This article is the first of three that will help you prepare for and undertake your NDIS Audit.
If you’re applying for NDIS Registration or undertaking your NDIS Registration Renewal with the NDIS Quality and Safeguards Commission, you’ll be required to complete the NDIS Self Assessment as part of your online application.
Depending on the types of NDIS Services and Supports you provide, you’ll be required to complete anywhere from 4 questions (for Verification providers delivering lower risk services) to 22 – or more – questions (for Certification providers delivering higher risk services).
In our experience, many of our clients initially find the NDIS Self-Assessment process confusing and overwhelming. But it doesn’t have to be that way. The following three tips will help you complete your self-assessment with confidence.
1. Understand the Purpose of the Self-Assessment
As a Registered NDIS Provider, you are required to comply with the NDIS Quality and Safeguarding Framework (the Framework), and within that, the NDIS Practice Standards (the Standards). Under the Framework, you need to undergo either a Verification or Certification Audit, to practically demonstrate how you comply with the Standards.
If you’re not sure whether you have to undergo a Verification or Certification audit, you can use our Vericert Pilot, available to free subscribers in amerginhub, to find out.
Self-assessment is the first step in any audit process, and in the NDIS registration and renewal processes, it takes place within your registration or renewal application. Self-assessment is, as the name suggests, an assessment you undertake of your own business and how it currently complies with the Standards.
Self-Assessment serves two main purposes:
- It helps you identify any ‘gaps’ in compliance – areas where you currently aren’t meeting the Standards, or where you could be doing something more or different in order to meet – or even exceed – the Standards. This is a fundamental part of Continuous Improvement, which is good business for any business. For this reason, even if you’re not being audited every year, it’s best practice to conduct a self-assessment at least annually.
- It helps your auditor to more quickly identify whether you’re meeting minimum requirements. One of the chief ways you demonstrate your understanding of your compliance obligations and make sure your business meets them is through comprehensive Policies and Procedures. However, auditors already have a big job to do in making an assessment of whether your business is complying with all the relevant requirements – they don’t have time to read through your Policies and Procedures word for word.
Your self-assessment acts as a guide for auditors – it shows that you understand the specific requirements you’re responding to and guides them to the particular documentation you have in place to make sure you comply. So, even though you’ll complete your self-assessment during your registration or renewal application, it will have direct implications for your audit. For this reason, it’s incredibly important to make sure your responses make sense and are helpful for your auditor.
2. Understand What You’re Responding To
This is an example of what a self-assessment question looks like in the online NDIS Registration application. NDIS Registration Renewal is undertaken in a different portal, so the questions look quite different – however they are the same.
The questions you are required to respond to will depend on whether you need to undergo a Verification or Certification Audit, and if you do need to undergo Certification, whether you are delivering any higher risk services that mean you’ll need to address additional Standards (for instance, High Intensity Daily Personal Activities, Specialist Behaviour Support, Implementing Behaviour Support Plans, Early Childhood Supports, Specialised Support Coordination and Specialist Disability Accommodation).
The above example is the first Standard from the Core Certification Standards; however, the below guidance applies to any of the self-assessment responses.
Each self-assessment question is essentially each Standard that your business is required to comply with. There is no guidance or explicit ‘question’ – simply the Standard and a box where you can write your response.
Each Standard has two parts. I have detailed these below, and provided examples (and interpretations) to help you break these down:
Participant Outcome – this is the overall outcome you are expected to demonstrate in order to meet the Standard. Given the person-centred focus of the NDIS and the Standards, each Outcome is written from the perspective of how Participants benefit as a result of your business complying with the Standard. You’ll see from the example that the Outcome for the Person-Centred Supports Standard is:
Each participant accesses supports that promote, uphold and respect their legal and human rights and is enabled to exercise informed choice and control. The provision of supports promotes, upholds and respects individual rights to freedom of expression, self-determination and decision-making.
In layman’s terms, this means that when delivering supports to NDIS Participants, you and your staff:
- understand participants’ rights (their legal rights, human rights and rights under the NDIS);
- respect those rights; and
- actively work to ensure those rights are enforced and protected.
Quality Indicators – these provide more detail about the specific actions or processes you should be undertaking, in order to meet the requirements of the overall Outcome and therefore, the Standard. Some Outcomes have 2 or 3 Quality Indicators associated, while others have up to 8 or 9. They are really valuable to understanding the specifics of what you are required to do to meet the Standard. Again, Indicators are written from the perspective of how Participants benefit. The three Quality Indicators associated with the Person-Centred Supports Standard are:
Each participant’s legal and human rights are understood and incorporated into everyday practice.
This means that your day-to-day service delivery includes processes to ensure participants’ rights are understood, respected, enforced and protected.
Communication with each participant about the provision of supports is responsive to their needs and is provided in the language, mode of communication and terms that the participant is most likely to understand.
This means that when you communicate with participants (at any point), the way you communicate with them caters to their needs. For instance, do they need an interpreter or translator? Assistive technology? Easy English? It is the participant’s right to have information provided to them in a way they understand, so they can make informed decisions.
Each participant is supported to engage with their family, friends and chosen community as directed by the participant.
This means that when you deliver services, you support participants to engage with their family, friends and community in a way that the participant wants. Of course, the way you do this, and the extent to which you do this, will depend on the type of support your business is providing.
Given you are obligated to comply with the Standards for however long you are registered as an NDIS Provider, it is well worth the effort to go through each of the Standards that apply to you and develop your own interpretations of each of their components, as I’ve done above. You’ll then be best placed to provide a response in your self-assessment about how you do these things.
3. Include the Relevant Information in Your Response
Self-assessment responses need to detail how you meet the requirements of each Outcome and its Indicators. To do this, consider:
- the policies and procedures you and your staff follow to meet the requirements;
- any forms and documents that support your policies and procedures to help you comply;
- how staff know what they have to do to comply;
- how you monitor your business’ compliance; and
- Any gaps you need to fill in order to fully comply.
The key to being able to easily respond to the self-assessment is having good quality policies and procedures in place – that you actually follow! – which you can refer to.
My biggest tip when it comes to your self-assessment? Have Policies and Procedures developed first! Use each Standard’s Outcomes and Indicators to make sure your documents cover everything they need to, and then refer to them in your self-assessment response. Your auditor will review your policies and procedures to make sure they match what you’ve said in your self-assessment – if they don’t, your auditor will be much more inclined to dig deeper and look for other discrepancies or issues.
Continuing the example of the Person-Centred Supports Standard, the Policies and Procedures you have in place might include a:
- Participant Charter – setting out participants’ right and responsibilities and that is consistent with your business’ Vision, Mission and Values, the Standards and relevant legislation and international obligations;
- Participant Rights and Responsibilities Policy and Procedure – detailing how the Charter will be implemented and communicated to participants;
- Service Access Policy and Procedure – outlining how participants are advised of their rights and provided with the Charter when they access your services, as well as how information is communicated in a way that participants understand; and
- Other service delivery-related policies and procedures, such as Assessment, Planning and Review; and Decision Making and Choice Policies and Procedures, that cover the above requirements and also ensure that staff support participants to engage with their family, friends and chosen community in the ways they prefer.
When you’re completing your self-assessment, refer to your policies and procedures directly – detail the documents you have and briefly summarise how they meet the compliance requirements of the Standard you’re responding to. If you’re already operating, respond in terms of what you and your staff do day-to-day, but also refer back to your policies and procedures. And importantly, be succinct – you only have 300 words to respond to each Standard. Remember too that you’ll need to upload examples of the documents you refer to at the end of the self-assessment.
I’ve provided an example response to the Person-Centred Supports Standard below:
We have a Participant Charter, which sets out our clients’ rights and responsibilities and complies with our business’ Vision, Mission and Values, as well as the NDIS Act 2013, NDIS Practice Standards (Rights and Responsibilities), United Nations Universal Declaration of Human Rights, United Nations Convention on the Rights of the Child and United Nations Convention on the Rights of Persons with Disabilities.
Our Participant Rights and Responsibilities Policy and Procedure describes how the Charter is to be implemented in the business and communicated to participants.
Our Service Access Policy and Procedure requires that staff provide participants with information about their rights when they access the service.
All of our participant-related Policies and Procedures require that information is communicated to participants in a way they can understand. This could include providing written information in Easy English, explaining information either face-to-face or over the phone and using interpreters and advocates.
We ensure each participant is supported to engage with their family, friends and chosen community as directed by the participant through our Service Access; Assessment, Planning and Review; and Decision Making and Choice Policies and Procedures.
Our Participant Charter is provided to all participants or their representatives and they are asked to sign an Acknowledgement Form confirming that they have been provided with information about their rights at intake. This is kept on their file.
Now, this is of course an example, and while you’ll no doubt be tempted to copy and paste it into your own response to this Standard, I strongly encourage you to follow the steps I’ve outlined above, so you actually understand and are empowered to confidently write your own responses to all the Standards that apply to you. Self-assessment will be required prior to every audit you undergo as a Registered NDIS Provider, so it’s worth the time and effort to understand the requirements from the get-go.
If you need help to understand the requirements of the Core NDIS Practice Standards in more detail, our Certification Webinar Series might be for you (even if you’re not a WA provider). Alternatively, if you’d like help with the NDIS Self-Assessment itself, our Self-Assessment Against the NDIS Practice Standards Course, available in amerginhub, is another useful resource.
Where do I start?
If you want to start preparing for your upcoming NDIS Audit or Aged Care Quality Review, you can download our Free Checklist – How to Ace Your Next Audit or Quality Review
Just click the link, fill out the form and we’ll send it to your inbox.
Some organisations are simply inexperienced in the audit process, while others – for a range of reasons – lack confidence in their own quality systems and processes. This can cause a range of negative emotions such as anxiety, stress and frustration that can spread like wildfire through a team – but it doesn’t have to be that way.
We have put together this FREE Audit Checklist to give you our tips on how you can best prepare for your next NDIS Audit or Aged Care Quality Review.