Process Map

Process - Step by Step

• All incidents reportable to the funding body, e.g. NDIS Quality and Safeguards and Aged Care Commissions and the Aged Care Quality and Safety Commission, must be investigated. 
• HWH also reviews non-reportable incidents where harm occurs to manage potential risks to the business flowing from the harm.

• ensure the immediate needs of the client are taken care of, including: 
  • providing appropriate medical attention or first aid if necessary, including a forensic medical assessment if appropriate
  • separating the alleged home support worker involved
  • any other appropriate support
• Perform a preliminary assessment to: 
  • Ensure the Incident Report has been completed 
    • establish a specific and accurate account of the incident
    • identify potential witnesses
    • if appropriate, arrange for the relevant home support worker to be stood down or moved pending the investigation
• consider the support needs of other clients, remembering they are not just potential witnesses
• Confirm the required reporting window by completing an Incident  Investigation - Reportable Incident eForm.
• Follow appropriate reporting requirements, including: 
  • the NDIS Quality and Safeguards Commission, icare etc. (reportable incidents)
  • the police (anything illegal such as assault, sexual misconduct or fraud)
• Preserve relevant evidence, including physical or documentary evidence (take photos and record descriptions of injuries if appropriate), which may be critical to an investigation by the police or HWH.

• Appoint a manager to coordinate the investigation; this should be someone separate from the team supporting the client.
• If the matter has been referred to the police for possible criminal charges, check with the police before starting an investigation.
• Keep relevant parties informed of the progress throughout the investigation.
• Set the purpose and scope of the investigation.
• Review the preliminary assessment, including incident reports, all known details, circumstances, timeframes and witnesses
• Appoint an investigator—Incidents involving worker-to-client assaults, serious unexplained injuries or potential criminal conduct are best handled by an external investigator. Ideally, someone experienced in interacting with clients
• determine the framework for the investigation, including: 
  • Scope and purchase
  • Timeframes 
  • Resources required 
  • Any requirements or conditions to ensure the maximum feasible involvement of the client 
  • Arrangements for an interview with the client in the presence of a support person 
  • Witnesses to be interviewed and the order of interviews 
  • Arrangements to interview the alleged perpetrator 
  • Documentary evidence to be reviewed by the investigator 
  • Arrangements for site visits 
  • Arrangements to obtain expert evidence, e.g. a forensic medical assessment 
  • Plans for communicating with other clients, families and workers 
  • Reporting and review arrangements (for more complex investigations) 
  • A plan for effective communication with the client, their family and advocate. 

• interview the client in a way the person can understand: 
  • Explain why the discussion is taking place 
  • Explain that the person has the right to ask for a break or end the discussion at any time 
  • Regularly check if the person would like a break 
  • Use open-ended questions rather than questions likely to result in ‘yes’ or ‘no’ answers 
  • Ask clear and brief questions using short words and sentences 
  • Break down complicated concepts or information into smaller chunks 
  • Ask the person to repeat the questions in their own words (if they have sufficient verbal skills) 
  • Allow enough time for the person to answer the question 
• The investigator should understand the key elements of investigations: 
  • Principles of procedural fairness 
  • Confidentiality and privacy 
  • The civil standard of proof 
  • Appropriate interview techniques 
  • Avoiding leading questions 
  • Evidence that is relevant to the facts at issue 
  • Weighing the evidence according to the type of evidence 
  • Recording the interview 
• The investigation process should: 
  • Balance formality with flexibility 
  • Consider all possible scenarios and causes in detail, along with all types of evidence 
• The investigation report should include: 
  • A description of the matter investigated 
  • Details of the allegations 
  • Details about the investigation, e.g. the witnesses interviewed 
  • Documentary evidence considered 
  • Summary of the key evidence 
  • Conclusions and findings based on the salient evidence while taking care to distinguish findings of facts and findings of opinion.

• The investigation manager scrutinises the investigation report carefully and considers whether: 
  • The findings are well-founded 
  • The investigator has provided a clear and strong case based on the reasonable probability that the events are likely to have happened according to one view or another 
  • All possible evidence has been sought and considered, and the investigation does not rely on a single piece of evidence or opinion, such as a forensic medical report 
  • The findings and recommendations include both matters of evidence and matters of outcomes (for clients and workers) 
• The investigation should also address any underlying patterns or causes of the incident so that systemic and practice improvements can be implemented to minimise the occurrence of similar incidents
• findings of evidence related to an alleged worker-to-client assault and whether allegations have been sustained or not sustained, the following language is recommended: 
  • ‘Sustained’— is used when there is sufficient evidence that the reported conduct occurred 
  • ‘Not sustained – insufficient evidence— is used when there is some evidence that the reported conduct occurred but not enough evidence to make a conclusive finding 
  • ‘Non-sustained – lack of evidence of weight’— is used when there is no evidence of weight that the reported conduct occurred 
• findings of outcomes should be considered from the client’s perspective to acknowledge and remedy the situation
• The client should be advised, at least in broad terms, of the decisions and actions resulting from the investigation, including actions taken or planned to prevent future occurrences
• The investigation manager should draw up an action plan to address the matters and monitor the plan until all actions are finalised
• appropriate action should be taken if an allegation against a worker is sustained—the worker must not work again in the same setting
• where an allegation was not sustained, consider whether it is appropriate for the worker to continue working with the client
• All investigations, whether allegations are sustained or not, provide opportunities for practice or systemic improvement
• For incidents relating to workers who lack skills in managing behaviours of concern or not getting the required support needed for complex work, the following may be considered: 
  • Additional training for workers 
  • Improved supervision of workers 
  • Changes to routines or rosters 
  • Reviewing and refining support plans for certain clients.

• The Principal responsible for Incident Management will assess based on the incident type. This investigation aims to establish the potential consequences of/risk from any harm that may have occurred due to the incident. 
• A harm incurred and to be investigated could be 
  • Physical, 
  • Psychological or
  • Financial or 
• a mixture of the above

• Review the Incident management worksheet and consider the level of harm, the people involved and the nature of the harm to rate
  • The level of consequences that may arise from the harm and
  • the probability that the consequence might occur.
• Was harm incurred (Y/N).
• Yes
  • Was a client involved? (Y/N)
  • Yes
    • Was this a medication incident?
    • Yes
      • Reportable Incident - Go to Step 2

• Any potential outcome assessed with a consequence of greater than MODERATE with a probability of greater than POSSIBLE should be referred for a further risk review by the Principals with a view to the adoption of an appropriate risk mitigation strategy.
• Refer Incident Harms Consequence - Risk Assessment methodology.