7.1 An object of the DSA is to ensure the provision of services that:

1. further the integration of persons with disabilities in the community and complement services available generally to such persons in the community,

2. enable persons with disabilities to achieve positive outcomes, such as increased independence, employment opportunities and integration in the community, and

3. are provided in ways that promote in the community a positive image of persons with disabilities and enhance their self-esteem.¹

CURRENT QUALITY ASSURANCE PROCESS

7.2 The principles in Schedule 1 to the DSA set out the rights and expectations people with a disability have in relation to services, and how those rights should be applied to disability services and programs.³ Every three years at least, the Minister must ensure that a review is conducted of the extent to which:

• each eligible organisation that has received financial assistance to provide services has complied with the terms and conditions on which the assistance was given; and
• the outcomes required by those terms and conditions have been achieved by people receiving the services.⁴

7.3 The Standards have been formulated by ADD to monitor compliance by services with the provisions of the DSA. They do not have the force of law, however, adherence to the Standards is a condition of service funding. They are intended as a guide to assist service providers to meet the objects, principles and applications of principles. The Standards comprise the following ten principles:

1. Each service user seeking a service has access to that service on the basis of relative need and available resources.

2. Each person with a disability receives a service which is designed to meet his or her individual needs in the least restrictive way.

3. Each person with a disability has the opportunity to participate as fully as possible in making decisions about the events and activities of his or her daily life in relation to the services he or she receives.

4. Each service user’s right to privacy, dignity and confidentiality in all aspects of his or her life is recognised and respected.

5. Each person with a disability is supported and encouraged to participate and be involved in the life of the community.

6. Each person with a disability has the opportunity to develop and maintain the skills required to participate in activities that enable him or her to achieve valued roles in the community.

7. Each service user is free to raise, and have resolved, any complaints and disputes he or she may have regarding the agency or the service.

8. Each agency adopts sound management practices which maximise outcomes for service users.

9. Each person with a disability receives a service which recognises the importance of preserving family relationships, informal social networks and is sensitive to cultural and linguistic environments.

10. Each agency ensures that the legal and human rights of people with a disability are upheld in relation to the prevention of sexual, physical and emotional abuse within the service.

7.4 All services must comply with the Standards as a condition of funding. The Standards have been recently supplemented by Standards in Action, which detail the practical steps that services should undertake to meet each Standard at a minimum and an enhanced level. Standards in Action also contains examples of good and bad service practice in relation to each Standard. ADD regards compliance with the Standards as constituting compliance with the objects, principles and applications of principles in the DSA.⁵

Self-assessment and surveys

7.5 The primary method used by ADD to monitor compliance with the Standards is annual self-assessment by services. The purpose of self-assessment is to ensure that services are achieving the outcomes detailed in their performance agreements (which are attached to their funding agreement) or their transition plans. Self-assessment is also intended to foster continuous quality improvement by evaluating a conforming service’s ongoing performance against the Standards. After completing the self-assessment, services are required to identify steps to improve the quality of their service.

7.6 ADD also surveys service users, who return their responses directly to ADD. If the surveys identify critical issues, such as health and safety breaches or allegations of abuse, ADD will contact the service provider immediately and monitor the service to ensure that appropriate action is taken. Other major issues identified in the surveys by service users must be included in the service’s action plan.⁶

Monitoring

7.7 ADD does not have a regular or systematic process for checking the accuracy of self-assessments prepared by services. Review of a service generally occurs only when ADD receives a complaint,⁷ or where specific issues of concern regarding a service have been identified. The Service Review and Support program within ADD investigates services where there are identified issues of concern. Where these concerns are significant, the service will be registered. A service under investigation will be required to implement an action plan that addresses deficiencies in service quality, and will be monitored until all outcomes in the action plan have been achieved. ADD is still developing these mechanisms. As ADD has limited resources for this program, it is targeted at non-government services, and does not apply to DOCS services.⁸ In addition, ADD proposes to have 45 Service Support and Development Officers each make scheduled visits to between 40 and 60 services over a 12 month period. Community Visitors attached to the CSC also visit services to monitor the well-being of service users.⁹

SUBMISSIONS CRITICAL OF QUALITY ASSESSMENT PROCESS

Standards are weaker than legislative requirements

7.8 Consultations conducted by the Disability Council of NSW revealed that the Standards, which were originally intended as a guide for implementing the objects, principles and applications of principles, have replaced them as the benchmarks for service provision.¹⁰ In submissions and consultations, people indicated concern that such a reliance on the Standards may not be appropriate, as they are not necessarily an accurate measure of compliance with the DSA, or indicative of quality service provision.¹¹ NCOSS reported widespread dissatisfaction with the Standards.¹² Submissions stated that the Standards did not reflect the principles and applications of principles,¹³ and were not clearly drawn from the DSA itself.¹⁴ It was argued that the Standards were weaker than the principles and applications of principles,¹⁵ with too much emphasis placed on written policies and procedures and not enough on the implementation of the principles.¹⁶ As a result, submissions considered that compliance with the Standards does not equate with achieving the outcomes sought by the objects, principles and applications of principles under the DSA.¹⁷

Standards reduce flexibility in service provision

7.9 Service providers argued that the Standards were too inflexible and only relevant to particular types of services,¹⁸ and particular kinds of needs.¹⁹ It was also considered that the Standards may conflict with occupational health and safety requirements.²⁰ Service providers were particularly concerned that the increasingly prescriptive Standards and Standards in Action had resulted in less diversity in service provision. It was argued that:

[the sector was] less diverse than it was, that it has fewer “different” models and there is less experimentation and preparedness to try out other options than there was in the 1980s … [O]rganisations wanted to be able to try out ideas, to be able to submit applications for funding to trial pilot programmes and to be able to connect with like-minded organisations to work on cross-organisational approaches. The current environment mitigates against this, and there was a general despair about anything really changing.²¹

Standards that are more and more prescriptive weaken the intent of the legislation by failing to recognise the different types of disability and different models of services delivery. This creates a mindset in the bureaucracy of what people with a disability are … and what community living is (ie, group home) which is then perpetuated through policy and planning decisions.²²

Self-assessment criticised

7.11 Submissions were critical of the assessment process used to monitor quality in service provision. They argued that a self-assessment process that involves ticking boxes is not an effective way to ensure that services meet the Standards or protect the rights of people with a disability.²⁵ Service providers noted that self-assessment was increasingly prescriptive and intrusive.²⁶

Monitoring and enforcement inadequate

7.12 The CSC stated that it had “consistently found that inadequate external monitoring and review mechanisms are a key contributing factor where services have failed to provide appropriate, or even safe services to people with a disability”.

It expressed concern that:

• performance agreements used by DOCS and ADD have not provided an adequate basis for imposing duties on service providers;
• powers of the funding body to take action when there are concerns about service quality are not satisfactory;
• service providers have been able to breach funding agreements without the funding body identifying or acting to correct the breach;
• there is no system for ADD to monitor performance and quality of disability services provided by DOCS; and
• valuable information about service quality is not collected or used by the funding body.²⁷

7.13 Consultations revealed extensive support for a new approach to achieve compliance with the objects, principles and applications of principles. Submissions, and people consulted by the Disability Council of NSW, advocated a return to the objects, principles and applications of principles as the benchmark for measuring quality and assessing whether transition plans and new services conform with the DSA.²⁸ It was argued that the approach must be less prescriptive and more flexible.²⁹

Suggested features of a new process

7.14 Service providers were of the view that industry expertise and knowledge, including experience in specialist service provision, is not valued. Service providers argued that they could contribute to discussions about what constitutes quality service provision, suggesting that the industry should develop its own measures of quality outcomes to feed into a quality assurance and accreditation process.³⁰ There was support for a process that includes peer assessment³¹ which dealt with issues of particular concern to service providers, such as liability, duty of care and occupational health and safety.³²

7.15 Submissions argued that there should be regular, active and independent monitoring of services to ensure compliance with the objects, principles and applications of principles.³³ That monitoring should have clear time frames and be transparent.³⁴ Submissions expressed the view that there should be a process of accreditation and continuous improvement,³⁵ which should also cover services operated by DOCS.³⁶

7.16 The CSC recommended that there should be base-line criteria below which no service should be funded or allowed to operate. The CSC was concerned that some non-conforming services, and in particular large institutions, were allowed to operate without any measures in place to protect even the basic safety and human rights of consumers. The CSC was of the view that the vagueness of the concept of “conforming as closely as possible” was a contributing factor in this.³⁷

THE COMMISSION’S VIEW

7.17 There is widespread community dissatisfaction with the Standards as a measure of quality. In contrast, there is consensus amongst individuals, consumer groups and service providers that the objects, principles and applications of principles remain valid and have a role to play in assessing service quality. Concerns were also expressed in submissions and consultations about the effectiveness of self-assessment by services against the Standards, and the need for independent review of service compliance with quality indicators, rather than review by ADD. The Commission considers many of these concerns to be valid, and recommends the establishment of a new independent mechanism to assess and monitor service quality.

A new quality assurance process

7.18 The key features of a new quality assurance process should be:

• the development of a revised set of Standards, based more closely on the objects, principles and applications of principles in the DSA, which focus on the outcomes to be achieved for people with disabilities;
• the establishment of an independent body to oversee and monitor the quality assurance process; and
• replacing the current self-assessment procedure with a more accountable system of peer review.

Establishment of a new quality assurance body

7.20 The current self-assessment process, and the quality monitoring by ADD, does not have the confidence of the disability services sector. The Commission is of the view that community support is essential if effective quality assurance is to be achieved. A more effective way of securing industry and consumer support is to develop a new quality assurance process with extensive input from all stakeholders in the disability sector. Greater confidence will also be achieved if quality monitoring is conducted independently of the service under review and the ADD. The Commission recommends the establishment of a new and independent body, based on the NCAC, to administer the quality assurance process, and to monitor quality. The Commission has referred to that body throughout this Report as the Disability Services Quality Assurance Council (“DisQAC”).

7.21 The functions of DisQAC should be developed in consultation with all stakeholders in the disability sector, including ADD. As a general guide, the functions could include:

• establishing the quality assurance scheme;
• assessing and certifying Stage 1 and Stage 2 transition services;³⁹
• assessing and certifying new services as conforming with the DSA;
• providing advice and support to services about quality service provision;
• monitoring whether services meet targets set in Stage 1 and Stage 2 transition plans;
• monitoring whether services are achieving continuous quality improvement;
• identifying and registering services of “concern”, where closer monitoring may be necessary;⁴⁰
• notifying the Minister if a service fails to comply with the requirements of the quality assurance process; and
• recommending to the Minister that sanctions be imposed on services that fail to comply with the objects, principles and applications of principles.

Standards should be redeveloped

7.23 In their current form, the Standards detail the manner in which the objects, principles and applications of principles should be implemented. The Commission is of the view that this may reduce flexibility and may stifle innovation. New standards are needed that focus on the outcomes for people with disabilities rather than the methodology used to achieve those outcomes. An effective quality assurance mechanism should take into account the fact that outcomes can, and should, be met in a number of different ways depending on the needs and wishes of the consumers and the type of service being provided. The new Standards should be developed by DisQAC in consultation with industry and consumer groups, and should reflect the spirit of the objects, principles and applications of principles more accurately than the current Standards.

Consumer involvement and peer review in assessing quality

7.24 As the Commission noted earlier, the major criticism during consultations and in submissions concerned the lack of independence and expertise in the quality assessment process. It was considered that internal assessment by the service and review by ADD was not sufficient to ensure quality service provision. The Commission is of the view that the self-assessment process should be made more accountable. While services should be required to demonstrate that they have achieved outcomes for consumers, those outcomes should be examined by an independent panel of consumers and service providers. Consumer and service provider input is vital if the assessment process is to involve “grass roots” expertise. Involving service providers in this type of peer review would also promote support for, and compliance with, the quality assessment process amongst service providers.

7.25 The panel would assess service outcomes against the revised Standards and the objects, principles and applications of principles, to determine whether the requisite level of quality was being achieved. If satisfied that a service was fulfilling its quality requirements, the panel would recommend to DisQAC that the service should be, or should continue to be, certified. DisQAC would assess the recommendation and make a decision as to certification.

Linking certification to funding

7.26 The Commission considers that the most effective way to enhance quality service provision is to link it to the recurrent and transition funding that services receive. The DSA should make this link clear by providing that the Minister may not approve funding to a disability service under the Act unless that service has been certified by DisQAC as meeting the necessary quality standards.⁴¹ This provision should apply to all services funded under the DSA, including DOCS services.

Period of certification

7.27 The NCAC may certify long day care centres for a period of one, two or three years, depending on the level of quality they are achieving. Services with the highest levels of quality provision are certified for three years, whilst those services which do not comply to the fullest extent with the Standards are assessed and certified every year or two. The Commission considers that such a system would be appropriate for disability services. DisQAC may choose to certify fully conforming services for longer periods than transition services. The details of the period for which services may be certified should be developed by DisQAC in consultation with industry and consumer groups.

Recommendation 26

The DSA should establish a new quality assurance mechanism.

As part of the new mechanism, the DSA should require the Minister for Disability Services to establish DisQAC as an independent body to oversee and monitor the quality assurance process, and certify disability services. The membership of DisQAC should comprise representatives of consumers and the service industry with recognised knowledge and expertise.

Recommendation 27

The functions of DisQAC should be developed in consultation with consumer and industry groups, but should include:

• establishing the new quality assurance scheme;
• assessing and certifying Stage 1 and Stage 2 transition services;
• assessing and certifying new services as conforming with the DSA;
• providing advice and support to services about quality service provision;
• monitoring whether services meet targets set in Stage 1 and Stage 2 transition plans;
• monitoring whether services are achieving continuous quality improvement;
• identifying and registering services of “concern”, where closer monitoring may be necessary;
• notifying the Minister if a service fails to comply with the requirements of the quality assurance process; and
• recommending to the Minister that sanctions be imposed on services that fail to comply with the objects, principles and applications of principles, the revised Standards (see Recommendation 28), or their transition plans.

Recommendation 28

The new quality assurance process should apply to all services funded or provided under the DSA, including DOCS services. The features of the new mechanism should be developed in consultation with consumer and industry groups, but should include:

• the introduction of a revised set of Standards, based more closely on the objects, principles and applications of principles in the DSA, which focus on the outcomes to be achieved for people with disabilities;
• replacing the current self-assessment procedure with a more accountable system of peer review; and
• independent monitoring and certification of services by DisQAC.

7.28 The DSA requires the Minister for Disability Services to review organisations funded under the Act at least every three years.⁴² The Commission is of the view that this requirement should remain. It should be additional to, and separate from, the quality assurance process. This provides ADD with the opportunity to review all aspects of the organisation’s operation. For example, it can consider financial issues, such as service viability, as well as service quality.

Recommendation 29

The requirement for three yearly review under section 15 of the DSA should remain.

1. DSA s 3(b).

2. DSA s 3(c).

3. See Ch 2.

4. DSA s 15.

5. Until recently, ADD had a detailed policy, in addition to the Standards, detailing what constitutes acceptable supported accommodation. The Accommodation Support Program – Policy and Guidelines (1996) provided that transition plans for supported accommodation must provide for community-based accommodation support services which:

• ·are based on use of a single family dwelling, or other regular community dwelling that is, a facility having the smallest residential grouping possible, with no more than six residents (maximum) in any one dwelling; and
• ·do not cluster or co-locate a number of houses, flats or units in the same street or in close proximity with one another.
The Minister revoked this policy on 8 October 1998.

7. A complaint may originate from a number of sources, for example, the Independent Commission Against Corruption, Community Visitors, service users, their families or advocates, ADD officers or the CSC.

8. NSW, CSC, The Lachlan Inquiry 1998: An Assessment of the Standard of Care at the Lachlan Residential Centre and of Progress Since the 1995 Investigation (1998) at Appendix III.

9. See Report 90 at Ch 4.

10. See Disability Council of NSW, Submission at 9.

11. DeafBlind Association NSW, Submission.

12. NCOSS, Submission.

13. See, for example, NCOSS, Submission; NSW Council for Intellectual Disability, Submission; and People with Disabilities (NSW) Inc, Submission.

14. Intellectual Disability Rights Service Inc, Submission.

15. See, for example, Deaf Blind Association, Submission; Institute for Family Advocacy and Leadership Development Association Inc, Submission; and Citizen Advocacy NSW, Submission.

16. Disability Council of NSW, Submission; and NCOSS, Submission.

17. The Spastic Centre of NSW, Submission.

18. NCOSS, Submission; and Kurrajong-Waratah Industries, Submission.

19. Centacare Sydney, Submission.

20. Paraquad NSW, Submission; and ACROD Ltd NSW Division, Submission at 5.

21. ACROD Ltd NSW Division, Submission at 4.

22. Paraquad NSW, Submission.

23. See the discussion of this policy at footnote to para 7.4.

24. NSW Government, Submission at 8.

25. NCOSS, Submission; Disability Safeguards Coalition, Submission; Physical Disability Council of NSW Inc, Submission; Ethnic Childcare, Family and Community Services Co-operative Ltd, Submission; CSC, Submission; and People with Disabilities (NSW) Inc, Submission.

26. ACROD Ltd NSW Division, Submission at 3.

27. CSC, Submission at 7-8.

28. See, for example, Disability Council of NSW, Submission at 9; Multicultural Disability Advocacy Association of NSW Inc, Submission; and Autism Association of NSW, Submission.

29. Paraquad NSW, Submission.

30. Consultation (Service providers, Sydney).

31. NCOSS, Submission.

32. The Spastic Centre of NSW, Submission at 8.

33. A Goges, Submission; CSC, Submission; B and D Dixon, Submission; People with Disabilities (NSW) Inc, Submission; Australian Quadriplegic Association Ltd (NSW), Submission; and NSW Statewide Disability Coalition, Submission.

34. Multicultural Disability Advocacy Association of NSW Inc, Submission.

35. CSC, Submission.

36. CSC, Submission at 8; Paraquad NSW, Submission at 2; and ACROD Ltd NSW Division, Submission.

37. CSC, Submission. The Commission makes recommendations concerning non-conforming services and base-line criteria at para 6.16-6.20.

38. See NCAC, “How the Quality Improvement and Accreditation System (QIAS) Works” (as at 29 June 1999) [http://www.NCAC.gov.au/ howqias.htm]; NCAC, “The 52 Principles of Quality Care” (as at 29 June 1999) [http://www.NCAC.gov.au/52.htm].

39. See para 6.16-6.20.

40. See para 9.13 and Recommendation 37.

41. See Recommendation 24.