Presenter: Jen Engels
Presented on 12 October 2022
Welcome my name is Jen Engels and I will be taking you through Module 5 of our Residential Aged Care NDIS Registration video series. Module 5 is all around Stage two on-site audit.
The first point to understand in this video is about evidence being proportional. So, it needs to be suitable for the size, scope, scale, of you as a provider and also consider the complexity of the supports that you provide. So, what this means is two providers may have slightly different evidence, or different approaches to undertaking their compliance and their day-to-day processes. If you consider a small provider that might have a single outlet, it might have two or three NDIS participants and just a handful of staff supporting NDIS participants.
If you compare that with a big national provider that has multiple sites, has dozens of participants and has also dozens of staff supporting those participants, evidence is going to look a little bit different. So, don't feel that there is this checklist or prescriptive guide of the evidence that you need to have because your evidence needs to also suit you. So, as long as you can demonstrate the requirements of the standard, the evidence needs to be fit for purpose for each organisation, so, proportional.
Having said that, there's no prescriptive guide, there is a tool that's been developed for you and this is part of the Toolkit and it's called an Evidence Guide. It is a guide, so don't feel like it's something that you need to meet all of the evidence requirements in that guide. So, it lists down some evidence that you may already have, based on the alignment between the Aged Care Quality Standards and the NDIS Practice Standards. So, it lists down some evidence there and it also provides some suggestions or other examples of evidence that you might like to consider. So, it is a good tool to go and have a look at, get you thinking about the types of evidence that you might need for your stage two and to ensure, that you are meeting the NDIS Practice Standards.
Stage two is about implementation. So, it's really about how you fulfil the requirements that you've documented in your policies and procedures which were reviewed at stage one. So, the types of evidence that auditors will be looking for is that they'll be looking for records of implementation. So, it might be files, or it might be registers, it might be file notes, it could be all manner of types of records. They will be chatting with people. So, conducting interviews across the organisation relevant to the NDIS scope and also they will be undertaking observations because it is an on-site audit. So, they will be observing the organisation service setting while they're there.
NDIS participants have a role in NDIS audits and so it is important to ensure that consent is in place prior to their engagement in an audit. So, it is important to share information with NDIS participants or their substitute decision-maker about the audit process.
All NDIS participants are automatically enrolled in the audit process, unless they wish to opt-out. So, they can choose to opt-out, it's not saying that every NDIS participant is required to be involved because it is about choice.
So, this means that you'll need to ensure that NDIS participants or their substitute decision-makers have that consent in place. If they choose not to consent, that's okay, but there needs to be a record of the opt-out. And what does consent mean? So, there could be consent for a chat with an auditor, or it could be consent for an auditor to review their file, or it could be consent for both of those things or an opt-out of one or both of those things.
It is an important part of evidence though. So, audit teams will certainly be looking to review participant files and chat to NDIS participants, or substitute decision-makers wherever possible.
One of the questions that's often asked about these audits, is how long will the audit team be on site? And there's no quick answer to that. It will depend, and this is something that goes back to quoting. So, it will depend on how big you are as an organisation, the complexity of the supports, how many NDIS participants that you support as well. So, each organisation is likely to be maybe a little bit different in terms of how long the audit team will be with you. The audit will be book-ended by an opening and closing meeting. The audit team will conduct those and during the audit, what the audit team will be doing is undertaking interviews with a sample of your organisational staff.
So, this includes governing body personnel, it includes a management team, direct support staff, and also clinicians where they are relevant. So, they'll be conducting those interviews. They'll certainly want to be conducting interviews with a sample of NDIS participants as well, and there is a minimum of five, is the requirement. However, some providers have less than five participants that they are supporting, and so where that is the case the audit team will aim to interview as many NDIS participants as is being supported by that organisation.
And just again, the audit team will be viewing samples of records. So, it is a sampling process. So, they won't have time to say to review every single record that you have. So, they'll be looking at a sample of NDIS participant files, staff files, meeting minutes, organisational registers, and so on.
During the interviews that audit team members have with stakeholders, it's often wondered what sorts of questions that they may ask. And so, when engaging with participants, it might be, there might be questions about the rights of the participants. There might be questions, about you know, the suitability of the supports that they're receiving, etcetera. For staff, it's likely to be about induction and training and what would you do if there was an incident, or maybe what would you do if there was a complaint. And for senior management and governing body personnel, there may be questions about how they ensure the continuity of supports for NDIS participants. Or maybe, you know what processes are available for NDIS participants to contribute to governance. What's on the screen here is just a snapshot. So, if you go to Part D of the Toolkit you will find that there is a more comprehensive list of questions. It should be noted though, these questions again aren't prescriptive. So, auditors won't necessarily use this list of questions they may have their own and obviously, questions rely on the previous answer as well, so questions will vary.
So, during the audit it's important to also know that the audit team will keep you updated on their progress. So, basically there'll be no surprises by the time you get to the closing meeting. They'll touch base with you from time to time during the audit. If they think that there might be a non-conformity, they will tell you about that as soon as they uncover it, because it may be you have evidence elsewhere that they haven't seen yet, and so again there'll be no surprises at that closing meeting.
At the closing meeting, that's where you are advised of the outcome of the audit. So, you will be advised about you know how you went. The overall findings, ratings of conformity and if there were any non-conformities.
If there are non-conformities, the first thing to know about that is that it is not the end of the world. None of us like to get non-conformities. However, they can be a really good learning process and also contribute to continuous improvement over time. So, although they're not ideal or what anybody wants, they're certainly not the end of the world, there are time frames in which to manage those non-conformities and your audit team will explain that.
However, if there is a non-conformity raised, you will have to prepare a corrective action plan and provide it to the audit body within seven days of the last day of the audit, so the closing meeting. And that corrective action plan, basically, is to document where you review the non-conformity, and you prepare a response to that. So, the tasks or remedies that you were going to put in place to address the non-conformity, who will take carriage of that work, who is responsible and also the time frame and your audit body will review that. You will have more than seven days to complete your non-conformities, so that's okay.
The audit body will give you a draft of the audit report and that way you can just check it over, make sure that it is factual and correct. And then the audit team will provide the final audit report to the Commission within 28 days and that will be via the Commission's operating system, the portal. So, you will see that there as well.
So, after the final stage 2 audit report has been submitted, it's then over to the Commission who will make a registration decision. And we've prepared a video Module 6 on registration decision that comes up next that explains that process, and there's also extra information in Part D of the Residential Aged Care Toolkit, if you'd like to read some more.
We hope this video has been helpful.