with establishing the participant’s values and preferences if a participant is unable to express these themselves.

Initial consent will be undertaken during the participant’s registration with the service. The prime responsibility for obtaining consent lies with the front-line worker who is to carry out the service. Consent can be sought from another individual, but only if they have enough knowledge to provide the right information and answer the participant’s questions correctly. Consent is equally valid whether it is expressed verbally, non-verbally (implied), or is written:

  • Implied consent is adequate for most of the support provided by the
  • Oral consent is enough for most interventions provided by doctors and other health professionals (e.g. commencing a manual handling process or use of complex medical procedures).

Oral consent should be recorded in the support plan with relevant details of the discussion, date and time of the entry, together with the name of the staff member legibly written. Oral refusal of consent, for any intervention, must also be recorded in the support plan in the same manner.

  • Written consent should be gained for the use of an advocate, or to share information by the participant and the healthcare professional. Note: Participants automatically opt-in and must request to opt-out of NDIS audit
  • Taking a photograph requires written consent to be obtained from any participant whose photo is being

3.0 Policy

  • Elevate Support Care recognises the importance of maintaining the privacy and confidentiality of all participants; however, there are times when it is essential to share information with other parties, such as government bodies and other service
  • Elevate Support Care will not provide any information to a person or authority without the participant‟s consent unless the disclosure is a legal
  • Elevate Support Care will inform all participants, upon entry into the service, about their rights to privacy and
  • Elevate Support Care will notify all participants that they have an opt-out option if their information is requested for audit

3.1 Guiding principles

  • Participants have the right to make decisions about things that affect their
  • It is presumed that participants have the capacity to make their own decisions and provide consent when it is required unless there is evidence
  • Participants are supported to make informed decisions when their consent is
  • Consent is obtained from the participant, or a legally appointed guardian, for life decisions such as accommodation, medical treatment, forensic procedures and behaviour
  • Consent for financial matters is obtained from the participant, or a legally appointed financial manager or the person appointed under a Power of
  • Participants are supported to identify opportunities to make decisions about their own lives and to build confidence in their decision-making
  • When a participant wants or needs support to make decisions, it is provided in ways preferred by the participant and by a supporter of their
  • Support with decision-making must respect the person‟s cultural, religious and other
  • If a participant wants support from family and friends, this is encouraged and
  • Support is provided in ways that uphold the participant‟s right to self-determination, privacy and freedom from abuse and
  • Decision-making and self-determination are not limited by the interests, beliefs or values of those providing the decision-making
  • The amount or type of support required by a participant to make decisions will depend on the specific decision or the
  • Participants are supported to make decisions that affect their own lives, even if other people do not agree with them or regard the decisions as
  • Participants are supported to access opportunities for meaningful participation and active inclusion in their community when they want
  • Information is provided in formats that everyone can understand and enables the participant, their supporters and others, such as legally appointed guardians, to communicate effectively with each

Diagram 1. Participant consent process

4.0 Procedure

If a participant wishes to provide consent so another person or organisation can access their personal information, then the following procedure is to be undertaken:

  1. The participant is informed that written or verbal consent is required before sharing any of their personal
  2. The participant is advised that their consent can be withdrawn at any
  3. Information about the consent is communicated in a method that is relevant to the
  4. The participant completes a Participant Information Consent
  5. A signed Participant Information Consent Form is placed at the front of the participant’s
  6. All relevant staff members are informed about consent

Diagram 2: Participant consent process

5.0 Related documents

  • Easy Read Documents and Forms
  • Participant Information Consent Form

6.0 References

  • Disability Services Act 1986 (Commonwealth)
  • Disability Discrimination Act 1992 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • NDIS Practice Standards and Quality Indicators 2020

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2.5 Complaints and Feedback Management
Complaints and Feedback Policy and Procedure1.0 Purpose

This policy is intended to ensure that complaints are handled fairly, efficiently and effectively. The resolution of complaints will be consistent with a rights-based principle which is also fundamental to the United Nations Convention on the Rights of Persons with Disabilities.

The complaint and feedback management system intend to:

  • provide a well-handled system than values the participant‟s opinions, and takes all feedback seriously, with the intent to improve the relationship between our organisation and our participants
  • empower all employees and participants to feel free to voice their complaint or provide feedback
  • allow us to respond to issues raised by individuals making complaints in a timely and cost-effective way
  • boost participant confidence in our administrative processes
  • provide Elevate Support Care with information that will help us deliver quality improvements in our services, supports, roles, and complaints handling

2.0 Scope

Our Complaints and Feedback Policy is Elevate Support Care‟s commitment to a positive complaints culture within our organisation, from the highest management levels to our frontline staff. The policy provides the foundation for all other components of a quality complaints management and resolution framework. The policy also provides guidance to our

staff and participants (who may wish to make a complaint or provide feedback) on our complaint management system’s fundamental principles and concepts.

A designated Complaints Manager will handle all complaints and feedback received by Elevate Support Care. All staff are bound by the National Disability Insurance Scheme (NDIS) Code of Conduct.

3.0 Policy

Elevate Support Care will create an environment where complaints and concerns, compliments and suggestions are welcomed and viewed as an opportunity for acknowledgement and improvement. This process is to ensure that individuals have the right to make complaints and are encouraged to exercise their right in a blame-free and resolution-focused culture, respecting an individual‟s right to privacy and confidentiality.

Elevate Support Care will appoint a staff member to be the designated Complaints Manager. The Complaints Manager is responsible for coordinating and handling complaints and feedback and ensuring the complaint or feedback is properly managed.

It is acknowledged that Elevate Support Care views all comments and complaints as a vital contribution to our internal review of performance and processes which assists in developing the continuous improvement of our services, as we work towards achieving our care commitment.

A person does not necessarily have to expressly state that they wish to make a complaint to have the issue or concern dealt with as a complaint. Regardless of whether an issue is big or small, it will be treated seriously, and Elevate Support Care will ensure the person is advised on how valuable their opinion is to our organisation. We will use such information to continuously improve our service delivery.

Participants, families, advocates or other stakeholders may submit a Complaint and Feedback Form regarding Elevate Support Care’s supports, services, staff, or contractors. The participants can be provided information in Easy Read format if required.

The Complaints Manager will ensure that the complainant can physically access all meetings to resolve the complaint by reviewing the environment to ensure that the meeting site is accessible for those with mobility issues.

It is our policy to follow the principles of procedural fairness and natural justice and comply with the requirements under the National Disability Insurance Scheme (Complaints Management and Resolution) Rules 2018 and NDIS (Procedural Fairness) Guidelines 2018 including:

  • informing a person if their rights or interests may be adversely or detrimentally affected in a direct and specific way
  • giving notice of each prejudicial matter that may be considered against them
  • giving a reasonable opportunity to be heard on those matters before the adverse action is taken
  • putting forward information and submissions in support of an outcome that is favourable to their interests
  • ensuring that the decision to take adverse action should be soundly based on the facts and issues that were raised during that process, and this should be apparent in the record of the decision
  • ensuring that the decisionmaker should be unbiased and maintain an unbiased

Elevate Support Care ensures complaints and feedback are managed effectively through:

  • implementing an open and transparent complaint handling system
  • observing the principles of natural justice and compliance with relevant mandatory reporting under Australian law
  • committing to the right of stakeholders to complain either directly or through a representative
  • undertaking procedural fairness to reach a fair and correct decision
  • taking reasonable steps to inform the complainant of the NDIS commission complaints process, including the use of various communication means, e.g. oral and written
  • maintaining complete confidentiality and privacy
  • abiding by the NDIS Code of Conduct
  • training staff in our complaint process and the rights of all stakeholders to complain
  • considering all complaints seriously and respectfully
  • advising participants and staff members of their right to complain
  • staff will be trained in complaint handling during assessments and orientation
  • guidance regarding the complaint process is outlined in the welcome information provided to our participants
  • provision of support for people who may need assistance to make a complaint
  • protection of complainants against retribution or discrimination
  • prompt investigation and resolution of complaints
  • communicating and consulting with participants, family and advocates during the complaints process and providing feedback and resolutions
  • interpretation and application of policies and processes
  • providing opportunities for all parties to participate in the complaint resolution process
  • ensuring that complainant is involved in the resolution of the complaint
  • keeping complainant informed of the progress of the complaint:
    • actions taken
    • the reasons the decisions are made
    • options to have decisions reviewed
  • ensuring that the decisionmaker or advocate is included and recognised in the process
  • accepting Elevate Support Care and staff accountability for actions and decisions taken due to a complaint
  • committing to resolving problems at the point of service or through referral to alternatives
  • committing to use complaints as a means of improving planning, delivery and review of services through our continuous improvement processes
  • referring complaints and feedback into our continuous improvement cycle
  • annually auditing the Complaints and Feedback Policy and

4.0 Definitions


An expression of dissatisfaction with an NDIS

support or service, including how a previous complaint was handled, for which a response or resolution is explicitly or implicitly expected.

RoleRole requirements
Complaints Manager

The role of the Complaints Manager is to:

● manage the complaint process

● manage reviews and make recommendations for continuous improvement using the information gained from the issue of the complaint

● stand independently from the management to allow participants and staff members to be able to make a complaint about the management of the organisation

● provide feedback and advice, as required

● review the complainant„s needs to ensure that their mode of communication is managed (e.g. Easy Read, large print, translated documents, etc.)

● collaborate with the complainant and their advocate

● keep all parties informed during all stages of the complaint management process

● handle all appeals related to the outcome of the complaint

● complete all necessary reports and documents, including providing information to complainants and management

● record all information into the Complaint Register

● review the Complaint Register at monthly management meetings.

  • Procedure

5.1 Complaint process

Complaints and suggestions can be made by:

  • using the Complaints and Feedback Form or the Anonymous Complaints and Feedback Form
  • contacting a member of staff, verbally or in writing, our staff must offer to document the complaint on behalf of the participant if required and refer the matter to the Director
  • contacting the Complaints Manager, verbally or in writing
  • responding to questionnaires and surveys
  • sending an email to our contact email
  • attending meetings/care conferences
  • contacting external complaint agencies, g. NDIS Quality and Safeguards Commission
  • communicating orally, in writing, or any other relevant

Complaints may be made by:

  • staff
  • participants
  • public
  • advocates
  • family members
  • carers
  • anonymous person/s.

Results are recorded in the Complaint Register, which allows for input into our continuous improvement processes. The Continuous Improvement Register will be used to record improvements that are established after the finalisation of the complaint management process.

If a complaint is about:

  • Support or services: The complaint will be dealt with by the Complaints
  • Staff member/s: The complaint will be dealt with by the Complaints Manager
  • CEO/Manager: An external person or body may be approached, g. NDIS Quality and Safeguards Commission.

All staff, participants, family and advocates, visiting health professionals and visitors are informed of our complaints process via:

  • participant welcome information
  • initial access to supports
  • staff orientation, induction and training
  • Meetings, reviews and assessments
  • participant agreements
  • contractor
  • Complaint management process

The process and investigation must adhere to the principles of impartiality, privacy, confidentiality, transparency and timeliness. Complaints will not be discussed with anyone who does not have responsibility for resolving the issue. Elevate Support Care must take into consideration any cultural and linguistic needs of a participant and provide the relevant support mechanism, such as an interpreter or similar.

Complainants are provided with access to our Complaints and Feedback form. These may be accessed via staff or management. The Complaints Manager will review the individual’s needs and undertake to assist them via the best means appropriate to suit their needs. The variance between individuals requires a personal approach, but may include:

  • offering an advocate
  • providing text telephone (TTY) service to people with a hearing impairment
  • ensuring the meeting site is wheelchair accessible
  • offering independent assistance to read and write to formulate and lodge a complaint
  • seek information from the complainant to determine any special requirements (e.g. access or communication).

The resolution outcomes from a complaint will recognise that people who make a complaint are generally seeking one, or more, of the following outcomes:

  • Acknowledgement:
    • genuinely listening without interruption
    • empathising
    • ensuring the complainant feels comfortable (e.g. being aware that staff may be defensive and consider how this is perceived)
    • acknowledgement of the effect of the situation on the individual
    • resolving to a good outcome
    • notifying regularly and promptly on steps
  • Answers:
    • clear explanations relevant to the issue which is provided ONLY once all the facts are
  • Actions (Action Plan):
    • what will be done?
    • who will do it?
    • action plan completion date
    • how progress will be communicated to all parties involved
    • oversight of
  • Apology:
    • consider the form of the apology and the managerial level of response
    • consider timeliness, sincerity
    • be specific and direct
    • accept responsibility if appropriate and provide information on the cause and impacts
    • provide an explanation without excuses
    • provide a summary of key actions agreed on to move forward and resolve the
5.2.1 Non-investigation complaint process

All complaints, where possible, will be managed directly and quickly at the point of service unless the complaint requires investigation (see the procedure outlined below). The non- investigation complaint process is as follows:

  1. Issue reviewed by the Complaints
  2. The complainant will be consulted, and the issue discussed, to determine actions required to resolve the issue. During this process, Elevate Support Care will offer complainant support from an independent advocate to reduce stress and
  3. All available options will be discussed with complainant and their
  4. Where possible, a collaborative decision is finalised (i.e. acknowledgement, answer, action or apology).
  5. The complainant is informed of the decision and the reasons for the
  6. The complainant can seek to have the decision reviewed if they are not happy with the resolution; this may lead to implementing the complaint investigation
  7. In the event of a complainant seeking a review, a review of the decisions may be resolved quickly by the Complaints Manager completing the above points (2 to 5)
5.2.2 Complaint Investigation Process Step 1. Acknowledge
  1. Acknowledge all complaints quickly, within one working day, where
Step 2. Review of the complaint
  1. Inform the complainant, before any consultative meeting, that they can an advocate or support a person present throughout the
  2. Offer to locate an independent advocate for the participant, if
  3. Involve the complainant and their advocate using a consultative process to ensure their voice, views and preferred outcomes are heard and
  4. Determine the type of outcome that the complainant is seeking (i.e. acknowledgement, answers, actions or apology). Information will be used to ensure that the complainant‟s feedback and requirements are at the core of the complaint investigation and management
  5. Inform the complainant of:
    • their right to an advocate and interpreter
    • the stages of the complaint management and decision-making process
    • mechanisms implemented to protect the complainant‟s privacy
  • their right to complain to the NDIS Quality and Safeguards Commission at anytime
  • actual progress and outcomes of the
  1. Determine the type of complaint (i.e. service, support or process).
  2. Notify the complainant and their advocate at each stage of the investigation and seek their
  3. If a consultative meeting is required, it will be held in a safe environment that has been determined by the complainant and at a time relevant to the participant. Where the complainant is a recipient of disability services under the NDIS, the participant‟s record will be checked for a preferred contact for complaints. The participant will also be asked if they would like to nominate a staff member from Elevate Support Care who is assigned to handle
Step 3. Assessing the complaint
  1. When assessing a complaint, the Complaints Manager must prioritise the complaint and determine a resolution pathway (where required).
  2. After the pathway is established, the complaint will be
  3. Feedback from the complainant or their advocate must be used as part of this process (e.g. consultation meeting data).
Step 4. Investigation and decision making
  1. When the complaint is lodged, the Complaints Manager should determine if it is practicable to find an immediate resolution (see 5.2.1 Non-investigation complaints process).
  2. During the investigation and decision-making process, the Complaints Manager will:
    • keep the complainant informed about each stage of the investigation process
    • consult with the complainant to gather information about the underlying issue/s
    • analyse antecedents and underlying issues when determining a decision
    • review and approve all written reports and documents, before them being sent out to all parties
    • respond to the complainant with a clear decision and any next actions (if any)
    • inform the complainant that they have the right to reject the outcome
  • inform the complainant of their right to make a complaint directly to the NDIS Commission by:
  1. phoning 1800 035 544 (free call from landlines) or TTY 133 677 (interpreters can be arranged).
Step 5. After the decision
  1. After investigation and a satisfactory response has been documented, the Complaints Manager will:
    • inform the complainant and their advocate of the decision, including the reason for the decision, and they will provide options for how the complainant can review the decision
    • ensure that the complaint investigation is satisfactorily completed
    • determine if the complainant is satisfied with the outcome
    • follow-up and consult with the complainant/s about any concerns
    • close out the

5.3 Review and improvement

Elevate Support Care takes a systematic approach to incorporate a review of all issues raised by a complaint to identify and address any possible systemic issues and determine any continuous improvement actions identified during the complaints process.

The review and improvement process includes:

  • ascertaining preventative actions and continuous improvement
  • considering if any systemic issues require addressing
  • recording the information regarding the complaint in the Complaint Register
  • recording the details of the improvement stemming from a complaint in the Continuous Improvement Register (if required)
  • training staff in any new systems or actions
  • adjusting policies and procedures
  • monitoring the complaint resolution according to the internal audit schedule
  • providing feedback to the complainant personally to inform them of the outcomes and influences their issue raised within our

5.4 Documentation

All employees are provided training regarding the complaints process during orientation and are provided with the Staff Handbook, which includes information on the complaints process provided (see 5.6 Staff Training).

The complaints process is available for participants, families, carers and advocates via the information provided in our Participant Handbook and through the provision of Easy Read documents (as required).

Documentation of the complaint process is as follows:

  • All complaints will be recorded in the Complaint Register, and information in the register will include the:
  • complaint details
  • identified issues
  • actions are undertaken to resolve the complaint
  • the outcome of the
    • All documents, including the Complaint and Feedback Forms, are uploaded into the computer
    • Copies of any information provided to the complainant are stored in their relevant
    • All documents are kept confidential, and access is only permitted to employees relevant to the The Complaints Manager determines who is relevant.
    • A copy of all complaint documents will be retained in the file for seven years from the record If the documents relate to a participant under the age of 18 years of age, the documents will be retained until the participant turns 25 years of age.
    • Statistical and other information will be collected to:
  • review issues raised
  • identify and address systemic issues
  • report information to the Commissioner, if requested by the NDIS Quality and Safeguards
    • A policy review will occur if there are legislative changes or when determined by a regular or annual internal audit

5.5 Unresolved complaints

Unresolved complaints will be referred to the Complaints Manager for investigation and resolution. Should the complaint not be resolved to the complainant‟s satisfaction, the complaint will be escalated to a person nominated by the complainant (with the complainant‟s permission).

When complaints cannot be resolved internally, the complainant may be referred to the:

NDIS Quality and Safeguards Commission

Phone: 1800 035 544 (free call from landlines) or TTY 133 677

National Relay Service and ask for 1800 035 544. Interpreters can be arranged.

An NDIS Complaint Contact Form can be completed online at

5.6 Staff orientation and training

The staff orientation process includes training all employees in the complaints and feedback process, including the NDIS Commission requirements. Our in-house training includes:

  • NDIS reporting requirements and contacts details
  • providing information regarding Elevate Support Care‟s complaint and feedback process and procedures (e.g. forms to complete and how to assist participants wishing to make a complaint)
  • identifying our Complaints Manager
  • encouraging employees to have a positive attitude towards complainants and a commitment to resolving all complaints
  • creating an understanding of how feedback and complaints inform and guide our continuous improvement cycle
  • understanding timeframes for reporting and resolving

Additional training will occur when practices and policies are changed due to a complaint, or if staff are still not sure how to handle a complaint upon commencing work at Elevate Support Care.

6.0 Related documents

  • Complaints and Feedback Form
  • Anonymous Complaints and Feedback Form
  • Complaints Process Checklist
  • Complaints Register
  • Continuous Improvement Policy and Procedure
  • Continuous Improvement Register
  • Continuous Improvement Plan
  • Participant Handbook
  • Staff Handbook
  • Staff Training Record
  • Staff Training Plan
  • Training Attendance Register – In-house
  • Training Register
  • Risk Management Policy and Procedure
  • Service Agreement

7.0 References

  • NDIS (Complaints Management and Resolution) Rules 2018
  • NDIS Practice Standards and Quality Indicators 2020
  • NDIS Act 2013 (Commonwealth)
  • NDIS (Procedural Fairness) Guidelines 2018
  • Privacy Act 1988 (Commonwealth)
  • Disability Services Act 1986 (Commonwealth)
  • Disability Discrimination Act 1992 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)

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2.6 Incident ManagementReportable Incident, Accident and Emergency Policy and Procedure

1.0 Purpose

Elevate Support Care will comply with the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.

It is our objective to maintain an incident management system that covers incidents that consist of acts, omissions, events or circumstances that:

  • occur in connection with the provision of supports or services to a person with a disability
  • has, or could have caused harm to a person with a

2.0 Scope

All staff members are responsible for ensuring the safety of all participants who access our services. All incidents must be reported as per this policy. Management is responsible for ensuring that staff are trained and undertake the NDIS Worker Orientation training module.

3.0 Definitions

IncidentActs, omissions, events or circumstances that occur in connection with providing supports or services to a person with a disability and have, or could have, caused harm to the participant.
Reportable incident

A reportable incident is any of the below:

The death of a person with a disability.

Serious injury of a person with a disability.

Abuse or neglect of a person with a disability.

Unlawful sexual or physical contact with, or assault of, a person with a disability.

Sexual misconduct, committed against, or in the presence of, a person with a disability, including grooming the person with a disability for sexual activity.

Use of restrictive practice in relation to a person with a disability where the use is not in accordance with an authorisation (however described) of a state or territory in relation to the person, or if it is used according to that authorisation but not following a behaviour support plan for the person

with a disability.

Incident management system

Incorporates all items listed below:

Acts, omissions, events or circumstances that occur in connection with providing supports or services to a person with a disability; and have or could have caused harm to the person with a disability.

Incidents that consist of acts by a person with a disability that occur in connection with providing supports or services to the person with a disability and have caused serious harm or a risk of serious harm to another person.

Reportable incidents alleged to have occurred in

connection with providing supports or services to a person with a disability.

  • Policy

Elevate Support Care recognises that many of the participants using Elevate Support Care services are at risk of incidents and accidents. Elevate Support Care‟s Reportable Incident, Accident and Emergency Policy and Procedure seeks to:

  • minimise risk and prevent future incidents through the development of appropriate participant-centred plans, staff training, assessment and review
  • ensure that there is immediate management of an incident, accident or emergency and that each of these events is prioritised, managed and investigated appropriately
  • identify opportunities to improve participant support quality by ensuring that the incident system is planned and coordinated and linked to the quality and risk management

Participants will be provided information in Easy Read format, as required.

The Director is the delegated officer listed in this policy and will manage, investigate and report all incidents as required. Within this process, the Director will ensure procedural fairness when dealing with an incident. Our organisation will follow all procedural fairness guidelines as required by the Commissioner.

5.0 Procedure

5.1 Incident management procedure

Elevate Support Care will establish a procedure that identifies, manages and resolves incidents, as follows:

Step 1. Inform of incident
  1. Support worker to report the incident to the
  2. Support worker completes an Incident Report that identifies and records details relating to the incident, e. people, place, time and date.
Step 2. Investigation
  1. The Director will determine, from the information provided, if the incident is classified as a reportable incident by the NDIS Quality and Safeguards Commissioner or a different type of incident:
    • A reportable incident must comply with the reportable incident reporting
    • Elevate Support Care will comply with the National Disability Insurance Scheme (Incident Management and Reportable) Rules
    • A general incident is an accident with non-reportable
  2. The Director will review the details of the incident:
    • People
    • The outcome, g. injury.
  3. The Director will investigate the incident/accident in accordance with the process outlined in the Incident Investigation Form to determine the required information:
    • Primary reasons for the
    • Underlying reasons for the
    • Immediate actions required to fix the cause of the
    • Preventative actions required for the
  4. Any information learned from incidents/accidents will be incorporated into our continuous improvement cycle to prevent the same incident/accident recurring in the
    • The analysis and investigation of each incident will vary based on the seriousness of the
Step 3. Support participant
  1. The Director ensures that the affected participant is supported and assisted:
    • Informing them that they have access to an advocate if the participant does not have an advocate, the Director can help access an independent
    • Reviewing their health status to assist and
  • Assessing the environment to ensure their safety and to prevent any
  • Ensuring their wellbeing and assisting in developing the participant’s confidence and competence so that they do not lose any function/s.
  1. The Director or their delegate will review the incident with the participant and collaborate with the person/s involved to manage and resolve the
Step 4. Analyse incident
  1. As part of our continuous improvement process, the information gained from an incident is used to amend or implement new practices:
    • when an investigation by a registered NDIS provider is necessary to establish the cause/s of an incident, the effects of the incident and any operational issues that may have contributed to the incident occurring and the nature of the investigation
    • if an incident requires the implementation of corrective action, an appropriate plan will be developed to adjust practices according to the nature of the action
  2. The Director or their delegate will undertake an appropriate analytical process to:
    • determine the cause of the incident
    • ascertain if the incident was an operational issue
    • consider the participant’s perspective, including:
      • whether the incident was preventable
      • how the incident was managed and reviewed
      • determining any remedial action required to minimise future impacts and prevent a
    • identify why the incident occurred, g. environmental factors, participant health
    • ascertain if current strategies or processes require review and
    • devise new strategies or procedures, if required
    • plan staff training for any new strategies
    • implement new strategies
    • evaluate the success of new strategies.

All Incident Investigation Forms, including the Final Report, must be closed out by the Director or their delegate, and one other Elevate Support Care staff member.

Step 5. Incident/accident minimisation and corrective action
  1. Elevate Support Care will risk-assess all participants in conjunction with our Risk Management Policy and
  2. Incident, accident, emergency minimisation and procedures are taught during staff orientation and regular ongoing training
  3. Risks will be identified, and control mechanisms agreed upon with
  4. Elevate Support Care will consult with participants, and relevant stakeholders, to design specific risk control mechanisms to reduce risk to participants and their
  5. Effectiveness of mechanisms will be evaluated via:
    • participant review processes, including support plan review
    • participant feedback
    • case
  6. Internal and external risk
  7. Reviews of policies and
Corrective actions

On completion of the incident analysis procedure, any corrective action will be implemented. Each corrective action identified will be evaluated to ascertain the action’s effectiveness, as per our Continuous Improvement Policy and Procedure, i.e. plan, do, check, act.

Step 6. Informing participants

Elevate Support Care will inform participants, or their advocate, of the outcome/s of the incident, either in writing or verbally dependent on the participant and the situation. Collaborative practice will be undertaken to ensure the participant and their advocate are involved in the incident’s management and resolution.

5.2 Staff training

Elevate Support Care recognises the importance of prevention to ensure our staff and participants’ safety. Our orientation process includes training in r and safety practices, including manual handling, infection control, safe environments, risk and hazard reduction.

Upon commencing employment with Elevate Support Care, all staff are trained in organisational incident management processes, including how to report an incident and who to report an incident to the Director). All staff are given full access to our organisational policies and procedures to provide guidance. A Staff Incident Reference Card is provided to all staff as a guide.

5.3 Reportable incidents

Staff must report any reportable incident immediately that it becomes evident.

The Director is responsible for reporting all reportable incidents to the NDIS Quality and Safeguards Commission. Reportable incidents are serious incidents, or allegations, which result in harm to any NDIS participant.

As a registered provider, Elevate Support Care is required to report serious incidents (including allegations) arising from the organisation’s service provision to the NDIS Quality and Safeguards Commission. Reportable incidents, involving NDIS participants, include:

  • the death of a person with a disability
  • serious injury of a person with a disability
  • abuse or neglect of a person with a disability
  • unlawful sexual or physical contact with, or assault of, a person with a disability (excluding, in the case of unlawful physical assault, contact with, and impact on, the negligible person)
  • sexual misconduct committed against, or in the presence of, a person with a disability, including grooming the person for sexual
  • the use of a restrictive practice in relation to a person with a disability, other than where the use is in accordance with an authorisation (however described) of a state or territory in relation to the person or a behaviour support plan for the
5.3.1 Reporting roles

The organisation will establish the following roles and ensure that allocated staff are aware of their responsibilities:

  1. Approved Reportable Incident Approver responsibilities:
    • Authority to review reports before submission to the NDIS
    • Submits new reportable
    • Views previous reportable incidents submitted by their
  2. Authorised Reportable Incident Notifier responsibilities:
    • Supports the Authorised Reportable Incident Approver to collate and report the required
    • Creates new reportable incident notifications to be saved as a draft for review and submission by the authorised Approver.
5.3.2 Reportable incident procedure

The Director will review the information and contact the police immediately to inform them of any suspected abuse.

Important note: Information on how Elevate Support Care reports abuse against children can be found in our Working with Children Policy and Procedure.

The Approver submits reportable incidents via the NDIS Commission Portal‟s My Reportable Incidents page.

  1. Complete an Immediate Notification Form and submit within 24 hours:
  • Approved Reportable Incident Notifier will create for
  • Approved Reportable Incident Approver will approve the report and submit it. Note: Approved Reportable Incident Notifier may create and submit, as required by the incident’s
    1. 5-day form to be completed within five days of key stakeholders being informed:
      • Approved Reportable Incident Notifier will create a form for
      • Approved Reportable Incident Approver will approve and submit the form. Note: Approved Reportable Incident Notifier may create and submit, as required by the incident’s
  1. Final Report will be submitted on the due date if requested by the NDIS Commission:
    • Approved Reportable Incident Notifier will create a report for
    • Approved Reportable Incident Approver will approve the report and submit it. Note: Approved Reportable Incident Notifier may create and submit, as required by the incident’s

Assessment of the incident by the Director, or their delegate, will involve:

  • assessing the incident’s impact on the NDIS participant
  • analysing and identifying if the incident could have been prevented
  • reviewing the management of the incident
  • determining what, if any, changes are required to prevent further similar events occurring
  • recording all incidents and responsive actions

5.5 Documentation

  • All reportable incident reports and registers must be maintained for seven (7)
  • This policy is to be reviewed on an annual basis, or when legislation changes
  • All participants, families and advocates are informed of this
  • All staff are trained in the procedures outlined in this
  • Training details are recorded in each employee‟s personnel fil

6.0 Reportable deaths (coroner)

Not all deaths need to be reported to the Coroner‟s Court of Victoria. Reportable deaths include deaths:

  • that are unexpected, unnatural or violent or resulted after accident or injury
  • that unexpectedly occur during or after a medical procedure
  • where the identity of the person or their cause of death is not known
  • where the person was in custody or

A person who can report a death to the Coronial Admissions and Enquiries

  • Persons who must advise the coroner of a reportable or reviewable death include

any person who had care or custody of a person placed in care.

  • Anyone who thinks a reportable death has occurred and that the court has not been advised should report the death without
  • The immediate family of a person who has died might report the death to the coroner if the person who has died was discharged from an approved mental health service within three months of the death

Procedure to report a death

In the event of a reportable death, the Director will undertake the following steps:

  1. Contact Coronial Admissions and Enquiries on phone number: 1300 309
  2. Complete a Medical Deposition online, if requested by Coronial Admissions and
  3. Advise the participant‟s family that they can request access to coronial documents by contacting the Registry on 1300 309 519

7.0 Related documents

  • Incident Report
  • Incident Investigation Form
  • Incident Investigation Form Final Report
  • Incident Register
  • Participant Handbook
  • Participant Orientation Checklist
  • Risk Assessment Form
  • Risk Management Plan
  • Risk Register
  • Staff Incident Reference Card
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house
  • Support Plan Review Report
  • Continuous Improvement Policy and Procedure
  • Reportable Incident, Accident and Emergency Policy and Procedure
  • Risk Management Policy and Procedure

8.0 References

  • NDIS (Incident Management and Reportable Incidents) Rules 2018
  • NDIS Practice Standards and Quality Indicators 2020
  • Privacy Act 1988 (Commonwealth)
  • Disability Services Act 1986 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)
  • Coroners Act 2008 (VIC)
  • Coroners Court of Victoria (information sighted – 9:12 am on 17/11/20)

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2.7 Human Resource ManagementHuman Resource Management Policy and Procedure

1.0 Purpose

Elevate Support Care‟s policy objective is to safely and effectively manage our staff. It is also our goal to create a structured, fair, safe and supportive environment that supports our staff to meet organisational requirements and to facilitate the delivery of high levels of participant service and satisfaction.

2.0 Scope

Human resources are used to describe both the people who work for our organisation and the management of resources related to our staff members. This policy is designed to incorporate many aspects of human resources and to comply with the Fair Work Act 2009 and NDIS Quality and Safeguards Commission requirements.

3.0 Policy

3.1 Human resource management principles

Our human resource management principles are as follows:

  • Only employ staff with appropriate qualifications, skills and competence are
  • All staff are required to undertake and successfully pass, the NDIS Worker Screening Check, NDIS Worker Orientation Program and any other state requirements before commencing
  • Adequate levels of staff members are maintained to provide quality support that meets the assessed needs of participants and organisational
  • Skills and competency levels of all staff are improved through ongoing supervision and support and through the implementation of comprehensive training programs and annual performance
  • All staff are required to hold current legislated work checks, professional registrations, licences, insurances and any other employment requirements (as needed).
  • Poor staff performance or allegations of misconduct will result in performance
  • Human resource management procedures are continually reviewed and
  • Expert external advice and information on human resource management are accessed by management, as and when
  • Working conditions for staff will comply with relevant legislation and be comparable with industry
  • Elevate Support Care will apply the following principles to all aspects of our relationship with our employees:
    • equity and fairness
    • respect for individuals, their privacy and confidentiality
    • accountability for actions and performance
    • encourage and support professional development
    • workplace flexibility and understanding of personal

3.2 Corporate governance management

A review of all persons who influence our governance is instigated to confirm they hold the relevant experience and knowledge to undertake their role. If a person requires additional expertise, then Elevate Support Care will arrange for the relevant education or training necessary.

3.3 Staff recruitment

Individuals are appointed based on their ability to meet criteria that are consistent with their role and position description. We employ staff who offer a range of skills and experience so that our organisation is managed effectively, and our services meet the needs of all participants. Roles are outlined in the organisational structure within Elevate Support Care‟s Corporate Governance Policy and Procedure.

All staff are recruited according to our Equal Employment Opportunity Policy (see below –

3.4. Equal Employment Opportunity Policy). All permanent vacancies are advertised externally and internally. Only those who successfully pass the NDIS Worker Screening Check and NDIS Worker Orientation Program will be employed by Elevate Support Care The Director is responsible for the recruitment and administration of all employees.

3.4 Equal Employment Opportunity (EEO) Policy

Elevate Support Care commits to:

  • providing equal employment opportunity to all prospective and current employees
  • promoting a fair and equitable work environment
  • complying with all relevant anti-discrimination legislation
  • creating and maintaining an environment in which diversity is valued, human dignity is respected, and people are treated with equity and tolerance
  • ensuring staff and visitors are free from any form of discrimination, harassment or

Our organisation chooses the best person for the job, regardless of:

  • race
  • nationality or ethnic origin
  • disability (physical, intellectual or psychological)
  • gender
  • age
  • sexual orientation
  • marital status
  • family status and responsibility (including pregnancy)
  • religious or political beliefs
  • activities or

3.5 Code of Conduct

All employees who are engaged by Elevate Support Care must abide by both the NDIS Code of Conduct and Elevate Support Care’s Code of Conduct.

3.5.1 NDIS Code of Conduct
  • Act with respect for individual rights to freedom of expression, self-determination and decision-making, in accordance with applicable laws and
  • Respect the privacy of people with
  • Provide supports and services safely and competently and with care and
  • Act with integrity, honesty and
  • Promptly take steps to raise and act on concerns regarding matters that may impact the quality and safety of supports and services provided to people with
  • Take all reasonable steps to prevent and respond to all forms of violence, exploitation, neglect and abuse against people with
  • Take all reasonable steps to prevent and respond to sexual misconduct against people with
3.5.2 Elevate Support Care Code of Conduct
  • Abide by the philosophy of our
  • Observe all the rules of our
  • Provide supports to participants in a safe, ethical manner with care and
  • Work safely and competently, in accordance with the policies and procedures of our
  • Respect the dignity, culture, values and beliefs of all
  • Do not discriminate against participants on any
  • Respond in flexible and innovative ways to support participant decision-making.
  • Do not discuss confidential issues with people outside the organisation; regard all information provided by a participant as confidential, and never disclose personal information to a
  • Do not harass other staff members of our
  • Do not alienate participants from their family or
  • Do not take illegal drugs or consume alcohol when on duty and when on the organisation or participant‟s
  • Never accept gifts or purchase items from
  • Do not engage in sexual misconduct with
  • Staff are never to take a participant to their (staff member‟s) home or engage in a relationship with a participant outside of a professional
  • Always positively represent our
  • Always wear clean and appropriate work clothes, or uniform, while at
  • Adhere to all our record keeping and accounting procedures.
  • Provide quality

4.0 Procedure

4.1 Process for filling a vacant position

4.1.1 Review the position
  1. Clarify the role and the need for the
  2. Develop or review the position
  3. Review position against requirements for the relevant registration
  4. Develop essential and desirable selection criteria, as per the position
  5. Determine how each of the selection criteria is assessed (e.g. written application and interview).
4.1.2 Advertise the position
  1. Positions are advertised internally and
4.1.3 Interview applicants
  1. The Director conducts the interviews and uses the appropriate interview
  2. All applicants will be asked the same The questions will explore the applicant‟s relevant skills and experience to perform the required duties.
  3. When interviews are completed, the preferred applicant will be
  4. Recruitment decisions and reasons for decisions made are
  5. Pre-employment/reference checks take
  6. The successful applicant will be notified, and feedback provided to unsuccessful
  7. An offer of employment will be made to the successful applicant, conditional on pre- employment checks:
    1. reference checks (if the position is a risk assessed role)
  1. mandatory worker screening (i.e. criminal record check and working with children check as per state requirements)
  2. registration check (as applicable to the role)
  3. insurances (as applicable to the role)
  4. licences (as applicable to the role)
  5. NDIS Worker Orientation Program Certificate
  1. Once appropriate checks are completed and satisfactory, an offer of employment will be sent to the applicant for signing before commencing

4.2 Procedure for a new employee

  1. The Director will complete an orientation procedure with all new
  2. A Staff Orientation Checklist will be completed by the new employee and signed off by the
  3. All forms and documents signed by the employee are filed in a personnel file with copies provided to the employee, as

4.3 New staff supervision

  • New staff members are inducted into their role and supervised
  • The Director mentors senior staff
  • A supervisor will appoint a delegated staff member to support the development of a new staff member‟s skills and knowledge. This orientation process will vary according to the experience of the new staff member but is usually for a minimum of two (2)

4.4 Position descriptions

  • All employees are provided with a position description which specifies their roles and
  • Position descriptions are reviewed and updated
  • Every employee is provided with a copy of their position description before commencing employment and if their position description is

4.5 Code of Conduct and Privacy and Confidentiality Agreement

  • All staff are required to comply with the Code of Conduct, which encapsulates the respectful, safe and professional delivery of support to our participants, representatives, community and any other
  • Employees are required to sign a Code of Conduct Agreement and a Privacy and Confidentiality Agreement on employment commencement. Disciplinary action will be taken if employees do not abide by these

4.6 Staff information

Elevate Support Care‟s policies and procedures contain critical information that all staff must know to complete their roles safely and effectively. New employees are provided the time to read all policies and procedures and are reminded during staff meetings and through communication with the Director to do so. A Staff Handbook is provided to all new employees to be used as a reference guide only.

4.7 Staff uniform

All staff representing Elevate Support Care are required to wear our uniform or other provided form of identification (e.g. name tags), so participants easily identify them as belonging to our organisation. Staff uniforms must be clean and neat before commencing work.

4.8 Record keeping

An employee personnel file is maintained for each staff member. These files may include the following:

  • employment application
  • criminal record check
  • working with children check
  • professional registrations
  • a signed offer of employment
  • photocopy of driver’s licence, car registration and insurance (wherever applicable)
  • signed Code of Conduct Agreement
  • signed Privacy and Confidentiality Agreement
  • training offered
  • training provided
  • mandatory training attendance record
  • evaluation of training events
  • mandatory NDIS worker screening check
  • mandatory NDIS Worker Orientation

All employees are entitled to view their file at any suitable time; this can be arranged directly with the Director.

Elevate Support Care must never employ a person as a staff member unless satisfied that all regulatory checks are current and in place.

4.9 Staff supervision and support

Supervision and support are essential to making our employees feel supported in their work and ensuring they perform satisfactorily. Additionally, supervision sessions provide an opportunity to follow-up on development issues noted in an employee‟s development and performance reviews. Elevate Support Care will supervise work performance issues at our office/s, in participants‟ homes and within the community.

Upon employment, all employees are provided with Elevate Support Care’s contact details. The Director is available to be contacted over the phone by the employee. Alternatively, the Director is available to meet with employee if they require time to discuss any issues or concerns.

Employee supervision relates to the monitoring of employee work practices against the expectations, needs and support services identified in the Service Agreement and our policies and procedures. The supervision requirements are determined by the employee‟s role and their current work knowledge and skills. The observation timeframe can vary from fortnightly, monthly, quarterly, half-yearly or annually as per our Staff Supervision Roster.

Our organisation will use a variety of data gathering methods, including but not limited to:

  • observing using a Staff Observation Checklist:
  • contacting and gaining feedback from participant
  • speaking with our supervisors
  • speaking with relevant providers who work with our participants
  • undertaking performance reviews

A staff member’s annual competency assessment, education and training, and performance appraisal also provide other avenues for our organisation to provide staff support and supervision. All staff can attend meetings and care conferences to ensure they are aware of participant support changes and to take the opportunity to provide input and feedback.

4.10 Performance development reviews

  • Elevate Support Care is committed to supporting staff to improve their efficiency and All staff members are expected to perform their duties to the best of their ability and to show a high level of personal commitment to always provide quality and professional service.
  • Performance development reviews are conducted annually in consultation with individual staff
  • Performance development reviews are based on the position description and an agreed work

The aims of the review are to:

  • conduct an honest and confidential discussion regarding work performance and the workplace between the staff member and the Director
  • discuss job performance in the context of a position description
  • discuss work problems and develop appropriate solutions
  • discuss possible ways of improving work performance; including identification of training and development needs or changes to work

Diagram 1. Staff recruitment and management process

4.11 Staff education and training

Elevate Support Care provides appropriate training and development opportunities for all staff; this includes:

  • identifying training needs through annual performance development reviews and ongoing staff and management input
  • providing appropriate training to meet identified needs
  • providing training opportunities for all staff
  • evaluating training to ensure it meets the needs of the staff member and assists to improve our operations and services
  • completing a training needs analysis
  • devising appropriate training plans to meet staff performance

4.12 Staff development opportunities

Elevate Support Care creates staff development opportunities, as follows:

  • Staff attendance (for up to three (3) days per year) at workshops, seminars and
  • Flexible working hours, so staff can participate in accredited study courses at recognised educational
  • Provision of learning resources for staff education, g. videos, research literature.
  • Training needs are discussed with each staff member upon recruitment, during annual performance reviews and supervision

4.13 Staff performance dispute procedure

Outlined below is the procedure used to deal with a staff performance dispute, not involving misconduct. Misconduct is an action by a staff member that results in instant dismissal.

4.13.1 Verbal warning

The staff member is told, as soon as possible, of any complaint concerning their work performance and is provided with an opportunity to discuss the complaint.

The Director, in consultation with the employee, will outline how the employee must improve their performance. Any assistance needed by the employee to improve their performance is identified and provided, wherever possible.

A date to review the employee‟s performance will be set, with consideration given to providing adequate time for the person to resolve the issue and reduce risk to the organisation.

4.13.2 First written warning

If the employee‟s performance is still unsatisfactory at the time of the second review, further discussion will take place. This review will include the employee, a representative of their choice (optional), and the Director.

The complaint against the employee and plans for improvement will be put in writing and will clearly state that a lack of development by a given date will result in a final written warning being issued. A copy of the first written warning will be provided to the employee.

4.13.3 Final written warning

If at the given date set, the employee‟s performance has not improved, there will be further discussion with the employee. This review will include the employee, a representative of their choice and the Director.

The complaint against the employee and plans for improvement are recorded in writing, clearly stating that a lack of growth by a given date will result in termination of employment. A copy of the final written warning will be provided to the employee.

4.13.4 Termination of employment

If the problem persists, after the date set in the final written warning, the staff member‟s employment may be terminated. The Director must approve the termination.

If the termination is not approved, an alternative process for managing the performance issue will be developed. Detailed notes of performance dispute management are recorded and kept in the employee‟s personnel file.

4.14 Staff grievance procedure

If a staff member has a grievance related to their employment or concerning another staff member, the following processes apply:

4.14.1 Discussion

The staff member may approach the Director to discuss the issue and seek advice on the issue. The consultation will be confidential. The staff member may put the matter in writing to their supervisor and request that the issue is raised with management. A decision on the issue and a discussion with the staff member will occur within seven (7) business days.

If the staff member considers that the discussion has not addressed their concerns adequately, they can seek external advice (e.g. union representative or another independent body).

4.14.2 Misconduct

Misconduct includes severe breaches of our policies and procedures or unacceptable behaviour that warrants the immediate dismissal of a staff member. Examples of misconduct include:

  • theft of property or funds from our organisation
  • wilful damage of property belonging to our organisation
  • intoxication through alcohol or other substances during working hours
  • verbal or physical harassment or discrimination of any other staff member or participant
  • disclosure of confidential information regarding the organisation to any other party, without prior permission
  • disclosure of participant information, other than information that is necessary to assist participants and to ensure their safety
  • conducting a private business from our premises or using the organisation‟s resources for private business without permission
  • falsification of any records belonging to the organisation
  • failure to comply with the organisation’s Code of
4.14.3 Seek advice

The Director must be informed immediately following receipt of an allegation of misconduct. If necessary, the Director will obtain external professional advice. The staff member should consider seeking advice from their union or another independent body.

4.14.4 Suspension of duties

A staff member is informed, as soon as possible, of any allegation of misconduct. The staff member may be suspended, with full pay, pending an investigation of the claim. A letter outlining the time, date and alleged misconduct will be provided to the staff member.

4.15 Leave

4.15.1 Application for leave

Any staff member taking leave must complete an Application for Leave Form. If the application form is not completed, payment will not be made for leave taken.

The application must be completed and approved before annual leave, long service leave, or if unpaid leave is taken.

4.15.2 Sick leave

A doctor‟s certificate is required for sick leave of more than two consecutive days. When sick leave is required, the Director should be informed as soon as possible and, at a minimum, at least two hours before the staff member’s usual start time. An Application for Leave Form must be completed immediately upon the employee returning to work after sick leave.

The Continuity of Support Policy and Procedure will be implemented to support participants during staff worker absences.

4.15.3 Personal/carer’s leave and compassionate leave

Personal/carer’s leave and compassionate leave are defined in the relevant award (this only applies if staff are under an award). To qualify for personal leave, an individual‟s reason for leave must meet the definition of personal/carer’s leave and compassionate leave within the award.

An Application for Leave Form must be completed immediately after a staff member returns to work. When leave is required, this should be communicated to the Director as soon as possible and, at a minimum of at least two hours, before the usual start time of the staff member.

4.15.4 Recording annual leave

Annual leave taken and owing to staff is tracked on our accounting system software.

4.15.5 Time sheets

Each staff member is required to maintain up-to-date time sheets. Time sheets must be submitted to the Director, as per the work agreement. The Director or their delegate will check time sheets against the roster hours to determine accuracy, before forwarding them to the administration office for payment.

4.16 Workers compensation

When a staff member suffers an injury or suffers from a disease, and work is a substantial contributing factor to that illness or injury, Elevate Support Care ensures that financial benefits and other assistance are provided, as required by the relevant state legislation and regulations.

4.17 Employee exit procedure

When an employee leaves Elevate Support Care, the following procedure applies:

  1. The Director conducts the exit interview, and the employee is asked to provide useful
  2. The exit interview is
  3. Completed documentation is viewed as relevant and used, if appropriate, integrated into the organisation‟s continuous improvement proce

5.0 Related documents

  • Application for Leave Form
  • Code of Conduct Agreement
  • Complaints and Feedback Form
  • Job Candidate Interview Form
  • Delegation of Responsibility and Authority Form
  • Offer of Employment Letter
  • Employment Check Register
  • Personnel File Contents Checklist
  • Performance Management Template
  • Employee Performance Appraisal
  • Privacy and Confidentiality Agreement
  • Staff Handbook
  • Staff Orientation Checklist
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house
  • Training Needs Analysis
  • Warning Letter
  • Delegation of Responsibility and Authority Policy and Procedure

6.0 References

  • Disability Discrimination Act 1992 (Commonwealth)
  • Australian Human Rights Commission Act 1986 (Commonwealth)
  • Fair Work Act 2009 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Safety, Rehabilitation and Compensation Act 1988 (Commonwealth)
  • Work Health and Safety Act 2011 (Commonwealth)
  • Workplace Gender Equality Act 2012 (Commonwealth)
  • NDIS (Practice Standards – Worker Screening) Rules 2018
  • NDIS (Code of Conduct) Rules 2018
  • NDIS Practice Standards and Quality Indicators 2020

Delegation of Responsibility and Authority Policy and Procedure

  • Purpose

Delegations of responsibility and authority are the mechanisms by which Elevate Support Care enables the staff of Elevate Support Care to act on behalf of Elevate Support Care.

The purpose of this policy is to establish a framework for delegating responsibility and authority within Elevate Support Care, in a manner that facilitates efficiency and effectiveness and increases accountability levels of our staff and volunteers’ performances.

Delegations are a crucial element in effective governance and management of Elevate Support Care and provide formal authority to staff and volunteers to commit the organisation and incur liabilities on behalf of the organisation.

Delegations of responsibility and authority within Elevate Support Care are intended to achieve four objectives:

  1. To ensure the efficiency and effectiveness of the organisation’s administrative
  2. To ensure that the appropriate officers have been provided with the level of authority necessary to discharge their
  3. To ensure that the most suitable and best-informed individuals exercise delegated authority within the
  4. To ensure internal controls are

2.0 Scope

The policy applies to all staff and volunteers of Elevate Support Care who have delegated responsibility or authority to act and sign documents on behalf of Elevate Support Care.

3.0 Policy

This policy sets out the circumstances under which the Director may delegate their responsibilities.

The Director is responsible for the management of the organisation and can delegate any of its functions. However, the Director may not delegate its power to adopt the:

  • strategic plan
  • business plan
  • annual

The Director is:

  • charged with the duty of promoting the interests and furthering the development of Elevate Support Care
  • responsible for the administrative, financial, and other business of Elevate Support Care
  • responsible for exercising general supervision over the staff and volunteers of Elevate Support

The Director may delegate any function, power, or duty conferred or imposed upon them, subject to this policy, to any member of the staff of the organisation.

Elevate Support Care is committed to the highest standards of integrity, fairness and ethical conduct; including full compliance with all relevant legal requirements and, in turn, requires that all managers, staff, volunteers and contractors, acting on its behalf, meet those same standards of integrity, fairness and ethical behaviour, including compliance with all legal requirements.

There is no circumstance under which it is acceptable for Elevate Support Care or any of its staff or contractors to, knowingly and deliberately, not comply with the law, or to act unethically in the course of performing or advancing Elevate Support Care‟s business.

4.0 Procedure

The overarching policy applies to Elevate Support Care as a whole. Units within the organisation must align their delegation of authority and responsibility policies with the central strategy. Delegations are to be exercised in a manner to ensure that delegated staff hold the requisite qualifications and skills.

4.1 Delegations to the Director

Delegations are attached to the position occupied, not to the occupant of the position. The responsibilities of a position appear in a duty statement, role statement, or statement of responsibility appropriate to the position.

Delegations reflect Elevate Support Care‟s organisational structure. Levels of authority are hierarchical through relevant lines of responsibility, up to and including the Director. Formal authorities held by any delegate are included in those held by that delegate‟s supervisor or line manager; a delegate who sub-delegates authority remains responsible and accountable for the decision or action.

The Director may, at any time, vary or terminate any delegation, subject to confirmation by the Board at its next meeting.

A delegation cannot be exercised where the officer holding the delegation has a conflict of interest or where the delegation will result, either directly or indirectly, in any tangible benefit to the delegate. In such cases, a transfer of the function to another appropriate position must be arranged by the Director.

Permanent changes to delegations, either permissive or restrictive, require written authority from the Director. The Director must approve any significant variation to the standard delegations.

This policy applies only to formal delegations. Delegations of an informal nature, where no commitment or liability is incurred on behalf of Elevate Support Care, are carried out in the normal business of the organisation without the requirement of written authority.

A staffing delegation can only be actioned by the delegate who holds management responsibility for the individual staff member. A staffing delegation example follows:

PositionAuthority to ensure staff replacementAuthority to authorise contracts

Authority to

access My Place



Financial OfficerNoNoYesYes

Corporate Governance – Quality,

risks, complaints and incidents

Reporting and recording risks, complaints and incidents



Work with participant





workers including allied health


5.0 Related documents

  • Corporate Governance Policy and Procedure
  • Human Resource Management Policy and Procedure
  • Delegation of Responsibility and Authority Form

6.0 References

  • NDIS Quality Standards and Practice Indicators 2020

2.8 Continuity of Supports

Continuity of Supports Policy and Procedure

1.0 Purpose

Continuity management is an integral part of our organisation’s operating plans, risk management and decision-making. Continuity of care to our participants falls within this remit. Continuity of care planning contributes to improved quality and safety of care; increases the satisfaction of the participant, staff and our organisation; and will maximise the use of resources to provide the appropriate level of care and access.

The participant’s NDIS Plan incorporates reasonable and necessary supports; any informal supports that are already available to the individual, i.e. informal arrangements that are part of family life or natural connections with friends and community services; as well as other formal supports, such as health and education. Elevate Support Care will ensure that the participant has consistent supports or services to allow them to undertake daily activities and supports to maintain their life choices.

2.0 Scope

This policy applies to Elevate Support Care staff workers managing and working with participants.

3.0 Policy

The Director will arrange schedules to ensure that participants know who will be attending to their needs and supports. The Director will pair a participant with a worker who holds appropriate skills and knowledge. Our participant requests are matched with their preferred staff workers wherever possible. Examples of meeting a participant’s wishes may include accessing a staff worker who speaks the participant’s first language, shares the same cultural background or meets specific criteria that have been requested.

A staff worker will be placed with participants whose locations are close to their home (where possible), to reduce travel time and increase staff satisfaction and retention.

Continuous support and predictability will be planned through the allocation of a consistent staff worker to a participant. All supports and strategies are recorded in the participant‟s plan. They will be used by the staff worker when supporting a participant’s preferences and needs (see Responsive Support Provision and Support Management Policy and Procedure).

4.0 Procedure

To ensure participants have timely and appropriate support, without interruption Elevate Support Care’s staff will:

  • access, read and comply with the participant‟s plan
  • review strategies listed in the support plan before the provision of support
  • provide quality services as per participant’s plan
  • document all the participant’s preferences and needs to allow for a consistent care approach
  • list all appointments and tasks related to the participant’s needs
  • allow allocation according to a participant’s requirements
  • inform the Director of any absences, in advance, to allow time to allocate a replacement who meets the participant’s criteria and, preferably, is known to the participant
  • contact participants if there are any changes, or potential changes, in their care
  • undertake emergency procedures, as required.

No appointments are ever double booked. When travelling to participants’ homes, it is essential that our staff worker‟s factor enough travel time to ensure correct arrival time.

4.1 Disruptions and changes

Elevate Support Care notifies participants when an unavoidable interruption occurs. The staff worker will make every attempt to inform the participants, via telephone and email, before any unavoidable disruptions to services or participant appointments. When it not

possible to contact the participant, they will be briefed on arrival at the next meeting or scheduled service.

The Director will contact a participant to:

  • seek the participant‟s agreement and to ensure that they are entirely aware of any changes
  • explain, in detail, alternative

In the case of an emergency, when a worker cannot attend work due to circumstances out of their control (e.g. illness or family emergency), Elevate Support Care will attempt to place a worker who is known to the participant. However, if this is not possible, we will send the best match available to the participant. Elevate Support Care will contact the participant and advise them of the situation and provide details of the replacement worker.

4.2 Absence or vacancy

When a staff member is absent, or a vacancy becomes available, then the Director will:

  • contact a staff worker who is a suitable replacement (e.g. a person with the relevant qualifications or language requirement)
  • provide, where possible, a staff worker who has worked with the participant previously and is aware of the participant‟s preferences and needs
  • select an appropriate replacement worker who will be sensitive to the participant’s requirements, ensuring care is consistent with the participant’s expressed preferences
  • inform the participant of the replacement’s details, where possible
  • upon completion of the service gather feedback from the participant on the replacement staff

A staff worker who is unable to work is required to contact the Director. If there is an intended absence (e.g. vacation or appointment), then the staff member must inform the Director at the earliest opportunity to allow time to prepare the participant.

4.3 Service agreement

Elevate Support Care ensures arrangements are in place so that support is provided to the participant, without interruption, throughout their service agreement. These arrangements are relevant and proportionate to the scope and complexity of supports delivered.

4.4 Critical supports

Contingency plans are drawn-up and adhered to ensure the continuity of care to all participants throughout their time with us. In the case of a disaster, planning will incorporate strategies that enable continual supports before, during and after the disaster. Critical planning will be undertaken for participants who have complex needs.

5.0 Related documents

  • Access to Supports Policy and Procedure
  • Responsive Support Provision and Management Policy and Procedure
  • Support Plan
  • Service Agreement
  • Contingency Disaster Plan Template

6.0 References

  • NDIS 2013 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • NDIS Practice Standards and Quality Indicators 2020

Telehealth Policy

1.0 Purpose

Telehealth, in the context of the Australian healthcare setting, can be defined as the use of videoconferencing technologies to conduct a consultation where audio and visual information is exchanged in real-time. Telehealth can be conducted between a Elevate Support Care clinician and a participant in a supported or unsupported format.

2.0 Scope

Elevate Support Care clinicians will review participants, then only undertake telehealth consultation with participants who have the capacity to participate in a videoconference, to ensure appropriate provision of support and access.

3.0 Policy

This policy has been designed to allow Elevate Support Care to meet the needs, interests and goals of our participants during natural disasters, pandemics, or when specific circumstances warrant this approach. During events of this type, changes and adjustments to our service provision may occur, requiring the adaption of current practices to meet government or participant requirements.

The role of telehealth, in the overall management of a participant, will be determined by the clinician and other relevant providers. The implementation of telehealth will depend on the specialty of the clinician and the participant‟s requirements and location. Clinicians should be mindful of the limitations of telehealth and communicate these limitations to all video conference participants.

3.1 Participant selection

Clinicians should determine which participants are suitable for telehealth based on available resources, technology and care requirements. Elevate Support Care will determine whether

a telehealth consultation is the most appropriate type of consultation for each participant. The decision to use telehealth incorporates the following factors:

  • Clinical: Continuity of support and the best model of support for the
  • Practical: Availability of appropriate technology and participant-end support. The quality of the technology at a remote site will play a significant role in the information received during the clinical
  • Participant needs: Ability to travel, and consideration will be given to their family, work and cultural situation. Clinicians should also consider the participant‟s capacity to participate (e.g. a video consultation may be inappropriate for participants with vision or hearing impairments).

3.2 Prior to a telehealth consultation

The clinician will advise the participant on how the consultation will proceed by:

  • providing the participant with plain language information about telehealth
  • informing the participant of the other available support options (if available)
  • informing the participant of any charges for telehealth consultations in comparison to other available options
  • indicating the length of the telehealth

Clinicians will ensure that the participant has been given adequate information regarding the telehealth consultation, and they will liaise with the participant-end worker to ensure the participant is sufficiently informed.

3.3. Seeking participant consent

Elevate Support Care clinicians should be satisfied that participants have consented to participate in the telehealth consultation.

In cases where the participant is not competent and cannot provide consent, consent should be obtained from an advocate in the same way as for a face-to-face consultation, using a Telehealth Consent Form. The clinician will arrange for a Telehealth Consent Form to be provided to the advocate who has the requisite legal authority (e.g. enduring guardianship), so they can provide consent on the participant‟s behalf.

While it is not Elevate Support Care‟s standard practice to record a video conference, on occasion, the participant will record the telehealth consult; therefore, their consent applies to this recording. Where a recording is made by Elevate Support Care for assessment purposes, the participant will be informed before any recording occurring. The participant must provide verbal approval to record the consultation and agree to the planned use of the recording at the start of the telehealth consultation.

3.4 Consultation

Telehealth is no different from any other type of consultation and should be conducted similarly to a face-to-face consultation. A telehealth consultation of high quality is one in which the participant has a voice, screens are shared, listed supports actioned, and active listening is undertaken as per current best practice models.

In supported consultations, a support worker is present with the participant for some, or all, of the video consultation. The support worker should confirm both their identity and that of the participant to the clinician.

For unsupported consultations, the participant may be alone or may elect to have a family member present. For the first unsupported consultation, the clinician and participant introduce themselves, and the clinician provides some background information, including their credentials and experience.

3.5 Privacy and confidentiality

Telehealth consultations should be private and confidential. Clinicians should have processes in place to facilitate this as per standard face-to-face consultations. The participant‟s privacy and confidentiality should always be maintained.

Elevate Support Care reviews privacy and confidentiality risks associated with telehealth consultations and develops procedures to mitigate such risks, which include, but are not limited to:

  • implementing an appropriate system to prevent interruptions during a consultation (at both clinician and participant end)
  • requesting that participants join a telehealth consultation in a quiet room where they will not be interrupted
  • alerting other staff that a telehealth consultation is being conducted and requesting not to be disturbed
  • storing all recorded telehealth conversations securely, so the participant‟s privacy and confidentiality are maintained
  • selecting telehealth video conferencing technology (hardware and software) that offers appropriate security features
  • storing all reports provided for, or generated from, the telehealth consultation securely online with password access
  • informing the participant if there is a valid and clinically appropriate reason for the recording of a consultation and requesting and receiving their verbal

3.6 Technology

3.6.1 Basic requirement of telehealth
  • The basic requirement of telehealth is the transfer of audio and visual data in real- time between the clinician and the
  • Only specific telehealth technology (hardware and software) appropriate for participants will be used to conduct telehealth
  • Encryption, ease of use and access is considered as part of the software selection (e.g. Zoom has encryption storage capacity and is accessible from home computers and tablets).
3.6.2 Adequate performance

The information and communications technology used for telehealth should be fit for the clinical purpose of the consultation. Specifically:

  • the equipment is reliable and works well over the locally available internet network and bandwidth
  • the equipment is compatible with the technology used by the patient-end health worker
  • the equipment and the network are secure, so privacy and confidentiality are assured during the consultation
  • the equipment is of a high enough quality to facilitate clear communication with all participants and to transfer accurate clinical
3.6.3 Risk management

Elevate Support Care will conduct a risk analysis to determine the likelihood and magnitude of foreseeable problems using telehealth consultations. The analysis will include:

  • identifying the limitations of technology being used
  • developing procedures for detecting, diagnosing and repairing equipment and repairing connectivity issues
  • availability of equipment and connections
  • software support services

Table 1. Possible risk management strategies

Computer breakdown

● Contact technician to repair

● Purchase a new computer

● Have a spare computer available

Privacy and confidentiality

● Consent in writing

● Verbal consent at the beginning of each consultation

● Encrypted video kept in participant‟s file

● Secure encrypted server

Internet failure

● Phone participant

● Reschedule

Encrypted end-to-end software

● Locate encrypted software

● Determine if accessible via participant systems

● Inform participant of any breach


● Encrypted storage

● Review for end-to-end encryption (currently being developed)

● Use of waiting room

4.0 Related documents

  • Telehealth Consent Form
  • Privacy and Confidentiality Policy and Procedure
  • Risk Management Policy and Procedure

5.0 References

  • NDIS Practice Standards and Quality Indicators 2020
  • NDIS Act 2013 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Australian Privacy Principles (Commonwealth)

Disaster Management Policy and Procedure

1.0 Purpose

The purpose of the Disaster Management Policy and Procedure is so our participants feel safe in the event of a disaster (natural or pandemic), knowing Elevate Support Care will provide them with continuity of service. Elevate Support Care focuses on maintaining service delivery to our participants in times of stress and uncertainty.

Though disasters and emergencies may be infrequent, we acknowledge our services are especially important before, during, and after such events, as many participants are beyond the reach of other services and Elevate Support Care provides them with an essential support lifeline.

Elevate Support Care recognises that preparedness for disasters and emergencies is a priority for our organisation and a requirement to ensure the safety of our participants.

Elevate Support Care will endeavour to provide an adequate level of service to our participants before, during and after all types of emergencies.

2.0 Scope

The scope of this policy includes our participants and staff. Our participants will be informed of our emergency procedures to assist them in preparing for an emergency, build their resilience, and maintain their confidence in Elevate Support Care.

Our staff will be well informed and prepared to assist participants in coping in an emergency within the community, and in strengthening Elevate Support Care‟s disaster resilience.

3.0 Policy

Elevate Support Care places the safety and care of our participants at the forefront of our operational procedures. During a disaster, our team will adhere to this policy framework, and also work within any additional guidelines and instructions provided to our organisation by state and federal government authorities.

During any type of disaster, our senior management will undertake the following actions:

  1. Follow all relevant government guidelines and
  2. Communicate Elevate Support Care‟s response to staff, participants and any other relevant
  3. Prepare participants (before any possible actions are taken) by informing how the current situation may affect their
  4. Brief our entire staff on any possible or real action steps required by
  5. Attempt to keep key workers allocated to the same
  6. Work towards maintaining continuity of support for each of our

4.0 Procedure

4.1 Preparing for disasters and emergencies

An emergency is a situation of grave risk to health, life or environment. A disaster is any phenomenon, natural or human-made, that has the potential to cause extensive destruction of life and property. The mere mention of either of these two words is enough to make the community, particularly our participants, extremely nervous.

Some disasters and emergencies Elevate Support Care may face include:

  • flood
  • fire
  • heatwave
  • snowstorm
  • storms or cyclones

Elevate Support Care will:

  • stay informed regarding all state/territory and federal government directives and act upon these directives appropriately
  • advise other organisations, who work with Elevate Support Care, of our disaster procedures and processes
  • identify personnel who are critical in the delivery of essential frontline services
  • identify Elevate Support Care participants, and their stakeholders, whose services may be impacted by the situation
  • implement this policy in conjunction with our Risk Management Policy and Procedure, our Information Management Policy and Procedure and our Human Resource Policy and

4.2. Supporting the supporters

Vicarious trauma is a real and grave health concern for staff and volunteers of community service organisations such as ours, mainly when working with disaster-affected individuals and communities.

Our Elevate Support Care will determine the best means to support our staff in a disaster situation and will implement all appropriate measures as detailed in our Human Resource Management Policy and Procedure.

4.3 Consumer preparedness

Elevate Support Care understands that it is more likely that our participants will be adversely impacted by an emergency or disaster than others in the community.

We acknowledge that we may not be able to provide the same level of service to our participants during, or immediately after, an emergency or disaster situation. For these reasons, all of our participants must be supported by Elevate Support Care to prepare for changes due to a disaster or an emergency.

Elevate Support Care will:

  • inform participants of the current situation and how the provision of their services and workers may be impacted
  • continue to provide participants with the same key workers if they are available
  • replace key workers with experienced workers who have the knowledge and skills to provide appropriate care to the participant
  • inform the participant of any service changes and outline reason/s for these changes
  • seek support within the local care community, if our staff are unavailable, and ensure that any new workers are appropriately experienced, trained and hold all relevant checks

4.4 Staff preparedness

Our team is our greatest asset; it is our focus that they and their loved ones remain safe during an emergency or disaster situation.

Elevate Support Care will help prepare our staff for an emergency or disaster by implementing the following:

  • inform staff of the situation and what is required by them via email, online messaging, Zoom meetings or similar
  • train workers in all required measures, g. infection control, social distancing and evacuation
  • seek feedback from participants regarding their services to adjust information distribution, if necessary
  • inform staff of our participant‟s requirements outlined in their support

5.0 Related documents

  • Risk Management Policy and Procedure
  • Information Management Policy and Procedure
  • Human Resources Management Policy and Procedure
  • Work Health and Environmental Policy and Procedure
  • Contingency Disaster Plan Template
  • Business Continuity Policy and Procedure

6.0 References

  • Work Health and Safety Act 2011 (Commonwealth)
  • Privacy Act 1988 (Commonwealth)
  • Disability Services Act 1986 (Commonwealth)
  • NDIS Practice Standards and Quality Indicators 2020

Business Continuity Policy and Procedure

1.0 Purpose and scope

Our organisation is focused on meeting regulatory compliance, achieving best practice standards and providing continuous quality supports to our participants.

We continuously work towards building our organisation‟s resilience and business capability to effectively manage change (e.g. legislative, emergencies) to ensure continuity of service.

Our organisation plans to ensure the business can:

  • manage crises effectively (within our control)
  • provide service and business continuity to participants
  • provide reassurance to staff and participants during times of uncertainty
  • implement our review and compliance structures and policy and

We will develop strategies to examine the risks and methodology of the business and implement changes required to address the risks identified.

Our mission

We believe that independence and choice is a fundamental right of all people regardless of their situation or personal challenges.

Our vision

Our goal is to provide a continuous, personalised service that supports our participants to enjoy a quality of life.

  • Procedure

Our organisation acknowledges that our staff and key personnel are essential to the provision of support and business continuity. Our business is not reliant on a small group of individuals to provide service provision.

In the event key personnel are unable to fulfil their duties, the business will still operate using workers who have the appropriate skills and experience to meet the needs of our participants. These workers may include:

  • staff trained to undertake the role of others in their absence
  • staff who are mentored and trained to increase their skills and knowledge
  • agency staff who we employ when required
  • regular casual

Also, we will conduct appropriate risk assessments to assist in mitigating risk and to understand priorities for risk management actions. We will identify strategic priorities and assist in preparing for effective recovery after an emergency or disaster. We will monitor and comply with government directives and keep our participants and staff informed. All records and plans will be kept updated to ensure the information available is precise and current.

Our organisation engages with all key stakeholders to ensure we receive diverse input to inform our business plan, policies and procedures, which may include, but not be limited to, working with community members, participants, other service providers, IT professionals, health professionals, government bodies and staff

We have a policy and procedure review structure in place that is linked to our organisational risk management practices. With government legislation continually changing, we will, on an ongoing basis, implement changes required to the actions of our business and our employees.

The Director will determine if there is a threat to the business and the way that it currently functions, which may require analysis of current work practices, a review of our services and price structures in comparison to our competitors.

3.0 Crisis management

Information obtained from various sources will be used to determine if our business model is appropriate. Our organisation will review our crisis management processes and implement appropriate and necessary structures to address emergencies and natural disasters, including ensuring computer data is securely backed up on a regular schedule to ensure that in the event of the system crashing, all data is recoverable.

We will ensure the following documents are regularly updated to provide current information to staff in the event of an emergency:

  • participant support plans
  • emergency plans
  • contact details
  • medication lists
  • critical supplies
  • critical

In the case of an emergency, we will implement the Disaster Management Policy.

3.1 Training

Training of staff and management is essential to business continuity. The Director will advise staff and participants of all training requirements, e.g. scenario training to inform staff of possible emergencies and the relevant procedures to follow.

3.2 Reviews and updates

We will use their risk management and continuous improvement policies and procedures to review current practices and to determine a plan of action for improvement. Improvements are likely, to ensure that our business continues to grow and develop. Our organisation will use all appropriate data to determine threats or risks to the business, our staff and our participants.

Staff will be kept up to date with any required changes to the service. Implementing best- practice standards is the key to ensure that the business moves forward with positive outcomes. Our staff will be trained to ensure that they are knowledgeable and professional.

We will ensure that all required business insurances are current, and our government regulatory requirements are met.

4.0 Related documents

  • Risk Assessment Forms
  • Risk Management Plan
  • Risk Register
  • Internal Audit Schedule
  • Continuous Improvement Policy and Procedure
  • Continuous Improvement Register
  • Continuous Improvement Plan
  • Human Resource documents
  • Business Plan
  • Contingency Disaster Plan Template
  • Staff Training Plan
  • Staff Training Record
  • Training Register
  • Training Attendance Register – In-house

5.0 References

  • NDIS Act 2013 (Commonwealth)

Section 1: Rights and Responsibilities