Monitoring processes

Page content: Overview | 2006-2007 Monitoring Statistics | How does DoH monitor compliance? | Monitoring tools | Action plans

Overview

The Health Services Act 1988 and Health Services (Supported Residential Services) Regulations 2001 support and protect SRS residents’ health, wellbeing and quality of life by establishing minimum standards of care. The Department of Health (DoH) monitors, trains and supports proprietors, assisting the industry to better understand its obligations to residents.

Section 10 of the Health Services Act 1988 sets out 8 principles to guide the provision of quality care to residents. The principles relate to; Healthcare, Nutrition and Environment, Safety, Dignity, Social Activities, Independence, Finances and Choice. The DoH is responsible for monitoring SRS, to ensure these principles are upheld for SRS residents.

DoH monitoring strategy for SRS is based on a risk management approach. This involves a particular focus on facilities that are at risk most of non-compliance, while maintaining periodic oversight of all other registered facilities. The following flowchart illustrates the Department’s monitoring approach:

Monitoring processes flowchart (58kb, pdf)

From time to time, individual proprietors fail to meet their obligations to residents despite the best efforts of the department to monitor and assist them. In those circumstances the department prosecutes identified breaches of the Act. Since the Health Services Act 1988 came into effect, the department has successfully concluded 36 prosecutions against SRS proprietors.

Building capacity in the SRS sector is also important. The department provides a series of information and training seminars to SRS proprietors at no charge, as part of helping proprietors better understand and manage key issues in SRS.

In 2008/2009, 29 information and training sessions for proprietors and SRS staff were delivered by the SRS Program on courses such as:

• Medication management
• Care planning
• Diabetes management
• Managing residents with challenging behaviours.

2006-2007 Monitoring Statistics

In 2006-07, the department conducted:

• 257 complaint investigations
• 668 physical inspections, including
• 132 facility audits
• 171 care audits
• 806 other monitoring activities

In total, these monitoring procedures spanned 185 facilities – equating to 96% of all registered SRS - during the 2006-07 year.

How does DoH monitor compliance?

Authorised Officers are appointed under the Health Services Act 1988 and based in the 8 department regions across Victoria. They monitor and enforce compliance with the Act, the Regulations and Conditions on registration by:

• Regular and random physical inspections, either announced or unannounced. These include Care Audits (focusing on resident care and documentation issues) and Facility Audits (focusing on construction/conditions of premises).
• Prompt and thorough complaint investigation involving announced or unannounced inspections that may, depending on risk analysis, lead to a Care and/or Facility Audit.
• Issuing Action Plans to proprietors to rectify issues of non-compliance where identified and conduct of follow-up inspections. Refer to the Action Plans section below.
• Assessment of renewal of registration applications (usually every two years) where the proprietor’s suitability, financial capacity and record of compliance with the Act, Regulations and any Conditions of the Registration are assessed.
• Imposition of sanctions for continued non-compliance, including refusal of an application for renewal of Registration, revocation of Registration and prosecution for breaches of the Act or Regulations.

In addition, departmental officers provide advice and education to assist proprietors in:

• Complying with the legislation
• Implementing best-practice measures

Authorised Officers can assist proprietors to understand and implement changes to procedures, practices and documents to ensure compliance with the legislation. This occurs both during inspections and as part of the department’s SRS seminar and training program.

Monitoring tools

Self Assessment tool - Version 1.4 (264kb, pdf)

Self Assessment tool - Version 1.4 (500kb, MS Word)

Facility Audit Tool (372kb, pdf)

Care Audit Tool - Version 1.4 (398kb, pdf)

Action plans

Where a proprietor has not met the minimum requirements as prescribed in the Regulations, the Authorised Officer will develop an Action Plan identifying what action needs to be taken by the proprietor to meet the regulatory requirement, and a timeframe for when the action should be completed. The timeframe is developed in consultation with the proprietor. Further announced or unannounced inspections may result.

The flowchart below depicts the response types of DoH where non-compliance is identified. Response types to non-compliance range from Administrative to Criminal sanctions against the Proprietor and facility.

Dealing with non-compliance flowchart (37kb, pdf)

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