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

4 Reviewer Methodology

Up to Office of Aged Care Quality and Compliance (OACQC)

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4.1 Reviewer Approach

The Quality Framework is a quality assurance process designed to monitor service providers’ performance against the Standards and assist service providers to continuously improve their services.

The focus of the review process is also to include supporting capacity building for providers and promoting development of internal systems and processes.

The review team is responsible for gathering and analysing information and evidence to establish if service providers are meeting the Standards. Evidence is usually more reliable when it can be confirmed by more than one process or piece of information.

Before making any decision about whether the service provider is meeting the Standards, the review team must ensure they have considered enough evidence and that the evidence reviewed is relevant to each expected outcome being assessed.

To ensure the process is fair, equitable and transparent reviewers must keep the service provider or their nominated personnel informed about the progress of the review. You will note in the previous section of the Guide concerning the purpose of the exit meeting, the first dot point advises it is to “provide verbal confirmation of the review findings.”

Unless there are exceptional circumstances, the findings reported to the service provider at the exit meeting should not be ‘new’ information but instead a summary of the information that reviewers have communicated throughout the course of the review.

In keeping with a collaborative and supportive approach, if the review team identify that an expected outcome is likely to be Part Met or Not Met the service provider should be informed of this as soon as possible.

This is to ensure that the service provider understands the rationale for the review team’s findings and has adequate opportunity to provide additional/alternative evidence to the review team.

4.2 Collecting Evidence – Potential Sources

Evidence is information that confirms or proves something. Evidence can include something that is written, something that is seen or something that is heard.

The evidence that services have will differ and may depend upon the size and structure of the organisation, the services provided and the staff and service user group. However, to just say that something is done, or describe a system or process that is in place, is not enough evidence to show that a Standard is met.

While it is important that staff and service users can talk about systems and processes during an on-site review, the review team must look for evidence from more than one source to verify any information they are given.

When on-site, the three key evidence sources available to reviewers are: documentation, interview and observation.

Documentation

Service providers can present any written information to the review team that they believe show they meet the Standards. This documentation might include:

• stakeholder information such as: brochures, pamphlets or other written material given to service users or other stakeholders, newsletters photographs or posters
• documents read by staff such as: policies, procedures, guidelines, work instructions, meeting minutes, memos, newsletters forms and other tools used by staff: referrals, intake and assessment tools, care plans, attendance records, feedback and complaint, improvement forms
• records: service user records, staff records, training records, feedback, complaint and incident/accident records, Quality Improvement Plans
• reports: quality activities, quality reviews, financial reports, annual reports, reports to the Board/Committee.

Interviews

Interviews enable information to be obtained verbally from a range of relevant stakeholders. Interviews can be used to confirm written evidence. Interviewees could include: managers, Board/Committee members, staff, service users, their representatives, community members and other service providers.

Interviewing a range of stakeholders enables the review team to gain information about the service and its operations from different, viewpoints. Stakeholder interviews are a useful way to check that there are feedback mechanisms in place that are understood, accessible and responsive to stakeholder input. Hearing about stakeholder experiences assists in assessing the effectiveness of the services systems and processes.

Some people being interviewed by reviewers will feel worried or anxious to some extent about the interview process. Interviewees may be concerned about saying the “wrong thing” and the consequences of this, or “not knowing” the answer to the reviewers questions. It is therefore essential that reviewers anticipate this and use a friendly and collaborative approach at all times.

When planning interviews reviewers should use a flexible approach, ensuring the location and timing of the interview is acceptable to the interviewee. This should include the option of the interviewee having others present. Top of page

Good interpersonal skills are extremely important for an interview to be effective and for the interviewee to feel safe and comfortable. Reviewers should at all times be aware of their verbal and non-verbal communication with the interviewee. This includes a reviewer monitoring the language they use, their tone of voice and body language. It is also important that reviewers do not make assumptions about interviewees reactions based on their own communication style. Reviewers should consider for example, that:

• minimal eye contact may be preferred by some interviewees
• the interviewee may be more relaxed talking outside rather than within the facility/office
• using open questions may assist in getting a response
• the interviewee should be made aware that there is no right or wrong answer
• an interviewees silence may indicate that they are not comfortable sharing the information that is being sought rather than them not understanding or knowing the answer to the question
• if this occurs, ask the interviewee if they have a problem with the question and consider using a more subtle line of questioning around the issue/s being discussed
• the interviewee should be reassured that if they prefer, the information they provide will not be recorded.

Accepted good practice on the interviewer’s part would include commencing the interview by:

• explaining the aim of the interview
• outlining the information to be covered
• confirming how much of the interviewees time is required
• asking the interviewee to explain their role and responsibilities, training and education.

The latter is important to ensure the interview questions are appropriate and not outside the scope of knowledge of the interviewee.

Always advise staff that if they need to attend to urgent matters, the interview can be rescheduled. You may not be able to ensure the confidentiality of the information provided by staff, however, you can reassure staff that they will not be referred to by name in the quality review report or to other staff or management in providing feedback.

Staff may feel more comfortable talking in a group. The on-site visit schedule provides time for a service delivery staff group meeting. This allows the group to be interviewed about their general work practices, but quality reviewers must also make time to speak to staff individually throughout the review process to ensure that information is corroborated.

Sometimes staff may provide the quality reviewers with their personal opinions or concerns with the organisation’s management. Quality reviewers need to be mindful of this and manage this situation appropriately while considering the information if necessary.

Where reviewers are seeking an explanation or trying to elicit information about a particular system or process it is appropriate to use an open questioning technique. Open questions invite descriptive information. For example, the reviewer might ask:

“How do you go about making sure that each service users’ clinical care needs are reviewed regularly”? or

“How are new Board/Committee members recruited”?

However, at times it may be appropriate to use a closed questioning technique. This is particularly relevant if the reviewer is having difficulty confirming information. Closed questions do not invite descriptive information. They seek a ‘Yes’ or ‘No’ response. For example:

“Did you have training in Occupational Health and Safety during orientation?” or

“Do you have a Conflict of Interest policy and procedure?”

Effective interview techniques also include attentive listening and not interrupting the interviewee when responding. It is important that reviewers do not make any assumptions and clarify any responses that they are unsure about with the interviewee. It can be helpful to repeat your understanding of what has been said back to the interviewee. This provides an opportunity for clarification and/or confirmation.

Observation

Observation can be used to confirm written and/or verbal evidence. Observation of the physical environment can be useful in gaining information about:

• accessibility
• service user and other stakeholder safety and security
• staff occupational health and safety
• the state of facilities and equipment
• general maintenance
• privacy and confidentiality
• staff interactions with stakeholders
• service user activities.

The extent to which observation can be used as an evidence source may depend on the nature and location of the service/s provided. For example, services may largely be provided off site and the opportunity for observation may therefore be limited.

4.3 Analysing Evidence

Reviewers must collect, review and analyse all evidence provided to assess each service provider’s performance against the Standards. Reviewers will be able to utilise the service providers completed self-assessment to assist in this process.

Reviewers must ensure that adequate relevant evidence has been reviewed and evaluated before making any decision about whether a service provider meets or does not meet each expected outcome.

There are three key considerations for reviewers when analysing evidence and rating performance against an expected outcome:

• is there adequate evidence to rate the service provider’s performance?
• is the evidence relevant to the expected outcome being assessed?
• is the evidence from a reliable source?

Reviewers should seek to confirm evidence from more than one source where possible, to ensure adequate evidence is considered. For example, information about documented evidence such as a policy or procedure can be confirmed at interview and/or where possible, by observing staff practices. One piece of evidence, not confirmed by another source, would generally not be considered enough evidence for a reviewer to base a decision on about whether an expected outcome is met.

Reviewers must also be satisfied that the evidence being considered is relevant to the expected outcome and the question being asked. To be considered as valid evidence the information provided should clearly relate to the requirement being assessed. If the information is not considered to be relevant, the service provider should be informed and given an opportunity to provide alternative evidence before making any decision about whether a service provider meets or does not meet an expected outcome.

Reviewers must also be satisfied as to the reliability of the evidence that has been provided. Documented evidence would usually be thought to be more reliable than verbal evidence. For example, seeing records of completed service user file audits would be considered as being more reliable evidence than a staff member talking about the file audit process.

First hand observation of a process or activity by a reviewer would also be considered as more reliable evidence than being given a verbal description of a process or activity.

Reviewers must also consider the reliability of the source providing verbal evidence and be satisfied that the person providing the information has the relevant knowledge and/or experience in that area and is the right person to do so. As mentioned previously, it is good practice to establish the role and responsibilities of each person at commencement of any interview. Top of page Once a reviewer has considered these key factors against the evidence provided they have responsibility for making a decision about whether a service provider meets or does not meet each expected outcome. Reviewers are accountable for their decision making and must at all times be satisfied that their analysis of the evidence gathered clearly supports the rationale for their finding. Evidence examples for each expected outcome are set out on the following pages. The evidence examples are categorised with reference to the related evidence source (document review, interview and/or observation), as applicable. These evidence examples are intended as a guide only to assist reviewers in their approach to reviewing and analysing evidence. They are not a list of prescribed evidence that service providers must have to meet the Standards. [

4.4 The Standards, Expected Outcomes and Evidence Examples

Standard 1. Care Delivery and Information
Each service user has access to and receives quality aged care services that meet their needs and respects their dignity and individuality. This is achieved through assessment, planning and regular review of each service user’s needs, in consultation with them and their nominated representative/family member/people.

Each service user is fully informed about service choices and their rights and responsibilities as a service user. This information is provided in a format appropriate to their needs and communicated in a way that is culturally acceptable to each service user.

Expected Outcome and Guide to requirements

Evidence Examples

1.1 Assessment Each service user is supported to actively participate in an assessment of their care needs. The assessment is conducted by appropriately experienced staff and considers: eligibility, priority of access, independence, physical, social, emotional and cultural care needs and clinical care needs, where applicable and with the agreement of the service user. Guide to requirements: The assessment includes each service user’s: life story medical history functional, cognitive and sensory status nutritional status/needs personal care needs special care needs clinical risk factors and where applicable: assessment of the resident’s ability to smoke safely, including the need for, and level of, supervision.

Policies and procedures could include: The assessment includes each service user’s: eligibility priority of access waiting lists service user assessment including who is responsible for assessment identifying the service users representative/s, where applicable refusing or ending a service receiving and making referrals cultural safety – assessment service quality and continuous quality improvement.

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Expected Outcome and Guide to requirements	Evidence Examples
1.1 Assessment (continued)	Other documentation could include: forms, checklists or other paperwork that is filled out from the time of enquiry or referral and shows how eligibility and priority of access is established completed assessment tools that include the information listed under the Guide to requirements forms, checklists or other paperwork that evidence the assessment occurred in consultation with the service user and/or their representative records showing that staff who assess service users have the necessary experience records of quality activities such as: service user file audit results feedback from service users about their entry to the service. Evidence at interview could include: staff responsible for intake and assessment explaining these processes from the time of enquiry or referral. This could include talking about: how a prospective service user accesses the service intake processes how and when an assessment is arranged what the service user is told about assessment who participates in the assessment how staff go about making sure each service user’s independence, physical, social, emotional, clinical and cultural care needs are identified in a culturally safe way how and when service users are told about the outcome of the assessment what service users are told about when service will commence.
1.2 Care Planning Each service user has a documented care plan that addresses their identified care needs and preferences. The care plan will be developed in partnership with the service user and/or his or her representative. This will include a cultural support plan which describes how assessed needs and service user preferences will be met in a culturally safe way. The care/cultural support plan includes strategies to maintain privacy and dignity, individual interests, customs and beliefs, independence and family connectedness, at the choice of the service user. Guide to requirements: Each service user has a copy of the care plan which addresses: all assessed needs and preferences of the service user what action is to be taken to meet assessed needs and preferences of the service user in a culturally safe and respectful way who is responsible for what care (staff with the necessary skills and qualifications, family members and/or other providers) when and where care is to be received (ensuring a culturally safe environment).	Policies and procedures could include: service user care planning including who is responsible for care planning service user involvement in planning identifying the service users representative/s, where applicable cultural safety - care plans and cultural support plans service quality and continuous improvement. Other documentation could include: the care plan and cultural support plan tool used by the service completed care plans that include all information listed under the Guide to requirements forms, checklists or other paperwork that evidence the care plan has been developed in consultation with the service user and that they have agreed to the plan and received a copy of the plan records that show staff who develop service user care plans have the necessary experience records of quality activities such as: service user file audit results feedback from service users about their involvement in care planning and their level of satisfaction with the service/s provided. Evidence at interview could include: staff responsible for developing care plans and cultural support plans explaining these processes. This could include talking about: expected timeframes between assessment and development of a care plan what the service user is told about care planning who is involved in care planning how staff go about making sure that each service user has a care plan that includes a cultural support plan.
1.3 Review Each service user is monitored to ensure: service delivery occurs as planned, their needs are regularly reassessed and the care plan is updated in consultation with the service user to reflect any change in needs and service user preferences. Guide to requirements: Service user and care plan review: occurs at least six monthly and where service user needs change identifies progress against planned goals/actions results in any change in needs and preferences being documented in the care plan.	Policies and procedures could include: service user care plan review including who is responsible for the reviews and how often they occur service user involvement in care plan review identifying the service users representative/s, where applicable cultural safety – review of care plans and cultural support plans service quality and continuous quality improvement. Other documentation could include: the care plan and cultural support plan tool used by the service which has the provision to record when review is due and has occurred completed care plans that show review is regularly scheduled and has occurred forms, checklists or other paperwork that evidence the care plan has been reviewed in consultation with the service user and that they have agreed to the reviewed plan and received a copy of the plan records that show staff who review service user care plans have the necessary experience records of quality activities such as: service user file audit results feedback from service users about their involvement in care plan reviews. Evidence at interview could include: staff responsible for the review of care plans and cultural support plans explaining these processes. This could include talking about: how often care plan review occurs what the service user is told about care plan reviews who is involved in care plan reviews how staff go about making sure that each service users care plan is reviewed regularly in a culturally safe way how staff go about making sure that the reviewed care plan/cultural support plan addresses all identified needs relating to independence, physical, social, emotional, clinical and cultural care processes to evidence that the service user agrees with the reviewed care plan processes to evidence that the service user receives a copy of the reviewed care plan.
1.4 Clinical Care Each service user’s clinical care needs are met. Guide to requirements: Each staff member works within their scope of practice. Clinical care needs include, as applicable: special care needs safe and effective management and administration of medication effective assessment, treatment and management of pain access to specialised palliative care services access to other specialist health care/allied health services functional care cognitive care sensory care nutritional care personal care. Note: The requirements within this outcome may have limited applicability or not be applicable to some organisations, depending upon the services provided to service users.	Policies and procedures could include: working within scope of practice what is clinical care planning clinical care who is responsible for delivering clinical care service user involvement in clinical care family or representative involvement in clinical care identifying the service users representative/s, where applicable cultural safety - care plans and cultural support plans: delivering culturally safe clinical care. Other documentation could include: the care plan used by the service has the provision to record all areas of clinical care needs as listed in the Guide to requirements completed care plans include all relevant clinical care needs forms, checklists or other paperwork that evidence that clinical care is planned and delivered in consultation with the service user records that show staff who plan and deliver clinical care have the necessary experience records of quality activities such as: service user file audit results feedback from service users about the clinical care they receive.
	Evidence at interview could include: staff responsible for planning and delivering clinical care explaining these processes. This could include talking about: scope of practice how clinical care planning occurs who is involved in planning and delivering clinical care what the service user is told about clinical care how staff go about making sure that the care plan addresses all identified clinical care needs in a culturally safe way how staff go about making sure that each service users clinical care needs are reviewed regularly processes to evidence that the service user agrees with the reviewed care plan processes to evidence that the service user receives a copy of the reviewed care plan.
1.5 Information Each prospective service user is fully informed about service choices and their rights and responsibilities as a service user. Guide to requirements: information about available services and eligibility to receive services is clearly documented. This information is communicated in a manner that is appropriate in format and culturally acceptable to each prospective service user to support choice and decision making each service user is offered a service agreement by the service provider which sets out the terms and conditions of the service/s to be received and the service user’s rights and responsibilities2 the service provider ensures that the content of the service agreement is fully explained to each service user (and/or their representative) in a culturally acceptable way prior to entering into the agreement a process is in place to enable service users to be represented by an advocate of their choice.	Policies and procedures could include: eligibility priority of access waiting lists assessment offering service refusing or ending a service using an interpreter information to be given to prospective service users rights and responsibilities identifying the service users representative/s, where applicable service agreements cultural safety - communicating in a culturally safe way service quality and continuous improvement. Other documentation could include: information about the service is recorded in a culturally acceptable way the information provided to service users includes all information listed under the Guide to requirements forms, checklists or other paperwork that evidence that information about the service is provided and explained to each service user in a culturally acceptable way records of interpreter use.
1.5 Information (continued)	Other documentation could include: the service agreement which sets out: the service/s to be received (emergency/planned respite, low/high care or other) the duration of the service (permanent or short term) the frequency of service where services will be provided (residential or community based) who will deliver the service the date services will commence he agreed fees payable and how these charges are determined the care plan the circumstances under which: either party can terminate the agreement the service provider can reallocate the service user’s place the service provider must help the service user to access alternative care the service user may choose to suspend the provision of care service user rights and responsibilities including: the right to make decisions about the care to be received information and consultation protection of privacy and confidentiality comments and complaints advocacy other rights and responsibilities as a service user records of quality activities such as: service user file audit results feedback from service users about the content and appropriateness of the information they have been given and general communication by the service.
1.5 Information (continued)	Evidence at interview could include: staff responsible for providing information to prospective service users explaining these processes. This could include talking about: what information is provided when this information is provided who receives this information what format this information is provided in service user rights and responsibilities how staff go about making sure that each service user and/or their representative understands this information under what circumstances an interpreter is used how an interpreter service is organised how service user consent is obtained to use an interpreter how interpreter use is recorded processes to evidence that all service users have received all required information processes to evidence that all service users have been offered a service agreement processes to evidence that all service users have received a copy of the service agreement. Observation of evidence could include: Looking at displays of posters, brochures, forms or other information at the service in an appropriate format informing service users about: services provided their rights and responsibilities interpreter use.
Standard 2. Management and Accountability
The service provider has implemented systems and processes which ensure the organisation is well managed and services are continually improved. This results in the delivery of culturally safe, quality services that are responsive to the needs of each service user, their representatives, staff and other stakeholders.

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Expected Outcome and Guide to requirements	Evidence Examples
2.1 Governance The service provider has clear and effective governance processes in place. Guide to requirements: Board/Committee members have appropriate skills, knowledge and experience to carry out their role Board/Committee members have an understanding of, and promote culturally safe service delivery the roles and responsibilities of the Board/Committee are documented meeting minutes and other records evidence that the Board/Committee carry out their roles and meet their responsibilities planning occurs to set strategic directions and promote the delivery of culturally safe quality aged care services the service actively engages with and consults the community about the services available and reflects this in service planning.	Policies and procedures could include: the organisation’s Mission and Vision selection, recruitment and appointment of Board/Committee members induction and training of Board/Committee members Board/Committee members Code of Conduct/Ethics Board/Committee members roles and responsibilities Board/Committee subcommittees Board/Committee member evaluation strategic, business and operational planning including development and review of plans stakeholder consultation compliance with funding agreements financial management and reporting risk management fraud conflict of interest delegation of authority cultural safety – providing a culturally safe service service quality and continuous improvement document control. Other documentation could include: the organisation’s Mission and Vision records evidencing that Board/Committee members have the required skills and a commitment to cultural safety Board/Committee member selection, recruitment and induction records Board/Committee member police checks records of Board/Committee member training in governance and management the organisation’s constitution organisational chart Board/committee meeting schedule, agenda, meeting minutes
2.1 Governance (continued)	information for stakeholders about the Board/Committees role Board/Committee reports records of planning activities including stakeholder consultation demographic data about the community and current service users strategic and business plans reports against organisational plans, targets and goals budget, financial records and reports including acquittals to funding bodies financial audit records insurances a risk register Quality Improvement Plan records of quality activities such as: Board/Committee member file audit results Board/Committee member evaluations Stakeholder feedback about governance of the organisation. Evidence at interview could include: Board members talking about: their skills and understanding of cultural safety their selection and recruitment to the Board/Committee the organisation’s Mission and Vision induction and access to other training Board/Committee roles and responsibilities service quality and continuous quality improvement management roles and responsibilities Board/Committee policies and procedures processes for policy development, authorisation and review strategic and business planning their knowledge of the community and service user demographic financial management and reporting risk management.
2.2 Management Systems The service provider has clear and effective management systems and practices in place. Guide to requirements: the service provider understands and complies with the funding agreement, including the Service Provider Guidelines the service provider understands and complies with regulatory and relevant legislative requirements management and staff accountabilities and delegations are documented, relevant to their roles service planning and development occurs and aligns with the organisation’s strategic directions financial, human and physical resources are allocated and used in ways that support quality care services that are delivered in a culturally safe and comfortable environment information management systems are in place to ensure the service users’ right to privacy, dignity and confidentiality in relation to the use of and collection of personal information information management systems are in place to ensure the safe and secure storage of documents and records, and enable effective use of information to meet the needs of each service user, staff, management and regulatory bodies a process to manage positive feedback, complaints and allegations is in place which is effective, accessible, and culturally acceptable to stakeholders the service provider works in partnership with other organisations to maximise access to services and/or enhance service delivery a continuous quality improvement program is in place to monitor and improve: the care and services provided to service users, and the management systems and practices of the service provider.	Policies and procedures could include: the organisation’s Mission and Vision Code of Conduct/Ethics selection, recruitment and appointment of staff induction and training of staff position descriptions delegation of authority legislative compliance compliance with funding agreements strategic, business and operational planning including development and review of plans internal reporting financial management and reporting risk management subcontracting Memorandums of Understanding purchasing goods and services asset management stakeholder consultation privacy, dignity and confidentiality information management systems document control feedback, complaints and allegations staff grievances working with other service providers cultural safety - providing a culturally safe service service quality and continuous quality improvement. Other documentation could include: organisational chart position descriptions records evidencing that management/staff members have the required skills and a commitment to cultural safety management/staff member selection, recruitment and induction records management/staff training records management/staff meeting schedule, agenda and meeting minutes management reports to the Board/Committee records of business/operational/program planning activities including stakeholder consultation
2.2 Management Systems (continued)	demographic data about the community and current service users reports against organisational plans, targets and goals budget, financial records and reports including acquittals to funding bodies Quality Improvement Plan Records of quality activities such as: management file audit results management appraisals stakeholder feedback about management of the organisation. Evidence at interview could include: Management/staff talking about: the organisation’s Mission and Vision their skills and understanding of cultural safety their selection and recruitment induction and access to other training their roles and responsibilities organisational structure – lines of reporting policies and procedures strategic and business/operational planning their knowledge of/access to relevant legislation and updates their knowledge of the community and service user demographic program funding, budget and targets financial management and reporting risk management service quality and continuous quality improvement cultural safety - providing a culturally safe service maintaining privacy, dignity and confidentiality in relation to information management with reference to the relevant legislation management of feedback and complaints management of staff grievances. Observation of evidence could include: Looking at: file storage areas within the service displays of posters, brochures, forms or other information in an appropriate format informing service users about: privacy, dignity and confidentiality service quality and continuous quality improvement feedback and complaint processes.
2.3 Risk Management A risk management framework is in place to ensure the safety of service users, staff and other stakeholders, and that quality care services are delivered. Guide to requirements: effective financial management processes are in place to ensure the service is, and remains, financially viable. Financial risks are identified and managed in an appropriate manner an asset management program is in place purchased goods and services are of a standard that ensure the delivery of quality aged care services procedures are in place to identify and address potential risks associated with the physical environment, chemicals or dangerous goods, and work practices procedures are in place for the management of natural disasters and other emergency events effective infection control procedures are implemented procedures are in place to identify and manage risk associated with: laundry services kitchen and food handling cleaning fire equipment open fire supervision resident smoking procedures are in place to identify and manage risk related to service delivery.	Policies and procedures could include: risk management, including clinical risk management financial management and reporting insurances delegations of authority internal reporting conflict of interest fraud legislative compliance information management compliance with funding agreements purchasing goods and services asset management occupational health and safety (OH&S) including: staff training in OH&S environmental risk assessment and reporting fire safety and equipment including open fire supervision handling and storing chemicals or dangerous goods hazard identification and reporting incident and accident reporting managing natural disasters and other emergencies infection control cleaning food safety and food preparation safe work practices travel maintenance (including building, equipment and vehicles) OH&S representatives and/or committee, as applicable. cultural safety – cultural safety and risk management service quality and continuous quality improvement.
2.3 Risk Management (continued)	Other documentation could include: Board/Committee reports risk management plan/risk register management reports to the Board/Committee reports against organisational plans, targets and goals asset register records evidencing that management/staff members have the required skills and a commitment to cultural safety management/staff training records: fire safety and general OH&S management/staff meeting schedules, agendas and meeting minutes forms, checklists or other paperwork that evidence that: all work sites have a regular safety assessment that is documented and reported staff have received training in fire safety fire safety equipment complies with the required standard/regulations preventative maintenance occurs hazards are identified, documented reported and addressed incidents and accidents are documented, reported and action taken as necessary infections are monitored and reported all of the above are monitored to ensure any emerging trends are identified and addressed Quality Improvement Plan records of quality activities such as: analysis of work site safety assessments analysis of incidents/accidents, infections stakeholder feedback about the safety/appropriateness of equipment.
2.3 Risk Management (continued)	Evidence at interview could include: Board/Committee, Management or staff, as appropriate, talking about: the organisation’s risk management framework their roles and responsibilities organisational structure – lines of reporting policies and procedures strategic and business/operational planning their knowledge of/access to relevant legislation and updates financial management and reporting program funding, budget and targets service quality and continuous quality improvement cultural safety – cultural safety and risk management: choice and decision making and risk management of emergencies OH&S policies, procedures and practices preventative maintenance. Observation of evidence could include: Looking at: access to the building entry and exit points safety and security measures facilities and equipment fire safety equipment evacuation plans storage and handling of chemicals infection control processes cleaning processes laundering processes catering processes, where applicable.
2.4 Human Resources Effective staff recruitment and retention ensure that service users’ needs are met. Guide to requirements: recruitment and retention processes ensure sufficient staffing levels are maintained at all times for the delivery of safe services services are provided by appropriately skilled staff that have an understanding of the cultural needs of the key stakeholders, including service users all staff and volunteers have a current police check that complies with the funding agreement staff and volunteers are provided with training and development activities relevant to their role an effective performance appraisal process is implemented for staff and volunteers.	Policies and procedures could include: selection and recruitment of staff including: advertising applications short listing interviewing notifying applicants referee checks sighting qualifications police checks staff contracts/agreements induction Code of Conduct Occupational Health and Safety privacy, dignity and confidentiality service quality and continuous improvement cultural safety – providing a culturally safe service equal employment opportunity workplace bullying and harassment workforce planning/staff retention training and development staff appraisal. Other documentation could include: recruitment advertisements position descriptions interview questions induction agenda, program or handbook forms, checklists or other paperwork that evidence: staff applications interview processes staff qualifications reference checks police checks staff contracts/agreements completion of induction ongoing training appraisal workforce planning, rostering, allocation
2.4 Human Resources (continued)	training budget Quality Improvement Plan records of quality activities such as: staff file audits to verify all required information is recorded the selection and recruitment process is completed in line with the services policy and procedure staff feedback about their selection recruitment and induction experience staff feedback about training and support, appraisal and working in the organisation. Evidence at interview could include: Board/Committee, Management or staff, as appropriate, talking about: selection and recruitment screening processes induction training and support appraisal their roles and responsibilities organisational structure – lines of reporting OH&S policies, procedures and practices management of emergencies service quality and continuous quality improvement cultural safety – cultural safety and risk management: choice and decision making and risk.

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