Quality Framework for the National Aboriginal and Torres Strait Islander Flexible Aged Care Program

Appendix 2: Examples Completed Self-Assessment

Page last updated: 17 February 2012

Example of a completed Assessment Matrix

Assessment Matrix
Expected OutcomesPlace a tick (3) in the appropriate box:MetPart MetNot MetNot Applicable
Standard 1: Care and Delivery and Informaion
1.1 Assessment
.
1.2 Care Planning
.
1.3 Review
.
1.4 Clinical Care
.
1.5 Information
.
Standard 2: Management and Accountability
2.1 Governance
.
2.2 Management Systems
.
2.3 Risk Management
.
2.4 Human Resources
.
Assessment
result:
Part Met
In the example above, the service provider has achieved an overall Assessment Result of Part Met.

The Part Met rating applies because the requirements of one or more expected outcomes have not been fully met. In this instance, expected outcome 1.5 Information has been rated as Part Met and expected outcome 2.4 Human Resources has been rated as Not Met.

Some examples of expected outcomes rated at self-assessment are provided on the next few pages. When completing the self-assessment it is not necessary to include lengthy information about policies and procedures or other types of evidence. It is acceptable to just list the name or number of the policy and procedure or other documents that you have as evidence and can provide to the reviewers.

Similarly, the purpose of the Assessment Findings sections is to provide a brief summary as to why your service have self-assessed as Met, Part met, Not Met or Not Applicable.

The following examples also demonstrate different approaches to documenting the Evidence Examples section.
Example of a completed Expected Outcome - self-assessed as 'Met'
Standard 1: Care Delivery and Information
The following examples also demonstrate different approaches to documenting the Evidence Examples section.
Expected Outcome 1.2: Care Planning
Evidence Examples
  • service user care planning policy and procedure
  • service user involvement in planning policy and prcedureplete
  • service user's representation policy and procedure
  • cultural safety: care plans and cultural support plans policy and procedure
  • service quality and continuous improvement policy and procedure
  • care plan and cultural support plan tools
  • service user completed care plans and cultural support plans
  • service user file audit results
  • service user survey results
  • staff files (qualifications and training)
Other information: Management and staff responsible for care planning will be available for interview.
self-assessment Findings
We conduct regular service user file audit results which show that all service users have a current care plan and cultural support plan that is based on assessed needs and preferences. Our care plans and cultural support plans detail the all action to be taken, who is responsible for care and when and where care is to be received.

We have records to show that service users are involved in care planning and that a copy of the care plan is always offered. However we have identified an opportunity for improvement in this area. (See Quality Improvement Plan).
Self-Assessment Rating: Met
Quality Improvement Actions
Action required to meet the Expected Outcomes
Optional action to support Continuous Quality Improvement:
Include room in the care plan to note when a service user and/or their representative refuse the offer of a copy of the care plan.
Example of a completed Expected Outcome self-assessed as 'Part Met'
Standard 1: Care Delivery and Information
Expected Outcome 15: Information
Evidence Examples
We have the following policies and procedures that relate to this expected outcome: Eligibility, priority of access and entry to the service, Giving service user information, Communicating with stakeholders and cultural safety, When to use an interpreter, service user rights and responsibilities and service agreements.

Information Pack: all new service users and/or their representatives receive the Information Pack. This includes all aspects of service user’s rights and responsibilities. We have this information in several for-mats to meet the needs of our stakeholders. Our staff always explains this information verbally as well. We will use an interpreter when necessary.

Our intake and assessment staff will be available to talk about these processes. We can show you copies of service user’s service agreements in their files.
self-assessment Findings
We checked a sample of service user’s files and found none of the files had any evidence that the Informa-tion Pack was explained or given to those service users. Yet we are confident that our staff always do this.
Self-Assessment Rating: Part Met
Quality Improvement Actions
Action required to meet the Expected Outcome:
Make sure the staff giving and explaining the Information Pack know that they must note that they have done this in the service user’s file. The entry should always be signed and dated by the staff member.

Add this requirement to our procedure.

Audit files in two months to check progress.
Optional action to support Continuous Quality Improvement:
Example of a completed Expected Outcome self-assessed as 'Not Met'
Standard 2: Management and Accountability
Expected Outcome 2.4: Human Resources
Evidence Examples
Human resources policies and procedures. Staff files.

Our new HR manager will be available to explain our processes and current situation.
self-assessment Findings
Our staff records do not currently have information about our selection and recruitment, screening, training or appraisal processes. The HR Manager has recently left and we are unsure whether the appropriate records have not been kept or have been misplaced. We have plans to implement a system to address this as soon as possible. Our new HR Manager will be starting in three weeks.

We have recently had a number of other staff leave and have had to suspend services to some community based care recipients/service users. We have recently commenced a staff recruitment strategy.
Self-Assessment Rating: Not Met
Quality Improvement Actions
Action required to meet the Expected Outcome:
Implement a human resources records management system to evidence:
  • recruitment and retention processes that ensure sufficient staffing levels are maintained
  • services are provided by appropriately skilled staff
  • police records checks for all staff and volunteers at commencement
  • training and development activities
  • an appraisal process is in place and appraisal occur as scheduled
Optional action to support Continuous Quality Improvement: