Community Care Common Standards Guide
Appendix 4: Self-assessment Tool
Table of contents
1. Overview of the Community Care Common Standards Guide- 2. The quality review process
- 3. The Community Care Common Standards
- Standard 1: Effective Management
- Standard 2: Appropriate access and service delivery
- Standard 3: Service user rights and responsibilities
- 4. Results and Performance Measures
- 5. Other Information and Resources
Appendices- Appendix 1: Information for Quality Reviewers
- Appendix 2: Acronyms and Glossary
- Appendix 3: National Program Documents and References
- Appendix 4: Self-assessment Tool
- Appendix 5: Example Completed Self-assessment Tool
- Appendix 6: Service Outlet Information and Desk Review Summary
- Appendix 7: On-site Visit Schedule
- Appendix 8: Quality Reviewer Tool
- Appendix 9: Quality Review Report
- Appendix 10: Improvement Plan
- Home and Community Care (HACC) Program
- Community Aged Care Package (CACP) Program
- Extended Aged Care at Home (EACH) Program
- Extended Aged Care at Home Dementia (EACHD) Program
- National Respite for Carers Program (NRCP)
For completion by service providers funded under the:
Introduction
This self-assessment tool has been designed to assist service providers to review their organisation’s processes and practices and determine the extent to which they are meeting the Community Care Common Standards. The document is available in electronic format and online (in some jurisdictions). Service providers completing the tool need to consider and document the processes and practices they have in place for the services they deliver and the outcomes (results) for service users. In the process, service providers should be able to identify any areas requiring improvement that may currently exist and determine what actions they will need to undertake to meet the Standards.Completing the tool may also assist service providers to identify further opportunities to improve service delivery and outcomes for service users as part of their continuous quality improvement programs.
Further information on completing the self-assessment is included in the Community Care Common Standards Guide Section 2: The Quality Review Process.
Self-Assessment Tool – Service Details
Contact details
Name of service providerName of service/outlet
Address of service outlet
Service/project ID number(s)
Contact person
Program funding
(please identify current number of packages and/or annual program funding as appropriate)
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| EACHD |
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|---|---|---|---|---|
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Detail NRCP service types: | HACC Program Detail HACC service types: | ||
Description of services
Brokerage/subcontracting/consortia details
(provide details of your brokerage arrangements if you broker services to another provider, i.e. if another provider delivers services on your behalf)Details of arrangements
| Special-needs groups the organisation is specifically funded to support (please tick as appropriate) |  | Other quality programs which the organisation participates in (please tick as appropriate) | ||
|---|---|---|---|---|
| People who are financially or socially disadvantaged | | ISO 9001:2008 | | |
| Aboriginal and Torres Strait Islander people | | QIC | | |
| People from culturally and linguistically diverse backgrounds | | ACHS | | |
| People living in remote or isolated areas | | ABEF | | |
| Veterans (including spouses and widows) | | Disability | | |
| People with dementia | | Residential Aged Care | | |
| People with a mental illness | | Other (please specify) | | |
| People with disabilities | | | | |
| People who are homeless or at risk of being homeless | | | | |
| Care leavers – people who have experienced institutional care, such as orphans and child migrants | | | | |
| Other (please specify) | | | |
Declaration
I hereby declare that the information provided in this self-assessment tool is true.Name*:
Signature:
Date:
Position:
Phone:
Fax:
*Name of person authorised to submit your response
Giving false or misleading information to the Commonwealth or State or Territory Governments is a serious offence.
Person to contact to answer queries in relation to the self-assessment, if different from above:
Name*:Position:
Phone:
Fax:
Email:
Standard 1: Effective Management
The service provider demonstrates effective management processes based on a continuous improvement approach to service management, planning and delivery.Expected Outcome 1.1: Corporate Governance
The service provider has implemented corporate governance processes that are accountable to stakeholders.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Organisational structure and decision-making processes
- Roles and responsibilities within the organisation
- Accountability and reporting processes
- Planning processes
- Financial management and reporting processes
- Monitoring and managing of compliance and service performance in accordance with contractual obligations, service/funding agreements, associated program guidelines and relevant professional standards
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.1: Corporate Governance | Not met | Met |
Expected Outcome 1.2: Regulatory Compliance
The service provider has systems in place to identify and ensure compliance with funded program guidelines, relevant legislation, regulatory requirements and professional standards.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Identifying the regulatory and legislative requirements with which the organisation needs to comply
- Identifying the requirements of funded program guidelines
- Managing and monitoring compliance with regulatory and legislative requirements and funded program guidelines
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.2: Regulatory Compliance | Not met | Met |
Expected Outcome 1.3: Information Management Systems
The service provider has effective information management systems in place.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Identifying, maintaining, sharing and storing information
- Policies and procedures that are suitable to the size, complexity and service provision of the organisation, reflect current practices and are accessible, as appropriate, to the board and/or management committee, senior management, staff, volunteers and service users
- Maintaining records of organisation practices (such as minutes of meetings, data, etc.), staff and volunteer records (such as personnel records) and service user records (such as service user assessments, records of care and service delivery, etc.)
- Communication strategies to ensure that all stakeholders including the organisation’s management, staff, volunteers and service users, are kept informed of service provision changes and developments that may affect them (this may include meetings, newsletters, personal communications, memos, etc.)
- Ensuring staff and volunteers’ knowledge of relevant information management systems
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.3: Information Management Systems | Not met | Met |
Expected Outcome 1.4: Community Understanding and Engagement
The service provider understands and engages with the community in which it operates and reflects this in service planning and development.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Monitoring the profile and needs of the community in which the service operates and applying this information to the planning and development of services
- Meeting the needs of people most in need of services, who are most disadvantaged and who have limited access to services due to cultural and linguistic barriers or special needs such as sensory losses or dementia
- Responding to changing community needs, within contractual obligations and service/funding agreements
- Liaising with funding bodies through funding applications to adjust the scope of services to meet changing community needs and contractual requirements
- Engaging service users, including special-needs groups and the community, in service development and management
- Working in collaboration with other community partners to meet the needs of identified groups within the community
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.4: Community Understanding and Engagement | Not met | Met |
Expected Outcome 1.5: Continuous Improvement
The service provider actively pursues and demonstrates continuous improvement in all aspects of service management and delivery.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Ongoing consultation with stakeholders including service users, management, staff, volunteers and the wider community
- Involving management, staff and volunteers in the management and development of the continuous improvement process
- Encouraging and facilitating ongoing feedback from service users and their representatives (including complaints, compliments and other feedback), management, staff, volunteers, the community, suppliers and other relevant stakeholders
- Ensuring feedback collected is recorded, considered by the organisation and acted on (if appropriate), and that the originator of the feedback is given information about the actions taken (if possible) and the outcome of the feedback is evaluated
- Monitoring processes to assess the effectiveness of service operations and to identify areas for improvement. (These could include: internal audits; service users staff/volunteer and other stakeholder satisfaction surveys; monitoring of organisation key performance indicators; reviewing the risk management plan; collation of feedback, accidents, incidents and hazards; determining the accuracy of policies and procedures to current practices)
- Maintaining an improvement plan
- Maintaining records of improvements that demonstrate what has been achieved over time
- Providing feedback on implemented improvements to service users, management, staff, volunteers and other stakeholders as appropriate
- Ensuring management, staff and volunteers have knowledge of and can participate in the organisation’s continuous improvement processes, as appropriate to their position
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.5: Continuous Improvement | Not met | Met |
Expected Outcome 1.6: Risk Management
The service provider is actively working to identify and address potential risk, to ensure the safety of service users, staff and the organisation.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Ongoing identification of risks
- Ongoing review of risks
- Identification and implementation of strategies to reduce the occurrence of the risks
- Identification of strategies to deal with risks should they occur
- Involvement of management, staff and volunteers in the identification of risks and preventative practices
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.6: Risk Management | Not met | Met |
Expected Outcome 1.7: Human Resource Management
The service provider manages human resources to ensure that adequate numbers of appropriately skilled and trained staff/volunteers are available for the safe delivery of care and services to service users.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Identifying required staff/volunteers skills and competence to ensure that there are adequate staff/volunteer numbers to meet funding requirements and to provide quality services that meet the assessed needs of service users
- Recruiting staff and volunteers (where used) with the appropriate skills, competence and qualifications
- Providing training and development opportunities for staff and volunteers to ensure appropriate skills and competence. This could include:
An induction or orientation program
Ongoing training based on the needs of the organisation and the individual
Orientation and training to address any special or specific needs of service users - Staff/volunteer leave and emergency backup staffing arrangements to ensure that appropriately qualified staff/volunteers are always available to provide the required services
- Strategies to promote and encourage staff/volunteer retention
- Monitoring and feedback processes for brokered/subcontracted staff
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.7: Human Resource Management | Not met | Met |
Expected Outcome 1.8: Physical Resources
The service provider manages physical resources to ensure the safe delivery of care and services to service users and organisation personnel.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Ensuring a safe and comfortable environment that is consistent with service users care needs and staff/volunteer safety
- Consideration of special-needs groups, including Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, people with dementia, people with a mental illness, people living in remote or isolated areas, people who are financially or socially disadvantaged, people with disabilities, veterans, people who are homeless or at risk of being homeless and care leavers (people who have experienced institutional care, such as orphans and child migrants)
- Ensuring a safe working environment that meets regulatory requirements
- Monitoring the safety and condition of service physical resources
- Identifying and monitoring any safety issues at the service user’s home that are relevant to the services they receive
- Training for staff/volunteers in identifying and reporting safety issues associated with physical resources
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 1.8: Physical Resources | Not met | Met |
Standard 2: Appropriate Access and Service Delivery
Each service user (and prospective service user) has access to services and service users receive appropriate services that are planned, delivered and evaluated in partnership with themselves and/or their representative.Expected Outcome 2.1: Service Access
Each service user’s access to services is based on consultation with the service user (and/or their representative), equity, consideration of available resources and program eligibility.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Identifying eligibility criteria
- Determining service user eligibility based on:
Program eligibility requirements
The service target group
Prioritised need relative to the demand for services - Informing the community and potential users of the services available, eligibility and access
- Access for people with special needs
- Managing a waiting list where appropriate
- Referrals for ineligible people where appropriate
- Actions when service users do not respond to a scheduled visit
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 2.1: Service Access | Not met | Met |
Expected Outcome 2.2: Assessment
Each service user participates in an assessment appropriate to the complexity of their needs and with consideration of their cultural and linguistic diversity.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Assessment tools that reflect the individual needs of the service user and the requirements of the funding programs/guidelines
- Assessments that clearly identify the care needs of service users and the needs of carer(s) where required, including the need for specialised assessments or referral to other services
- Service users and/or their representatives, where required, actively participating in the assessment process and being informed of the outcome in a timely manner
- Assessments taking account of and considering relevant information obtained from other current comprehensive assessments of the service user by other service providers or agencies
- Consideration of special-needs groups
- Staff conducting assessments having the necessary skills and competence
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 2.2: Assessment | Not met | Met |
Expected Outcome 2.3: Care Plan Development and Delivery
Each service user and/or their representative, participates in the development of a care/service plan that is based on assessed needs and is provided with the care and/or services described in their plan.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Care/service planning reflects the needs of service users and the requirements of the funding programs/guidelines
- Care/service plans are developed in partnership with the service user and/or their representative and are based on assessed needs and service user preferences
- Service users are informed about their care/service plans
- Care/service planning:
Is goal oriented and/or outcomes based (goals should be observable and measurable where possible) - Recognises and addresses the requirements of service users with complex care needs
Promotes functional and social independence and quality of life - Consideration of special-needs groups
- Service users are consulted with and provided with a service agreement or offer that includes:
The services that may be offered to meet the service user’s care needs, including agreed procedures to follow if the service user does not respond to a scheduled visit
The circumstances under which the type, duration or frequency of service delivery may be changed, refused, suspended or withdrawn - Staff conducting care plan development and delivery have the necessary skills and competence
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 2.3: Care Plan Development and Delivery | Not met | Met |
Expected Outcome 2.4: Service User Reassessment
Each service user’s needs are monitored and regularly reassessed taking into account any relevant program guidelines and in accordance with the complexity of the service user’s needs. Each service user’s’ care/service plans are reviewed in consultation with them.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Monitoring and regularly reassessing service users’ care needs, preferences, goals and outcomes
- Revising service user care/service plans as required
- Following the procedures for reassessment and care/service planning
- Making changes to service delivery in consultation with and explained to the service user and/or their representative
- Staff conducting service user reassessments having the necessary skills and competence
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 2.4: Service User Reassessment | Not met | Met |
Expected Outcome 2.5: Service User Referral
The service provider refers service users (and/or their representative) to other providers as appropriate.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Facilitation of referrals and participation in the coordination of care with other service providers and agencies
- Compliance with referral and coordination processes contained in relevant State/Territory and Commonwealth legislation, where applicable
- Consideration of the needs of service user’s representatives with referral to other service providers if needed
- Protocols between agencies to facilitate the referral of service users
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 2.5: Service User Referral | Not met | Met |
Standard 3: Service User Rights and Responsibilities
Each service user (and/or their representative) is provided with information to assist them to make service choices and has the right (and responsibility) to be consulted and respected. Service users (and/or their representative) have access to complaints and advocacy information and processes and their privacy and confidentiality and right to independence is respected.Expected Outcome 3.1: Information Provision
Each service user, or prospective service user, is provided with information (initially and on an ongoing basis) in a format appropriate to their needs to assist them to make service choices and gain an understanding of the services available to them and their rights and responsibilities.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- The service provider compiling, reviewing and updating service user information, giving consideration to service user needs and feedback and funding program requirements
- All service users and prospective service users being provided with information in formats appropriate to their needs throughout their contact with the service, including on first contact, during assessment, on service commencement, during reviews and on an ongoing basis, to ensure that the service user remains aware of their rights and responsibilities and has the opportunity to discuss the care and services they receive
- Consideration of special-needs groups
- Service users being consulted with and provided with a service agreement or offer that includes:
The services that could be offered to meet the service user’s care needs
The circumstances under which the type, duration or frequency of service delivery may be changed, refused, suspended or withdrawn - All service users being assisted to fully understand the information provided to them
- Staff/volunteers being aware of the information provided to service users and prospective service users
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 3.1: Information Provision | Not met | Met |
Expected Outcome 3.2: Privacy and Confidentiality
Each service user’s right to privacy, dignity and confidentiality is respected including in the collection, use and disclosure of personal information.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Compliance with State/Territory and Commonwealth legislation regarding:
Collection, use and disclosure of personal information
Service users’ rights to access their personal information - Each service user’s right to privacy, dignity and confidentiality being respected
- Consideration of special-needs groups
- Staff/volunteers being aware of and respecting service users’ rights to privacy
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 3.2: Privacy and Confidentiality | Not met | Met |
Expected Outcome 3.3: Complaints and Service User Feedback
Complaints and service user feedback are dealt with fairly, promptly, confidentially and without retribution.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Providing service users with information about the complaints and feedback processes
- Effective complaints management processes that include:
Enabling service users to complain if they wish to do so
Protection of service users’ rights
Recognition of service users with special needs
Roles and responsibilities of staff/volunteers
Timely responses
Provision of feedback about each complaint to the complainant and, where appropriate, to staff and/or volunteers
Assistance to service users to access external complaints process
A complaints form - Inclusion in the complaints process of all negative feedback from service users and inclusion in feedback processes of all positive feedback
- Ensuring complaints are dealt with without retribution to the complainant
- Ensuring service users (or their representatives) and staff/volunteers are aware of the complaints process
- Effectively recording, monitoring, collating and analysing complaints to identify trends
- Reporting complaints to board and/or management committee and/or senior executives on a regular basis, informing them of action taken in response to complaints including changes/modifications to service delivery
- Consideration of special-needs groups
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 3.3: Complaints and Service User Feedback | Not met | Met |
Expected Outcome 3.4: Advocacy
Each service user’s (and/or their representative’s) choice of advocate is respected by the service provider and the service provider will, if required, assist the service user (and/or their representative) to access an advocate.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Providing service users with information about their right to an advocate of their choice
- Providing assistance to service users to access and use an advocate
- Staff/volunteers understanding the role of advocates and being able to work with an advocate
- Consideration of special-needs groups
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 3.4: Advocacy | Not met | Met |
Expected Outcome 3.5: Independence
The independence of service users is supported, fostered and encouraged.Practices and Processes
Service providers will need to consider the following practices and processes in preparing their responses to the self-assessment questions below:- Individualised assessment of service users including an assessment of their physical (including mobility and dexterity), social and psychosocial independence (including decision making), focusing on the service user’s strengths and abilities
- Provision of support in daily living activities that aims to consolidate and, where possible, improve the service user’s existing capacity for independent living rather than building dependencies
- Encouragement of and support for service users to seek support (when required) from family, community groups and others to foster their independence and inclusion in their community
- Consideration of special-needs groups
- Documented policies and procedures for these practices and processes.
Self-assessment Questions
What practices and processes do you have in place to meet this expected outcome?| Self-assessment against EO 3.5: Independence | Not met | Met |