Audit

1. GOVERNANCE AND MANAGEMENT
1.1 The organisation has an accountable and transparent governance arrangements that ensure compliance with relevant legislation, regulations and contractual requirements.

Do the service Manager and Staff have a sound knowledge of the legislation that is require to facilitate in the operational effectiveness of this service?

Does management and staff understand the legislative compliance requirements relevant to the service type and receive information to inform them of any relevant changes?

The health and safety policy is available to other parties, including regulatory authorities, suppliers, contractors and those visiting the workplace?

Site management can demonstrate their understanding of the sites legal obligations for health and safety.

1.2 The organisation ensures that members of the governing body possess and maintain the knowledge and experience required to fulfil their roles.

Has training been undertaken to allow site leadership and staff members to maintain knowledge and skills required to fulfil their roles?
Including:
a) Assisting with medication
b) Provide Positive Behaviour Support
c) MAYBO - Assault Avoidance & Physical Intervention
d) First Aid Certification
e) Preventing Abuse, Neglect & Exploitation
f) Epilepsy
(Sighted - a sample of up to date training records. Photo required)

Do members undergo induction relevant to their responsibilities and duties? (Sighted and verified training matrix up to date. Photo required)

Does the service have a process for identifying and addressing any gaps in skills, knowledge or experience of team members?

1.3 The organisation develops and implements a vision, purpose statements, values, objectives and strategies for service delivery that reflect contemporary practice.

Are staff and customers made aware of Endeavour Foundations' purpose, mission, organisational values and behaviours, as well as objectives and strategies for service delivery?

The Vision and Values Statement has been sighted? (photo required). Team can describe the vision, purpose and values of the organisation?

Both Manager and staff could clearly articulate and outline Endeavour Foundations objectives?

1.4 The organisations management systems are clearly defined, documented and monitored and (where appropriate) communicated including finance, assets and risk.

Do customers have access to financial support (if applicable) and staff act in accordance with their roles and responsibilities in relation to supporting customers to manage their finances?

The Manager of the service is aware of their financial delegation and will complete monthly variance reports. Staff will support people at the service with money as required.

Customers at the service have either the Public Trust or private financial administrators in place to support people with their finances, with people being as independent as possible with staff providing support as required. There is evidence of people being upskilled in the use of their own money.

1.5 Mechanisms for continuous improvement are demonstrated in organisational management and service delivery processes.

How does the service measure, monitor and document performance against internal audit outcomes? Are plans in place to address gaps and actions completed to ensure continuous improvement. Are there records from Community Visitor reports and are actions been addressed ?

" The Service management and staff measure, monitor and document performance against internal audit outcomes, established plans to address any standard/s not met have been completed to ensure improvements are implemented.
(Explain how)

1.6 The organisation encourages and promotes processes for participation by people using services and other relevant stakeholders in governance and management processes.

Are service meetings held, minutes recorded and distributed as scheduled in the Service Meeting Procedure. Evidence demonstration of active participation from relevant stakeholders in developing/reviewing service provision and improvements. (family, advocates, support networks)

Families have been provided with service meetings as per QP 1200: Service Meeting Procedure, in the last 12 months. Auditor was able to sight previous years meeting minutes where there is evidence of families being informed of service improvements and changes.
Staff are provided with monthly meetings and agenda items are recorded and outcomes that are not addressed are added to the next meeting.

1.7 The organisation has effective information management systems that maintain appropriate controls of privacy and confidentiality for stakeholders.

How does the business service maintain appropriate controls of private and confidential information?
(Auditor to sample service folders and ensure customer consent and media release forms are signed off by the customer or substitute decision maker)

The service manages the security,(integrity and storage of information hard copy and electronic data).confidentiality, privacy, retrieval, archiving, transfer and disposal of information as per the Client Records Management procedure.
(View a sample of folders indicated that consent and media release forms have been filled out.)

2. SERVICE DELIVERY
2.1 Where the organisation has responsibility for eligibility, entry and exit processes, these are consistently applied based on relative need, available resources and the purpose of the service.

How does the service assist customers who exit/transfer from the service, seek alternative support options where their current needs will be best met?
(Explain)

Service management and staff are able to demonstrate Endeavour's referral processes. Referrals to the service have processed as per Endeavour's Intake process.

2.2 The organisation has processes to communicate, interact effectively and respond to the individuals decision to access and/or exit the services.

What processes are in place for informing potential new intakes of services available e.g.: vacancy listing with DOC's, expos, marketing events, open days, etc.

The service is currently at capacity ?

2.3 Where an organisation is unable to provide services to a person, due to ineligibility or lack of capacity, there are processes in place to refer the person to an appropriate alternative service.

What networking activities are in place that maintain organisational awareness of internal and external services?

The manager of the service maintains connections with the Local Area Coordinator (DOCS) and is familiar with departmental processes. Manager will liaise with other service providers and agencies as required, e.g. Blue Care , Honey Bee and employment agencies. The manager maintains a working relationship with other Endeavour Services in the local area.

3. RESPONDING TO INDIVIDUALS NEEDS
3.1 The organisation uses flexible and inclusive methods to identify the individual strengths, needs, goals and aspirations of people using services.

What methods are used to identify the individual strengths, goals and aspirations? How does the service maintain current and accurate support/planning information for each person and how does it their support requirements.

The service maintains current and accurate support/planning information for each customer that is applicable to their support requirements. .Each customer at the service has a plan in place that:
- identifies and records their needs, strengths, and
aspirations
- documents how service will be delivered within the
parameters and criteria of the service type being delivered
- includes the customer and people of their choice in all aspects of planning
- provides opportunities for the customer to fulfil valued roles in the community
- Is reviewed within agreed timeframes

3.2 The organisation formulates service delivery that respects and values the individual (e.g. identity, gender, sexuality, culture, age and religious beliefs).

How does the service provide opportunities for customers to be included in events and activities in the community to develop and maintain their individual skills relative to their participation in the community.
(Auditor to sight examples and list)

3.3 The organisation ensures that services to the individual/s are delivered, monitored, reviewed and reassessed in a timely manner.

Can the service present planning documents that highlight Individual Support/Progress Notes and processes for the ongoing review of needs, goals, preferences, aspirations and achievements customers?

The service monitors and records progress against people identified outcomes with people, There is clear documentation of progress against identified outcomes
The use of legend its consistently being used, and documented outcomes or actions are documented within individual support/progress notes with the legend ""P"" . This information is e reviewed each quarter and summarised within the progress summary, for each identified action or outcome.

3.4 The organisation has partnerships and collaborates to enable it to effectively work with community support networks, other organisations and government agencies as relevant and appropriate.

What Partnership arrangements and collaborative strategies are in place, are planning meeting's held annually, with each person receiving service/support. Can the service demonstrate that family members/advocates/guardians as appropriate are invited to the planning meetings.

Each customer whose planning/support information was sampled for the audit have a current Individual Plan in place which articulates their support requirements, likes, dislikes, strengths and aspirations. Planning information details future endeavours that are to be supported by the service to achieve. Plans have been reviewed within required timeframes and evidence noted of involvement by person/s of the customer's choice in the planning review process.

4. SAFETY, WELL-BEING AND RIGHTS
4.1 The organisation provides services in a manner that upholds people's human legal rights.

Are restrictive practice in use, are appropriate approvals and documentation in place including current positive behaviour support plan. All aspects of RP been appropriately monitored reviewed and reassessed as per dates set.
Are Customers are supported in a way that promotes their health and wellbeing as per Endeavour's health and wellbeing procedure. Health management plans, CHAPS, medication information, safe eating plans, epilepsy management plans?

Individual AW - Summary correlates with medication on site, with CHAPS completed 29/06/2015 and evidence of actions completed.

Individual CN - Summary correlates although it should be documented when generic brands replace , what is documented on summary (sertraline apo .50mg, Canestan) CHAPS completed 03/09/2015 - nil actions. Person self injects insulin and this has been documented within support information.

Individual GC - CHAPS has been dated 2015, although the particular date to be included when visiting GP. Summary correlates with mediation on site.

Individual JP - CHAPS completed 15/06/2015 - actions addressed. Ensure medication summary is completed correctly when visiting GP , with panamax documented on additional info, Rhinochort not being initialled by the GP. Person has been diagnosed with Epilepsy and although the service will contact ambulance in the first instance, it is recommended that this information to be placed in Health Management Plan and included into support information.

4.4 People using services are enabled to access appropriate supports and advocacy.

How would the service provide advocacy support to allow customers to participate in decision making about services they receive ?

4.5 The organisation has processes that demonstrate the right of the individual to participate and make choices about the services received.

Sample customer folders and ensure consent forms are signed by the persons legal guardian or relevant informal decision -makers

5. FEEDBACK, COMPLAIANTS AND APPEALS
5.1 The organisation has fair, accessible and accountable feedback, complaints and appeals processes.

How does the service ensures that any concerns or complaints are responded to and dealt with in a timely manner and the complainant satisfaction has been determined.
Auditor to review Riskman reports to ensure any complaints have been adequately addressed

Interviews with customers at the service:
- indicate their willingness to raise concerns or complaints directly with the service staff/management.
- Are aware that they will not disadvantaged as a result of making complaints, lodging appeals or providing feedback.

5.2 The organisation effectively communicates feedback, complaints and appeals processes to people using services and other relevant stakeholders.





How do customers, and their support networks, receive information that is accessible and in a format that is appropriate to them, in relation to:
- internal complaints processes
- external complaints processes
- access to support when making a complaint, lodging an appeal or providing feedback
- assistance to make a complaint e.g. communication support such as interpreters
- how to engage an independent mediator where complaints and appeals remain unresolved.


All customers at the service have good comprehension and verbal skills with no additional communication aids required.

Manager/staff discussed ways in which customers who require additional communication aids are supported at the service and tools used.

Customers are able to:
- indicate their willingness to raise concerns or complaints directly with the service staff/management.
- are aware that they will not disadvantaged as a result of making complaints, lodging appeals or providing feedback.

5.3 People using services and other relevant stakeholders are informed of and enabled to access any external avenues or appropriate supports for feedback, complaints or appeals and assisted to understand how they access them.

?????

5.4 The organisation demonstrates that feedback, complaints and appeals processes lead to improvements within the service and that outcomes are communicated to relevant stakeholders.

In relation to:
- internal complaints processes
- external complaints processes
- access to support when making a complaint, lodging an appeal or providing feedback
- assistance to make a complaint e.g. communication support such as interpreters
- how to engage an independent mediator where complaints and appeals remain unresolved.

All customers and their family have received a Shared Responsibility Agreement which outlines avenues for external/internal complaint/concerns and appeals.

6. HUMAN RESOURCES
6.1 The organisation has human resource management systems that are consistent with regulatory requirements, industrial relations legislation, workplace health and safety legislation and relevant agreements or awards.


Are Effective human resource management systems, including recruitment, induction and supervisory processes in place .
Have Edmen contractors been inducted ?
Sight yellow cards ?


All new staff have received Induction (organisational, site, role) that address mandatory requirements and the knowledge necessary to fulfil a role within the service.
Sighted Positive exception cards for ?????
Sighted Edmen induction records for ????

The manager meets with, support and monitors staff during their probationary period and ensure all induction requirements have been completed as per induction checklist.
Staff have completed all mandatory training requirements as per renewal dates and the manager monitors training records.

6.2 The organisation has transparent and accountable recruitment and selection processes that ensure people working in the organisation possess the knowledge, skills and experience required to fulfil their roles.


Are people working in the service qualified or skilled to perform their nominated role?


Personnel/HR files show evidence that staff have qualifications and experience relevant to their roles
Staff at the service have been appointed in accordance with Endeavour's recruitment and selection procedure:
- the selection criteria is reviewed to ensure that the staff are selected with the knowledge, skills and experience required to fulfil their roles.

The service undertakes a process to identify and respond to the learning and development needs of staff and volunteers working in the service.
- Training and assessment is delivered by persons with appropriate knowledge, skills and experience.
Training records are available to evidence training undertaken.

-The site trains workers to perform their work safely, and verifies their understanding of that training. Able to site SWP’S for operational tasks which includes a sign –off competency checking system.

6.3 The organisation provides people working in the organisation with induction, training and development opportunities relevant to their roles.

All new staff have received Induction (organisational, site, role) that address mandatory requirements and the knowledge necessary to fulfil a role within the service.

6.4 The organisation provides ongoing support, supervision, feedback and fair disciplinary processes for people working in the organisation.

Are Staff informed and have access Endeavour's Assistance Program (EAP) that provide counselling and/or other services.

Service staff are aware of their right and the process:
- to raise grievances and to have disputes resolved
- to access support when involved in grievances and/or disputes
- to be informed of the outcomes of grievances and/or disputes where appropriate
- to engage external grievance investigation companies who can provide an objective investigation into grievances if required.
-There are documented procedures, agreed to by Workers, for the Worker involvement and consultation on health and safety matters, including a procedure for dealing with health and safety issues, and resolving disputes if they arise.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.