Human Services Assignment

Human Services Standards: NDIS service provider self-assessment report and quality improvement
plan
Service provide: Solomon Fraternity
Main site address: Jane Avenue
Additional sites:
Additional sites:
Contact name: Jerome Kamara
Position: Manager
Due date:
Date submitted:
Submitted to:
Declaration: In providing this self-assessment I:
 declare that this information is true and correct
 agree to provide required supporting information to
demonstrate compliance with the standards if requested
by the department
Signature:
Name and position:
Standards indicators, evidence and actions for quality improvement plan
Standards 1: Empowerment
Criteria 1.1 People understand their rights and responsibilities
Common evidence indicators
 The relevant charters of right are displayed and provided in an accessible format that
facilitates understanding by all people.
 Rights and responsibilities are developed and provided in an accessible format that
facilitates by all people.
 Information is provided in an accessible format about: the quality of service they can
expect to receive from the service provider; their right to an advocate including how to
access one; their right to privacy and dignity; the process for accessing their records;
feedback processes; complaints, appeals and allegations processes; the extent of their
rights; their right to be free from abuse, neglect, violence and preventable injury.
 People’s understanding of their rights and responsibilities is confirmed.
Documents: Equal Employment Opportunity Act 2010, The Victorian Charter of Human Rights and

Responsibilities Act 2006, United Nations Convention on the Rights of the Child ( UNCRC), United
Nations Declaration on the Rights of Indigenous People, Victorian Government Aboriginal
Inclusion Framework, Child Wellbeing and Safety Act, Department of Health and Human Services
policy and funding plan, Disability Act, Duty of Care, Housing Act, Occupational Health and Safety
Act 2004, The Family Violence Protection Act 2008, Working With Children Act, Information
Privacy Act 2006, Department of Health and Human Services Privacy Policy,
Knowledge and awareness:
A staff, volunteers and carers need to understand the rights and responsibilities of all people as
well as records. Information from rights charters identifies these rights and programs for accurate
information. Having knowledge of the service location is also important for accessibility.
Community leaders have the responsibility of informing the community about these rights and
providing support through training and inductions
Evaluation and monitoring:
Regular reviews on the quality allow people to check the quality of the services. Record checklists
also indicate that the people have accessed and use files and data systems on their rights. Proper
feedback mechanisms provide proof of the people’s understanding and thoughts on the
programs. This shows gaps on how staff, volunteers and service providers can offer quality
support. Process reviews also show people’s involvement and service plans.
SELF-ASSESSMENT RATING: MET/PART MET/NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Solomon fraternity will conduct self-assessment in the following ways.
 Use team meetings effectively for reflecting on practice. Notify everyone before the
meeting about the topic to be discussed so that they can think about it beforehand and
come prepared to contribute. ƒ
 Place reflective practice high on the agenda so that housekeeping matters don’t take
priority over the time available. ƒ
 Use a ‘talking stick’ or toy microphone to hand around so that everyone has the
opportunity to contribute. ƒ
 Encourage everyone to be open to new ideas. ƒ
 Identify changes to be implemented. ƒ
 Identify a date to review the outcome of the changes.
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
Solomon fraternity encourages families to be part of the self-assessment process and it is
respectful to keep everyone informed about how the service is progressing in working towards
achieving the identified goals. It is the bound of Solomon fraternity as a service provider to review
and revise the services its offer to its clients. Solomon fraternity want to rate itself assessment to
be met.
Standard 1: Empowerment
Criteria 1.2 People exercise their rights and responsibilities
Common evidence indicators
 The service provider can demonstrate how the relevant charter of rights is promoted and
enacted in practice throughout the service.

 People are supported in their choice to use an advocate
 People are satisfied with the supports they are provided around exercising their rights and
responsibilities.
 People know what to do if their rights are violated.
 People are satisfied with the quality of the service they receive.
 People are satisfied that their privacy and dignity are maintained.
 The complaints, appeals and feedback systems can be easily accessed by all people.
 People are satisfied with the management of review and appeals.
 Processes are in place to respond to allegations of misconduct/abuse in ways that ensure
people are protected from future harm.
 The service provider demonstrates that: where a person’s disability or behaviour requires
some restriction of theirs rights, the least restrictive alternative is applied only when
necessary and for as little time as possible; strategies are in place to empower and provide
appropriate support for each person who has some restriction placed on their rights;
strategies are in place to regularly monitor and review all interventions that restrict rights.
Documents:
Documents, which have response to racism and restriction to rights and documents on
discrimination, cultural abuse and support services, provide information for service providers.
These are necessary for restrictive practices such as children and youth as well as family plans.
Other documents include cover issues such as abuse in support services. Through documented
processes, it provides reference to interventions and behavioural factors.
Knowledge and awareness
Service providers need to be knowledgeable about the rights of people in all types of services.
Awareness facilitates for smooth procedures during formal complaints on violation of rights.
Proper information directs on how to respond to misconduct issues, mere allegations and abuse.
Restrictive measures are important for decision-making. Training records ensure that the carers,
volunteers and staff are aware and equipped with knowledge about the practices.
Evaluation and monitoring
Mentoring and evaluation supports effective implementation of rights and responsibilities. It
shows that the reports and registers have information of real cases and that there is the use of the
right response mechanisms. This is also a check on the effectiveness of the feedback systems and
support services, and the adherence to rights and responsibilities. All services need quality
maintenance and effective management. An analysis of the complaints and appeals ensures that
there is respect for people’s dignity and privacy. In cases where the evaluation is incomplete or
unsatisfactory, feedback on proper measures becomes necessary.
SELF-ASSESSMENT RATING: MET/PART MET/NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
Standard 2: Access and Engagement
Criteria 2.1 Services have a clear and accessible point of contact
Common evidence indicators
 The service environment is safe and encourages people to make initial contact with the
service, and participate in the longer term where applicable.

 Services are physically accessible to people and provide a flexible response to enhance
accessibility where possible.
 Service-delivery hours are responsive to the needs of people accessing the service.
 The service environment uses resources and symbols that are responsive to people’s
needs, cultural and/or Aboriginal and Torres Strait Islander background, disability, age or
developmental stage.
 The service provider identifies service accessibility issues and uses a range of strategies to
address these.
Documents
Important documentation processes describe the demographic data and other important
information related to it. Data collected includes information on people’s feedback, location of
the service delivery and hours of access, barriers to service and the unfulfilled needs.
The planning documents show related aspects such as amenities and cultural background and
demographic data. This could be background of the Aboriginal or Torres Strait Islander
background.
Important information also includes feedback related, service locations, types of services, hours
and access factors.
Knowledge and awareness
Having awareness on service access and planning is important for staff, volunteers, carers and all
stakeholders. Showing evidence of these demonstrates competence and ability to provide support
and advice in service planning.
Evaluation and monitoring
Evaluation includes monitoring the use of data for planning in location of service delivery location
and the types of services as well as the hours of access. It highlights the feedback mechanisms and
data on the number of people accessing the service, level of support that they receive and
awareness of service access. This process identifies the unmet needs
Documented Processes require regular reviews of the extent of people’s involvement, service
providers and stakeholders. It points at the links to the service delivery and planning as well as the
effectiveness of the feedback on stakeholder’s use of the service.
SELF-ASSESSMENT RATING: MET/PART MET/ NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
Standard 2 Access and Engagement
Criteria 2.2 Services are delivered in a fair, equitable and transparent manner.
Common evidence indicators
 Priority to access for services is based on relative need, available resources and
considers the best interests of people including children.

 Information is provided to all people in an accessible format that facilitates
understanding regarding: entry and exit rules; criteria to determine priority for service;
conditions that may apply to services being provided; any fees or costs, as applicable.
 Policies and processes are in place which document: screening and eligibility; priority of
access; waiting list management.
 Data and feedback mechanism are in place to identify and address barriers to access.
 The service utilises active engagement strategies.
Documents
It describes documents on eligibility assessment for non-discriminatory based approaches for
children, service procedures, client needs and risks. It identifies priority areas, management
strategies, service allocation, termination of service, its feedback mechanism, people engagement
and the changing needs of different people.
Documentation of feedback gives details on service access barriers. It also identifies the
operational hours, the rules of exit and entry, service priority areas, conditions for application,
costs and appeals.
Knowledge and awareness
It requires a demonstration of knowledge in the assessment process of the eligibility in service
access, prioritisation process, management of the waiting list, costs, rejection of service,
termination and costs. An understanding of active engagement strategies and evidence of the
service provider’s involvement and the strategies used are important.
Evaluation and monitoring
All service types need to align with the documentation processes used for service requests,
referrals, screening, prioritization, eligibility and waiting list. It shows the accuracy applied in
reasons for refusal to offer services or service termination.
It ensures that the feedback mechanism analyses the effectiveness of the service delivery through
the people’s feedback. This shows whether the services are satisfactory or not.
Monitoring a wide range of data regularly identifies any trends and barriers for effectiveness in
performance. It also checks the eligibility criteria and user profile for any gaps. Such records point
out the challenges in service access and strategies for addressing the gaps. Such regular reviews
provides an explanation on the process and the people’s involvement. It also shows links to the
service planning delivery and the people’s feedback through regular checks on staff, carers,
volunteers and stakeholders.
SELF-ASSESSMEN RATING: MET/PART MET/NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
Standard 2: Access and Engagement
Criteria 2.3 People access services most appropriate to their needs through timely, responsive,
service integration and referral.
Common evidence indicators

 The service provider demonstrates responsiveness to referrals and requests for
services.
 The service provider works collaboratively to manage demand.
 The service provider is a visible and active participant in a referral network, with people
referred to a range of universal and secondary/specialist services using clear referral
pathways.
 The service provider establishes and maintains coordinated service pathways with
relevant funded organisations, including Aboriginal and Torres Strait Islander and
culturally and linguistically diverse funded organisations.
 The service has documented systems to guide staff in providing information, advice and
referral to other services.
 In situations where the service provider is unable to provide a service, the person is
provided with information in accessible formats about alternative services; a referral to
other services.
 People are satisfied with the management of their referrals and the integration of their
services
Documents
Documented processes show:
 Response requests for services or their referrals
 Alternative services
 Shared information
 Level of the user’s understanding of information sharing
 Children’s needs, the vulnerable and high risk persons
 Alternative services in simplified information
 Network systems and various coordinated services such as Aboriginal and Torres Strait
Islander
Information on:
 Alternative services
 Referral processes
 Feedback mechanisms
Records on
 Network referral patterns
 Coordinated pathways
 Meetings, peoples involvement and referral network participation
Documents supporting various services for the homeless, children, youth and family.
Knowledge and awareness
Evidence of service providers having an understanding of:
 the target timeframes like receipt of referrals and service requests
 extra information like referrals to other services not within the system
 vulnerable person’s needs ( e.g. children and culturally alienated groups)
 referral procedures
Records on services for the homeless, Child and Family Service Alliance
Evaluation and monitoring
Incoming and outgoing service responsiveness ( capturing processes like service-delivery, referral-
assessment)
Regular reviews of information on:
 alternative services
 effective feedback systems for satisfactory referral management and service integration

networks
 participation in referrals
 Documented processes for people’s involvement, service providers, stakeholders and the
people’s feedback on the service providers.
Monitoring of services for homeless people from family violence and training needs for service
providers such as volunteers, staff, carers, and stakeholders
Evaluation of services for children, youth and family services including participation in Child and
Family Service Alliance
SELF-ASSESSMENT RATING: MET/PART MET/NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
Standard 3 Wellbeing
Criteria 3.1 Services adopt a strengths based and early intervention approach to service delivery
that enhances people’s wellbeing.
Common evidence indicators
 The service provider supports the person to identify their strengths and aims to build
on these capabilities.
 The service provider adopts active engagement and early intervention strategies.
 Policies and processes reflect early intervention, strengths based, holistic and
collaborative approach to service delivery. The service provider strengthens and
builds capacity with families, where appropriate.
Documents
Documentation of processes for:
 Active engagement and early intervention plans for family and other systems
 Strength based plans
 Holistic and integrated approaches
 Capacity building and improvement of families and carers
Documentation in homelessness services for:
 Case management frameworks
 Solution based practices
Knowledge and awareness
Demonstration of service provider knowledgeability in:
 Active engagement plus early intervention plans
 Strategic support for persons
 Strength based approaches

 Holistic and unified service delivery methods
 Capacity building for family and carers
Awareness of records on positions, training, supervisions and staff files
Knowledge of services for homelessness section with its staff records, management frameworks
and solution based practices.
Evaluation and monitoring
Evaluation of common services through:
 regular checks on staff competency through strength based, active engagement, early
intervention and capacity building methods
 regular monitoring of documented processes for linkage to practice
 trends in beneficiaries view of a service
Feedback mechanisms for people’s :
 mode of active engagement
 intervention strategies
constant reviews of documented processes show:
 people’s involvement ( including clients and service providers )
 service planning and delivery links
people’s feedback (in service, staff, volunteers, carers and stakeholders)
SELF-ASSESSMENT RATING: MET/PART MET/NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
Standard 3 Wellbeing
Criteria 3.2 People actively participate in an assessment of their strengths, risks, wants and needs.
Common evidence indicators
 People actively participate in an assessment of their strengths, risks, wants and needs.
 The service provider seeks information and the involvement of other key parties, as
appropriate, in order to better assess or understand a person’s situation.
 Policies and processes outline the scope of the required assessment.
 Where initial assessment indicates the need for immediate assistance, the service
provider supports the person to have those needs met.
 The service provider has effective systems in place to determine what resources or
services are required to meet the needs of the person.
 Assessment takes into account people’s age, ability gender, sexual identity, culture,
religion or spirituality.
 People are supported during assessments by an appropriate person who is sensitive to

and understands their cultural needs.
 People’s language and communication needs are identified and responded to. People
receive a copy of their assessment in a format that facilitates understanding.
Documents
Documents on the systems for conducting and assessing records on:
 Assessment scope
 Assessment timeframe ( for quick assessment)
 Active involvement of clients ( service users)
 Streamlined process and reduction of multiple assessments
 Individual choice of representation
 Rights to turn down a proposed action or activity
 Other key parties involved
 Personal data such as age, gender, sexual identity, culture
 Persons language and communication gaps or related strategies
 Important resources for meeting individuals needs such as communication aids
Assessment records of show that people have:
 Taken part in active participation in accordance to strength, risk, want or need
 Comprehend the assessment and have appropriate copies
The assessment scope is in line with the service requirements and client groups and involves basic
needs, risk or comprehensive assessments.
Document format depends on findings of the assessment with service, action or individual plans.
This documenting stage is followed by the issuance of a copy.
Knowledge and awareness
In all services, there is need for all services to show:
 Knowledge and awareness of the assessment systems used
 Staff and service providers’ training records in line with alternative communication
support and needs
Evaluation and monitoring
All services need:
 Regular monitoring to connect the documented process with the service practice through
client records
 Evidence of feedback mechanisms that involve clients or service beneficiaries
 Regular reviews to reflect on people’s involvement, service planning and delivery links and
people’s feedback
SELF-ASSESSMENT RATING: MET/PART MET/ NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan
STANDARD 3: Wellbeing
Criteria 3.3 All people have a goal oriented plan documented and implemented. This plan includes
strategies to achieve stated goals.

 People actively participate in all aspects of the planning process.
 Planning processes are guided by relevant legislation, departmental policies and sector
frameworks.
 The service provider demonstrates that the planning process is underpinned by the rights
of each person to exercise control over their lives.
 Where appropriate, the service provider actively engages family members, carers,
significant others and/or an independent advocate in the planning process.
 Planning takes into account people’s age ability, gender sexual identity, culture, religion or
spirituality.
 The service provider actively advocates for service options that best meet people’s needs.
 Planning takes into account the health and wellbeing issues of the person.
 People are supported during planning by an appropriate person who is sensitive to and
understands their cultural needs.
 People have a documented plan (s) that:
-reflects the strengths, needs goals, supports and long term outcomes specified by the
person
-describe how these goals will be achieved, including timelines
-documents actions to minimise risk in the least intrusive manner
-identify health and wellbeing needs, as appropriate
-includes input from family, carers and other service providers, as appropriate.
 People receive a copy of their plan and any revised plans in a format that facilitates
understanding.
Documents
All services use documented processes for individual planning on:
 Clients’ rights and independence
 People’s participation and representation in planning
 Involvement of other key parties
 Timeframe used in planning
 Client’s background, personal data, identity and orientation
 Client copies of the plan
Records on planning feature:
 Personal strengths, timeframes and goals
 Set goals and timeframe for achieving strategies
 Steps towards risk reduction
Knowledge and awareness
All services should demonstrates :
 Knowledge of planning systems by the staff and service providers
Evaluation and monitoring
All services need to evaluate:
 Their monitoring and implementation processes for monitoring, timelines and audits
through surveys and other mechanisms
 People’s response on services for satisfaction on the planning
 Evidence on support provided to the people for active participation, people’s level of
understanding on the planning process, and copies of their plans. They also require a plan on

people’s cultural needs
 Strengths, gaps, goals and support or long-term results for individuals]
 Ways of achieving the goals and stipulated timelines
 Risk reduction actions in minimal and restrictive forms
 Input from family and service providers
 Regular reviews of documentation, people’s involvement, service planning and delivery, as
well as feedback from people
Service specific indicators: Disability Services
 People access personal assistance, in home, residential or community supports to assist
them to live as independently as possible
 People are supported to identify, choose and manage their own daily and lifestyle routines.
Documents
Documentation for:
 Individualised planning and personalised support plans
 Service accessibility and easy assistance for home based, residential and community support
 Community and collective systems highlighting family, kinship, and community ties for the
personalised Aboriginal and Torres Strait Islander people
Knowledge and awareness
Staff and volunteers demonstration of knowledge in individual plans and support systems for
independent existence.
Evaluation and monitoring
 Individual plans and people’s ability to s identify, choose and elf-manage routines and
activities on a daily basis
 People’s satisfaction of choices made and details in personal plans
SELF- ASSESSMENT RATING:MET/PART MET/ NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
STANDARD 3: Wellbeing
Criteria 3.4 Each person’s assessments and plans are regularly reviewed evaluated and updated.
Exit/transition planning occurs as appropriate.
Common evidence indicators

 Each person’s assessments and plans are reviewed within set timeframes or to reflect
changing needs.
 People actively participate in the review and evaluation of assessments and plans
 Review and evaluation takes into account people’s age, ability, gender, sexual identity,
culture, religion or spirituality
 Review and evaluation takes into account people’s health and wellbeing needs.
 People are supported during review and evaluation by an appropriate person(s) who is
sensitive to and understands their cultural needs.
 The service provider supports people (or a nominated/appointed support person) to be
actively involved in monitoring and reviewing their plan.
 Plans are updated or renewed to reflect changing needs or goals and progress towards
stated goals.
 The service provider collaborates with other services to enhance exit/transition planning
to meet people’s needs.
 The service provider has documented processes for exit/transition planning and case
closure that involves the person or their nominated representative.
 People are satisfied with the support they receive to achieve their stated goals.
 People are informed of the steps necessary to re-access the service as required.
Documents
Documents describing regular reviews and updates of individuals plans in line with:
 Set timelines for reviews and monitoring
 Active participation by people
 Individual cultural, religious and spiritual needs; gender, age, sexual orientation and
identity
 Health, safety and wellbeing needs
 Persons cultural support base
 Partnerships with other service systems
Documentation processes for exit and transition planning and how to rea-access the services
Knowledge and awareness
Service providers understanding of system and regular reviews or updates for individual
assessments and plans
Evaluation and monitoring
Regular reviews and updates on assessments and plans featuring:
 Identification of needs arising
 Active participation, schedule for reviews and outcome plus provision of copies of revised
assessment/ plan
 Motivation of people to connect the right people for support in cultural needs
 Health, wellbeing and safety considerations
 Assurance of the implementation of conferences and co-meetings in line with
requirements
-Analysis of the level of satisfaction through reviews and feedback s for informed choices
-Monitoring review timeframes mechanisms and quality mechanisms using audits, and service-
user surveys
-regular review of documentation process for people’s involvement, service links to delivery and
planning, and feedback mechanisms for service providers
SELF-ASSESSMENT RATING:MET/PART MET NOT MET (delete as applicable)

Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
STANDARD 3: Wellbeing
Criteria 3.5 Services are provided in a safe environment for all people, free from abuse, neglect,
violence and/or preventable injury.
Common evidence indicators
 The service provider promotes an environment where people are free from abuse,
neglect, violence and preventable injury.
 The service provider has clearly documented polices and processes for responding to
potential or actual harm, abuse, neglect, violence and/or preventable injury.
 People are safe from abuse, neglect, violence and preventable injury, in service
environments.
Documents
Safety promotion documentation processes capturing, detection of potential risks, abuse, neglect,
violence and preventable injuries using processes in:
 Personal safety ( anti abuse, neglect, violence and preventable injury)
 Risk prevention
 People support ( those affected with abuse, neglect and potential risk)
 Behavioural management
 Occupational health and safety ( e.g. Incident, accident and hazard reports)
 Control of infection
 External compliance
 Manual handling
-Accessible formats of information on facilities, service providers and internal/external safe
environments. Includes training on rights and abuse prevention
-Document process describing systems on safety, peoples security, safety planning in family
reunions
Knowledge and awareness
-Evidence of service providers’ knowledge and awareness of duty, support needs and specific
references.
-Records of familiarity with:
 Signs of neglect and abuse
 Available support or abuse reports
 Specific risk factors faced by people
 Response mechanisms in a variety of cases e.g. emergency evacuation.

 Behavioural management tactics
 Processes for reporting and monitoring
 Safety and health controls
-Proof of documentation systems for violence affected persons, strategies to deal with them and
safety procedures
-service providers knowledge and awareness of risks such as abuse, violence and neglect.
-Understanding of the preventive measures and a conducive environment for the disabled.
Evaluation and monitoring
-Appropriate feedback mechanisms with data confirmation on how people:
 Receive and understand information from service providers
 Access and comprehend actual risks, negligence and timeframe responses
 Receive and understand services offered by the program
-Feedback mechanisms for service providers on service delivery approaches, reporting
mechanisms, actual risks and duty of care expectations
-recorded incidents of accidents and hazards
-constant reviews of the process documents and people’s involvement, service planning and
delivery, and feedback to caregivers
-
Service specific indicators: where out-of-home care, residential services, day programs, refuges,
crisis accommodation and/or respite services are provided
 The service provider ensures that the environments it provides are safe, hygienic and
clean, and includes, where relevant, access to:
-adequate common space as well as places where people can find privacy
-appropriate and well-maintained equipment and furniture
-adequate lighting and ventilation
-appropriate physical accessibility
-food that is varied, adequate in amount and based upon nutritionally-sound principles
-sustainable safe and nurturing home environments, which support the development and
stability of people
-processes for people to have input into decisions regarding daily life.
 The service provider implements documented procedures for
-maintenance of service environments, building and equipment
-infection control
-fire risk and other emergency management consistent with legislative and department
guidelines
Documents
Documentation f processes describing systems of safety, hygiene and cleanliness. These include:
 Fire and emergencies
 Safety and security
 Maintenance and management equipment, furniture, lighting and ventilation
 Physical accessibility
 Food safety and nutrition
 Chemical usage and storage
 Control of infection through cleaning
 Occupational health, safety and hazard reporting

-Regular monitoring records of internal and external environment systems, food safety ,
emergency and safety maintenance
-record of peoples involvement in independent life choices
Policy and procedure documentation in response to the risks within the service environment as
well as potential risks for other users
Knowledge and awareness
 Services needs to analyse their feedback mechanisms in order to confirm:
-People’s receipt of information and understanding levels for safe, hygienic and clean
environments.
-Effective access and comprehension of rights involved
Volunteers and staff need to grasp:
-ways of ensuring safety and clean environments
-people’s involvement in daily decisions
 Awareness of environment systems records for safety reviews and maintenance
 Up to date compilation of records for emergency fire and evacuation drills
 Regular reviews on documentation to show peoples involvement, service planning and
delivery as well as feedback mechanisms.
Evaluation and monitoring
Regular monitoring of service providers for:
 Knowledge and awareness
 Alignment of practices with documentation processes such as client audits
SELF-ASSESSMENT RATING: MET / PART MET/ NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
STANDARD 4: Participation
Criteria 4.1 People exercise choice and control in service delivery and life decisions.
Common evidence indicators
 People are satisfied with the choices they are provided, where possible, regarding the

services to be delivered.
 People are supported in decision making by their advocate and/or their appointed
representative, as appropriate.
 People’s right to dignity of risk is respected
 Service providers support people to access technology, aids, equipment and services that
increase and enhance their decision making and independence
 The service provider supports people to develop and maintain their personal, gender,
sexual, cultural, religious, and spiritual identity.
 The service provider:
-provides people with information, in a format that facilitates understanding, to enhance
informed decision making and choice
-involves family members and significant others (as appropriate) to assist with decisions
and choices.
Documents
Documented process describe processes within the Aboriginal People and how they exercise
choice and control in the service delivery plus decisions in life. These feature:
 Organizational statements like vision statement, strategic plan and equity
 Unified arrangements and services offered by Aboriginal community service organizers
 Details of cultural advocates and their involvement or availability
-Documents also focus on an integrated approach that is holistic for personal choices, decision
making and family involvement
-document approach to cultural support plans and cultural information for the Aboriginal People
in specific format as well as outline showing :
 Personal choices and the decision making process
 How to uphold cultural and spiritual identity
Knowledge and awareness
Service providers such as staff, volunteers and carers show grasp of :
 How to give support to Aboriginal people through informed choices, control of service
delivery and life decisions
 The significance of cultural and spiritual links for the Aboriginal people
 Information access for the Aboriginal and their spiritual and cultural identity elements
Evaluation and monitoring
Considerations for :
 Modes of feedback on Aboriginal peoples satisfaction in:
- decision-making and choices
-maintenance and strengthening of cultural and spiritual identity
 Feedback approaches and data on service providers comprehension of:
-partnership services in choice and decision making for the Aboriginal people and
processes shaping this
-information and resources necessary for the Aboriginal people
_assessment and planning data and its reflection on the partnership services for decision
making and planning for the Aboriginal people. ( records include information on family,
care teams meetings and consultation with the service community , elders and family
members)

SELF-ASSESSMENT RATING: MET / PART MET / NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
Sss
STANDARD 4: Participation
Criteria 4.2 People actively participate in their community by identifying goals and pursing
opportunities including those related to health, education, training and employment.
Common evidence indicators
 The service provider supports people to:
-identify and access community resources and facilities
-identify and overcome barriers that may prevent or restrict their participation in the
community
-participate in a range of education, recreation, leisure, cultural and community events
that reflect their interests and preferences
-participate in social roles in line with their interest and preferences
-access information about their community.
 People are satisfied with the support they receive to meet the goals they have set in
relation to community participation.
Documents
 Includes documented processes that support Aboriginal people in active community
participation in line with their preferences, cultural and interest affiliations. These
include:
-referral pathways or partnership service arrangements in collaboration with Aboriginal
services
-identification of challenges to active community participation for the Aboriginal and
strategies to mitigate them ( e.g. transport provision, transfers, staff attendants and
clients involved)
-Delivery of information in a cultural friendly format with an outline of varied services and
community support services
-Documents supporting community plans with goals and actions
Knowledge and awareness
 Service providers including volunteers need knowledge on Aboriginal services, community
and cultural events as well as their activities
 Staff knowledge and awareness of barriers hindering Aboriginal people in community

participation, and how to overcome the barriers by supporting them to pursue interests
 Records of assessment, community plans, goals and actions
Evaluation and monitoring
 Evidence of the Aboriginal people being supported to participate actively in community
 Evidence of service providers having knowledge of barriers and challenges preventing
Aboriginal people’s participation in community services and personal interests or
preferences
 Checks on assessment records and planning with participation goals and actions
 Regular monitoring of documented processes for the participation of Aboriginal people in
community activities including:
-participation and feedback by Aboriginal staff, clients, relevant organizations and elders
-feedback on service plans and service delivery featuring the Aboriginal people
Service specific indicator: Disability Services
 People are supported to move freely in their environments and communities, including
accessing public transport.
 People are supported to access a range of affordable housing options.
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
STANDARD 4: Participation
Criteria 4.3 People maintain connections with family and friends, as appropriate.
Common evidence indicators
 The service provider supports people to establish, maintain and enhance links with their
families, friends or other support networks, as appropriate.
 People are satisfied with support they receive to maintain connections.
Documents
Documented processes for supporting the Aboriginal people in reconnecting, maintenance and
strengthening their family and community links. It includes:
-referrals to the Link Up, and Koorie, Heritage Trusts Koorie Family History Service

-family and community involvement in planning and decision making
-Community elders involvement for support towards cultural links and participation
Knowledge and awareness
 Service providers show an understanding of the systems used to support the Aboriginal
people to reconnect, keep and strengthen family larger community ties
 Service providers show service awareness of the Link Up Victoria and Koorie Heritage
Trust and ways they can refer Aboriginal people for services
Evaluation and monitoring
 Records for assessment and planning for proof that Aboriginal people obtain support to
connect, maintain and strengthen social ties from family, extended community and
friends through goals and strategies
 Feedback systems showing Aboriginal people’s access to services for reconnecting,
maintenance and strengthening of ties and connections
 Documented process reviews for stronger ties and connections of the Aboriginal people
through:
-staff, client, organizational and community elders involvement and their feedback
-inbuilt feedback from service planning and delivery with the Aboriginal People
SELF-ASSESSMENT RATING: MET / PART MET/ NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
STANDARD 4.4
Criteria 4.4 People maintain and strengthen connection to their Aboriginal and Torres Strait
Islander culture and community.
Common evidence indicators
 The service provider provides culturally competent services which respect a person’s
Aboriginal and Torres Strait Islander cultural identity.
 The service provider maintains appropriate community linkages and collaborates with
Aboriginal services to meet the cultural needs of Aboriginal and Torres Strait Islander
people.
 Assessment, planning and actions promote cultural safety and connectedness and respect

the cultural and spiritual identity of Aboriginal and Torres Islander people.
Documents
 Documented process describing system that have:
-Service provider strategies to support service access for the Aboriginal and Torres Strait
Islander
-Cultural competencies for service delivery
-people support to and assessments of related individual cases and plan in line within the
needs of the Aboriginal and Torres Strait Islander people
-ideal community links and conjoined services offering Aboriginal services ( e.g.
memorandums)
Knowledge and awareness
 Having understanding that the processes are in order for stakeholder training for
competent services
 Board member records and service provider training on strategies, strengthening and
cultural competencies for service delivery
 Understanding of strategies for strengthening cultural competency for Increased access to
services by Aboriginal and Torres Islander
Evaluation and monitoring
 Identification of service providers in active involvement with Aborigines and their services
e.g., events, referrals, partnerships, consortia, memorandums etc.
 Regular review of:
-service access as well as support plans for the Aboriginal people
-service involvement and the links to services
-management of cases and individuals in line with the documented processes for service
inclusion and other needs
-Feedback from the Aboriginal service providers and non-Aboriginal carers in service
competencies
 Knowledge and comprehension of board members and service providers for regular
monitoring systems
 Feedback and service provider response to provider links
 Regular review of documented procedures showing:
-people’s involvement in the service
-service links to planning and delivery
-feedback to clients
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.

STANDARD 4: Participation
Criteria 4.5 People maintain and strengthen their cultural, spiritual and language connections.
Common evidence indicators
 The service provider provides culturally competent services which respect a person’s
culturally and linguistically diverse identity.
 The service provider maintains appropriate community linkages and collaborates to meet
the cultural, spiritual and language needs of people.
 Interpreters are used, as required, to support more effective communication.
 People with culturally and linguistically diverse backgrounds are assisted to maintain their
cultural identity and connection to community.
Documents
 Documentation of processes describing maintenance and strengthening systems in
cultural, spiritual and language aspects
 Documentation of processes to highlight service access and interpretation
 Accessibility of information for individuals in a culturally competent service

Knowledge and awareness
Service providers show understanding of:
-cultural and language diversity
-interpreter services
-community links and specific cultural services
Evaluation and monitoring
Regular reviews of:
 Cultural; services and links to involvement ( e. g meetings and forums)
 Case and individual assessments and plans for cultural specific strategies and goals
 Peoples feedback and other cultural services
Identification of records for active services and involvement with links and partner networks ( e.g.
referrals, and consortia)
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.

STANDARD 4: Participation
Criteria 4.6 People develop sustain and strengthen independent life skills.
Common evidence indicators
 People are supported to develop and maintain independence, problem solving, social and
self-care skills appropriate to their age, developmental stage and cultural circumstances.
Documents
 Documented processes for support systems in social development, maintenance,
independence and problem solving. Individual case management and people engagement
strategies ( e.g., education leisure, events )

Knowledge and awareness
 All service providers need knowledge of :
-support systems for problem solving, self-care, social development, skills development and
cultural needs.
-appropriate records ( e g plans and assessments )
 Staff participation in training, people support for people support in maintenance and
strengthening of independence, social, problem solving and self-care skills
Evaluation and monitoring
 Records for assessment and planning records prove people support in development and
maintenance of independence, skills and wide range of goals and age, cultural,
development strategies like in 4.5
 Regular reviews of:
-personal and case management in line with the processed documents
-peoples feedback for satisfactory service, support, maintenance, independence, problem
solving and self-care
 Regular review of documentation for:
-people’s involvement ( staff, carers, volunteers, stakeholders)
-service links for planning and delivery
-feedback from people service users
Service specific indicator: Disability Services
 People exercise control over their finances.
Documents
Documents describing systems for appropriate life and self-care skills for young people and
placement support
Knowledge and awareness
Service providers directly involved in the service demonstrate knowledge of:
 -appropriate life and self-care skills for young people
 -records in maintenance and assessment plans
Awareness of records for staff ad service provider training, induction, etc.

Evaluation and monitoring
 Regular monitoring of service providers with life and self-care skills
 Review of record data like plans and feedback for satisfactory service plans
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
GOVERNANCE AND MANAGEMENT
Criteria The service provider maintains and improves its governance and management processes
to deliver high quality human services
Common evidence indicators
 The service provider’s governance and management processes are effective and
transparent and there are clear management and staff accountabilities.
 The service provider’s strategic and annual planning informs the delivery of services to
improve outcomes for people accessing services.
 The service provider effectively meets its legal obligations and contract management
requirements.
 The service provider works actively with its clients, service partners and other external
stakeholders to improve the quality of its services.
 The governing body process the skills, knowledge and experience required to fulfil their
role.
 The service provider has robust financial management systems in place.
 The service provider has robust legislative compliance systems in place.
 The service provider has a continuous quality improvement system in place.
Documents
Documents on people support to enable clients choose control mechanisms for administrative
and personal finances
Knowledge and awareness
Service providers need an understanding of systems used to help people manage their finances

Evaluation and monitoring
 Review of feedback from people and response on financial management
 Records of ideal financial control used by people
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET / (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
RISK MANAGEMENT
Criteria The service provider’s effective risk management policies and processes manage client
issues, human resources and the sustainability of services.
Common evidence indicators
 The service provider has an effective risk management plan that meets policy
requirements.
 The service provider complies with relevant accountancy standards.
 The service provider has an active occupational health and safety policy and process.
 The service provider’s insurance policies are maintained.
Documents
Knowledge and awareness
Evaluation and monitoring
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET / (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan

Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
HUMAN RESOURCES
Criteria The service provider manages human resources to ensure that appropriately skilled and
trained staff, carers and volunteers are available to safely provide services to clients
Common evidence indicators
 The service provider’s recruitment processes ensure that staffs, carers and volunteers
provide safe and high quality services to people accessing services.
 The service provider has a thorough process for pre-employment criminal history checks
and the screening and registration of carers.
 The service provider’s recruitment, supervision, training and development processes
support staff, carers and volunteers to address the needs of people using services,
including Aboriginal people and culturally and linguistically diverse people, in order to
improve service quality.
Documents
The documents approach includes policies, procedures and specific work protocol. Use of written
material such as brochures, photographs and newsletters and memorandums are essential. Digital
documents like emails and files used for staff records and information are also available.
Knowledge and awareness
Knowledge of service provider categories and the documented processes are helpful for members
and service providers. Important documents cover:
 Training records and procedures
 Meeting agendas
 Manuals and memos or guides
Service providers also need knowledge of:
 Information provided
 Interpreters
 Different language formats
Evaluation and monitoring
Demonstration of knowledge on organizations approach to quality improvement and evidence of
systems and processes. These show the implementation of :
 Complaints/incidents
 Reports( financial, periodic, audit0
 Feedback mechanisms for focus groups, surveys and client or staff complaints
 Audit files

 Benchmarking
 Quality plans
 Risk management plans
 Minutes of meetings
 Observations
 Interviews

SELF-ASSESSMENT RATING: MET / PART MET / NOT MET / (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
INFORMATION MANAGEMENT
Criteria The service provider has effective information systems to sensitively managed client
information, improve services and meet the needs of the broader community.
Common evidence indicators
 The service provider sensitively manages client information and maintains client privacy
and confidentiality.
 Client information is retained and disposed of appropriately and sensitively.
 Information is provided to clients in ways that are accessible to clients seeking
information.
 The service provider has an effective information management system in place which is
easily accessible to staff to support planning and service delivery.
Documents
Knowledge and awareness
Evaluation and monitoring
SELF-ASSESSMENT RATING: MET / PART MET / NOT MET / (delete as applicable)
Action required to meet the criteria: Must be transcribed to quality improvement plan

Action to support continuous quality improvement: Must be transcribed to quality improvement
plan.
ASSESSMENT MATRIX –Human Services Standards
Place a tick ( ) in the appropriate box: Met Part Met Not Met
Standards 1: Empowerment
1.1 People understand their rights and responsibilities.
1.2 People exercise their rights and responsibilities.
Standard 2: Access and Engagement
2.1 Services have a clear and accessible point of contact
2.2 Services are delivered in a fair, equitable and transparent
manner.
2.3 People access services most appropriate to their needs through
timely, responsive, service integration and referral.
Standard 3: Wellbeing
3.1 Services adopt a strengths based and early intervention
approach to service delivery that enhances people’s well-being
3.2 People actively participate in an assessment of their strengths,
risks, wants and needs.
3.3 All people have a goal oriented plan documented and
implemented. This plan includes strategies to achieve stated goals.
3.4 Each person’s assessments and plan are regularly reviewed,
evaluated and updated. Exit/transition planning occurs as
appropriate.
3.5 Services are provided in a safe environment for all people, free
from abuse, neglect, violence and/or preventable injury.
Standard 4: Participation
4.1 People exercise choice and control in service delivery and life
decisions.
4.2 People actively participate in their community by identifying
goals and pursuing opportunities including those related to health,
education, training and employment.
4.3 People maintain connections with family and friends, as
appropriate.
4.4 People maintain and strengthen connection to their Aboriginal
and Torres Strait Islander culture and community.
4.5 People maintain and strengthen their cultural, spiritual and
language connections.
4.6 People develop, sustain and strengthen independent life skills.

ASSESSMENT MATRIX –Governance and Management
CRITERIA
Place a tick Met Part Met Not
Applicable
Governance and Management
The service provider maintains and improves
its governance and management processes
to deliver high quality human services.
Risk management
The service provider’s effective risk
management policies and processes manage
client issues, human resources and the
sustainability of services.
Human resources
The service provider manages human
resources to ensure that appropriately skilled
and trained staff, carers and volunteers are
available to safely provide services to clients.
Information management
The service provider has effective
information systems to sensitively manage
client information, improve services and
meet the needs of the broader community.

Quality improvement plan
Criteria Planned action Who is
responsible
Due date Outcome/review
Date
complete
Action required to meet the criteria
Optional areas for improvement
Self-assessment checklist

Please ensure you have completed the following information before submitting your self-
assessment to the Standards and Regulation Unit.
Your service provide details
The assessment matrix
Your evidence examples for each criteria
Self-assessment findings for each criteria
A self-assessment rating for each applicable criteria
The quality improvement plan’ Actions required to meet the criteria’ where
you have rated an expected outcome as part met or not met. (Transcribed
from applicable standard/s).
The quality improvement plan ‘Optional action to support continuous quality
improvement’ where you have rated an expected outcome as Met, but
indentified improvement opportunities. (Transcribed from applicable
standard/s).
Previous quality improvement plan submitted showing progress and actions
completed
Client file audit completed and results submitted
Staff, volunteer and carer file audit completed and results submitted