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Systemic issues and implications for service provision

27th December 2018

Following the Notice of Advice sent to Victorian disability service providers by the Disability Services Commissioner on 21 November 2018 regarding systemic issues arising from the review of disability service provision to people who have died, DSC delivered a series of presentations on this topic across the state at safeguarding forums organised by National Disability Services.

This article summarises the key issues highlighted in these presentations on the review of disability service provision to people who have died, and the implications they have for service provision.

Click here to read the inaugural review of disability service provision to people who have died 2017-18.


 

Safe mealtime assistance

Key themes

  • Poor management of choking and aspiration pneumonia risks
  • Poor compliance with food plans
  • Lack of mealtime management plans altogether

Implications for service provision

  • How does your service identify the people with disability who may need swallowing assessments, require mealtime assistance, customised nutrition plans, etc?
  • How are staff trained and kept knowledgeable on individual diet plans and need for mealtime assistance?
  • Are records or charts kept up-to-date detailing meals and the consistency of meals provided, and reviewed regularly?
  • How often are reviews and audits done of existing swallowing assessments and meal plans?
  • How do you communicate with other service providers and ensure continuity of care?

Communication support

Key themes

  • Lack of adequate communication plans or other supports for individuals who are non-verbal or require support to communicate
  • It is a fundamental human right to have freedom of expression – see Disability Act 2006, Convention on the Rights of Persons with Disabilities, Department of Health and Human Services policy and practice advice, etc.

Implications for service provision

  • When was the last time existing communication plans were reviewed by a professional?
  • When was the last time service users without a communication plan were assessed to see if they required one?
  • If your organisation has a large number of transient or casual staff – how are they trained to communicate with service users in a meaningful way?

The fundamental question is – if a service user isn’t supported to communicate in a way that works for them, how can they let people know when they are unwell, in pain, or require medical attention?

Quality and existence of health plans

Key themes

  • DSC found evidence of missing or illegible case notes, contradictory or non-contemporaneous case notes
  • Obligations under Disability Act 2006 and the Health Records Act, Restrictive Practices, Health Standards
  • These are people with potentially complex health and disability supports – detailed documentation and plans are required, but don’t always exist.

Implications for service provision

  • Do your staff understand their obligations regarding record-keeping and information transfer?
  • Are medication records kept up-to-date? Is medication dispensed accurately, rather than as an unauthorised chemical restraint?
  • How often are management reviewing health records for inaccuracies, key themes, etc?
  • What are the trigger points for calling an ambulance, Nurse on Call, Hospital Emergency Department?

Quality of record keeping

Key themes

  • Evidence of out-of-date or absent records
  • These are people with potentially complex health and disability supports – detailed documentation and plans are required, but don’t always exist.

Implications for service provision

  • Do you have simple and clear shift handover processes to ensure that key information is transferred between shifts?
  • How are general observations recorded in a meaningful way?
  • How are records shared and key information shared between service providers to ensure continuity of care?

 


 

We acknowledge and send our condolences to the families, friends and carers of people with disability who have died. We are grateful for their valuable input, at a difficult time in their lives, to assist in informing areas of service improvement for others.

Level 20, 570 Bourke Street,

Melbourne, Victoria, 3000 Australia

Call for enquiries or complaints - 1800 677 342

Email for enquiries or complaints - complaints@odsc.vic.gov.au