NDIS RISK MANAGEMENT SYSTEM (THE “SYSTEM”)

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NDIS RISK MANAGEMENT SYSTEM (THE “SYSTEM”)

Last amended: 29/08/2024

  1. Background

Owned by the Risks Manager: Monique Everton, Practice Manager, 0458360666, su*****@******************ns.com.

For and on behalf of Bradley Russell Everton, Trading as Synergy Mind Solutions (“we”, “us”, “our”).

Made in response to the National Disability Insurance Scheme (Quality Indicators) Guidelines 2018 (the “Guidelines”) made pursuant to the National Disability Insurance Scheme (Provider Registration and Practice Standards) Rules 2018 (the “Rules”).

  1. Plain English summary: What is this all about?

 Operating as a provider under the National Disability Insurance Scheme (“NDIS”) comes with risks. This System:

  • outlines our key risks, including risks to NDIS participants, financial and work and safety risks, and risks associated with the provision of supports; and
  • is designed to help management to identify, analyse, prioritise and manage key risks, recognising that not all risks are predictable, and that some risks cannot be eliminated entirely.
  1. How this System is designed

This System requires management to adopt a well-known, continuous four-step method to identify and manage our risks: plan-do-check-act. This method is summarised in the diagram below:

  1. Proportionality

In management’s view, this System is proportionate to our size and scale, and the scope and complexity of the supports provided.

  1. Key Risks and Core Principles

We recognise our long-term reputation, financial viability, and ongoing provider-status are dependent to a high degree on our ability to adhere to the letter and spirit of the Guidelines. In everything we do, we are committed to ensuring that we:

  • meet our legal obligations;
  • provide person-centred supports;
  • respect individual values and beliefs of NDIS participants;
  • respect each NDIS participant’s privacy and dignity;
  • affirm the rights of NDIS participants to make independent and informed choices about their care; and
  • take steps to ensure each NDIS participant accesses our supports free from violence, abuse, neglect, exploitation and discrimination (collectively, our “Core Principles”).

As a NDIS provider, we are exposed to several key risks:

5.1 The regulatory framework may change

The NDIS is highly regulated by the Australian Government (“Government”). Any future changes may have an adverse effect on the way we operate, and on our financial performance.

5.2 Demand for our services or supports may fall

In the ordinary course of our business, we face the risk that demand for our services and/or supports may fall below expectations due to a number of factors, including reputational damage and loss of NDIS provider status. Reduced demand would reduce our profitability by reducing the amount of Government funding we are entitled to under the NDIS.

We manage this risk through our marketing plan, and by following a number of policies and procedures to ensure we remain compliant with the NDIS rules, including policies to do with our conduct and the conduct of our staff, reportable incidents, and complaints.

5.3 Our reputation may be damaged

We operate in a commercially sensitive area of the economy in which our reputation could be adversely affected should we, or the NDIS provider/NDIS “industry” generally, suffer from adverse publicity. Examples of adverse publicity may include complaints, reports of inappropriate supports, enquiries or investigations, health and safety issues affecting NDIS participants, staff or visitors, failure to ensure that our facilities and equipment are well maintained, poor service delivery, or a breach of our Core Principles.

Adverse effects to events like these may include online or other public complaints, questions or investigations from the NDIS, media coverage, and increased compliance costs to manage or remedy underlying issues.

5.4 Increased competition

New entrants to the NDIS provider space, competing with us to provide similar supports to NDIS participants, are anticipated. A substantial increase in the level of competition we face could result in reduced margins and revenue. This could have a materially adverse effect on our financial performance and limit our ability to achieve our strategic objectives.

5.5 Retention of key management and workers

We rely on management and workers with significant specialised knowledge relating to our services and supports. If we are not able to retain key members of our team, we may not be able to provide supports to the same standard, which may undermine our ability to comply with the Rules and reduce demand for our services or supports. This, in turn, may limit our ability to operate and to grow.

5.6 Insurance claims, litigation, and enquiries

As a NDIS provider, we are exposed to the risk of professional and public liability claims, litigation, NDIS audits, and coronial inquests. We have insurance arrangements in place to mitigate some of these risks. However, any actual or threatened litigation against us could cause us to incur significant expenditure, distract us from our work, affect our financial performance, and also cause adverse publicity.

5.7 Staff may leave and we may not be able to attract new skilled and trained staff

Our business is dependent on staff with expertise. There is a risk we may not be able to maintain or expand an appropriately skilled and trained workforce to meet the needs of NDIS participants. This may be due to:

  • industry labour shortages;
  • increases in wages that we cannot profitably afford;
  • any disputes with staff;
  • an inability to offer competitive wages, benefits and professional growth opportunities; and
  • staff choosing to use their skills in other areas, e.g. in hospitals.

If any of these things happen, it may increase our costs, reduce our profitability, and affect our ability to service NDIS participants while executing on our Core Principles.

5.8 We may not meet our growth targets

Our growth depends on many factors that are not fully under our control. We need to identify and invest in new services or supports demanded by NDIS participants. There is no assurance we will be able to do that. This could affect our performance.

5.9 Our fixed costs may reduce our flexibility

Our capital expenditure includes fixed costs related to facilities, including maintenance costs and taxes. A reduction in revenue caused by reduced demand for our services or supports, or an inability to increase fees charged to NDIS participants, together with our high fixed costs may adversely affect our performance and profitability, and limit our strategic options.

5.10 We may not meet our forecasts

Our future performance depends on many assumptions. Various factors, known and unknown, may affect our performance and cause our actual results to be varied significantly from what we expect. We can’t guarantee we will meet our objectives or succeed.

5.11 A workplace accident or incident may occur

There is a risk that liability arising from a workplace health and safety matter may be our fault. To the extent that we bear such liability, it will impact our financial performance to the extent not covered by insurance. In addition, we may be liable for monetary penalties, which may adversely affect our financial performance.

5.12 We may be unable to secure adequate insurance coverage to cover all claims

Management is committed to maintaining adequate insurance consistent with industry practice, including professional indemnity, and public liability insurances. However, no assurance can be given that such insurance will continue to be available in the future, or that it will be available on commercially acceptable terms. There is also no guarantee that any cover will be adequate to cover claims made against us, or any claims that we make. We may be unable to continue to secure insurance to cover all anticipated risks or the cost of insurance may increase above anticipated levels. This may result in us either paying too much for insurance or being unable to adequately insure some business risks.

5.13 We reply on information technology systems (IT systems)

We use IT systems throughout our operations and support functions. These systems are used for both internal and external purposes, including:

  • NDIS participant communication and supports;
  • labour and roster management; and
  • accounting and financial reporting.

Our IT systems may be adversely affected by a number of factors, including computer viruses, user error, equipment faults, physical damage, and hacking and we may not always receive support from IT vendors. Any such events may cause significant disruptions to our business operations, and it may be costly to repair or replace equipment or recover lost data.

5.14 Changes to tax rates

Any changes to tax laws may affect our returns, profitability or viability.

5.15 Catastrophic events

Insured or uninsured events like fires, widespread health emergencies, floods, earthquakes, pandemics, epidemics, wars or strikes could affect our ability to operate, the value of our assets, our staff, and our ability to provide supports. Some of these events are uninsurable (or prohibitively expensive to insure adequately). To the extent they occur, there may be adverse effects for our operations and financial performance.

  1. System to mitigate key risks

6.1 Compliance Policy

We have a compliance culture. This means we comply with all relevant laws, regulations, industry and professional codes, standards and guidelines, as well as internal policies and procedures.

Our Risks Manager has primary responsibility for overseeing the development, implementation, testing and continuous improvement of our compliance management system.

All staff (including management, employees and contractors) are responsible for the development and implementation of our compliance systems and the System, and for the fostering of a compliance culture. All staff must adhere to compliance obligations, undertake relevant training, and report all compliance concerns, issues, complaints and breaches to management promptly. Staff who breach compliance obligations may be subject to penalties and/or disciplinary action.

6.2 Staff and NDIS participant safety comes first

Each staff member must (in addition to their other obligations):

  • comply with applicable workplace safety and health laws;
  • provide services and/or supports in a safe and ethical manner, and in accordance with our Core Principles;
  • maintain competence in his or her field;
  • not provide services or supports outside their experience or training;
  • ensure that appropriate first aid is available to deal with any misadventures during the provision of a service or support; and
  • obtain appropriate emergency assistance (for example from an Ambulance Service) if any serious misadventure occurs during the provision of a service or support to a NDIS participant.

Priorities

Evidence shows that the top causes of workplace injuries include:

  • muscular stress;
  • falls on the same level;
  • harassment and bullying; and
  • work pressure.

The nature of our work, particularly caring for NDIS participants, presents specific hazards for workers and NDIS participants. Common hazards we have identified include the following:

6.2.1 Fatigue

Fatigue affects safety in the workplace. It can impact on workers’ mental and physical health, as well as the health and safety of those around them, such as co-workers, NDIS participants, carers, and members of the public.

Fatigue increases the likelihood of incidents and injuries in the workplace, particularly when doing safety critical tasks where significant consequences may arise if errors occur – for example, when driving a vehicle or when physically assisting a NDIS participant.

We recognise that fatigue can result in reduced productivity and an increase in near misses, incidents and injuries, even when the signs of fatigue may not be obvious.

We are committed to mitigating this risk, including by:

  • reading and following the advice of workplace safety regulators, including Safe Work Australia’s guidance: https://www.safeworkaustralia.gov.au/doc/guide-managing-risk-fatigue-work
  • designing working hours and rosters to allow for good sleep opportunities and enough recovery time;
  • imposing daily work hours, maximum average hours and total hour limits;
  • requiring minimum breaks on a regular basis, especially during longer shifts;
  • managing overtime and shift swapping;
  • having processes to manage accrued leave balances, including maximum limits of leave accrual to encourage workers to use it;
  • filling vacant positions as soon as reasonably practicable;
  • ensuring appropriate equipment is used at the workplace, including ergonomic furniture;
  • encouraging staff to report concerns they have about work-related fatigue;
  • planning for expected changes in work flow, including anticipated peaks and troughs in demand for our services;
  • providing air conditioning and water;
  • maintaining well-lit, safe and secure working spaces; and
  • encouraging staff to participate in regular exercise.

6.2.2 Slips, trips and falls (“STFs”)

Injuries that may result from STFs include sprains, strains, back and disc injuries, permanent long-term injuries, and even death. Common sources of risk include:

  • uneven flooring;
  • changes to flooring (e.g. floorboards to carpets);
  • sloping surfaces;
  • poorly maintained floor surfaces;
  • slippery floor surfaces (e.g. from cleaning);
  • spills;
  • cluttered space;
  • poor lighting;
  • poorly marked steps and edges;
  • loose/unanchored rugs and mats;
  • loose cords and cables;
  • weather;
  • inappropriate footwear; and
  • obstructed views

We mitigate these risks by:

  • reading and following the advice of workplace safety regulators, including from Safe Work Australia: https://www.safeworkaustralia.gov.au/system/files/documents/1702/slips_and_trips_fact_sheet.pdf
  • identifying NDIS participants at heightened fall risks and supervising them while moving about on the premises (including exiting the premises);
  • training staff to recognise STF hazards;
  • providing sufficient recycling and rubbish bins;
  • having a regular cleaning schedule;
  • encouraging staff to clean their work areas before they leave every day;
  • providing storage areas separate to work areas where practicable;
  • provide sufficient power sockets and computer service jacks;
  • secure stacking of goods (e.g. avoiding “towering” stacks); and
  • visual cues (such as warning strips and signs) about changed or uneven surfaces.

6.2.3 Infection risks

As part of our services or supports, staff and NDIS participants may come into physical contact with each other. We may also be exposed to saliva, droplets, and blood. To manage the resulting infection risks, we have implemented an Infection Control Procedure.

6.2.4 Hazardous manual tasks

We have looked at our work activities and identified activities that require:

  • forceful exertions, such as pushing, pulling, lifting and gripping;
  • awkward postures, such as bending, over-reaching, arching and twisting;
  • vibrations to the hands, arms or body;
  • repetitive movements or forces and or sustained for more than 30 seconds; and
  • a lot of time to complete.

We have reviewed the advice of workplace safety regulators, and have read their practical guidance and Codes of Practice, e.g.: https://www.safework.nsw.gov.au/__data/assets/pdf_file/0009/187812/Preventing-and-responding-to-work-related-violence.pdf

We have sought to eliminate as many potentially hazardous tasks as possible, including tasks requiring heavy lifting. We have trained workers on how to lift safely, recognising that this, alone, is not a successful mitigant.

Staff involved in lifting, repositioning and moving NDIS participants are trained in how to do this and to ensure that the NDIS participant consents before being moved or touched in any way. However, because the nature of our business is psychological, the staff know this should not be a requirement of their position and that they can call an ambulance if an incident occurs that requires the participant to be lifted, repositioned or moved.

6.2.5 Violence

From time to time, we may be exposed to acts of violence. This may include:

  • the throwing of objects;
  • pushing, shoving, tripping, grabbing;
  • striking, kicking, scratching, biting, spitting or other physical contact; and
  • attacking with knives, guns, clubs or other types of weapons.

Workers may be exposed to work-related violence from a range of sources, including NDIS participants, carers, family members, other staff, and members of the public.

We have read the Preventing and Responding to Work-Related Violence guide produced by SafeWork NSW:  https://www.safework.nsw.gov.au/__data/assets/pdf_file/0009/187812/SW08582-Preventing-and-responding-to-work-related-violence.pdf

We have also taken the following steps to mitigate the risks:

  • Secured our building with locks on the doors.
  • Reduced public access at night.
  • Communication systems are in place.
  • Limited cash and valuables are located on site.
  • Cash-handling procedures are implemented, including strong preferences for electronic fund transfers.
  • Limited access to dangerous implements that could be thrown to injure someone.
  • Procedures for opening and closing the business.
  • Mandatory reporting (as required by law).
  • Intake procedures to assess NDIS participant compatibility and suitability.
  • Behaviours and triggers are identified, and strategies to address them are implemented.
  • Time is taken for understanding NDIS participant disabilities, issues, triggers and behaviour management plans.
  • Behaviour and treatment programs are reviewed after incidents.
  • When a NDIS participant is known to have a history of aggression, a management plan is in place, developed by qualified people.
  • Training is provided, as necessary, on violence prevention measures, emergency responses, de-escalation strategies, including careful listening, acknowledging concerns and encouraging reasoning.
  • Positive behaviour strategies employed for managing behaviours of concern.
  • Management reviews of risk control measures, including after incidents or staff reports/concerns.

6.2.6 Working in people’s homes

Our staff are not required to work in people’s homes.  If a participant chooses to engage in their psychological therapy from home, this is done by telehealth communication.

6.2.7 Workplace bullying

Workplace bullying is repeated and unreasonable behaviour directed towards a worker or a group of workers that creates a risk to health and safety in the workplace.

Bullying may be psychological, physical or even indirect. It can be obvious or subtle. It includes:

  • abusive or offensive language or comments;
  • aggressive or intimidating behaviour;
  • belittling or humiliating comments;
  • practical jokes, hazing or initiation; and
  • unjustified complaints or criticism.

To mitigate the risk, we:

Bullying is completely unacceptable to us, and is prohibited in our Code of Conduct.

6.3 Compliance with specific policies and procedures

To help mitigate risks, all staff members (including management) must follow our:

  • Compliance Policy (above);
  • Escalation Policy (below);
  • Code of Conduct;
  • NDIS Incident Management System;
  • NDIS Complaints Management and Resolution Policy;
  • Work Health and Safety guidelines;
  • Infection Control Procedure; and
  • Privacy Policy.

This System is intended to be read with these policies and to support delivery of their objectives.

6.4 Escalation Policy

To protect our reputation, and to mitigate our key risks, it is essential that all compliance breaches, potential compliance breaches, and imminent breaches are reported to the Risks Manager promptly in accordance with this System.

All people involved in breach reporting, investigation and rectification must act in good faith, and:

  • in our best interests as a NDIS provider and in the best interests of NDIS participants; and
  • in accordance with our Core Principles.

No blame will be assigned to staff reporting accidental breaches or those identifying errors in accordance with this System. However, staff committing deliberate or negligent breaches may be subject to disciplinary processes including, without limitation, professional misconduct notifications and/or regulatory and/or criminal actions.

If a staff member becomes aware of a breach a potential breach, or an imminent breach, he/she must notify as soon as practicable, and in any event within 24 hours, the Risks Manager and senior management. Failure to do so exposes us and staff to potential business and legal risks and may result in disciplinary action against the staff member.

6.5 NDIS Participant records

Staff must comply with the relevant State legislation and/or Commonwealth legislation relating to health information. Staff must keep appropriate records that are accurate, legible and contemporaneous for each NDIS participant service or support.

6.6 Insurances

Management is responsible for ensuring appropriate insurances are in place in relation to services and/or supports we provide to NDIS participants.

6.7 Reputation management

Management is responsible for monitoring public comments, complaints and adverse publicity (including online) and for taking steps to mitigate risks related to adverse publicity.

6.8 Risks Manager to monitor proposed changes to the NDIS and the regulatory framework within which we operate

The Risks Manager will use reasonable efforts to stay up to date on the NDIS rules and regulations, including by regularly checking the NDIS website and participating in continuous education about proposed and actual changes to the way in which the NDIS is regulated. The Risks Manager will assess proposed changes to the NDIS for us and escalate any material changes to management for discussion.

6.9 Management responsible for financial operations, human resources, marketing and information technology planning

Having regard to our Core Principles, our strategic objectives, and the size, scale and complexity of our services and/or supports, management is tasked to:

  • establish and maintain appropriate financial systems (including the ability to generate financial management reports) to monitor our financial health, including fixed and variable costs, and to ensure we stay solvent and profitable;
  • establish and maintain appropriate human resources systems to monitor staffing, anticipate and manage disputes with staff, plan and record training initiatives, and plan for future recruitment needs (if any);
  • establish and maintain appropriate marketing efforts to monitor competition levels, and support our continued growth;
  • establish and maintain information technology systems to support the delivery of services and/or supports to NDIS participants, comply with privacy and record-keeping requirements, and to support management’s strategic objectives; and
  • establish and maintain compliance systems under this System to identify our key legal and compliance obligations, to manage compliance risks, to monitor compliance and to support the Risks Manager and management to maintain our compliance culture.

Review of this System

Periodically, and at least annually, the Risks Manager will meet with management to review this System critically to ensure its appropriateness in light of our size and complexity at the time, and to help to identify, analyse, prioritise and manage our key risks.

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