NDIS Incident Management Policy for Safety and Compliance

If you want to raise something now, call Bloom on 1300 771 465, email hello@bloom-healthcare.com.au, or use the feedback page. To go directly to the regulator, contact the NDIS Quality and Safeguards Commission through the contact details published at ndiscommission.gov.au. Interpreters can be arranged, and you can complain anonymously.

Easy Read version of the incident management policy

The policy

Introduction

Bloom Healthcare desires to be known for providing quality service delivery and is sought out as a 'participant provider of choice'. This includes having a clear process for the management and reporting requirements for incidents or alleged incidents that involve or impact participants during service delivery.

Bloom Healthcare management and employees are committed to:

• Ensuring the rights of people with disability are upheld and supported.
• Providing a high standard of duty of care and ensuring the safety and well-being of each participant using our services, our employees, and members of our community.
• Fostering a culture of continuous improvement with a proactive approach to preventing incidents.
• Promptly and appropriately responding to the incident in an equitable, objective, and fair manner.
• Recording all incidents, reporting (if required) and investigating (if required).
• Ensuring the principles of procedural fairness are maintained by providing those affected an opportunity to give their side of the story and to comment on any adverse views.
• Maintaining an incident management system to aid in recording, managing, and resolving incidents.
• Ensuring the incident management policy and process is provided to participants and stakeholders via email or hard copy during onboarding and at any time by request.

This Incident Response and Management Policy outlines the processes and procedures to be followed in the event of an incident to ensure that any incidents are identified, assessed, contained, and resolved promptly and effectively.

Scope

This policy defines incidents including serious incidents and incidents which are reportable to a number of professional and governing bodies: the NDIS Quality and Safeguards Commission, the Australian Health Practitioner Regulation Agency (Ahpra), and the Office of the Australian Information Commissioner (OAIC).

An incident is broadly defined as acts, omissions, events, or circumstances that occur in connection with providing NDIS supports or services to a person with a disability and have, or could have, caused harm to the person with a disability; and acts by a person with a disability that occur in connection with providing NDIS supports or services to the person and which have caused serious harm, or a risk of serious harm, to another person.

Specific types of reportable incidents include:

• The death of a person with a disability.
• Serious injury of a person with a disability.
• Abuse or neglect of a person with a disability.
• Unlawful sexual or physical contact with, or assault of, a person with a disability (excluding, in the case of unlawful physical assault, contact with and impact on the person that is negligible).
• Sexual misconduct committed against, or in the presence of, a person with a disability, including grooming of the person for sexual activity.
• The use of a restrictive practice in relation to a person with a disability, other than where the use is in accordance with an authorisation of a State or Territory in relation to the person, or a behaviour support plan for the person.
• Data breach or breach of personal information.
• Injury or death of a worker while on duty.
• Any incident involving crimes such as assault, theft and fraud.

This policy applies to all employees and contractors at Bloom Healthcare.

Purpose

The purpose of this policy is to ensure timely and effective responses are taken to address immediate participant safety and well-being; to be accountable to participants for actions taken immediately and planned in response to their experience of a critical incident; to ensure due diligence and responsibilities to participants are met; to support the provision of high-quality services through the full and frank reporting of adverse events; to assure and enhance the quality of service and supports through monitoring and acting on individual incidents as well as trends identified through the analysis of incident reports; to support organisational consistency; and to ensure that identified deficits in service and support are addressed.

Roles and responsibilities

All employees and contractors. Every employee and contractor of Bloom Healthcare is responsible for reporting all incidents to their manager, who will assess the situation to determine whether it is reportable. They should also identify potential witnesses and report the incident to their manager. They are responsible for providing support to participants in the event of an incident and ensuring that immediate needs are met, such as providing first aid or medical attention and separating the alleged worker involved.

Managers. Managers are responsible for investigating all incidents and determining whether they are reportable. They will also be responsible for ensuring that the Incident Response Form is completed within 24 hours of the incident occurring.

NDIS Quality and Safeguards Commission. Responsible for receiving reports of serious incidents and ensuring that appropriate action is taken.

Australian Health Practitioner Regulation Agency (Ahpra). Responsible for the registration and accreditation of health practitioners in Australia. Ahpra needs to be notified of incidents involving health professionals, such as abuse or negligence.

Office of the Australian Information Commissioner (OAIC). Responsible for receiving reports of data breaches and ensuring that appropriate action is taken.

Procedure

Bloom Healthcare undertakes a two-step process whereby the staff member completes an electronic link regarding the incident, and the manager then completes a corrective action plan. All information is stored within Bloom Healthcare's appropriate database.

Allegations of abuse against Bloom Healthcare workers

The Director or their delegate will take all allegations of abuse seriously and clarify what is being alleged with the person making the allegation. In the case of an allegation of sexual misconduct, the Director or their delegate will immediately notify the police. They will assess whether a child or young person is 'at risk of significant harm' and, if so, make a report to the Child Protection Helpline.

The Director or their delegate will determine whether the allegation is a reportable allegation, a reportable conviction, or reportable conduct, and will report reportable allegations and reportable convictions to the Ombudsman within 30 days of receipt. They will consider whether the police need to be informed and, if so, make a report. Confidentiality will be maintained at all times, with systems in place to deal with any breaches of confidentiality.

A risk management approach will be undertaken after an allegation to ensure the protection and safety of children, staff members, contractors and volunteers, and decisions will be made to manage the risks identified. An investigational plan will be developed, obtaining relevant information from a range of sources, which may include a statement from the person against whom the allegation has been made and any other relevant documentation.

If the allegation is being investigated by a State or Territory authority or the police, Bloom Healthcare will be guided by their advice as to whether it should independently investigate. If Bloom Healthcare carries out the investigation, the information gathered will be assessed and a finding made as to whether the allegation is false, vexatious, misconceived, not reportable conduct, not sustained or sustained. The reasons for the finding will be clearly recorded to ensure that decision-making has been transparent.

The staff member, contractor, volunteer or student will be advised of the outcome of the investigation in writing, including the finding, any follow-up required, and any rights of appeal. They will be advised that the Ombudsman has been notified, and that the Commission of Children and Young Persons has been notified of any relevant employment proceeding. All relevant State and Territory authorities will also be informed of the outcome.

Bloom Healthcare will consider whether the incident or allegation is reportable to the NDIS Commission under this policy and procedure.

Throughout, the person subject to the allegation will be treated with fairness and their employee rights upheld. Depending on the nature of the allegation, they will be informed immediately, and arrangements made for a support person to attend the meeting, though that support person must not participate in the discussions. Accurate documentation of all conversations will be made and all records kept confidentially. Counselling or support will be offered to the person subject to the allegation. Depending on the nature of the allegation, that person may be suspended pending further investigation. After all investigations are completed, they will be given verbal and written notification of the outcome.

Training and supervision

Training and supervision are important to ensure that everyone in our organisation understands that child safety is everyone's responsibility. Bloom Healthcare's culture aims for all staff and volunteers, in addition to parents, carers and children, to feel confident and comfortable in discussing any allegations of child abuse or child safety concerns.

The management team trains staff and volunteers to identify, assess and minimise risks of child abuse and to detect potential signs of child abuse. Staff and volunteers are equipped with the knowledge, skills and awareness to keep children and young people safe through ongoing education and training. New employees and volunteers are supervised regularly to ensure they understand Bloom Healthcare's commitment to child safety, and to check that their behaviour towards children is safe and appropriate. Any inappropriate behaviour must be reported to the Director or their delegate.

Staff found to be non-compliant with this policy are subject to appropriate disciplinary action, including but not limited to counselling, further training and development, demotion, suspension, warning, referral to appropriate legal and regulatory bodies, termination of employment (with or without notice or any payment), or termination of engagement in the case of contractors.

Confidentiality

Bloom Healthcare will handle any allegation of abuse, and in particular child abuse, in a confidential manner. See the Privacy and Information Storage Policy.

Record keeping

Full, timely and accurate participant notes must be kept about cases of suspected, observed or alleged harm, risk of harm, abuse or neglect of participants. Any incident or complaint-related documentation generated as a result of this policy must be kept in accordance with the Incident Management Policy and Procedure, the Feedback and Complaints Management Policy and Procedure, and the Risk Management Policy and Procedure.

Policy review

The policy will be reviewed after any reportable incident to ensure that it is up to date with current best practices in preventing and responding to child abuse incidents and allegations, or as a result of legislative or regulatory change or improvement.

Training

All new employees and contractors will receive training on this policy during their induction. Bloom Healthcare will provide regular training to ensure that all employees and contractors are aware of this policy and understand their responsibilities.

Monitoring and evaluation

Bloom Healthcare will monitor and evaluate the effectiveness of this policy on an ongoing basis, using feedback from employees, clients and customers, as well as data detailed on the Incident Register. The Director/s and management team will be responsible for ensuring that the policy is implemented effectively, and that progress is tracked and reported to relevant stakeholders. Employees and contractors are encouraged to provide feedback and suggestions for improving the policy and related procedures.

What this means for you as a participant or family member

What counts as an incident

Under the NDIS rules, an incident is an act, omission, event or circumstance that happens in connection with providing NDIS supports and that has caused harm, or could have caused harm, to a person with disability. It also covers acts by a person with disability, occurring in connection with their supports, that cause serious harm or a risk of serious harm to someone else.

Two things follow from that definition, and they surprise people. First, an incident does not have to have caused actual harm — a near miss counts. Second, an incident does not have to be proven. Alleged incidents are still incidents, and providers are required to record and respond to them as such.

The reporting timeframes

A reportable incident is a narrower category that a registered provider must notify to the NDIS Commission, not just record internally. This obligation exists regardless of how the provider has handled the matter internally.

Within 24 hours of becoming aware of the incident, the provider must submit an Immediate Notification Form for a death, serious injury, abuse or neglect, unlawful sexual or physical contact or assault, sexual misconduct, or an unauthorised restrictive practice that has resulted in harm.

Within 5 business days, a 5 Day Form must be submitted, giving further information and describing what has been done. For an unauthorised restrictive practice that has not caused immediate harm, this is the only form required.

Failing to report within these timeframes can result in an infringement notice or other compliance action against the provider.

Restrictive practices

The Commission regulates five categories of restrictive practice:

• Seclusion — sole confinement in a room or space where the person cannot leave voluntarily, or is led to believe they cannot.
• Chemical restraint — medication or a chemical substance used primarily to influence behaviour. This does not include medication prescribed by a doctor to treat a diagnosed mental disorder, physical illness or physical condition.
• Mechanical restraint — a device used to restrict movement primarily to influence behaviour, not including devices used for therapeutic or non-behavioural purposes.
• Physical restraint — physical control of a person's body or movement.
• Environmental restraint — restricting access to areas or activities.

A regulated restrictive practice is only authorised when it is clearly written into a behaviour support plan, authorised by the responsible state or territory body, used as a last resort after other options are exhausted, used for the shortest possible time with a plan to reduce and eventually eliminate it, proportionate to the actual risk of harm, and the least restrictive option available.

Behaviour support plans have their own requirements. An interim plan must be developed within 1 month of a specialist behaviour support provider being engaged, and a comprehensive plan within 6 months. The plan must contain a functional behavioural assessment and specific evidence-informed strategies. The participant and their family, guardian or other relevant people must be consulted, and the details of any regulated restrictive practice must be provided in plain English. Plans containing regulated restrictive practices must be reviewed if the person's circumstances change, and at least every 12 months. Their use is reported to the Commission monthly.

Every unauthorised use is a reportable incident.

Your rights when something happens

Immediate support. Workers are required to meet your immediate needs first, including first aid and medical attention, before anything else.

To be told. You are entitled to know what actions were taken immediately and what is planned in response to what happened to you.

To be heard. Procedural fairness means everyone affected gets an opportunity to give their account and to comment on any adverse views formed about them. That applies to you.

To have the policy. The incident management policy and process must be given to you during onboarding, by email or hard copy, and at any time you ask for it again.

To be safe from retaliation. Providers and workers must not threaten you, obstruct you, or retaliate against you for raising a concern or making a complaint. That is not a courtesy — it is a Code of Conduct obligation and it carries penalties.

To escalate. If you are not satisfied with how something has been handled, you can take it to the NDIS Commission for independent review. You do not need the provider's permission and you do not need to have exhausted their process first.

To bring someone with you. Independent advocacy support is recognised under the NDIS Act. See the advocacy policy.

Incidents and complaints are different things

An incident is an event, or alleged event, during or because of service delivery that has caused or is likely to cause significant negative impact on health, safety or wellbeing.

A complaint is an expression of dissatisfaction about a staff member or the service. It goes through the complaints management and resolution system rather than incident reporting.

The same situation can be both, and raising one does not preclude the other.

Raising something with Bloom

Feedback can be given through written surveys, conversations with staff, or anonymously. If you make a complaint, the process is:

1. You submit it — by phone, email, the feedback page, or in conversation.
2. A staff member is appointed to investigate and resolve it. The Director or their delegate writes to you confirming it has been received and giving a date by which Bloom expects to have resolved it.
3. It is investigated and a plan to resolve it is developed. You are told about that plan and given the chance to say what you think of it.
4. You tell Bloom whether you are satisfied with the outcome.

You are entitled to make a complaint without a staff member reacting badly to it.

Escalating to the NDIS Quality and Safeguards Commission

The Commission is the independent federal regulator. It registers providers, audits them against the NDIS Practice Standards, publishes and enforces the NDIS Code of Conduct, runs the worker screening system, regulates behaviour support and restrictive practices, and receives reportable incidents and complaints.

Anyone can complain to it — a participant, a family member, a carer, a worker, another provider, or any concerned person. Current phone, TTY, email and online form details are published at ndiscommission.gov.au, along with Easy Read materials. Interpreters can be arranged and complaints can be made anonymously.

The Commission can support you to raise the concern with the provider yourself, or talk to the provider on your behalf. Where a criminal offence may have been committed, it can refer the matter to police.

If it finds a breach, its options include imposing or changing conditions on a provider's registration, suspending or cancelling registration, issuing infringement notices, requiring corrective action or a compliance plan, banning individuals from working in NDIS roles, and referring serious matters to law enforcement or child protection.

The NDIS Code of Conduct

Eight obligations apply to every provider, their key personnel and their workers, registered or not: act with respect for individual rights to freedom of expression, self-determination and decision-making; respect the privacy of people with disability; provide supports and services safely and competently, with care and skill; act with integrity, honesty and transparency; promptly raise and act on concerns about matters affecting the quality and safety of supports; take all reasonable steps to prevent and respond to violence, exploitation, neglect and abuse; take all reasonable steps to prevent and respond to sexual misconduct; and not charge or represent higher prices for goods supplied to NDIS participants without reasonable justification.

Worker screening

Everyone in a risk-assessed role — any role with more than incidental contact with participants — and all key personnel must hold an NDIS Worker Screening Clearance. The check is run by state and territory screening units in coordination with the Commission and assesses whether a person poses a risk to people with disability. Clearances last up to five years.

You are entitled to ask whether the worker attending you holds a current clearance.

The three regulators, and which is which

Different kinds of incident go to different places.

• NDIS Quality and Safeguards Commission — safety and quality of NDIS supports, reportable incidents, complaints, behaviour support and restrictive practices, and worker conduct.
• Ahpra — registration of health practitioners. Concerns about the conduct, performance or health of a registered practitioner can go to Ahpra as well as, or instead of, the Commission.
• OAIC — privacy. A data breach or a breach of your personal information is reported there.

You can approach any of these directly. They are independent of each other and of Bloom. Note that the Commission is a different body from the NDIA, which administers plans and funding — check you have the right organisation's contact details before you call.

Common questions about incident management

Does something have to be serious before I report it?

No. A near miss counts, and so does something that could have caused harm but did not.

What if I am not sure whether it is an incident or a complaint?

Raise it anyway and say what happened. Bloom is required to work out which process applies. It can be both.

Can I report anonymously?

Yes, both to Bloom and to the NDIS Commission. Anonymity can limit how much anyone can follow up with you, so weigh that up.

Will making a complaint affect my services?

It must not. Retaliating against you, threatening you or obstructing you is a Code of Conduct breach and carries penalties.

Do I have to complain to Bloom before going to the Commission?

No. You do not need the provider's permission and you do not need to have exhausted their process first.

How quickly does a serious incident have to be reported?

Most reportable incidents must be notified to the Commission within 24 hours, with a further form within five business days.

Will I be told what happened after an incident involving me?

You are entitled to know what was done immediately and what is planned in response.

What if I think a restrictive practice was used on me or my family member?

Ask whether it is in an authorised behaviour support plan. If it is not, it is unauthorised, and every unauthorised use is a reportable incident that must go to the Commission.

Can I bring an advocate?

Yes. Independent advocacy is recognised under the NDIS Act and providers must cooperate with advocates.

Where do I get a copy of the policy?

It is provided during onboarding by email or hard copy, and at any time on request. Call 1300 771 465.

Contact

Registration no: 4-JR6F5KX
Provider no: 4050148863

• Phone: 1300 771 465
• Email: hello@bloom-healthcare.com.au
• Hours: Monday to Thursday 7:30am–6pm, Friday 7:30am–5pm, Saturday by appointment
• Feedback and complaints

Related policies

• Emergency management policy and disaster plan — how services continue, or are safely suspended, during an emergency
• Advocacy policy and your right to an advocate
• Feedback and complaints