What is this division about?
Division 2 of the core module is about making sure your service has high-quality governance and operational management. Governance and operational management can sound a bit overwhelming, but they do not need to be – particularly for a service-for-one. There are normally more risks for larger organisations, which means they need more governance and operational systems to manage those risks. Services-for-one also have risks, but the systems to manage those risks do not need to be as complex or time consuming.
What is governance?
Governance is a set of rules that guides what organisations do and how they do it. All legal organisations, large or small, need governance.
The Governance Institute of Australia defines governance as ‘the system by which an organisation is controlled and operates, and the mechanisms by which it, and its people, are held to account. Ethics, risk management, compliance and administration are all elements of governance’.
Division 1 – Rights and responsibilities focused on how a service-for-one meets the legal and human rights of the person. The requirements in that division are part of your governance and management requirements. For example, the policies you develop for that division and the laws you need to be aware of, are all part of your governance and operational management – as are any procedures, forms or registers you develop. Remember to try to keep things simple.
Community Door has some useful free resources that are worth taking a look at.
Why is it important?
The NDIS Quality and Safeguards Commission (NDIS Commission) is responsible for overseeing the quality and safety of NDIS supports and services. This includes NDIS providers of any size and with any number of participants.
The NDIS Commission wants to make sure that all services, including services-for-one:
- have a governing body that is appropriate for them. Think about who has overall responsibility in your service-for-one. A governing body can be an individual or a group of people, but does not need to be a formal board of directors or committee of management like in large organisations. It may be that your service-for-one has two directors, a few partners or even one person who has final responsibility for the service-for-one’s operations. You could even have an external group of advisors to help you govern your service-for-one, such as a consultative committee
- comply with state or territory and Commonwealth laws
- have a purpose and a documented plan
- follow the plan to make sure the service-for-one understands and meets its responsibilities including:
- financial
- legal
- regulatory
- contractual
- have a governing body or group of advisors with the skills and knowledge to do their job effectively. If they do not have all the skills and knowledge they need, you can include developing these as part of their professional development
- think about governance and operational risks for services-for-one, such as the needs of the person, workers and other stakeholders
- monitor the performance of the service-for-one and find ways to keep improving
- have clearly defined levels of responsibility, including in governance and operations. This helps workers know who will take over if a decision-maker is away and what responsibilities the new decision-maker will have
- understand actual or perceived conflicts of interest and have processes to minimise them, such as a short policy, and procedure and conflicts log
- give the person opportunities to contribute to governance and to the policies and processes that affect their rights and supports
- keep up to date with changes in laws, regulations and standards requirements. These requirements could be NDIS-specific, such as the Practice Standards, or broader, like industrial relations or tax laws.
What will the auditors be looking for?
Auditors will look for evidence to show that the service-for-one is providing services in line with NDIS quality and safeguarding requirements, including that:
- your governing body has the right skills for your service-for-one and to support the person
- your policies and procedures are accessible and easy to follow for the workers and the person
- you ask the person for their input into your policies and procedures
- workers know the management structure of the service-for-one and who is responsible for what
- workers know who fills in for whom and what their responsibilities are
- your governing body supervises the quality and safety of your service-for-one
- your governing body has ways to keep improving your service-for-one
- there is a current strategic plan. This document shows the big picture for your service-for-one and how you are planning to achieve this
- workers are supervised and given performance appraisals and professional development to make sure they are able to do their jobs well
- feedback, complaints and incidents are managed, following NDIS requirements, for the person, workers and stakeholders
- the governing body understands its role in the service-for-one
- your governing body keeps up to date with all legal responsibilities.
Tables of evidence
How to use the tables in this guide
We have included the following tables as checklists to help you prepare for your online self-assessment and your audit.
Each table includes examples of evidence that will help you show the auditor that you are meeting the practice standard that is described at the top of each section. These are examples of evidence only. You are likely to have other examples of evidence you can also show the auditors.
The questions before each table are the quality indicators for each practice standard. These help you to assess your progress towards meeting each practice standard. Each question is numbered. The numbers in the table relate to the numbers for each question.
There is also a large table at the end of the printable document (PDF) that you can use as a checklist to keep track of the evidence you are providing and the practice standards you are meeting. The numbers in this large table also relate to the quality indicators for each standard.
Remember that the auditors will also consider evidence including:
- your policies and procedures
- feedback from the person, key stakeholders, workers and chosen communities, such as sporting, social or religious groups and other providers (where necessary)
- observation during the audit process.
We have not listed these in the tables as they apply across almost every practice standard.
Governance and operational management
Outcome
The person’s supports are managed by strong governance and operational management systems that are relevant and proportionate to the:
- size of the service-for-one
- scale of the service-for-one
- scope and complexity of the supports you deliver.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Does the governing body give the person an opportunity to contribute to the organisation’s governance? Does the person have a say about the organisation’s policies and processes? This includes the policies and processes that relate to the supports they receive and to the safeguarding of their rights.
QI 2. Has the governing body implemented a clear structure to make sure the service-for-one can meet its responsibilities? This includes financial, legislative, regulatory and contractual responsibilities. Is there a clear structure, like a regular meeting, to monitor and respond to quality and safeguarding matters related to delivering supports to the person?
QI 3. Has the governing body identified the skills and knowledge required for it to govern effectively? Do members of the governing body complete training to fill any gaps in their skills and knowledge?
QI 4. Does the governing body’s strategic and business planning consider:
- legislative requirements?
- organisational risks?
- other requirements related to operating under the NDIS
- the needs of the person and the workers?
- the wider organisational environment?
QI 5. Is management’s performance monitored by the governing body to make sure management continues to improve? This includes monitoring how well it responds to individual issues.
QI 6. Do suitably qualified and experienced people manage the service-for-one? Does management have clearly defined responsibility, authority and accountability for providing supports?
QI 7. Is there is a documented system of how responsibility and authority are delegated to another suitable person if there is no one to fill that role?
QI 8. Are perceived and actual conflicts of interest managed and documented? This includes through developing and maintaining organisational policies.
| The type of evidence you can use | QI 1 | QI 2 | QI 3 | QI 4 | QI 5 | QI 6 | QI 7 | QI 8 |
|---|---|---|---|---|---|---|---|---|
| Meeting minutes | Yes | No | No | No | Yes | No | No | Yes |
| Business and strategic plan | No | No | No | Yes | No | No | No | No |
| Records of governing body, and management skills and knowledge (skills matrix, copies of resumes, training records) | No | Yes | Yes | No | No | Yes | No | No |
| Delegations register | No | No | No | No | No | No | Yes | No |
| Conflict of interest register | No | No | No | No | No | No | No | Yes |
Risk management
Outcome
Risks to the person, workers and the service-for-one are identified and managed.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Are risks to the organisation identified, analysed, prioritised and managed? This includes risks to participants, financial and work health and safety risks, and risks related to providing supports.
QI 2. Is there a documented system that effectively manages risks? Is this system relevant and in proportion to the size and scale of the service-for-one and the scope and complexity of supports you provide?
QI 3. Is support delivery linked to a risk management system? This system should include:
- incident management
- complaints management
- work health and safety
- human resource management
- financial management
- information management
- governance.
| The type of evidence you can use | QI 1 | QI 2 | QI 3 |
|---|---|---|---|
| Risk assessment for individuals | Yes | Yes | Yes |
| Risk register and records of risk assessment | Yes | Yes | Yes |
Quality management
Outcome
The person benefits from a quality management system that is relevant and in proportion to the size and scale of the service-for-one and promotes continuous improvement of support delivery.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Is there a well-maintained quality management system that is relevant and in proportion to the size of the service-for-one, as well as to the scope and complexity of the supports they deliver? Does the system specify how to meet the requirements of legislation and the Practice Standards? Does the service-for-one review and update the system to improve support delivery?
QI 2. Does the service-for-one’s quality management system have a documented program of internal audits that are relevant and in proportion to their size, as well as the scope and complexity of supports they deliver?
QI 3. Does the service-for-one’s quality management system support continuous improvement? Does it use:
- outcomes?
- risk-related data?
- evidence-based practice?
- feedback from the person and the workers?
| The type of evidence you can use | QI 1 | QI 2 | QI 3 |
|---|---|---|---|
| Risk register and records of risk assessment | No | No | Yes |
| Compliance table and a register identifying relevant laws | Yes | Yes | Yes |
| Records of internal audits, which include: audit schedule audit reports corrections and corrective actions inputs into continuous improvement register | Yes | Yes | Yes |
Continuous improvement register, which includes:
| Yes | Yes | Yes |
Information management
Outcome
The person’s information is managed well. This includes making sure that it is:
- easily identified as information about the person
- accurately recorded
- current
- confidential.
The person’s information is easily accessible to them and appropriately used by relevant workers.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Does the service-for-one have the person’s consent to collect, use and keep their information or to share their information (including assessments) with other parties? This includes details of:
- why your service-for-one has collected the information
- how you will use the information
- who you will share the information with.
Does the service-for-one tell the person about when they would share their information? For example, does the person know that their information could be shared without their consent if your service-for-one is required or authorised to share it by law?
QI 2. Does the person know how their information is stored and used? Does the person know how and when they can access or correct their information? Does the person know how and when they can remove or change their consent?
QI 3. Is there a well-maintained information management system that is relevant and in proportion to the size of the organisation? Does the system record the person’s information in an accurate and timely way?
QI 4. Does your service-for-one store documents in a way that is relevant and in proportion to the scope and complexity of supports you deliver? For example, your service-for-one should have storage procedures that specify:
- who can use the documents and for what purposes
- how documents are kept secure
- how and when documents can be transferred, retrieved, retained, destroyed or disposed of.
| The type of evidence you can use | QI 1 | QI 2 | QI 3 | QI 4 |
|---|---|---|---|---|
| Record of consent, such as a signature, audio or video file, that explains what personal information is collected and why | Yes | Yes | No | No |
| Brochures, newsletters, posters or other types of communication that are available and accessible in a way that meets the person’s communication needs | No | Yes | No | No |
| Clearly documented systems to make sure person information is collected, used, accessed, stored, secured and destroyed appropriately | No | No | Yes | Yes |
Feedback and complaints management
Outcome
The person knows about and has access to your service-for-one’s complaints management and resolution system. Complaints and other feedback are:
- welcomed
- acknowledged
- respected
- well managed.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Is there a well-maintained complaints management and resolution system that is relevant and in proportion to the scope and complexity of supports delivered, as well as the size of the organisation? Is the complaints management and resolution system fair? Does it comply with the requirements under the NDIS (Complaints Management and Resolution) Rules 2018?
QI 2. Does the service-for-one give the person information about how to give their feedback or make a complaint? This includes:
- support that is independent of the service-for-one
- the person’s right to use advocates.
Does the service-for-one create a supportive environment for people to provide feedback and make complaints?
QI 3. Does the service-for-one show that it is always trying to improve the way it manages complaints and feedback? For example, does the service-for-one:
- regularly review its complaint and feedback policies and procedures?
- ask what the person thinks about the accessibility of the complaints management and resolution system?
- take on and apply the feedback to the organisation?
QI 4. Do all workers know about and comply with how they must handle complaints and are they trained in doing so?
| The type of evidence you can use | QI 1 | QI 2 | QI 3 | QI 4 |
|---|---|---|---|---|
| File notes | No | No | No | Yes |
| Meeting minutes | No | No | No | Yes |
| Brochures, newsletters, posters, or other types of communication are available and accessible in a way that meets the person’s communication needs | Yes | Yes | No | No |
| Records of worker training | No | No | No | Yes |
| Feedback and complaints register | No | No | Yes | No |
Continuous improvement register, which includes:
| No | No | Yes | No |
Incident management
Outcome
The person is protected by the service-for-one’s incident management system. This system makes sure that incidents are:
- acknowledged
- responded to
- well managed
- learned from.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Is there a well-maintained incident management system that is relevant and in proportion to the scope and complexity of supports delivered, as well as the size and scale of the organisation? Does the incident management comply with the requirements under the NDIS (Incident Management and Reportable Incidents) Rules 2018?
QI 2. Does the service-for-one give the person information about incident management? This includes how incidents involving the person have been managed.
QI 3. Does the service-for-one show that it is always trying to improve the way it manages incidents? For example, does the service-for-one:
- regularly review incident management policies and procedures?
- review the causes of incidents?
- review the way incidents are handled?
- review the outcomes of incidents?
- ask what the person and workers think about the incident management system?
- take on and apply the feedback?
QI 4. Do all workers know about how they must handle incidents and are they trained in doing so? Do all workers comply with incident management procedures?
| The type of evidence you can use | QI 1 | QI 2 | QI 3 | QI 4 |
|---|---|---|---|---|
| Brochures, newsletters, posters or other types of communication that are available and accessible in a way that meets the person’s communication needs | No | Yes | No | No |
| Records of worker training | No | No | No | Yes |
| Incident register and forms | No | Yes | No | No |
Human resources management
Outcome
The person’s support needs are met by workers who:
- can do their role well
- have relevant qualifications
- have relevant expertise and experience
- provide person-centred support.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Are the skills and knowledge that each position requires identified and documented? Documentation should include the responsibilities, scope and limitations of each position.
QI 2. Does the service-for-one have well-maintained records of worker pre-employment checks, qualifications and experience?
QI 3. Does the service-for-one have an orientation and induction process in place that new workers complete? This includes completing the mandatory NDIS Worker Orientation Program.
QI 4. Is there a system to identify what training and education workers need to make sure they meet the needs of the person? Is there a system to plan, facilitate, record and evaluate the effectiveness of this training and education? Does the service-for-one understand what training is mandatory? Does it include this training in relation to worker obligations under the NDIS Practice Standards and other NDIS rules?
QI 5. Is there timely supervision, support and resources available to workers that is relevant to the scope and complexity of supports the service-for-one delivers?
QI 6. Does the service-for-one manage, develop and document the performance of workers? This includes through giving feedback and offering development opportunities.
| The type of evidence you can use | QI 1 | QI 2 | QI 3 | QI 4 | QI 5 | QI 6 |
|---|---|---|---|---|---|---|
| Records of worker training | No | Yes | No | Yes | Yes | Yes |
| Records of worker orientation including the NDIS Code of Conduct and NDIS Worker Orientation Module | No | No | Yes | No | No | No |
| Worker screening records | No | Yes | No | No | No | No |
| Position descriptions and worker contracts | Yes | No | No | No | No | No |
| Records of pre-employment checks (e.g. police check and Working With Children check) and resumes | No | Yes | No | No | No | No |
| Worker performance reviews | No | No | No | No | No | Yes |
Continuity of support
Outcome
The person has access to timely and appropriate support without interruption.
Quality indicators (QI)
Auditors will assess your progress towards this outcome using the following quality indicators:
QI 1. Does the service-for-one manage daily operations in an efficient and effective way to avoid disruption and ensure continuity of supports?
QI 2. If a worker is away or resigns, is there a suitably qualified and experienced person who can step into their role?
QI 3. Are supports planned with the person to meet their specific needs and preferences? Are these needs and preferences documented and provided to workers before they start working with the person?
QI 4. Does the service-for-one have plans in place to make sure that support is provided to the person without interruption during their service agreement? Are these plans relevant and in proportion to the scope and complexity of supports the service-for-one delivers?
QI 5. If changes or interruptions to supports are unavoidable, are other arrangements explained to and agreed with the person?
QI 6. Are there disaster preparedness and planning measures to allow critical supports to continue?
| The type of evidence you can use | QI 1 | QI 2 | QI 3 | QI 4 | QI 5 | QI 6 |
|---|---|---|---|---|---|---|
| Participant support plan | No | No | Yes | Yes | No | No |
| File notes | No | No | No | No | Yes | No |
| Staff rosters and rostering arrangements | No | Yes | No | No | No | No |
| Risk register and record of risk assessment | No | No | Yes | Yes | No | No |
| Business continuity plan | Yes | No | No | Yes | No | No |
| Emergency disaster response plans and procedures | No | No | No | No | No | Yes |