Community Visitors Annual Report 2014–2015 Mental Health

Transcription

Promoting the human
rights, interests and
dignity of Victorians
with a disability or
mental illness
Community Visitors
Annual Report
2014–2015
Mental Health
Residential Services
Disability Services
Malcolm Sturrock
Sail boat, 2012
gouache on paper
28 x 38cm
Community Visitors Annual Report 2014–2015
© 2015 Office of the Public Advocate
ISSN 1836–3296
Cover
The artwork which inspired the design of this annual
report is by Malcolm Sturrock.
Sturrock has been a member of the studio at Arts
Project Australia since 1993.
His repertoire comprises painting, printmaking,
3D construction and ceramics. He has an eclectic
approach to his art practice and often explores a wide
range of themes and motifs including ships, animals
and landscapes.
Sturrock is a mixed-media artist who utilises a wide
range of techniques and materials that best suit the
subject he is investigating.
Several of Sturrock’s early drawings and paintings were
collected in the 1970s and are now part of Arts Project
Australia’s Sidney Myer Fund Permanent Collection.
He has exhibited in 12 group shows and his work is
included in private collections.
OPA chose Sturrock’s ‘Sail boat’ for this annual report
because a boat on choppy seas is an apt metaphor for
the continuing rough ride experienced by many people
with a disability, a mental illness or other vulnerability in
accessing dignified, safe and effective care and support
where they live.
Printed on Ecostar, a recycled and
environmentally responsible paper stock
made carbon neutral with 100% post
consumer recycled waste and Forest
Stewardship Council certification.
The bright colors of the yacht sails represent Victoria’s
volunteer Community Visitors who lend their eyes and
ears on behalf of the community to monitor facilities
and report on good or poor practices for these fellow
Victorians in their annual report to Parliament.
Office of the Public Advocate
Level 1, 204 Lygon Street, Carlton, Victoria 3053
Local call: 1300 309 337 TTY: 1300 305 612
Fax: 1300 787 510 DX 210293
www.publicadvocate.vic.gov.au
Ordered to be printed
VICTORIAN GOVERNMENT PRINTER
September 2015
Parliamentary Paper No. 72, 2014–2015
The Hon. Martin Foley MP
Minister for Housing, Disability and Ageing
Minister for Mental Health
Minister for Equality
Minister for Creative Industries
Level 22, 50 Lonsdale Street
MELBOURNE VIC 3000
30 August 2015
Dear Minister
RE: COMMUNITY VISITORS ANNUAL REPORT 2014-2015
In accordance with the Supported Residential Services (Private Proprietors) Act 2010, the
Mental Health Act 2014, and the Disability Act 2006, please find enclosed the 2014-2015
Annual Report of the Community Visitors Residential Services, Mental Health and Disability
Services Boards.
This year’s report continues to reflect their findings in relation to the disturbing propensity of
reports about abuse, neglect and exploitation of residents and consumers when in the care
of others – in this case, service providers.
It also highlights the lack of community engagement for residents and the limits to their
opportunities, as well as the dearth of therapeutic activities for consumers.
The findings have been drawn from 5367 visits by 416 Community Visitors across the state.
The Community Visitors Boards commend the report to you and thank you for your support
of the program to date.
According to Community Visitors, there is still important work to be done to prevent
fellow Victorians with a disability from being abused, neglected and exploited. Community
Visitors are the principal ambassadors of the Interagency Guideline on Abuse, Neglect and
Exploitation (IGUANA) across services and they expect to report to you next year in relation
to their work against that.
In the meantime, they look forward to continuing to work with you to maximise the
opportunites for citizens with a disability in residential and care environments.
Yours sincerely,
Colleen Pearce
Public Advocate and Chairperson of the Combined Board
4
Contents
4
Letter of transmission
6
Message from the Public Advocate and Chairperson
10
Introducing the Combined Board
12
About Community Visitors
13
Reporting Regions/Divisions
14
Mental Health
Statewide Report and Recommendations
64
Disability Services
25
Regional Reports:
72
Regional Reports:
72
84
94
104
Appendices
25
26
28
29
30
31
34
37
40
Barwon-South Western Region
Eastern Metropolitan Region
Gippsland Region
Grampians Region
Hume Region
Loddon Mallee Region
North and West
Metropolitan Region (North)
North and West
Metropolitan Region (West)
Southern Metropolitan Region
44
52
Regional Reports:
52
54
55
56
57
58
59
60
61
Gippsland Region
Grampians Region
Hume Region
North and West
North and West
Metropolitan Region (West)
East Division
North Division
South Division
West Division
114
Community Visitors
2014–2015
116
Facilities eligible to be visited by
Community Visitors 2014–2015
118
Acronyms
Message from
the Public Advocate
and Chairperson
The value of the Community Visitors
Reporting of abuse and neglect
Community Visitors voluntarily commit
their private time, on behalf of the Victorian
community, to monitor the treatment, care and
effectiveness of services and facilities for fellow
citizens with a disability or a mental illness.
Community Visitors have been intensively monitoring
and reporting incidents specifically related to abuse,
neglect and assault since 2009–2010. Since then,
1145 incidents have been reported (half in Disability
Services), including troubling cases of assault by
staff, serious and unexplained injuries, and people
living in fear of violence.
The group homes, supported residences and
mental health facilities that received their 5367
visits over the past year are subject to state laws
and regulations that require them to provide safe
and effective care and treatment.
High-profile cases of abuse, and the subsequent
dismissal of staff committing abuse, confirm the
Boards’ concerns of a systemic problem.
265
287
209
183
110
100
50
14/15
13/14
12/13
11/12
10/11
0
stream
6
Mental Health
Total
200
150
They are the backbone of the program.
I commend them for their resilience, energy
and commitment.
Disability Services
250
91
I would particularly like to acknowledge the
valuable work of Regional Convenors who
support teams of volunteer Community Visitors all
around the state. They shoulder additional duties
and provide extra time and energy to support the
Community Visitors Program. They are the first
point of contact, not only for their Community
Visitors, but also for service provider management
who they meet on a regular basis. They are
responsible for addressing and resolving complex
issues and spend many hours entering data into
our database to make this report possible.
300
09/10
Community Visitors are dedicated and selfless
in their work and help OPA fulfil its mission of
promoting and protecting the rights and interests
of people with a disability. They are an important
element of Victoria’s social capital.
number of issues identified
However, Community Visitors are a unique
‘double check’ that these frameworks are being
adhered to with the results the community
expects. They are the eyes and ears of ‘us’,
the average citizen, that all is well - or not - for
residents and patients.
Figure 1: Community Visitor reports of abuse, neglect and
assaults, 09/10 to 14/15
It is pleasing to note a decrease in the number
of incidents reported in Disability Services this
year over last, but reports continue to climb
in Mental Health and Supported Residential
Services (SRS). This is in part because of higher
awareness of abuse and violence in the former
sector thanks to Community Visitors and media
coverage of their findings, but is not so much
the case yet in mental health and SRS.
The majority (74 per cent) of these Notifications
(Table 1) concern clients in disability residential
services and all of Notifications across the three
streams concerned allegations of assault, neglect,
abuse and violence.
Without Community Visitors, more people with
disabilities and mental illness would be victims
of abuse, neglect and exploitation. There is no
doubt of this, as report-after-report over the
last 27 years testifies.
In recent years, staff-to-resident abuse has
been reported in all settings. This year’s
annual report highlights resident-to-resident
abuse as requiring much more attention by
way of increased staff training, resources and
alternative accommodation options.
Abuse inquiries
Inquiries into violence and abuse of people with
disability in institutional settings have been a
feature in the policy environment this year with
three announced within months of each other:
The case study at the end of my message
highlights resident-to-resident issues.
• the Victorian Ombudsman investigation into
the reporting and investigation of allegations
of abuse in the disability sector
Notifications to the Public Advocate
The Boards, under their relevant Acts, can
report a matter to the Public Advocate. A
Notification process to the Public Advocate
from Community Visitors was implemented in
2010-11 to ensure that sexual assault, serious
abuse and other serious matters get the
attention they deserve.
Year
•
the Senate Community Affairs References Committee’s inquiry into violence, abuse and neglect against people with disability in
institutional and residential settings
• the Victorian Parliamentary Inquiry into abuse
in disability services.
Disability residential services
Mental health services
Supported residential services
2010–11
13
6
1
20
2011–12
21
4
5
30
2012–13
17
3
2
22
2013–14
20
7
0
27
2014–15
16
3
2
21
87 (72%)
23 (19%)
10 (8%)
120
Total
Total
Table 1: Notifications to the Public Advocate, 11/15 (The total is less than 100% due to rounding)
7
Community Visitors made an important contribution
to all three inquiries and the Community Visitor
Disability Board presented to the Victorian
Parliamentary Inquiry in June.
Understandably, many of the submissions to
these inquiries, especially from families and carers,
expressed continued frustration and distress at the
lack of progress in addressing issues of abuse in
these settings.
Community Visitors, as you will read in this
year’s annual report, are united with them in their
resolution and determination to execute their legal
function to defend the human rights of the residents
and patients and do what they can to bring the
community’s attention to these serious issues.
Mental health
Attacks on mental health staff and on patients by
other patients is a serious concern for Community
Visitors. Some patients and mental health staff are
traumatised by this, resulting in precious work days
lost and set backs in patient recovery.
as a form of suitable accommodation for people
with chronic mental ill health must be addressed.
The protocol in development by the department
between the mental health and the SRS sectors
has stalled for over two years. Community Visitors
recommend that this be finalised as a matter
of urgency.
A further issue highlighted by Community Visitors
in relation to SRS is the declining number of beds
in this sector over the last year. This year, 135 beds
were lost with the closure of three regional SRS,
a concerning development given the continued
projected increases in the Victorian population
and commensurate increase in need.
There is a chronic shortage of accommodation
options for people with an intellectual disability.
Adults and children continue to live long-term in
facilities established to provide short-term respite
breaks for residents and their families. In turn, this
means families in need of respite are unable to
access these much-needed services.
Community Visitors highlight in this report the
lack of meaningful and recovery-orientated
activities in services, and the inability of some
services to secure the patient’s right to an
independent second psychiatric opinion, as
factors in patients becoming bored, frustrated,
and despairing of their chance for recovery.
For some residents of group homes, the lack of
accommodation options has dire consequences.
In case studies in this annual report, Community
Visitors report on troubling situations where
residents who are obviously incompatible, remain
living in abusive situations. Service providers
often cite the lack of alternative accommodation
as the reason residents continue to live in such
circumstances.
Accommodation issues
Supporting staff to deliver quality care
The lack of appropriate accommodation
options following discharge from mental health
inpatient care remains an abiding issue for
Community Visitors.
Scattered throughout this report are numerous
good practice case studies that illustrate how
dedicated and professional staff make a valuable
and important contribution to the lives of many
people with an intellectual disability or a mental
illness. Their knowledge, experiences and skills are
acknowledged along with the important role they
play in enhancing the quality of life of the people
they care for.
Under the new Mental Health Act, Community
Visitors have the right to monitor the Prevention
and Recovery Care centres (PARCs), which they
have found an excellent new step-down service,
however, these stays are limited to 28 days. The
most vulnerable public mental health patients are
routinely discharged, following inpatient treatment
to SRS.
While there have been improvements in SRS in
recent years as a result of additional funding from
the state government, they are, nevertheless,
dangerously ill-equipped to provide the support
needed to residents with serious and ongoing
mental health needs. Longer-term, the SRS model
8
Staff sometimes work in challenging situations
that demand patience, creativity and ingenuity.
Community Visitors report on situations where the
staff support has been crucial in securing better
outcomes for the person with a disability and in
supporting their participation and inclusion in the
wider community.
With the roll out of the NDIS to full scheme, the size
of the disability workforce will more than double
in the coming years. The expansion of the service
system will need to be supported by an adequately
skilled and appropriately trained workforce to
meet the demand for services. There is need for a
more coordinated approach to the training of staff
across the sector and the difficulties in attracting
and retaining good staff must be addressed by
governments and service providers.
NDIS
Community Visitors in Disability Services have
noted that the NDIS trial in Barwon is proving
to be of significant benefit to many people with
a disability.
This is a historically significant program of the
federal government and is to be applauded. It
carries the promise of intergenerational change
for many Australians. However, there are issues
for people with an intellectual disability having
their support needs better understood.
Community Visitors welcome the NDIS
acknowledgement of this by establishing an
Intellectual Disability Reference Committee. It
will advise on the effectiveness of the scheme’s
design and how NDIS can better engage and
connect with people with intellectual disability
to enable them to live fulfilling lives.
Community Visitors have also noted the
establishment of the NDIA Mental Health Sector
Reference Group to provide expert advice about
the progressive integration of psychosocial
disability into the scheme.
The requirement of the NDIS legislation, that
clients have a permanent and enduring disability
to qualify for long-term support, is at odds with
the recovery model of mental health. Anecdotally,
Community Visitors have reported that it is deterring
some people who need the long-term support
NDIS can offer, from engaging with the scheme
at all. Those who decide to commence their NDIS
application, find they have to grapple with very
mixed messages about their future potential.
Finally, I would like to thank all Community Visitors
who have worked so diligently during the year on
behalf of their fellow citizens, the residents and
patients they visit and the families and carers who
share their passion for rights.
On behalf of the Victorian community, I
acknowledge and express my appreciation for
their service.
case
study
One Disability Accommodation Service
house run by the Department of Health and
Human Services (DHHS) was the subject of
two notifications and repeated advocacy by
Community Visitors, this year.
In August 2014, Community Visitors noted
numerous assaults (throwing, kicking and
punching) initiated by a young man towards
his older co-residents (50 years plus) as well
as to staff. Community Visitors also noted poor
practices relating to the completion and filing of
incident reports and the absence of documented
behaviour strategies and staff training to respond
adequately to behaviours of concern.
The Public Advocate contacted the executive
director of the region for reassurance that the
residents were safe and that any on-going
threat to their safety was being addressed.
In response, DHHS acknowledged that, in the
period January to December 2014, there had
been 28 incident reports submitted that related
to physical assaults and occasions where the
younger resident had attempted to pull down
the pants of the older residents.
Despite this, the department concluded that
they had “no evidence to substantiate the
concern regarding resident compatibility”.
In May 2015, Community Visitors reported
another 12 category-two incidents in the
same house involving assaults to co-residents
since January and expressed their ongoing
concern about the serious emotional and
physical risk to the older residents at the house.
At a meeting in June 2015, DHHS advised
Community Visitors that the younger resident
was placed on the Disability Support Register
for alternative accommodation but no suitable
vacancies were currently available for him.
DHHS also advised that they had been trying
to engage a particular behavioural expert to
work with staff in the management of behaviours
at the house, but there was a long wait for this
specialist assistance.
Colleen Pearce
Public Advocate and
Chairperson of the Boards
9
Introducing the
Combined Board
Above (L-R): Dawn Richardson (RS); Dave Parker (RS); Rosemary Shaw (OAM, DS); David Roche (DS); Mike Hadley (MH); Jim Paterson (MH); Public
Advocate Colleen Pearce (Chair).
Colleen Pearce
Public Advocate and Chairperson of Mental
Health, Residential Services and Disability
Services Boards
Ms Pearce has over 30 years experience in
the community and health sectors and has
spent her working life helping society’s most
disadvantaged people, and advocating for a
better deal on their behalf.
Ms Pearce is a proud Yuin woman whose country
is in New South Wales. She served her first term as
Public Advocate 2007–2014. This is her second term.
Colleen is also a member of the:
• Victorian Equal Opportunity and Human
Rights Commission Board
• Connecting Home Board, an organisation providing services to the Stolen Generations.
In 2003, Ms Pearce received a Commonwealth
Centenary Medal for her contribution to
community services in Victoria.
10
Community Visitors
Mental Health Board
Mike Hadley
Mr Hadley was born in Birmingham, England, and
spent most of his working life in the aircraft engine
industry in Coventry.
He arrived with his family in Australia in 1981 to
take up the position of Chief Inspector Special
Projects (turbine blades) at ANI National Forge
in West Footscray, and has held various senior
inspection and quality assurance positions since.
After retiring his quality assurance consultancy,
and looking for a way by which he could contribute
something to the community, Mr Hadley joined the
Community Visitors Program ten years ago and is
a Regional Convenor in the Mental Health stream.
He joined the Community Visitors Mental Health
Board in 2013.
Jim Paterson
Mr Paterson was appointed as a Community Visitor
in 2010 and this is his first term on the Mental
Health Board. His academic qualifications include
MBA, BA, DipT(Sc) and Diploma of Social Science.
Community Visitors
Disability Services Board
David Roche
A National serviceman, he served on active service
in South Vietnam as an infantry officer. He continued
his Army service retiring as a Lieutenant Colonel
to accept a civilian appointment as an analyst and
Business Manager for the Department of Defence.
Mr Roche is qualified in public policy and
management, business management, project
management and training. He is an Associate
Fellow of the Australian Institute of Management
and a member of the Gippsland Regional Council
of Adult Community and Further Education.
On transfer to the Victorian Department of Justice,
he had responsibilities for courts administration and
the human rights of prisoners before retiring from
paid employment in 2009.
He lives in Korumburra, South Gippsland, and has
a history of active involvement in local and regional
community-based organisations.
Community Visitors
Residential Services Board
This is Mr Roche’s second term on the Disability
Services Board having served in 2009-2010. He
is Chair of the Combined Board’s Policy Review
Steering Committee, a Panel Secretary and a
former Regional Convenor.
Dawn Richardson
Rosemary Shaw OAM
Ms Richardson has a background in
telecommunications, training and disability. She has
served on the committee of management for the
Communications, Electrical and Plumbing Union
and has spent six years in a voluntary position
managing Food Relief.
Ms Shaw OAM has been an active Community
Visitor since 1999 and this is her first term on the
Disability Services Board.
She joined the Community Visitors Program in 2006
in the Western Region in the disability stream and is
now a Residential Services Community Visitor and
Regional Convenor in the Barwon Region.
Dave Parker
Mr Parker joined the Community Visitors Program
in 2004 and has been a Regional Convenor since
2006. This is his second term on the Residential
Services Board.
He is a retired former Royal Australian Navy
service man. While there, Mr Parker spent over
six years as an instructor in submarine daily
operations and electrical systems.
She worked part-time for Yooralla for eight years
until the end of 2014 providing one-on-one
personalised care services.
Her community activism is extensive; she
volunteers with the Young People in Nursing
Homes National Alliance supporting young people
in Aged Care and those likely to go into it due to
the shortage of suitable accommodation. She is
also a committee member with the Uniting Church,
supports the Royal Children’s Hospital and founded
Kids Under Kanvas, a camping program for children
and young people with disabilities, which is now
under the auspice of Wesley Mission.
In 2014, Ms Shaw was awarded an Order of
Australia for her service to the community through
volunteering with fourteen organisations, mainly in
the disability sector.
Previously, Mr Parker completed an Advanced
Welfare Officers course as he volunteered as
a Welfare and Pension Officer for the Warrandyte
Branch of the Submarine Association of Victoria
for many years. He was also a volunteer facilitator
in Nutrition Australia’s ‘Cooking for One or
Two’ program.
11
About
Community
Visitors
Community Visitors are independent volunteers
who safeguard the interests of people with a
disability. They are supported by the Community
Visitors Program which is part of OPA.
The program is organised into three streams to
reflect the type of services visited:
• Mental Health – visits are made to consumers and residents in mental health facilities providing 24-hour care
• Residential Services – visits are made to people who reside in Supported Residential Services (SRS) and require additional support
• Disability Services – visits are made to institutions and community-based facilities
for people with a disability.
Where an issue cannot be resolved at facility level,
it is usually taken to a more senior manager in the
agency and/or the departmental regional office.
Serious matters may be referred for action within
OPA and dealt with as part of the Public Advocate’s
broader powers.
While the vast majority of visits are scheduled and
unannounced, a significant number are in response
to specific complaints. This includes referrals to the
program via OPA’s Advice Service. On occasions,
repeated visits are necessary to certain facilities over
a short period in response to serious issues identified
and at the discretion of the Community Visitors.
The ongoing support, training and recruitment
of the Community Visitors and the boards is the
responsibility of staff in the Volunteer Programs Unit.
The legislative framework is derived from the
following Acts of Parliament:
• Mental Health Act 2014
• Supported Residential Services
(Private Proprieters) Act 2010
• Disability Act 2006.
The legislation establishes three respective
boards: Mental Health, Residential Services and
Disability Services. These boards are responsible
for reporting the activities, issues and findings of
the Community Visitors to the Victorian Parliament
each year, through the relevant minister.
Community Visitors are appointed for three years
by the Governor in Council. They are empowered
by legislation to visit specified facilities, to make
enquiries of residents and staff and examine
selected documentation in relation to the care of
people residing at the facilities. Community Visitors
usually make unannounced visits and visit in teams
of two or more.
At the conclusion of each visit, the Community
Visitors prepare a report summarising the findings
and indicating items where action is required. A
copy of the report is provided to the most senior
staff member at the facility or the proprietor in the
case of an SRS.
12
Stream
Community Visitors 14/15
Mental Health
77
77
Disability Services
262
Total
416
Table 2: Number of Community Visitors by stream, 14/15
Stream
Mental Health
Visits 14/15
1450
855
Disability Services
3062
Total
5367
Table 3: Number of Community Visitor visits made, 14/15
Reporting
Regions/
Divisions
Department
of Health and
Human Services
Former
Department
of Health
North & West
Metro
Eastern
Metro
Southern
Metro
Loddon
Mallee
Grampians
Hume
Barwon
South
Western
Metro
Gippsland
Regions
Mallee
Western
District
Loddon
Goulburn
North
Eastern
Melbourne
Former
Department
of Human
Services
Divisions
Hume
Moreland
Brimbank
Melton
Ovens Murray
Outer
Eastern
Melbourne
Outer Gippsland
Western
Melbourne
Central Highlands
Barwon
Bayside
Peninsula
Inner Eastern
Melbourne
North
Inner
Gippsland
Southern
Melbourne
West
East
South
13
Statewide Report and
Recommendations
Recommendations
Mental Health
The Community Visitors Mental Health Board
recommends that the State Government:
1.
amend the Mental Health Act 2014 to
ensure that Community Visitors have unfettered access to read and take copies
of incident reports relating to the treatment and care of patients
2. expand treatment and support options to:
• reduce waiting times in emergency departments and minimise aggression
• manage people with substance abuse issues and prevent the circulation of
illicit drugs in mental health facilities
•
better support people who have both a mental illness and an intellectual disability or neurodegenerative disorder as well as behavioural issues
• reduce inappropriate patient placements by adding to the capacity of acute, youth, aged and mental heath services
7. publish guidelines to ensure open air access for a minimum of 2 hours daily is available to
all patients
8.
finalise and distribute the Supported Residential Services and mental health service
protocol to improve the support of people discharged from mental health facilities
9. lobby the Commonwealth Government to maintain the Disability Support Pension to
all forensic patients
10.
increase the recurrent funding for the Community Visitors Program to engage sufficient numbers of specialist and administrative staff to support the work of
the volunteers and to recruit and train the number of Community Visitors required to visit all designated facilities on a regular basis and liaise effectively to address the issues
identified on visits.
• improve access to suitable accommodation upon discharge
3.
remove the impediments to patients accessing independent psychiatrists for
second opinions in accordance with the changes and funding provided under the
new Mental Health Act
4.
provide funding to engage social workers
and welfare workers to meet the high
demand for patient support during treatment
and discharge planning
5.
ensure meaningful therapeutic activities are available in all facilities through minimum standards related to activities and increased funding for occupational therapists
6. publish minimum response times for the repair of facilities and equipment that are a danger to patient health, safety or recovery
Mental Health
15
Statewide
Report
Key issues
During the year, Community Visitors have
enquired into, and reported on, 1330 issues
related to the treatment and care of patients
in mental health units as a result of 1450 visits
made by Community Visitors. Reported issues
included deaths in care, episodes of assault
and sexual assault, boredom aggravated by the
lack of meaningful activities, significant delays
in maintenance and facility upgrades, long
waits in emergency departments, constraints
in treatment options due to staff turnover and
recruiting lags, difficulties in accessing funded,
independent second opinions and a lack of
discharge options.
There were notable examples of dedicated and
professional care by nurses and clinicians in
treating people with complex needs, managing
complicated social welfare issues and sourcing
appropriate accommodation.
Creative solutions to mental health challenges
have been demonstrated not only by tailored
approaches to specific individual needs but also by
the Safewards Project which has helped reduce the
use of seclusion and restraint, and an expansion of
the Statewide Mental Health Police and Ambulance
Response scheme.
The introduction of the Mental Health Act
2014 proceeded relatively smoothly, however,
Community Visitors in some regions continued
to report difficulties in accessing and obtaining
copies of incident reports. The Ombudsman’s clear
recommendation in October 2014 was that facilities
should provide incident reports to Community
Visitors and the former Department of Health
accepted this recommendation.
Challenges in mental health
The range of specialist units treating mental
illnesses across country and metropolitan regions
is extensive. Mental Health Community Visitors visit
children’s, adolescent’s, and adult acute units; brain
disorder, veterans’ post-traumatic stress disorder,
aged persons acute and residential, personality
disorder, mood and eating disorder, emergency
departments, forensic mental health units,
Community Care Units (CCU) and Secure
Extended Care Units (SECU).
Since the commencement of the new Act on 1
July 2014, Community Visitors have also visited
21 Prevention and Recovery Care (PARC) units
located throughout Victoria. While there was some
initial confusion surrounding the role of Community
Visitors at one or two of these services, overall,
the visits to these services have gone well and
Community Visitors have been impressed with
the standard of care provided at PARCs.
This complex range of facilities and diversity of the
patients in them presents an interesting challenge
to our volunteer Community Visitors. The Board
acknowledges the rich mix of life experiences
the Community Visitors bring to their visiting
and advocating for the human rights and care of
persons in Victoria’s mental health system. Each
visit concludes with the completion of a written
report for the facility manager and these reports
and service provider responses form the basis
of this annual report.
A shortage of volunteers in some places such
as Mildura and Geelong, has meant that some
facilities have been unable to be visited monthly.
The program continues to try and recruit in these
difficult areas. Some regions have also chosen not
to visit extraordinarily busy emergency departments
due to the difficulty of not adversely impacting on
their function.
The Community Visitors Mental Health Board
acknowledges the extent of the challenge facing not
only people with a mental illness and their families,
but also clinicians, nurses, allied health staff, and
carers as they try to function effectively within an
under-resourced system facing constant demand.
16
Mental Health
No. of units visited
No. of CVs
Requested visits
Scheduled visits
Total visits
Mental
Health
Stream
7
5
7
15
22
19
13
28
212
240
Gippsland
5
3
3
67
70
Grampians
8
4
1
81
82
Hume
11
9
6
141
147
Loddon Mallee
10
6
22
81
103
Northern Metropolitan
24
11
27
229
256
Southern Metropolitan
35
15
44
234
278
Western Metropolitan
21
11
16
236
252
140
77
154
1296
1450
Region
Barwon-South Western
Eastern Metropolitan
Total
Table 4: Total visits Mental Health Stream 14/15
The Mental Health Act 2014
The implementation of the Act required extensive
preparation by all service providers and that worked
fairly well. This included briefing sessions and
written material for patients, families and carers.
However, Community Visitors continue to note
issues related to their access to incident reports
and patient access to second opinions.
Access to incident reports
In the course of their enquiries, it may be necessary
for Community Visitors to obtain a copy of an
incident report. While Community Visitor access to
incident reports has improved in many regions this
year, there are still instances where hospitals resist
providing them or the reports have redactions that
limit their usefulness.
Mental Health
The Board believes that the Act needs to be
amended to clarify the right of Community
Visitors to both view and take copies of incident
reports as part of their functions.
Independent second opinions
A frequent early complaint by a compulsory
patient to a Community Visitor is ‘I am not unwell,
I don’t belong here.’ In many instances, this leads
to a request for a second opinion about their
assessment as a compulsory patient.
Community Visitors welcomed the government’s
announcement of an allocation of $1 million in
the 2014-2015 budget to fund the provision of
second opinions by independent psychiatrists.
However, a number of acute unit patients
complained that second opinions were only
available from other psychiatrists employed by
the same public provider. Independent second
opinions from private psychiatrists were not
available. Discussions with the department
revealed that the administrative arrangements to
engage and pay for independent second opinions
have yet to be finalised. There have been
Medicare arrangement complications and the
issue remains unresolved. The Board will continue
to pursue this issue with the department.
Anecdotally, there appears to have been
little uptake in advanced statements or the
identification and naming of nominated persons
to date.
After some early delays, patient access to
hearings by the new Mental Health Tribunal
appear to be running smoothly with appropriate
support for patients by their treating teams.
The new Act and the new bodies instituted by
the Act required the preparation of protocols to
assist in smooth working relationships with the
Community Visitors Program. The Board and
OPA staff will continue to finalise operational
protocols with the Department of Health
17
and Human Services (DHHS), Mental Health
Complaints Commissioner and the new Mental
Health Advocacy Service managed by Victoria
Legal Aid.
Other serious incidents
Serious incidents and assaults
• Assaults – patient to patient and patient to staff (including attempted strangulations and the stabbing of a patient with a broken radio aerial)
Deaths in care
Community Visitors reported a number of deaths
in care over the reporting year. In all these
instances, the deaths had been reported to the
Chief Psychiatrist and the Coroner. Coronial
investigations can take some time – two years
is not unusual. Typically, mental health facilities
conduct internal reviews of these incidents and
identify systemic and other issues relevant to
the incident. It is common for Coroner’s reports
to include a range of recommendations that the
facility will refer to as ‘already implemented’.
Community Visitors are always concerned about
deaths in services and appreciate being informed
of changes to protocols or procedures initiated by
subsequent internal reviews. OPA pursues these
issues where appropriate.
80
70
67
60
55
50
40
30
20
10
0
13/14
14/15
reporting year
Figure 2: Mental Health Stream assaults and violence
12/13 to 14/15
18
• Sexual assaults – patient to patient and patient to staff (including sexual aggression and sexualised behaviour)
•Self-harm
•
Patient violence (including the invasion and trashing of the nurses station, setting fire to a patient’s room, damage to unit furniture, fittings and facilities)
These episodes are reported in more detail in the
regional reports that follow.
The extent of aggression in units treating acutely
unwell patients is of great concern.
Patients have a right to feel safe and to be safe.
Community Visitors are frequently approached by
patients who say they don’t feel safe. Sometimes
that feeling is associated with the patient’s illness
and a previous experience of trauma. Sometimes
it is triggered by witnessing a violent outburst or
assault in the unit. Certainly, people can be at
risk because of the physical limitations of the unit
design, the patient mix, or competing demands
on staff. In two regions, patients reported being
afraid of a patient with Huntington’s disease
who was aggressive and/or sexually uninhibited.
Whatever the reason, patient safety should never
be compromised and efforts to improve safety need
to be ongoing and of the highest priority.
Staff safety and wellbeing is also at risk in mental
health facilities. Sick leave because of injury and
the long-term effects of stress on staff also affect
patients and their families: directly, on the quality of
care provided, and indirectly, through the impact on
health budgets. These issues have been discussed
with Community Visitors at liaison meetings in a
number of regions.
39
12/13
Community Visitors have reported on a number of
serious incidents in adult acute, youth units and
SECUs. These include allegations of:
In relation to almost all incidents reported, providers
appeared to respond appropriately with referrals
to police, on-call psychiatrists and counsellors.
Nonetheless, the risk of violence in acute and
SECU is ongoing and of serious concern. Patients
who approach Community Visitors saying they feel
unsafe have their concerns referred to staff who
invariably provide additional support.
Mental Health
550
500
450
498
400
350
300
198
200
150
Illicit drugs
50
safety
activities/programs
facility management
treatment
0
legal/human rights & information provision
Patients with drug addictions including the drug
Ice present a particular challenge, not only to their
own welfare but to that of other patients when
drug dealing occurs in the units. Hospitals have
responded with a number of measures which have
included searches by drug sniffer dogs, frequent
and unannounced room searches, the provision
of lockers for visitors, restrictions on visitors, and
restrictions on unescorted leave.
100
issue groups
Community Visitors were informed of several
episodes where illicit drugs had been introduced to
the units and consumed by patients with dangerous
impacts on their health and mental stability. The
methods of introduction have included smuggling
of illicit drugs by visitors and patients returning from
leave, and drugs tossed over fences or slipped
under doors. Patients are routinely advised of the
dangers associated with taking unprescribed, and
even non-prescription drugs, in combination with
their prescribed medication regime. The effects are
unpredictable and harmful.
190
269
250
175
The intensity of workload on staff in acute
units is significant. By way of example, DHHS
statistics reveal that a typical 25-bed acute unit
in the Northern Metropolitan Region manages
approximately 500 admissions and 500 discharges
a year where the average length of stay is around
12 days. The constant influx of acutely ill patients
co-located in acute units with patients on the way
to recovery and discharge presents a very difficult
management challenge. Bed spaces are under
constant pressure and there are limited areas
for staff to manage patients who need intensive
support and supervision.
Figure 3: Mental Health Stream by issue groups 14/15
Treatment and care
Safety and security
In some regions, Community Visitors regularly and
repeatedly report issues related to the locking of
units or facilities within units. These include the
locking of garden and courtyard areas and activity
rooms. Episodes of aggression, importation and
consumption of illicit drugs, the risk of potential
absconding (over low walls) and general concerns
for patient safety and security are the stated
justifications for the locking of facilities.
While some areas are locked to ensure patient
safety, in some facilities this has meant that large
numbers of patients spend their entire stay indoors,
which is totally unsatisfactory.
Mental Health
Community Visitors recorded 498 issues related to
the treatment and care of people with a disability,
however, many of their observations of staff are
positive. Many patients contact a Community
Visitor via OPA’s Advice Service after they are
first admitted to an acute unit, when they can be
acutely unwell and highly anxious or agitated.
Common complaints include: ‘I am not sick,’. and
‘I don’t belong here,’ ‘The medication isn’t right
for me,’ ’I don’t want injections,’ and ‘I am being
held against my will’. Some patients complain they
are not being treated respectfully by nursing staff.
Other patients are understandably worried about
who will look after their children, families, pets,
rent, and gardens. These concerns are sometimes
complicated by difficult family circumstances or a
lack of community supports.
19
issue types
treatment (incl. all aspects of psychiatric care incl. ECT)
209
information provision
138
maintenance and new works
123
discharge issues
97
availability/suitability programs
84
medical care (non-psychiatric)
80
legal rights
65
general appearance and cleanliness
61
hazards/safety issues
60
program staff
53
assaults inc. sexual assault
47
suitable facilities/equipment for programs
38
least restrictive environment
38
aggression, intimidation, harassment
37
dignity
35
smoking provisions
31
admission process/emergency department issues
27
food/catering
26
privacy
17
Illicit drug and alcohol issues
15
environmental hazards
14
restraint and seclusion
12
availability/suitability of beds
9
security of possessions
8
ethnic and cultural sensitivity
4
gender sensitivity
2
number >
0
50
100
150
200
250
Figure 4: Mental Health Stream number and types of issues identified 14/15
20
Mental Health
case
study
The right to communication is a basic right
that should not be limited without good cause.
Community Visitors report a range of practices
and complaints related to patient access to
mobile phones and landlines. Some patients
have expressed frustration at having their phones
removed or at being unable to recharge them.
Personal mobiles are sometimes removed when a
patient is photographing other patients or making
offensive or repeated calls to external parties.
A treating psychiatrist may direct the confiscation
of a patient’s mobile phone to reduce the patient’s
level of agitation. Access to a phone in the unit is
usually available to enable essential communication.
However, in one service in the Western Metropolitan
Region, Community Visitors reported, for some
months, that a pay phone was out of action and in
need of repair before it was finally fixed.
Some patients raise objections about their
medication regime and possible side effects.
Community Visitors refer these complaints to
clinicians and their experience over many instances
of such referrals is that medication reviews are
frequent and ongoing. Where specific medications
have had previous adverse reactions, this should
normally be noted in a patient’s medical file. This
is an area to which advance statements can
contribute, as clinicians need to have regard to
these when making treatment decisions. Community
Visitors expect to see more patients take up this
option as they become more familiar with the
new arrangements. The practical management of
these statements will present challenges as the
circumstances of a person’s admission may impede
the ability to locate the document.
Community Visitors have seen a number of
instances where a patient’s illness appears
extremely resistant to treatment. These situations
can place extraordinary demands on treating teams
and often require social welfare support.
Social welfare
The importance of social workers and their
role is consistently reported by Community
Visitors. In addition to the complexity of the
illnesses themselves, patients can have a
complex mix of social concerns that trouble
and frustrate them. Issues include child care,
marital and family disputes and dysfunction, pet
care, rent maintenance, home repairs, suitable
accommodation and post-discharge support.
Mental Health
A female patient was admitted to a SECU after
a stay in another hospital acute unit. Her
psychiatrist determined that her illness and dual
disability, with outbursts of aggressive behaviour
towards staff and patients, required a different
environment and approach.
The patient’s aggressive behaviour continued in
the SECU with assaults on fellow patients and staff.
The police were called on some occasions. It is
notable that the person’s co-patients demonstrated
great understanding of her struggle, including a
male patient assaulted by her: “It’s not her fault –
she is unwell.”
The patient’s outbursts and treatment were subject
to ongoing review by her treatment team and the
hospital’s Critical Incident Review Committee.
The patient was introduced to a behaviour
modification program that resulted in improvements.
The patient eventually progressed to escorted leave
each day and her mother (the patient’s long-term
carer) was involved in treatment options.
There was continuing review by the treating team
to develop appropriate approaches the patient’s
illness. Discharge and accommodation support
options were researched and funding sourced to
support treatment options.
The resources involved in the patient’s treatment
over several months were extensive and involved
psychiatrists, nurses, social workers at the hospital,
her mother, a community agency, DHHS, a case
manager and an OPA guardian. Her recovery is still
incomplete but the degree of care from the SECU
was exemplary.
These issues can exacerbate agitation, impede
recovery, and present obstacles to safe and
timely discharge. They contribute to the severe
bed management challenge facing acute and
SECU facilities.
Social work and nursing staff activity in this
area is intensive. There are many examples
where the support provided is well beyond
what might be expected.
Community Visitor reports demonstrate that there
is greater demand for social welfare support than
the resources to provide it. The social worker role
in assisting people to find appropriate discharge
accommodation is complicated by the severe
lack of appropriate accommodation options.
21
Seclusion and restraint
Despite the instances of aggression noted earlier,
there has been an overall reduction in the episodes
of seclusion and restraint recorded in Victorian
mental health facilities. Factors contributing to
this improvement include the increased availability
of low intensity rooms, gender specific areas,
hospital driven attention to seclusion practices
and increased focus and publication of seclusion
statistics. However, some Community Visitors
have also reported an increase in the use of High
Dependency Units (HDU) to contain patients
previously held in seclusion.
Further reductions in the use of seclusion and
restraint are desirable. The implementation of the
Safewards trial in a number of acute and other
mental health facilities across the state may assist
this. Seven regional and city-based services have
involved 18 acute, SECU, adolescent, youth, and
aged mental health units in the trial, which aims to
make mental health units calmer and more pleasant
places for people to safely recover, work and visit.
The trial proper commenced in March 2015 and will
run for 12 months. Staff comments to Community
Visitors have been supportive of the initiative.
Hospital staff report improvements in general
mood as well as reductions in seclusion episodes.
Community Visitors look forward to the completed
evaluation and report of the trial.
Incompatibility/Inappropriate placement issues
Community Visitors periodically note inappropriate
patient placements. These can range from placing
acute patients with non-acute, young patients with
aged, geographic remoteness of a patient from
family and carers and the co-location of patients
with active minds with patients with dementia or
brain injury. These placements cause distress to
both patients and their families. While the turnover
in most acute units is high with an average length
of stay of less than a fortnight, Community Visitors
have noted several instances of patients being in
acute units for more than 100 days and, in two
instances more than a year. While service providers
work to minimise these instances, the cause usually
lies in a lack of appropriate accommodation and
support options.
Legal rights and information provision
There were 269 issues reported in relation to legal
rights and the provision of information. Some issues
concerned tribunal procedures and access to
22
second opinions. Other issues related to dignity and
privacy (including access to phones and computer
technology), gender and cultural sensitivity issues,
as well as leave and discharge arrangements.
Community Visitors report that some facilities
provide comprehensive information about patient
rights, hospital and tribunal procedures, appeal
and complaint mechanisms and contact details for
mental health advocacy and support organisations.
Disability Support Pension
The Commonwealth Government foreshadowed
cancellation of forensic patient entitlement to the
Disability Support Pension. If implemented, this
would have a significant impact on forensic patients
and the operating budget of the Thomas Embling
Hospital. Community Visitors joined state health
departments, forensic patient hospitals and facilities
in strongly advocating against this move.
Facility management
Community Visitors reported 198 issues related
to the maintenance and refurbishment of mental
health facilities. The standard of facilities and
responsiveness to issues reported by Community
Visitors varies across the state from excellent
to inadequate.
Newer facilities and refurbished units are generally
excellent and well-regarded by patients. Older
facilities are more difficult to maintain. In some
regions, such as Hume and Ballarat, Community
Visitors have been documenting the need for
substantial upgrades to some facilities for many
years. Unfortunately, the design constraints of
mental health facilities to avoid ligation and hanging
points, the fireproofing requirements of furnishings
and the specifications for furniture (to prevent
them being thrown or used as missiles) can make
refurbishment an expensive undertaking. Some
maintenance delays pose serious risks to health
and safety. For example, at the Monash Medical
Centre, incomplete repairs left exposed wiring in a
bedroom that continued to be used for patients.
Activities and programs
This year, 175 issues related to activities and
recreation opportunities were recorded. Patients
frequently complain of boredom and having
‘nothing to do.’ This is particularly an issue at
weekends. The employment of occupational
Mental Health
therapists is also an ongoing issue. Where
occupational therapists are available, Community
Visitors report programs that include: music
therapy, art, excursions to off-site venues, exercise
and relaxation regimes, diet management and
healthy living sessions.
The contribution of activity programs to the
patient’s post-discharge health and wellbeing is
not easily quantified but it is very likely that they
speed patient recovery and contribute to minimising
subsequent hospital presentations. Community
Visitors report that, where there are comprehensive
activity programs, there is a lower level of violence
and less use of restraint and seclusion. Community
Visitors regard these programs as an investment
in preventative mental health care and effective
patient recovery that would justify greater financial
investment which needs to be reinforced through
the national standards for mental health services.
Currently, the standards set no minimum level
for activities and this needs to change to ensure
this important area of patient wellbeing does not
continue to be overlooked.
Relinquishment of aged
care mental health beds
This year, nursing staff and residents in a number
of aged care units approached Community Visitors
with concerns about the potential sale of aged
care mental health facilities to private providers.
The Board referred this concern to DHHS which
advised that the decision to relinquish licences or
sell aged care mental health beds was a health
network decision. Beds have been relinquished
The incidence of mental illnesses in the aged
population is a growing challenge. The role of the
Community Visitors does not extend to private
providers and, as aged mental health beds transfer
to the private sector, those patients will lose the
benefit of the independent review provided by
the Community Visitors Program. The Board will
maintain an active interest in this matter.
Government initiatives
Transition Support Units (TSUs)
- Austin Health/ Monash Health
A new unit to support people with dual disabilities
is under construction in the Northern Metropolitan
Region and it should commence operation in
late 2015/early 2016. A unit in the Southern
Metropolitan region is still at the planning stage.
Mental Health
These units will provide an additional 23 muchneeded beds to assist people with a dual disability
to move from acute care to greater independence
and, ultimately, community life.
Thomas Embling Hospital
Forensicare Victoria manages the Thomas Embling
Hospital (current capacity 116 patients); the only
forensic care hospital in Victoria. The hospital has
been advised of budget approval ($9.5 million) to
build an eight-bed HDU. This will assist in meeting
the high demand for prisoners requiring acute
mental health care. It will also reduce the difficulties
arising from co-mingling acutely unwell prisoner and
forensic patients.
Forensicare continues to advocate for an additional
facility to treat forensic patients and women in a
medium secure setting.
The Mental Health and Police Response
(MHaPResponse)
This program subsumes the Police and
Ambulance Crisis Emergency Response (PACER)
project reported last year. The expanded program
now combines police and psychiatric clinical teams’
response to incidents across 21 mental health
service areas statewide.
Community Visitors report hospital feedback
that the program has provided better-managed
incident responses, reduced emergency
department presentations and reduced agitation
among mental health unit presentations admitted
via the MHaPR scheme.
National Disability Insurance Service (NDIS)
The implementation of the NDIS and its impact
on the lives of people with a mental illness is still
unclear. The Board and OPA staff continue to seek
information on the implementation of the NDIS.
There is uncertainty as to the extent that community
mental health programs are to be included in the
NDIS but the Board has been told by DHHS that
all existing acute clinical services and the facilities
visited by Community Visitors will continue to be
state-funded.
23
Service provider responsiveness
Regional Convenors (senior team leader volunteers)
report that written responses to issues raised in
visit reports are generally timely and appropriate.
However, in some regions, Regional Convenors or
program staff have had to chase responses as they
are not provided as a matter of course.
Community Visitor and provider liaison meetings
are required under the protocol between OPA
and DHHS and volunteers find these meetings
extremely useful in exploring issues. Many Regional
Convenors report strong and responsive support
from hospitals for these meetings, however, this is
not the case in all regions.
24
Mental Health
Regional
Reports
The Barwon-South Western Region
encompasses the area from Geelong to the
South Australian border. The facilities visited by
Community Visitors in Geelong are managed by
Barwon Health, and the facilities in Warrnambool
are managed by South West Healthcare.
These facilities consist of two adult acute inpatient
units, one aged persons mental health residential
unit, three emergency departments, two CCUs,
and a PARC. Community Visitors did not visit
emergency departments in the region this year.
A shortage of Community Visitors, particularly in
the Geelong area, has placed significant limitations
on the number of visits this year. OPA is actively
recruiting Community Visitors in this region, and
hoping to address this issue in the coming year.
The adult acute unit at the Swanston Centre in
Geelong has introduced the Creating Safety Program,
including the appointment of a dedicated Safety
Officer who reviews all incidents where restrictive
interventions have been employed. This has reduced
the seclusion episodes and their duration. Substance
use, and particularly the use of the drug Ice, has been
identified as a key factor where the use of restrictive
interventions has increased at times.
Treatment and care
With the introduction of advanced statements in
the new Act, Community Visitors have been keen
to ascertain how many consumers are choosing
to complete these. Barwon Health is still to clarify
this; however, a Recovery and Treatment Plan
is in development, to be used in both inpatient
and community settings, and this will incorporate
advanced statements and the appointment of
nominated persons.
Safety
Issues have been raised by the move to smokefree facilities at Barwon Health. At the CCU/PARC,
consumers are no longer able to smoke in the
facility grounds. This means that consumers are
smoking outside the perimeter of the facility, close to
a busy thoroughfare. Staff are also concerned that
consumers are vulnerable to exploitation and abuse
by passers-by and approaches from drug dealers,
particularly at night-time. Staff at the facility are
attempting to gauge the impact of the changes in
regulations on consumer safety and clinical practice.
Community Visitors were impressed with the
comprehensive and diverse therapeutic program
in the acute inpatient unit at the Swanston Centre,
which is provided with the assistance of a number
of external agencies and skilled volunteers.
Community Visitors highlighted that there are
no SECU beds in Geelong; consumers must be
transferred to Ballarat Psychiatric Services if they
require this level of care. Community Visitors are
concerned about the impact this has on family and
friends wishing to visit their relatives and friends.
Barwon Health acknowledges that the lack of SECU
beds may cause adverse impacts on the patient,
their family and friends particularly in terms of travel
time and financial costs, however, neither Barwon
Health or South West Healthcare have any plans to
introduce its own SECU in the foreseeable future.
Mental Health
Community Visitors and Barwon Health
management have met quarterly to discuss issues
of concern and facilitate improved communication.
Barwon Health has responded to issues in a
timely manner and has regularly provided detailed
statistics on issues such as seclusions, restraint
and emergency department presentations.
It is anticipated that this working relationship
between Barwon Health, South West Healthcare
and the Community Visitors will further develop with
25
an increased number of visits to facilities resulting
in more benefits for consumers.
Eastern Health and St. Vincent’s Hospital
(incorporating St. George’s Hospital and St.
Vincent’s Hospital) manage the mental health
services visited in the Eastern Metropolitan
Region.
The services comprise five adult acute units, two
aged acute units, four aged persons residential
mental health units, one child and youth unit, three
CCU and three emergency departments. This year,
three PARC units were visited, which are co-jointly
managed by MIND, Mental illness Fellowship and
the two health services. The statewide specialist
personality disorder unit, Spectrum, is also located
in this region.
Special initiatives at St. Vincent’s and Eastern
Health in the Reducing Restrictive Interventions
Program have been effective in managing
aggression and lessening the need for seclusion
and restraint. There has, however, been many
occasions of extreme violence resulting in damage
to infrastructure and harm to staff and co-patients.
In one instance, at St. Vincent’s Acute Inpatient
Service, a man was held in seclusion for 63 hours.
His was a complex case, difficult to manage and he
assaulted staff during the incident. He was regularly
monitored until his behaviour settled. Community
Visitors were able to access records and felt his
care at that time was according to set procedures.
Another patient in the acute unit also assaulted staff
resulting in several claims for workplace injuries.
Both patients had been on the units for considerable
lengths of time before discharge was possible.
At Maroondah Acute Inpatient Unit, the aggression
of one patient resulted in police being called to the
unit twice to control and restrain him. The police
also had to attend the next day for showering and
ongoing management.
Allegations of sexual assault at St. Vincent’s and
at Maroondah acute units were followed through
appropriately with referral to police and support
being offered to the complainant.
Patients have needed to be restrained while being
transported from the emergency department or
26
to Electroconvulsive Therapy (ECT) especially
when those units are housed in a different and
separate part of the hospital. Initiatives have been
implemented to mitigate fear and anxiety, especially
through the use of sensory rooms and equipment.
The possibility of serious incidents, introduction
of illicit drugs, self harm or falls has resulted in
modifications to the environment such as more
frequent locking of doors, restricting access to
certain areas, installing higher fences and stricter
supervision by staff. Mandatory searches of the
premises at St. Vincent’s are required three
times a day.
Treatment and care
The most common issues raised by patients are
that they are not unwell and, therefore, should
not be in hospital. Patients are also concerned
about the medication ordered and whether it is by
injection or oral.
This year, there have been several very long-stay
patients on the acute units, in particular. This
has been because of dual disability, behavioural
problems that were difficult to manage and a
shortage of suitable accommodation for people
with complex needs. One case was referred
to the Chief Psychiatrist to find a resolution.
There have been two people at Canterbury CCU
with complex needs who have been difficult to
appropriately accommodate. There can also be a
long wait for suitable support services to become
available though care coordinators can assist in the
emergency departments.
Complaints about emergency departments include
one man who discharged himself because the
environment in which he had to wait was too noisy
and frightening. Another was sent home after
being seen by triage. Both were admitted to the
unit the next day after intervention by the police or
community treatment team. St. Vincent’s is trying
to lessen the frightening experience with ear plugs,
eye shades and other sensory measures.
There have been difficulties in meeting the fourhour limit of stay in emergency departments where
there are medical conditions or other complicating
factors that need to be attended to. An increase
in emergency department presentations has been
noted in those coming in as a result of illicit drug use.
As St. Vincent’s is an inner-city hospital, however,
38 per cent of presentations are from outside the
catchment area or of people who are homeless.
Mental Health
Workers have been employed to assist in providing
ongoing support for these people.
The CCUs are trying to facilitate the transition of
some patients from either SECUs or the Dame
Phyllis Frost Centre into rehabilitation programs with
well-managed staged entry.
There are new initiatives to provide more
community support, and diversion programs are
being trialled. These are cooperative schemes
between mental health workers, police and general
practice to minimise hospital admissions and
decrease restrictive interventions.
There have been continuing difficulties in recruiting
permanent managers for the aged care residential
facilities. All services have been accredited despite
these problems.
With the introduction of the new Act, there have
been a number of issues, particularly with the
implementation of the tribunal system. Difficulties
have been experienced by facilities in preparing the
necessary paperwork and negotiating the difference
in computer systems.
Peter James Centre uses teleconferencing for
the hearings.
Some patients have been confused with a
compulsory treatment order of six months’
treatment, interpreting this as six months in hospital
rather than the possibility of community treatment.
Community Visitors have advocated for second
opinions though patients are still experiencing
difficulty in accessing them. The funding for this
service is available but has not materialised.
Facilities associated with St. George’s Hospital
experienced some difficulty with the changes to
nursing home management. This seems to have
been sorted.
Free access to phones has been an issue
where regular damage to pay phones has taken
place. Cordless phones have been available as
replacements but do necessitate the patient asking
a staff member for that access with consequent
loss of privacy and a possibility of access being
controlled and limited.
There is a wide range of information freely available
on a range of subjects for patients, residents and
carers. Leading up to a smoke free environment,
Mental Health
information on the QUIT program and other helpful
organisations was freely available as well as selfhelp sheets.
Facility management
Upkeep and maintenance of all facilities is
constant due to the pressures of daily use and,
sometimes, damage from aggressive episodes.
St. Vincent’s conducts monthly building audits
and replacement furniture, painting and repairs
are ongoing everywhere.
The older facilities are particularly difficult to
maintain. The HDU and seclusion areas of St.
Vincent’s are now not suitable for the demands
placed on them. Constant maintenance is not
sufficient to provide a therapeutic environment.
At the Peter James Centre, the bathrooms are
in a very poor state. Refurbishment quotes are
extremely high and necessary work is being
continually delayed. Apart from safety concerns,
privacy is also affected as few doors can be
fastened and intrusion by co-patients is possible
at any time.
Other work needed includes occupier indications
on bathrooms at Maroondah, adjustment to shower
heads at Ringwood PARC and fixing of a leaking
roof at Linwood House PARC.
There have been long delays at St. Vincent’s
in providing a renovated garden area that is
accessible and secure. Major renovations have
included new entrance arrangements and security
into St. Vincent’s and similar works are planned for
Box Hill Hospital with a family room included.
There are a wide variety of activities and programs
offered in the various facilities in the region.
Activities range from quiet pursuits in the sensory
rooms to the use of gym equipment.
In the residential care units, use of garden areas
is very important though access can be limited by
the need for close staff supervision. The adolescent
unit uses the garden for activities and then uses
the produce in cooking sessions. At the Footbridge
CCU, there has been a focus on diet and health
with special programs being run. Cooking sessions
at St. Vincent’s at the weekends have been
welcome. Program staff have prepared activities
that are available for easy use over weekends.
27
A research project at Riverside House is being
undertaken to look at dementia management
through the use of touchpad technology. Ipads
have been in use already and have been shown to
assist with the maintenance of family connections
in the aged care units.
Facility management
A new HDU was completed during the year and
provides a modern and efficient atmosphere for
those patients who are acutely unwell.
Relationships between the various health services
and Community Visitors are excellent. Regular
quarterly liaison meetings occur when there is
open discussion in which rationale for treatment
options, management issues, new initiatives and
any problems are raised. Incident reports and key
performance indicators are available. Staff are
generous with their time on other occasions too
and are prepared to listen to and consider the
findings and suggestions of Community Visitors.
The tenor of both health services is a commitment
to good care and the exploration of new ideas that
may benefit those in their care.
Gippsland Region
The Latrobe Regional Hospital manages the
mental health services in the Gippsland Region.
Community Visitors visit one adult inpatient unit
which includes two dedicated adolescent beds,
one SECU, one aged persons inpatient unit,
one CCU, one emergency department and
one PARC.
Community Visitors have been monitoring monthly
incident report summaries which provide valuable
information on total incidents by overall severity
rating. Three reported unexpected deaths during the
months of March and April 2015 have been noted.
On enquiry, all of the deaths occurred while
individuals were being cared for by the Community
Mental Health Service although one was receiving
ECT for depression.
The poor state of the courtyard of the adult inpatient
unit has been reported in past years with graffiti
spoiling the appearance of the area for patients.
This matter is now being addressed with a funding
program to provide an upgrade in the near future.
Seclusion rates have been greatly reduced over
the year.
On a number of occasions, Community Visitors
reported on the poor general appearance and
cleanliness of the CCU, with the community room
and unit windows particularly needing attention.
The aged persons unit continues to provide a
comfortable and caring facility. New dining furniture
has been provided during the year.
Two visits have been made to the PARC in
Bairnsdale and, on each occasion, Community
Visitors were impressed with the facilities available.
Patients and staff were very positive on each visit.
A lack of educational and recreational opportunities
is still of concern to patients at most services with
complaints of boredom and few interesting things
to do. Displayed programs of events have been
very limited with no activities listed on many days.
Generally, Community Visitors obtained acceptable
and timely responses from staff on any issues
raised. Access to incident reports is provided,
although these are stored electronically and require
staff assistance to access.
Quarterly liaison meetings have been well-attended
and provide regular access to senior management.
In September 2014, two patients sought assistance
with various concerns to do with their postdischarge management. In each case, staff were
able to assist with information and satisfactory
outcomes were obtained.
28
Mental Health
Grampians Region
The mental health services in this region are
provided through Ballarat Health Services.
There are six units in Ballarat. Two are for
adult and aged acute care, there is a SECU,
CCU, aged residential unit and two emergency
departments. Community Visitors also visit
nursing homes in Nhill and Stawell, each having
six funded beds for aged mental health care.
The emergency departments have not been
visited this year.
A recent resignation has reduced the number of
Community Visitors to three which means there is a
shortage of volunteers to cover all the facility visits.
In August 2014, Community Visitors reported
that several patients and staff were attacked at
Sovereign House, the only SECU in the region,
with one staff member consequently taking leave.
Community Visitors also became aware of incidents
such as unauthorised leave and attempted self harm
at the Ballarat Hospital adult acute unit through
incident report summaries. Unfortunately, these
were often obtained some time after the events had
occurred making it difficult for Community Visitors
to talk with the relevant patients and consider the
service implications of these matters.
Treatment and care
Sovereign House SECU
For the past three years or more, Community Visitors
have highlighted in the annual report the need for an
upgrade to the Sovereign House SECU. This secure
facility is far too small to accommodate the long-term
patients who are in need of a secure environment
nor does it encourage wellness. There is no space
for a womens’ lounge, as there are only one or two
women residing in this 12-bed unit at any given time.
Even meals now need to be served in two sittings to
provide a little more space while dining. New carpet
and limited painting have slightly improved the unit’s
appearance. Swipe cards on bedroom doors now
provide additional night-time security.
ongoing submissions for a unit upgrade have so
far been unsuccessful. Staff informed Community
Visitors that the former government had promised
$8 million for this upgrade, if elected. It is
disappointing that Ballarat Health Services has not
made a formal request for capital funding since the
change of government.
Eastern View CCU
This facility provides for and encourages clients to
attend programs and supports in the community
to assist their wellness and to move back to
living independently. Smoking is an ongoing issue
and staff are limited in being able to enforce the
hospitals non-smoking policy. Smoking on the
street just off the property creates a very untidy
environment with butts on the ground so clients sit
on their verandas and butt in empty tins near nonsmoking signs.
There is a lack of security for belongings as
bedroom doors still do not have either locks or
swipe cards. Options for better security are being
explored. Community Visitors hope that this matter
is expedited.
Acute Units
In the adult acute unit at Ballarat Hospital, a
noticeable reduction in the use of seclusion has
been observed by Community Visitors, while an
increase in the use of the Psychiatric Intensive Care
Area (HDU), has been observed.
Over the last three months, current incident reports
have been made available at the time of visits but
they are for the previous month and not up to the
date of the visit. When Community Visitors inquire
about incidents, the responses are often vague and
differ depending on who they ask.
Aged Persons Units
At the Steele Haughton Aged Persons Acute Unit,
patients indicate they are happy with their treatment
and care and issues are seldom raised with
Community Visitors.
Staff had installed a sensory room to assist
patients with relaxation but the space is again
required as a bedroom so a small, disused
bathroom is being considered (but not satisfactory)
for this usage. Community Visitors are repeatedly
informed at service provider meetings that the
The Macpherson Smith Nursing Homes in Stawell
and the Iona Nursing Home in Nhill provide
adequate care, and all issues raised by Community
Visitors have been responded to in a timely manner.
Mental Health
29
The aged mental health beds at these facilities are
sometimes used for general patients, as there is
currently little demand for aged mental health beds
in these towns.
Residents at the Steele Haughton Aged Residential
Unit have a variety of activities every day: outings,
a wedding parade, music times, visits to op shops,
shopping, as well as hair and make-up sessions
to name a few. The residents appear to enjoy
telling Community Visitors about their experiences.
Residents also indicate they are happy and wellcared for and they seldom raise an issue. Unit
management makes good use of volunteers to
assist in running of programs. At the Sovereign
House SECU, yoga, tai chi and drums are just a
few of the activities offered to occupy patients.
On the other hand, perhaps because of the short
stay of patients, the Steele Haughton Acute Unit
has few organised activities. Patients watch TV,
read newspapers or perhaps have a doze.
Hume Region
Mental Health Services are managed by
Goulburn Valley Health, and North East and
Border Mental Health Services. There are two
adult acute units, two aged acute inpatient
units, two aged residential units, two CCUs,
two PARCs and two emergency departments.
During this reporting cycle, Community Visitors
reported on two patient deaths. A male patient who
was well-known to mental health services, left the
Kerford Acute Inpatient Unit and took his own life.
A female patient in Grutzner House, a
psychogeriatric nursing home, sustained a serious
fall, in which she badly broke her hip. Clinicians
determined that the person’s hip should not be
operated on and she was returned to the facility.
She died a short time later and her death was
referred to the Coroner for investigation.
There are very few activities at the nursing homes
in Nhill and Stawell. Community Visitors have
suggested that it may help create a wellness
environment for residents in the facility at Nhill if
newspapers and updated magazines could be
left in the aged mental health wing, rather than
these being removed daily and shared with general
nursing home patients.
Community Visitors have appreciated the increased
provision of incident reports from mental health
facilities. Community Visitors noted three specific
assaults of staff by patients at Wanyarra and Kerford
acute mental health units and at Blackwood Cottage
Aged Persons Mental Health Unit. An incident report
from Wanyarra Acute Mental Health Unit detailed
an incident where a patient hit another patient to
protect a staff member from a serious assault.
Safety
Treatment and care
At the Eastern View CCU, there is a lack of security
for belongings as bedroom doors still do not have
either locks or swipe cards
Community Visitors have been impressed with the
building, philosophy and staff of the two Hume
PARCs which have proven to reduce admissions to
acute inpatient care. Community Visitors view the
provision of a vegetable garden at Wodonga PARC
as very conducive to resident recovery.
There have been regular quarterly meetings with
senior management of Ballarat Health Services
who are supportive of the Community Visitor role
and respond when necessary to issues raised.
They regularly provide an overview of the programs
across the region and recently indicated they had
received the keys for a Mother and Baby Unit in
Ballarat, opening soon.
30
Community Visitors were interested to learn of ten
new single accommodation units, specifically for
local homeless people within the Wangaratta area,
which will extend the range of discharge options for
mental health patients.
At Wanyarra Acute Adult Inpatient Unit, patients
complained to Community Visitors that snack
food items such as cheese and biscuits had been
removed and that they were hungry between meals.
Patients also complained about the provision of only
bread and margarine at morning tea, which they
said was unpalatable. Fruit is now available.
Mental Health
Community Visitors reported that, at an acute mental
health unit, two female patients had been inpatients
for approximately 100 days each. Community
Visitors were informed that these patients have
complex dual disabilities and behaviours which were
proving extremely difficult to manage.
case
study
Community Visitors noted a person in their
forties diagnosed with Huntington’s Disease
residing at an aged persons mental health
unit displayed both aggressive and sexualised
behaviours towards other patients and staff.
The person was discharged to the community,
where they lit a serious fire at the home of a
family member, resulting in the home being
uninhabitable. Fortunately, no-one was injured.
The person admitted to lighting the fire and is
currently in prison on remand. As the person
is now seen as presenting a serious risk to
themselves and others in the community and
has a terminal degenerative cognitive disorder,
they are at risk of spending the rest of their life in
prison, depending on the court’s decision.
This case highlights the lack of secure residential
options for people with Huntingdon’s Disease or
similar conditions who do not meet the criteria of
the Mental Health Act but who have behaviours
which pose a risk to themselves and others.
Community Visitors responded to a call to OPA’s
Advice Service from a patient at the Kerford
Inpatient Unit, claiming that staff had not prioritised
her receiving a Mental Health Review Tribunal
hearing. Community Visitors raised the issue
with staff at the facility and were satisfied that
procedures had been followed.
At the Benambra Residential Service, Community
Visitors received complaints from patients regarding
their being resident in a Victorian mental health
facility, but subject to court, parole, probation
and other commitments in New South Wales.
Community Visitors were informed by staff that they
were engaging with the New South Wales services
to assist patients.
Mental Health
Facility management
Two grants totalling over $1.5 million had been
received for redesigning the HDU at Wanyarra
Acute Inpatient Unit. This will include separate
wings for males and females including lounges,
a family room and space suitable for tribunal
hearings, including a waiting area.
Community Visitors reported that carpet at the
Kerford Acute Unit should be replaced and ‘block
foam’ lounge chairs in the unit were too low to
sit down in and get up from. Community Visitors
were informed that chairs and carpets would be
replaced as funds allow.
Community Visitors have reported on an apparent
lack of activities for patients at Wanyarra Acute
Inpatient Unit. The unit does not have an
occupational therapist but an ‘activity coordinator’
due to reduced funding.
Community Visitors were advised by the unit that
patient involvement in activities varied depending
on their ill health or motivation. Intern psychologists
provide cognitive behavioural therapy and
‘mindfulness’ sessions to assist with motivation
and encourage participation.
Bendigo Health and Ramsey Health provide
mental health services for two adult acute
inpatient units, one aged persons’ acute
inpatient unit, one aged persons’ residential
unit, one CCU, one SECU, one PARC, one
YPARC and two emergency departments.
As there are no Community Visitors currently
based in Mildura, fewer visits were made
there as it required Community Visitors to
travel long distances.
Numerous patient-to-staff and patient-to-patient
assaults were reported in Loddon Mallee during
the year; a number by one patient. The patient,
initially in Simpkin House, a psychogeriatric facility,
was admitted to the Marjorie Phillips Aged Acute
Inpatient Unit following the attempted strangulation
of a staff member. As assaults continued on
both patients and staff for a number of weeks,
Community Visitors were very concerned.
31
Management of the patient was challenging,
although staff commitment to assist the patient
achieved a successful outcome. Industrial action
followed the initial assaults at Simpkin House,
resulting in no patient admissions for 12 weeks.
Two sexual assaults by the same patient were
reported in the Alexander Bayne Centre (ABC);
firstly, on a nurse in the HDU and, the second, two
weeks later on a patient on the open ward. At the
time of the second assault, the one-on-one security
presence had been withdrawn as it had been
deemed no longer clinically necessary.
A patient was stabbed with a broken radio aerial in
the acute unit at Mildura by another patient and a
number of patient to-staff assaults were reported.
case
study
In October 2014, Community Visitors reported
concerns about various possible ligature points
on the newly installed support structure for
shade sails at the ABC. They were advised by
the manager that these ligature points had been
considered and deemed to be no more risk
than other attachments to the building, such as
gutters and downpipe clips, but they would be
added to the ligature point audit.
It was decided, on review, that there may be a
risk. In January 2015, Community Visitors again
reported their concern. In February, they were
advised that ligature points may be modified.
Subsequently, one ligature point was partially
covered. In April, a patient attempted suicide by
hanging from a ligature point on the structure,
after climbing on to a chair. Their attempt may
have been successful had other patients not
supported the person’s weight until staff arrived.
A code blue medical emergency, was called
and the patient’s life saved. The ligature point
used was removed immediately and extensions
to shade sail poles completed in July 2015.
Everyone involved in the incident was debriefed.
To minimise risk, chairs are no longer allowed to
be taken from the dining room. Bendigo Health
conducted a full review and made changes to the
policy about ligature points following the incident.
The patient sustained no serious or long-term
physical effects.
32
A patient self-harmed with a razor blade on three
separate occasions during one admission in the
ABC. There was no record of a room search having
been conducted. This follows a similar incident
reported in last year’s annual report. Subsequently,
actions were taken by management to mitigate
future risk.
A patient was admitted to the ABC following advice
that he would be considered for a rehabilitation
bed. Some months previously, he had two strokes,
resulting in physical symptoms, depression,
some memory loss and cognitive deficits. After
twelve days, the patient was told he was to have
outpatient rehabilitation instead. Staff noted his
disappointment and lowered mood. The patient
subsequently cut his wrists using a butter knife.
Community Visitors requested to view the incident
report but one had not been written. Prior to
discharge, an outpatient rehabilitation appointment
was arranged.
Another patient was assaulted with a butter knife
and had hot Milo thrown over her.
In relation to all these incidents, counselling was
offered to patients, staff, and families, police
referrals made, and assistance sought from relevant
organisations, as appropriate.
Treatment and care
Staff shortages impacted on patients in the region
again this year.
At the Mildura Acute Inpatient Unit, severely unwell
patients are locked in the HDU but sometimes
without a staff member present. This could be
viewed as seclusion or seen as inadequate oversight
of patients. There was, and still is, an ongoing
staffing shortage and no access to agency staff.
In September 2014, staff at the ABC stated there
had been staff shortages on a regular basis for
months. Patients could not be taken on escorted
leave and activities were limited. During seclusion
checks, assistance for other patients was limited.
Some patients have insufficient personal items and
no support from family or friends to provide them.
Patients must often rely on their own networks for
assistance.Staff try to support patients within their
constraints. However, one patient in the HDU at the
ABC waited four to five days before staff provided
clean clothes and arranged care for pets locked in
her house.
Mental Health
Restricted psychiatric hours at the SECU impacted
availability for patient reviews. One patient waited
over three months between face to face reviews
with their treating psychiatrist. However, Bendigo
Health took measures to mitigate the outcome of
limited psychiatric coverage.
Improved admission processes at Bendigo
emergency department, and use of the short-stay
ward provided greater comfort for patients waiting
for admission or discharge. However, a number
of lengthy waits for admission were noted. Out
of 2562 patient presentations, 41 waited over 20
hours. Many resulted from the need to address
physical health issues. The average length of stay in
the emergency department is seven hours.
One patient has waited more than a year for
accommodation closer to his family, due to limited
accommodation in which the needs of both the
patient and co-patients can be safely met. Another
from Mildura, has remained at the ABC for 468
days to the end of the reporting year, receiving
specialist care, while personalised arrangements
are made for his ongoing support after discharge.
A patient in Mildura, concerned about her drug and
alcohol problems, requested support, but there was
no assistance available.
good practice
In direct contrast to the past, patients at the
ABC now enjoy excellent facilities. Persistent
reporting by Community Visitors may be partly
responsible for this outcome.
Extensive renovations have taken place
including: repainting, new curtains, new sofas,
‘softer’ lighting, large tranquil murals depicting
an oasis theme in the dining room and waterfalls
in the HDU. Patients comment positively. Tree
murals where patients leave messages of hope
and affirmation on discharge are being used in all
units. There are new synthetic turf and patientinspired and planted gardens now in all outdoor
areas. Their installation, and a new sensory room
improving patient comfort and quality care, have
been initiated as part of the Safewards program
undertaken across all Bendigo Health facilities.
Bendigo Health is the only service in Victoria
using the Safewards program in its aged care
units. Use of Safewards is credited in part for a
notable drop in seclusions in the second quarter
from 37 per cent down to 6.4 per cent. The third
quarter was marginally higher at 7.2 per cent,
still an impressive result.
Facility management
Staff were congratulated on care of patients and
speedy remediation works following a major flood
event at the ABC and the PARC. Extra staff were
provided during this period to ensure patient safety.
Patients at Vahland SECU and CCUs are very
happy with the NEW Art Therapy group and
compliment staff on the use of age-appropriate
material, and flexibility around attendance.
There is no carer support worker at the ABC, only
a half-time staff allocation across all Bendigo Health
mental health units. Face-to-face contacts are
down from 60 a month to two.
Community Visitors noted during one visit to the
ABC, 12 of 19 patients were ‘previous’ drug users
and admitted partially, or totally due to this. Staff
at the ABC would like to see it become a drug
rehabilitation centre after de-commissioning; Vahland
SECU has also been suggested for this role.
Mental Health
At the PARC, a new laundry is available to patients
directly from the recreation room.
A new perimeter fence at ABC improved patient
safety. Twenty three patients absconded during the
year, compared to 43 last year.
YPARC is a very attractive dedicated space
for young people who appreciate the care they
receive there.
New tables have been provided at Vahland CCUs.
Measures to try to mitigate patient and staff
discomfort due to inadequate air-conditioning have
been implemented in the ABC.
Patient concerns due to a lack of written treatment
plans have reduced this year, following frequent
random audits of the patient clinical files.
Large ‘recovery orientated’ posters are now
prominently displayed in Vahland SECU lounge
and informational brochures/posters prominently
displayed in acute units following the new Act.
33
Bendigo Health and Ramsay Health staff are
proactive and responsive in clarifying issues for
Community Visitors. This is very helpful and much
appreciated. Incident report data has generally been
made available monthly since 15 January for all units
except Simpkin House, and, until recently, Mildura
Acute Inpatient Unit. Access to incident reports has
improved and Community Visitors are now able to
view these on request. However, the names of staff
continue to be blacked out in all reports.
North and West
There are four providers of mental health
services in the region.
Austin Health manages a mother-baby, adult
acute, SECU, children’s, adolescents, brain
disorder, veterans’ post-traumatic stress disorder,
a Community Recovery Program, a PARC and an
emergency department.
Northern Area Mental Health Service (NAMHS)
manages a PARC, CCU and two adult acute units
and has oversight of four mental health beds in the
Northern Hospital emergency department.
North West Mental Health Service (NWMHS)
operates an aged person’s mental health residential
unit and an aged person’s acute inpatient unit.
Forensicare manages the Thomas Embling Hospital,
a seven-unit forensic mental health hospital.
Serious incidents at the Austin Acute Inpatient and
SECU units have included:
• patient-on-patient and patient-on-staff assaults
• a patient setting fire to their room
• a patient breaking windows and causing collateral damage to the unit
• a patient invasion of, and trashing of, the
nurses’ station.
All of the above incidents were appropriately handled.
34
good practice
At the Austin Hospital, all incidents are reviewed
by the Critical Incident Review Committee
(CIRC). Its function is to monitor the incidence of
serious incidents and near misses, identify trends
and risks, recommend changes to protocols and
disseminate learnings throughout the service.
The CIRC is chaired by the medical director and
membership includes the director, consultant
psychiatrists, unit managers, senior nurses,
and consumer consultant and support staff.
It operates on a rigorous peer review basis,
encourages a problem-solving approach and
fosters a reporting culture
A Community Visitor attended a CIRC meeting
to see it in operation. The CIRC is an exemplary
exercise in thorough and responsive clinical and
management governance.
Two deaths in care occurred in NAMHS during
the year:
• a male patient in NPU2 in September 2014
• a male patient in NPU1 on October 2014
All appropriate protocols and notifications to the
Coroner and Chief Psychiatrist were followed up
and staff were counselled in accordance with
hospital procedures. The circumstances of the
deaths will be the subject of a Coroner’s inquiry.
Treatment and care
The treatment and care observed by
Community Visitors across all units in the region
was of a very high order. Patient requests to
Community Visitors were generally related to
treatment plans, medication, or requests for
second opinions. Most requests in acute units
were lodged early in a patient’s treatment when
higher levels of agitation and confusion are
experienced. Unit staff responses to matters
raised were uniformly timely and accomplished
with good humour, even when the request had
been made and answered before.
It is notable that the average length of stay in
an acute unit is approximately 13 to 14 days.
The philosophy of care is to restore the patient
to effective living in the community as soon as
practicable.
Mental Health
good practice
During the year, the acquired brain injury unit
(Mary Guthrie House) admitted a patient with
grievous brain injury. The patient, a refugee, had
lost verbal language and his wife and children
were overseas, creating a complex mix of
clinical, social and cultural challenges.
When first seen by Community Visitors, the
patient was almost totally uncommunicative and
incapable of sleeping on a proper bed due to
pronounced twitching. The unit responded by
finding a carer who spoke his language, locating
regionally based relatives, working on the
cultural issues including the acquisition of simple
phrases in the refugee’s first language by the
treating nurses, and intensive therapy.
When last seen by Community Visitors, the
patient was smiling, reading and writing in his
own language, engaging with simple phrases
and using a proper bed.
Community Visitors acknowledge the
extraordinary efforts of staff in the progress
achieved and the care provided.
On occasions, all hospitals are confronted by
patients with complex needs whose illness
is resistant to treatment. The Austin SECU
cared for a female patient with dual disabilities
whose behaviour included unpredictable violent
outbursts of temper, as well as assaults to other
patients and staff. Considerable resources were
devoted to this patient, and intensive programs
devised to support her recovery. The concern
and care displayed by all levels of staff involved
in the care of this patient were impressive. The
patient is progressing and staff are involved in
the search for appropriate community-based
accommodation in conjunction with her case
manager and guardian.
Prevention and Recovery Units (PARCs)
the Austin MHCSU and Mind Australia. A useful
exchange of perspectives and practices between
the two agencies has occurred.
The new Act proceeded largely without comment
from patients to Community Visitors. This reflects
the intensive briefing sessions conducted by all
hospitals for patients, carers and staff. All acute
units have displayed well-designed posters and
leaflets outlining the key elements of the new
Act, the Mental Health Tribunal procedures,
and information on advance statements and
nominated persons.
NAMHS units have been participating in the
statewide Safewards project designed to reduce
the level of aggression in acute units. Anecdotal
comments from the staff are supportive of the
approach and outcomes. The approach includes
the display of information about the personality
of the nursing staff, photos, hobby interests and
nursing goals.
NAMHS has also continued its commitment to
the Police and Ambulance Crisis Emergency
Response (PACER) Project. The Government’s
$15 million commitment to expand this program
across the state has enabled the NAMHS to staff
an additional PACER shift. The project continues
to reduce mental health emergency department
presentations, facilitate more effective police
responses to mental health crisis calls and facilitate
less-agitated admissions to acute units.
In addition to prompt and detailed responses to visit
reports; Austin Health and NAMHS all participate
in quarterly meetings with the Community Visitors
Program. The meetings, attended by senior
operations and clinical staff, address issues raised
and direct appropriate follow-up action. All services
provide strong support to the program.
PARCs were included in Community Visitor
schedules this year. The Preston and Heidelberg
Heights PARCs are both purpose-built and welldesigned for the accommodation and programs
conducted on site. Resident comments to
Community Visitors have been unstinting in their
praise for the treatment and care provided. The
Heidelberg PARC is a joint venture between
Mental Health
35
Thomas Embling Hospital
(Statewide service)
Seclusion episodes have remained steady at about
21 episodes a month for the last three years.
The Victorian Institute of Forensic Mental Health,
Forensicare, is a statutory authority responsible
for the provision of adult forensic mental health
services in Victoria.
Treatment and care
Forensicare manages the Thomas Embling
Hospital, a forensic mental health hospital providing
116 acute and continuing care beds.
The average length-of-stay for a forensic patient is
six to eight years and some patients remain in care
for over 20 years.
In June 2015, an unlawful killing trial of a patient
of another patient was finalised. This related to
an event at the hospital in December 2012. The
accused was found not guilty by reason of mental
impairment. The normal sentence in such cases
is a judicial order for treatment for a designated
period at Thomas Embling Hospital. Counsel for the
hospital advocated against such a course, in this
case, and the court said it paid close attention to
the matters raised. The court imposed a Custodial
Supervision Order to be served in prison. This came
as a significant relief to staff and patients.
Community Visitors have remarked in previous
years that, while Thomas Embling is a ‘secure
hospital’, specialising in forensic patients, it is a
hospital and does not have the facilities or staff to
manage patients with internal security comparable
to a high security prison.
No patient-on-patient assaults have been brought
to the attention of Community Visitors, however,
the number of assaults on staff and the resulting
injuries and loss of days are of concern. Almost no
episodes were recorded in the first six months of
the reporting year. The last six months recorded the
following injuries to staff:
Jan
Feb
3
4
Days lost
19
21
Seclusion episodes
15
20
Injuries to staff
Mar
Apr May
Jun
Av.
4
4
9
4
39
68
49
44
40
17
22
33
20
21
Table 5: Staff Injuries/days lost resulting from patient assaults/
aggression 2015, 14/15
36
The hospital fosters growing independence as
treatment progresses. Patients move from units
treating acutely unwell patients with fully catered
meals, through to units caring for patients with
ongoing conditions, and finally to units managing
patients with degrees of community integration,
in preparation for conditional or final discharge. In
the latter stages, patients can undertake part-time
employment and exercise, increasing independence
with the responsibility and personal expense of
shopping and preparing their own meals.
Since 2014, the hospital has been educating and
supporting the patients for the planned introduction
of a strict no-smoking regime from 1 July 2015.
The rationale is the reduced general health and
life-shortening result of long-term smoking and
the duty-of-care to long-term patients and staff.
The State Government has since legislated to ban
smoking on all public premises, including hospitals
and their precincts.
In collaboration with support and advocacy
organisations, the hospital provides patients
with continuous information about patient rights,
complaints procedures, recovery and other
treatment-related information. This is provided
on notice boards, well-designed brochures and
leaflets, and briefings to patients and families.
In May 2015, a forensicare patient sought an
independent psychiatric second opinion. After
considerable administrative research by the
hospital, it was determined that there was no
mechanism to access the funding set aside to
pay a private practitioner. Further investigation
by OPA with DHHS revealed that administrative
arrangements to access the funding had not yet
been put in place.
Disability Support Pension – Removal of
Forensic Patient Entitlement
Forensic patients are currently the beneficiaries of
the Federal Government Disability Support Pension
(DSP). The Federal Government announced its
intention to remove this entitlement as part of its
budget strategy.
Mental Health
Community Visitors consider the DSP is an
essential component of a forensic patient’s recovery
and reintegration with the general community.
The pension is used to purchase their food and
cooking provisions, pay rent on their transition
accommodation, and pay for particular education
and training courses. All of these preparations
are essential components of consideration by the
Forensic Leave Panel when extended leave is under
consideration. The loss of the DSP would impose
an additional cost of approximately $800,000 a
year to the hospital’s operational budget.
Approval for a new HDU
The hospital has been advised of budget approval
($9.5 million) to build an eight-bed HDU. This is
designed to alleviate the high level of demand for
involuntary treatment for prisoners from the men’s
prison system and difficulties staff experience
treating more acutely unwell prisoners. Current
indications are that the design, construction and
commissioning will take at least two years.
Forensicare provides strong support and followup to issues raised. Quarterly liaison meetings
are attended by the operations manager, all unit
managers and representatives from the Community
Visitors Program. Responses to issues are reported
and minuted.
North and West Metropolitan
Region (West)
Notification to the Public Advocate
A serious physical assault occurred when one
patient refused to perform a sex act on another
patient. The two people were in a HDU and it
seems no staff member was present. When a staff
member intervened, it appears they were unable to
call for assistance as the alarm had been switched
to silent. This incident is subject to a police and
internal investigation.
The parents of the victim in the above incident say
they requested their teenager be moved to another
mental health facility after the incident but were
told this was not possible. Instead, the patient
was given weekend leave to their family and then
discharged. Within a week, they were admitted to
another acute unit.
At Broadmeadows Adult Acute Unit One, a patient
in the HDU said he was afraid to be moved into
the general ward as he had been assaulted there
and staff confirmed this. A female patient at the
same unit was convinced that there were one
or more “sexual predators” in the unit and was
concerned about the safety of a young girl who she
thought had been approached. Community Visitors
reported both these matters in their visits reports
and were satisfied that the matters had been
followed up to protect patients’ safety.
Treatment and care
North West Mental Health Service, Inner West
Mental Health Service, Mid-West Mental Health
Service, Orygen Youth Services, Mercy Health
Services and the Royal Children’s Hospital
manage mental health services in this region.
There have been a variety of complaints by patients
in relation to their treatment and care. These include
issues related to smoking, medication, ECT, lack of
interaction with nursing staff, restraint, and several
issues related to food.
These services consist of four adult acute inpatient
units, two aged acute inpatient units, two aged
persons mental health residential units, one adult
rehabilitation unit, four CCUs, one eating disorders
and neuropsychiatric unit, one mother-baby unit,
two adolescent units and four PARCs.
At the Royal Melbourne Hospital eating disorders
unit, a patient complained to Community Visitors
that she was unable to obtain soy products and
adhere to a vegan diet as most of the meals
provided were egg and cheese-based. Community
Visitors were advised by staff that soy milk diets
were only available for lactose intolerant patients.
Mental Health
37
case
study
Some of the young patients at the Banksia
Adolescent Inpatient Unit, who have eating
disorders, were showing signs of being anxious
when their meals were late. The meals also did
not comply with their dietary requirements and
preferences. Staff who made enquiries about
this, said the kitchen staff refused to change
the meals and questioned the necessity of the
instructions from the dieticians.
The stress caused by these situations led to
Codes Grey on the unit. After consultation
between senior nursing and kitchen staff,
and input from the dietician, there has been a
marked improvement in the services that the
kitchen now provides.
One female patient stated that she is unhappy
about having daily blood tests and being taken to
her room by security. She also did not like being
washed by a male staff member. In answer to
questions from the Community Visitors, staff stated
that she was not having daily blood tests, security
personnel were not permitted on the unit unless
there was an emergency and she was certainly not
being washed by a male staff member.
The other issue that is commonly raised is the lack
of suitable subsidised housing and appropriate
accommodation options for residents to move into
following discharge. This sometimes extends the
time that residents have to remain in CCUs and in
other services.
A resident at the Norfolk Terrace CCU was very
anxious because he had to pay rent for his public
housing unit and rent to the CCU. This was due
to the six-month time limit whereby, if a resident
spends more than six months away from his public
housing unit, the unit is reallocated to someone else.
Staff were asked to provide the resident with
support in meeting his appointment times and with
other assistance to return to his public housing unit
without undue delay.
A patient told Community Visitors that he came to
the acute unit voluntarily but he felt held against his
will. Community Visitors asked staff to explain to
the patient why he was in the facility, his treatment
plan, and what he could expect. The patient’s case
manager was also asked to assist the patient to
access his money.
38
A patient at Broadmeadows Adult Acute Unit
was unhappy with his treatment and surroundings.
His family wanted him to sign a ‘Nominee
Statement’ which he refused to do. He advised that
he had a case manager or social worker - he was
not sure which.
Community Visitors asked him to consult this person
and to seek free legal support related to his refusal to
sign. After discussion, he told the Community Visitor
that he understood that he did not have to sign
anything he did not wish to, and that he was free to
seek advice. He has stated he had no further issues.
A female resident wanted to see her medical file but
was told that it was not there. She also wanted to
know why her medical file was given to her sister
without her consent. The Nurse Unit Manager
(NUM) stated that only authorised staff have access
to the consumer’s medical records and Western
Health has no record of releasing this resident’s file
to her or her sister.
Facility management
In both August and October 2014, Community
Visitors noted patients sleeping on mattresses on the
floor because they were too tall to lie full length on
the hospital beds at the Royal Melbourne Hospital
Adult Acute Inpatient Unit. The facility now uses a
‘bed bank’ at the hospital to alleviate this issue.
Community Visitors reported that sensor lights
at the Broadmeadows CCU were accidentally
disconnected during the extensive renovations. The
engineering department was to re-connect these to
illuminate the grounds and this will bring the CCU
back to its original safety status.
Community Visitors were informed that the
bathrooms in Unit 6 at the St. Albans Hospital had
been leaking for some months which was later fixed.
The payphone at Orygen was reported as being
out-of-order in February, June and July. Patients
can use a phone in the staff office but that does not
allow them any privacy.
Southstone Lodge was part of the Melbourne
Health network and was opened in 1997 and
closed in December 2014. It was a 30-bed mental
health aged residential facility. The individual health
networks are independent and are free to open and
close facilities at their discretion in the best interest
of their local communities. Although precise reasons
for the closure are not known, the accreditation
requirements are understood to have played a part.
Mental Health
It is believed that, after appropriate consultation, 25
residents were rehoused in suitable accommodation.
Safety
At the ORYGEN Youth Health Inpatient Unit,
Community Visitors noted that for more than 12
months the doors to the courtyard and basketball
area have been locked. The Visitors were informed
that the doors needed to remain locked until the
perimeter wall was modified. This modification is
designed to reduce the number of abscondings
but will not eliminate them. The NUM stated that
funding had been approved but had no further
details as to expected date of completion.
At both the Sunshine Adult Acute Inpatient Unit
and the Sunshine Hospital Rehabilitation Unit,
Community Visitors reported seeing holes in the
walls. In February 2015, they reported12 holes in
SECU at the Rehabilitation Unit; in March, 13 holes
(two of which had been concealed with paper and
sticky tape) and in June, 12 holes (as well as the
unit smelling of urine).
The height of the chairs in the dining area of the
Banksia adolescent unit at the Royal Children’s
Hospital are considered to be a health and safety
issue as they are too low at the table, causing a
great deal of discomfort. This issue was first raised
in November 2014 and shows no signs of being
resolved. The Regional Convenor emailed the NUM
and was told the replacement chairs were on order
and should arrive within three months, but they had
not been replaced at the time of the Community
Visitors visit in June 2015.
There have been a number of issues related to illicit
drugs. A variety of strategies have been trialled
in acute units to address these issues including
inspections by drug sniffer dogs, lockers in foyers
for visitor use, and the use of CCTV cameras.
Community Visitors spoke with the Royal Melbourne
Hospital Volunteer Coordinator who seems
passionate about having the volunteers working in
the eating disorders unit and other mental health
units. The coordinator said she would be more
than happy to help with induction of volunteers and
police checks. She is also willing to make art and
craft supplies available to a craft group. However,
the impetus to start a group such as this must come
from the NUM of the unit concerned.
Mental Health
A patient at the Royal Melbourne Hospital
Special Eating Disorders and Neuropsychiatric
unit complained about the lack of activities and
said that, although there were group activities
scheduled, staff rarely conducted these. She
complimented one nurse who did conduct some of
the advertised groups. During the three weeks that
she had been in the unit, the patient had attended
three groups of half to one hours’ duration. A
written response from NUM acknowledged that
there were gaps in the activity schedule. The
response said that the dietician would conduct a
weekly nutrition group and the NUM will conduct
a weekly group to explain the various treatments
available to people living with an eating disorder.
The Acting NUM at the Banksia Unit told Community
Visitors that she had been instructed not to provide
Community Visitors with incident reports until further
advised. At a subsequent meeting with the Clinical
Director at the Royal Melbourne Hospital, it was
agreed that hard copies of incident reports would be
available in a file for Community Visitors to access
during their monthly visits, but none were available
during the June 2015 visit.
During a recent visit to an adult acute unit,
Community Visitors learned that the NUM of
the adult acute unit was reluctant to provide
Community Visitors with access to incident reports
due to a lack of procedural guidance from DHHS.
The NUM stated that about 100 incident reports
could be created in a single month and that these
are segregated into four levels of seriousness and
stored on the Riskman Database. As Community
Visitors do not wish to be presented with a high
volume of unrelated reports, it is unclear which
levels of incidents are most appropriate.
Further problems occur when the NUM is absent
as the database only permits selective access
and staff do not have full authority to access
the incidents, thus creating an artificial but
effective barrier to Community Visitor access.
The Ombudsman’s Report of 14 October 2014
recommended that the Secretary of the former
Department of Health give directions to clarify the
scope of the Act for the definitive resolution of
these issues, and when published, it is hoped that
all issues concerning Community Visitor access to
incident reports will be overcome.
The situation regarding requests for written
responses is still problematic in several facilities,
but there has been some improvement generally
39
and a marked improvement, particularly at the
eating disorders and neuropsychiatric units at the
Royal Melbourne Hospital.
Earlier in the year, a meeting was held with a clinical
director and area managers from several health
networks operating in the region to discuss issues
and matters of mutual interest. The response of
the managers was very supportive of Community
Visitors and it was decided to hold such meetings
on a six-monthly basis.
Physical assaults and verbal abuse have occurred
in the mental health facilities of Monash Health and
Peninsula Health between patients and between
patients and staff. Altercations do not always result
in actual physical injuries but patients report feeling
fearful and unsafe around an aggressive co-patient.
Some incidents have resulted in physical injuries to
staff, for example, a broken rib, as well as emotional
stress and psychological after-effects requiring
stress leave and sick leave.
Treatment and care
Bed availability
The pressures for admission to inpatient beds have
been acute throughout the year. Monash Health
introduced an internet-based system to identify
empty beds at Casey and Dandenong hospitals with
Monash Medical Centre allowing the admission of
patients anywhere. The downside of this streamlined
allocation may mean the hospitalisation of patients
far from their family and friends and admission to
age-inappropriate settings. At Dandenong Hospital
Unit Two, it has resulted in the mixing of young and
older patients, where the activities program and
the ambient atmosphere was designed for young
people. Also, the sending of patients from Unit
One, the adult acute inpatient unit, to Unit Four, a
SECU for long-term patients; the use of empty beds
in HDU normally reserved for seriously disturbed
patients, and the creation of ad hoc ‘pop-up units’
of extra beds resulting in the patient numbers being
in excess of the registered numbers.
Medical treatment
Patients admitted to all hospitals frequently complain
about their treating psychiatrist. The doctor may
40
disregard the patients’ expressed concerns about
the prescribed medications when adverse effects
are experienced, or the doses given. Poor doctorpatient communication drives patients to seek a
second opinion, which is compounded if nursing
staff do not attend to the patient’s request. As there
is no access at present to additional funding to
assist in providing external consultations, second
opinions are provided by internal staff psychiatrists
and may not be truly independent.
At the Alfred Hospital psychiatry units, Community
Visitors have been impressed by the responsiveness
of the nursing and medical staff to the patients.
Nursing staff and psychiatrists readily discuss the
treatment regimen with Community Visitors as
active collaborators in the welfare of patients. Any
issues raised are treated seriously by the NUMs
without defensiveness. A similar open approach is
reported by Community Visitors who visit Casey,
Dandenong and Frankston hospitals. However, at
Monash Medical Centre, even though assurances
are provided in the written responses to Community
Visitor reports, action in relation to reported
concerns seems to take a long time to occur.
Illicit substances
This year has seen a concerning increase in the
use of methamphetamine substances (Ice) or
synthetic cannabis by people requiring admission
across all hospital acute mental health units.
This leads to uncontrolled aggressive behaviours
resulting in physical attacks on other patients and
staff, frequently resulting in injuries to themselves
and others, and significant damage to walls and
furniture. Some patients use as well as deal in
these substances, receiving supplies from friends or
relatives brought secretly inside or pushed under an
external door to the unit.
Dandenong Hospital inserted a steel panel across
the foot of the door closing a gap and considered
bringing in police sniffer dogs to locate hidden
stashes on Unit Two. When under the influence
of these substances, patients are removed
from the open areas and placed in seclusion for
varying periods of time until their demeanour and
responsiveness have settled.
Community Visitors have been impressed by the
tolerance and understanding shown by the staff
who care for these patients under very challenging
circumstances. Contrary to popular belief,
schizophrenia still remains the primary reason in
over 60 per cent of hospital admissions.
Mental Health
Restraint and seclusion
The use of restraint and/or seclusion has decreased
in all hospitals this past year. Monash Health
received DHHS funding to introduce a Safewards
trial in five mental health units: three at Dandenong
Hospital and two at the Kingston Centre aged
mental health units. The need for and frequency of
restraint use and seclusion is monitored. Peninsula
Health, though not yet included in this initiative, has
managed to significantly reduce the frequency of
restraint and seclusion even though the use of illicit
substances by patients is a concern.
Community Visitors are now authorised to visit
seven PARCs and were welcomed at these, though
one manager initially questioned their right to enter
and engage with the residents.
Requests for a second medical opinion or to change
a treating doctor sometimes seem to take some
time to address and staff can appear obstructive
to patients but, when explanations are given, with
printed information, patient anxieties reduce.
The removal of patients’ mobile telephones and
the controls exercised by staff over their use is a
common complaint. Recently, Casey, Dandenong
and Monash Medical Centre hospitals installed
mobile telephone charger units for a dozen
appliances at a time, located in the nurses’ station,
assuring security and ready access when patients
want them. This advance has reduced the patients’
frustration and the frequency of irate outbursts.
Removal of a personal mobile still occurs when a
patient engages in photographing other patients,
making offensive or multiple external calls.
Patients in the acute psychiatric inpatient unit at
Monash Medical Centre complain they do not
receive due respect from some nursing staff in their
daily interactions. This concern has been reported
by patients to staff, and Community Visitors have
raised this in their reports to the NUM for resolution.
Common complaints relate to patients having no
clear understanding of the reason for admission
and feeling dissatisfied when they are made a
compulsory patient under the Act; or they say they
have received limited or no provision of printed
materials about the unit, its layout, and operations.
All mental health units are expected to provide
admitting patients with a personal copy of a Patient
Information Folder. Dandenong Hospital Units
One, Two and Four advised Community Visitors
Mental Health
the information folders were being redeveloped so
none were available to their patients, contributing
to confusion and limited understanding of their
environment. Conversely, the Alfred Hospital
provide a board on the ground floor detailing helpful
information on the mental health service’s recovery
program and the weekly inpatient recovery group.
In this advancing technological era, patients want
access to computers and personal iPads, but these
are banned at the Monash Medical Centre acute
psychiatric inpatient unit. The Alfred acute inpatient
units allow patients to use technology in all but the
HDU area, which has reported problems with filters.
Inpatients have the right to amenable pleasant
surroundings yet, at the adult acute inpatient unit at
Monash Medical Centre, patients have been denied
free access to the large external rear courtyard
since December 2013, following an attempted
absconding. Access has been denied or allowed
only under nurse supervision for short periods even
though the height of the fences has been raised.
Community Visitors report on the prevention of
access to that courtyard at every monthly visit,
receiving various explanations from the NUM and
director, most recently that wi-fi coverage for the
operation of the safety alarm does not extend there.
This unresolved situation has affected inpatients
who have to remain indoors through all seasons.
The enclosed central courtyard is available but used
daily by patients who smoke, giving non-smokers
a choice between a grubby smoke-filled external
space or remaining inside the unit. In contrast,
the Alfred mental health units now provide outside
areas to all general unit patients.
Discharge planning
Timely discharge of patients is dependent on the
availability of suitable accommodation. As many are
homeless or in temporary housing when admitted,
with no fixed abode and problematic relationships
with family or friends, often compounded by
additional disabilities or complex dual diagnoses,
the likelihood of a successful transition to the
community is low.
The invaluable work of the social workers in all three
networks to make strenuous complex enquiries
relating ot these matters is invaluable. Monash
Health is planning to construct a separate ten-bed
transition support unit to provide interim housing
for patients with dual disabilities and the seven
PARC facilities also provide short-term rehabilitation
accommodation options. Patients can remain in
41
hospital for longer than is clinically required because
of the limited accommodation options in this region.
Low-cost suitable housing is urgently needed.
Community Visitors have campaigned over several
years for regular recreation activities to be provided
at all mental health facilities in the region as an
essential element of therapeutic programs. Efforts
have been made across all networks to respond,
with varying success. Dandenong Hospital’s
Unit One has provided creative activities for a
considerable time and Frankston Hospital’s 2 West
Adult Mental Health Unit has expanded its daily
program activities, providing a busy scene.
Monash Medical Centre’s Adult Psychiatric Inpatient
Unit has languished considerably in providing
regular activities, relegating the patients to wander
aimlessly around the corridors. To address this, new
appointments this year include an occupational
therapist who leads an activities program designed
to appeal to a wide range of interests; a parttime exercise physiologist to assist in structured
gym exercises since equipment was reinstated;
and a pastoral care volunteer attends weekly
for contemplative discussions. Other interesting
activities occur in several CCUs and PARCs: pet
therapy visits by a Delta Program dog or adopting
a resident cat, gardening and a weekly barbeque
involving residents and patients.
The Alma Community Care Unit in St Kilda has
installed a dedicated leisure room with adjoining
kitchen facilities. Monash Health’s Kingston Centre
for aged mental health patients undertook a review
of recreational activities and Community Visitors are
pleased to see the mobile residents from Allambie
Unit transported to interesting day outings and
engaging in in-house activities.
The provision of interesting activities for patients
in the Biala Assessment Unit often fails to capture
patients’ interest. The lack of activities at weekends,
when activities coordinators are off duty, remains
onerous for those patients who may not have
family or friends to visit them. Last year, Community
Visitors reported on the lack of magazines, books,
DVDs and DVD players. This lack has partially been
resolved at Monash Medical Centre, Casey and
Dandenong Hospitals as Community Visitors have
brought in books and magazines although materials
are often removed and not returned.
42
Facility management
Many facilities in this region provide tidy, clean
and pleasant environments and attractive garden
areas. The courtyard at the Monash Medical Centre
Adult Acute Psychiatric Inpatient Unit, however,
is regularly reported to be dirty and unkempt with
bird-droppings. Similar reports made at Kingston
Centre aged mental health units showed rapid
responses to improve conditions.
Budget constraints require funds to be found to
meet the essential costs of maintenance, repair
and replacement. While some health networks
manage to do so, others do not. A major obstacle
in replacing essential machines or services appears
to be the bureaucratic requirements for multiple
quotations to be obtained and the maintenance
schedules of work.
Some older facilities, like the Monash Medical
Centre Adult Inpatient Psychiatric Unit are sorely
in need of complete renovation although facelifts
have occurred through painting of common areas
and provision of some murals. Repairs to structural
damage, broken machines or bathroom doors
remain unresolved for weeks at a time and have
required escalation to the director for speedy
resolution. In one case, shoddy repairs meant
that exposed wiring in a room remained for four
weeks before being repaired. The newly renovated
five-bed Wellness and Recovery Unit for Eating
Disorders at Dandenong Hospital, received patients
transferred from Monash Medical Centre. It is a
light, bright, colourful self-contained unit with a
sitting area for games and television and additional
small rooms for meals together or family sessions.
Peninsula Health has obtained grants to undertake
systematic upgrades to its aged mental health
unit and turned a barren garden area into an
attractive pleasant area complete with new garden
furniture. Renovations are underway at Peninsula
Health’s Carinya Dementia Care Units, including
the expansion of doorways to allow bed-bound
patients to be wheeled outside for fresh air in warm
weather. Plans are also in train to create an outdoor
garden area for Frankston Hospital’s 2 West Adult
Mental Health Unit and patients may participate in
vegetable and flower cultivation.
The Alfred Hospital routinely replaces furniture every
five years and will finalise the purchase within two
months once the preferred supplier is approved.
Mental Health
At Monash Health a centralised management
system by the Carer and Consumer Directorate
has improved the responsiveness to Community
Visitors’ reports after notification of outstanding
responses from different facilities. Recurring issues
at particular units are identified for action and
advocacy by Community Visitors.
Regular liaison meetings are held between
Community Visitors and both the Alfred Health
and Peninsula Health networks. All issues raised
by Community Visitors have been responded to
efficiently by these health networks.
Mental Health
43
Recommendations
Recommendations
The Community Visitors Residential Services
Board recommends that the State Government:
1. finalise and distribute the SRS and mental health service protocol by 31 December 2015
2. monitor the protocol to assess whether it translates into effective local supports for
SRS residents with mental health issues
3. clarify and simplify the SRS incident reporting requirements so that staff and proprietors clearly understand the difference between recordable and reportable incidents
9. ensure Pension Level Project funding is
incorporated into SAVVI funding on an ongoing basis to enable all residents in pension level SRS to receive the supports
they need
10. increase recurrent funding to the Community Visitors Program to engage sufficient numbers of specialist and administrative staff to support the work of the volunteers and to recruit and train the numbers of Community Visitors required to visit all SRS on a regular basis and liaise effectively to address the
issues identified on visits.
4. ensure proprietors and staff receive mandatory training in
a) dealing with residents diagnosed with a mental illness
b) incident reporting
5. finalise a notification protocol with the
Public Advocate of incidents or allegations
of violence and abuse in order to reduce
the risk for SRS residents
6. expand the ‘Supporting Connections Program’ to provide additional support to proprietors to maintain a safe home-
like environment to minimise abuse,
neglect and violence
7. institute an effective prosecution
regime of proprietors that fail to meet
their legislative obligations and publicise
the issues involved in any such
prosecutions to the sector
8. amend the SRS regulations to the 2010 Act to allow Community Visitors to inspect any document pertaining to their role, unless
it is a medical record
45
Statewide
Report
The impact of mental illness in SRS
The Residential Services sector has become a
primary accommodation resource for people
experiencing chronic mental illness and other
disabilities who may not be able to live with family.
Often a place in an SRS is the person’s only
alternative to homelessness. The loss of SRS beds,
particularly in rural areas, compounds the lack of
accommodation options for these Victorians.
difference of understanding between pension-level
SRS and above-pension SRS which are often run
by former health care personnel. The latter are
generally open and transparent with incidents as
they know they can learn from them to improve
services, whereas some of the former still consider
the number of incidents as equating with a poorly
run facility, so they routinely underreport them.
The perception among mental health services
that SRS are formal or step-down clinical services
means that many people with mental illnesses
may be inappropriately placed in SRS. Community
Visitors across the state have reported that SRS
staff have experienced significant issues in sourcing
mental health and/or drug and alcohol support
services in a timely manner for their residents.
In addition, Community Visitors reported many
SRS staff do not understand what should be
recorded as an incident or whether it is reportable
to the department.
The Barwon case study highlights that despite
SRS staff commitment to support people with
complex, chronic mental health and substance
abuse issues, without timely backup from local
support services, residents are unlikely to be able
to sustain their SRS tenancy.
In the Loddon Mallee Region, an SRS resident
attempted suicide prior to being taken to in-patient
mental health care.
The protocol between area mental health services
and SRS, which has been under review for over
two years, is yet to be finalised. The board urges
the two sections of the department to conclude this
protocol as a matter of urgency.
The absence of any requirement for mental healthspecific training for SRS staff and the low staff to
resident ratio of 1 to 30 remain serious concerns
for Community Visitors. This year’s coronial inquiry
into an SRS resident death by their mentally unwell
roommate demonstrates the consequences of
ignoring these issues.
Incident Reporting
Community Visitors observed a variety of practices
in incident reporting at SRS, with a marked
46
Community Visitors have identified that all staff need
to attend an initial round of compulsory training on
incident reporting in order to build capacity and
understanding of this practice change. This needs
to be followed by regular incident reporting update
training sessions in order to maintain this change
and build consistent practice across the sector.
The recent departmental initiative of a new Incident
Report book has been reported by Community
Visitors as having improved reporting practice.
Community Visitors commend the department on
implementing it.
Abuse, neglect and violence
This year, Community Visitors have reported on
resident aggression towards fellow residents and
staff as well as verbal altercations that escalated
to violence. On occasion, resident aggression
and destruction of property was so severe that it
necessitated staff locking themselves in while the
police were summoned. In many instances, these
violent episodes led to resident evictions.
Sexual assault and harassment continue to be
reported across the state and, in one tragic
incident, an allegation of this nature may well have
led an alleged perpetrator to commit suicide.
Community Visitors were shocked to report a
serious case of neglect this year at a pensionlevel SRS where the proprietor ceased to supply
Residential
Services
Stream
No. of CVs
Requested visits
Scheduled visits
Total visits
toilet paper to residents. When questioned by
Community Visitors, the proprietor said that
residents had agreed to the change. It was a
significant victory for Community Visitors to
overturn this unfair imposition on residents.
9
6
2
66
68
40
11
10
182
192
Gippsland
6
5
2
21
23
Grampians
10
7
0
93
93
Hume
2
6
0
23
23
Loddon Mallee
7
7
6
49
55
18
7
7
93
100
42
21
12
216
228
11
7
7
66
73
145
77
46
809
855
The Board sees this as one of many examples
highlighting the value of Community Visitors in
protecting the rights of these vulnerable individuals,
including their financial independence.
Region
The Board is concerned that allegations of abuse,
neglect or violence require a higher level of
Community Visitor action, which generally means
increased visits. However, the impact of these
serious concerns was never taken into account when
the program’s funding was set by the department.
Proprietor attacks on Community
Visitors performing their role and
departmental response
The Board reports that Community Visitors have felt
threatened and intimidated when visiting services
run by the proprietor of Dependable Care Pty Ltd.
As a consequence, two Community Visitors have
ceased their involvement with the program.
Dependable Care operates four pension-level SRS
in two regions: Barwon South Western Region
and North and West Metropolitan Region, with the
problems concentrated in the latter.
Since early 2013, Community Visitors have reported:
• incidents where Community Visitors
experienced rudeness, intimidation
and bullying during visits
•
at the direction of the proprietor, the person
in charge during visits required Community
Visitors to wait until the proprietor or their representative arrived at the facility before
the visit report could be discussed
Barwon South Western
Total
Table 6: Total visits Residential Services Stream 14/15
• criticisms of Community Visitors by the
proprietor which highlighted a fundamental misunderstanding of their role
•
denigration of Community Visitors when performing their legislative role by the
proprietor’s making allegations that they
are ”telling lies and being motivated by a
desire to close [the SRS] down”
•
in the view of Community Visitors, the
proprietor lodging reprisal complaints in response to notifications the Community
Visitors have made to the department
about issues in these facilities.
• the person in charge at the time of the visit refused to sign the visit report
All these issues have been raised with the
proprietor in the Community Visitors’ notifications
by the Manager of the Volunteer Programs and
by the department. Mediation was arranged and
the proprietor withdrew the day before it was
due to occur.
47
The Board and program staff have repeatedly
raised these matters in both regional and statewide
departmental liaison meetings seeking action
by the department to stop the intimidation and
harassment of these volunteers.
In June, in light of the department’s continuing
inaction on these issues, the Board decided to
write to the Minister to seek a meeting to address
these concerns.
The department promptly responded by organising
a meeting between the Public Advocate and the
Volunteer Program Manager with the North and
West Metropolitan Regional Director and the
regional SRS Manager. It was agreed at the meeting
that the department would investigate these issues
to ascertain if any breaches of the legislation had
occurred and, if so, what action was appropriate.
In addition, there was a discussion about how to
jointly manage this situation into the future, if the
behaviours continued.
The department also agreed to write to the
proprietor seeking clarification of her partner’s
status. Community Visitors have sought clarification
of this person’s role in order to establish his
authority to access the residents’ personal files.
The Board will continue to monitor this matter,
act where necessary and report on any future
developments in the interests of protecting
Community Visitors.
70
60
66
62
52
50
40
30
Community Visitors have noted many instances
of poor SRS maintenance. This situation is
exacerbated if the SRS proprietor does not own
the building housing the SRS. The response to
maintenance issues in this situation ranges from the
proprietor responding promptly and referring issues
for action to those claiming that, as they do not own
the building, maintenance is not their responsibility.
In many instances, it has taken the Community
Visitors repeatedly reporting these maintenance
concerns before action to address them occurs.
Support for Vulnerable Victorians Initiative
(SAVVI) and Pension Level Project
Community Visitors have observed over the year
that the Supporting Connections workers, funded
under the SAVVI Program, are of great assistance in
enhancing the lives of SRS residents so are pleased
to see this funding continue.
The Board welcomed this year’s extension of the
Pension Level Project (PLP) funding for those eligible
SRS not in receipt of SAVVI money and hopes that
it will continue indefinitely. The PLP is enhancing
the living environment for eligible residents and
ensures that residents with higher support needs
are not being discriminated against based on which
pension-level SRS in which they reside.
Viability of the sector
Community Visitors have reported a loss of 135
beds from three SRS this year, with one facility
closing and two transferring to aged care. All
three SRS were situated in regional Victoria where
affordable accommodation options for people
reliant on Centrelink payments are scarce and
remaining SRS have few vacancies.
Since 2012-13, the program has reported on the
loss of 640 beds from this sector, many of which
were located in rural or regional areas.
20
10
0
12/13
13/14
14/15
reporting year
Figure 5: Residential Services Stream abuse, neglect and
violence 12/13 to 14/15
48
Building maintenance
The one bright spot is Seaview House SRS,
Portland. This SRS was threatened with closure
three years ago as it had only five residents,
however, by January 2013; the number of residents
had climbed to 47. This facility is now viable and
everyone involved - staff, residents, their families
and the local community – are to be congratulated
on keeping Seaview House open.
85
health
80
87
90
65
64
personal support
60
physical environment & fabric
70
30
37
30
social independence & choice
40
39
50
safety
23
20
13
10
food
finances
0
privacy, dignity & confidentiality
A further example of concern was when OPA’s
Policy and Research Unit began a project into the
effectiveness of the Supported Residential Services
(Private Proprietors) Act 2010 for residents. The
research officer met with senior departmental
staff to interview them for this important research
project, however, the departmental representative
refused to answer any questions “on the record”.
100
abuse
Quarterly meetings between the Residential
Services Board and the management of the
Authorised Officer Program became difficult due
to the program’s expectations that problem issues
would be addressed promptly; however, that has
often not been the case. One example was when
Community Visitors in one region were denied
access to the medication administration sheets
as they were interpreted by the proprietor to be
medical records (which visitors cannot access) and
the regional Authorised Officer agreed with this
view. Consequently, the matter was raised at the
statewide liaison meeting in the hope that it could
be quickly addressed, however, the departmental
representatives decided to query why Community
Visitors wanted to see such records, rather than
addressing the misinterpretation that had occurred.
The Board has been concerned over the past year
about the relationship between the program and
the department. The Board was so disappointed
by the department’s inaction on one proprietor’s
repeated attacks on Community Visitors that it,
eventually, wrote to the Minister.
issue groups
Relationship with the department
Figure 6: Residential Services Stream by issue groups 14/15
The program trusts that these relationships will
improve over the coming year.
Implementation of the National Disability
Insurance Scheme (NDIS)
Community Visitors remain concerned about
aspects of the implementation of the NDIS in the
Barwon region including how SRS residents access
eligibility assessments and obtain services.
Community Visitors have reported that some
residents with NDIS plans have been able to access
a greater range of services that enhanced their
lifestyle and resulted in less behaviours of concern.
SRS proprietors and staff are now routinely
included in the planning process, provided the
resident agrees, as they often understand and can
help articulate the person’s needs.
However, there have continued to be issues
with responsiveness from the National Disability
Insurance Agency (NDIA) and the absence of case
management in plans has meant that some SRS
residents have struggled to get services as they have
been left to their own devices. In many instances, it
was the persistent reporting of Community Visitors
and proprietors’ work with the agency that has led
to positive outcomes for SRS residents.
49
issue types
health care
59
abuse/neglect/violence
41
incident reports
33
staffing and support
29
maintenance
24
other hazards
23
building fabric
19
health referral Information
17
hygiene
15
complaint processes
15
individuality and choice
13
resident mix
13
fire safety
12
support plans
12
access to information
10
support to move/relocations
8
financial matters
8
activities
8
medication
8
residential statements
7
meals and beverages
7
heating/cooling
7
cleaning
6
personal equipment
6
internal fixtures and fittings
5
education/job opportunities
5
decision making
5
privacy
5
dietary needs and preferences
3
community
3
food safety
2
evacuation procedures
2
call system
2
grounds maintenance
2
evictions
2
access to water and beverages
1
bedding and linen
1
storage facilities
1
interpersonal relationships
1
communication
1
grooming and clothes
1
first aid
1
number >
0
10
20
30
40
50
60
70
Figure 7: Residential Services Stream number and types of issues identified 14/15
50
Ombudsman investigation
of Mentone Gardens SRS
In September 2013, Mentone Gardens, a pensionplus SRS, which housed 39 elderly residents, went
into liquidation owing over $4.5 million including
substantial resident bonds.
Ombudsman Victoria’s investigation uncovered
that Mentone Gardens had not produced proper
financial records for its entire 25-year history. During
that time, the department had prosecuted this SRS
twice for Act breaches:
• in 1995 the proprietor pleaded guilty and was fined for breaches of resident care
•
in 2000, the proprietor pleaded guilty and was fined for care plan and accident record breaches. The Magistrate described the proprietor’s conduct as “appalling”.
The Victorian Ombudsman, Ms Deborah Glass,
recommended that the government make ‘ex
gratia’ payments to these residents, including their
estates, to compensate for their loss because her
report demonstrated that the department failed in
its regulatory role.
She also reviewed the department’s capacity to
respond to a similar situation today and concluded
that it had not taken the necessary steps to
regulate SRS providers into the future.
This finding is of serious concern to the Board,
particularly in light of the earlier report on a
proprietor’s attacks on Community Visitors and the
need for a regulatory response to that issue.
good practice
Community Visitors congratulated one SRS
on the provision of family violence prevention
information. The volunteers would like other SRS
to follow this lead.
51
Regional
Reports
Barwon-South
Western Region
There are three pension-level SRS and four
pension-plus facilities in this region.
case
study
A proprietor of a pension-level SRS agreed
to accommodate a person with a serious
substance-abuse issue.
Cooperation between SRS proprietors,
departmental Authorised Officers and
Community Visitors in the region has achieved
good outcomes for residents.
The proprietor was prepared to work with the
resident to help them overcome their addiction.
However, it took three weeks for local drug and
alcohol services to respond to the proprietor’s
repeated calls to assist the resident.
Health
Community Visitors observed that, despite such
willingness by the proprietor to assist the person,
including locating a responsive GP for them, their
behaviour caused such disturbance at the facility
that they were evicted.
All SRS provide a very high standard of health
care, addressing residents’ needs in a timely
manner. Doctors are visited and ambulances
called, when required.
One pension-level SRS had a resident who
had several falls. The person was admitted to
hospital for ten days, where they had staples
inserted in their head, and lost weight. On
return to the SRS, staff spent many hours
educating the resident how to move safely
around the facility.
Abuse and neglect
Community Visitors reported that a resident
at a pension-level SRS caused significant
damage to the building. Police were called
and after ensuring that residents were safely
in their rooms, staff locked themselves in the
kitchen until police arrived. The perpetrator
was subsequently evicted. Community Visitors
noted that no Incident Report was prepared
regarding this incident.
Community Visitors also noted that, at another
pension-level SRS, a resident was evicted for
aggressive behaviours towards staff.
The person was moved and subsequently evicted
from another pension-level SRS after a week,
due to these on going behaviours of concern and
stealing from local shops to procure alcohol.
Community Visitors remain concerned about
what happens to people who can no longer find
a place in an SRS.
Community Visitors are also apprehensive about
the placement of people with complex substance
abuse needs at SRS as there are often few other
available accommodation options. However, as
this case study demonstrates, it is difficult to locate
community-based specialist services willing to
support SRS proprietors to safely accommodate
and treat people with complex needs.
Personal support
Community Visitors report that SRS are generally
well managed, clean, tidy and with varied activities.
In addition, well-trained staff provide a high standard
of personal support to residents to meet their needs
and improve their wellbeing. Support plans are
always very informative and are updated regularly.
Across the region, Community Visitors report that a
large variety of nourishing meals are served at both
pension-level and pension-plus facilities.
52
At one pension-level SRS, Community Visitors
noticed that the brakes on a resident’s walker
were faulty and there were no handgrips. Staff
were informed and the walker was repaired to
the Community Visitors’ satisfaction.
hospital pharmacist to provide medication
administration training to staff. This has led to
a marked reduction in medication errors.
Incident Reports
Privacy, dignity and confidentiality
There has been some confusion in the
region distinguishing between ‘reportable’
and ‘recordable’ incidents. Pension-plus
SRS seem to record many more incidents
than pension-level facilities.
At a pension-plus SRS, it was reported that a staff
member entered a resident’s room during a private
medical procedure. There was a staff altercation,
which caused management to intervene and
subsequently provide additional training to staff.
Community Visitors note that the department’s
provision of a new Incident Report book to simplify
reporting has led to more incidents being recorded.
Social independence and choice
In pension-plus facilities, incidents seem to
be mainly people falling and some medication
dispensing errors, while in pension-level SRS,
the main incidents are verbal altercations
between residents or disruption to daily routines.
At one pension-plus facility catering to mainly
frail-aged residents, there were several incidents
of missed medication at prescribed times.
This was rectified by staff having training from
a registered nurse and, now, all new staff are
observed at five medication distribution sessions
before proceeding to do it on their own.
Proprietors at two pension-level SRS reported
difficulties in dealing with the NDIA. The plan
coordinator responsible for two residents failed to
return phone calls.
Staff also reported that jargon in NDIS plans makes
them difficult to understand how funding is allocated.
Proprietors at both facilities stated they would like
to have a greater role in contributing to plans and
follow-up as they know the needs of the person
with a disability well. Proprietors were also unclear
about who was responsible for ensuring plans were
implemented.
Safety
good practice
Community Visitors were very impressed that,
after a young Themar Heights resident died
following a long illness, the proprietor organised an
extensive celebration of the resident’s life involving
SRS residents and the wider local community.
At a pension-level SRS, some residents do not
return to the facility until very late at night. Staff
are concerned that the closure of the local police
station will result in their being unable to report any
missing residents locally and that responses to
serious incidents may take longer.
Community Visitors reported many mistakes
with the administration of medication at one
SRS. The manager organised for the local
Activities
SRS in the region offer many and varied activities to
suit individual resident needs.
53
good practice
At Surfcoast, a personal trainer comes twice
a week to conduct ‘boxercise’ and other
exercise sessions, which residents enjoy very
much, including some who exercise while
seated. Residents at this facility also attend a
hydrotherapy pool weekly.
At Brooklyn House, the Christmas Party was
a big success with a lot of delicious food;
the facility was beautifully decorated and the
residents preformed a play for visitors.
Once again, the management of Themar Heights
took five residents to Queensland where they
visited Noosa and the Goldcoast.
The closure of Queenscliff and Geelong Lodges has
meant a loss of 75 beds in the Geelong area. This
is a huge loss and it is now virtually impossible to
gain access to a SRS bed in Geelong.
The residents’ families, management, staff and
the people of Portland are to be congratulated on
their efforts to keep Seaview House open, after
being threatened with closure about three years
ago. The staff, residents and their families, and the
local community fought to keep the facility open. In
January 2013, there were only five residents and,
after a huge struggle, there are now 47 beds that
are fully occupied. Community Visitors understand
that this makes the facility financially viable. The
facility is now fundraising to buy a 20-seater bus to
build on existing services.
This region is divided it into two geographic
areas, based on Local Government Areas with
40 SRS. In the inner part of the region, there
are six pension-level and 17 pension-plus SRS,
many specialising in support to the elderly. In
the outer part of the region, 11 pension-level
and six pension-plus SRS, cater to a diverse
range of support needs.
Community Visitors and departmental Authorised
Officers work well together, complementing each
other’s expertise in the interests of residents. There
has been a noticeable improvement in record
keeping because of departmental audits.
54
Health Care
In the inner east of the region, the high proportion
of incident reports relating to falls gives an
indication of the primary focus on elderly residents,
particularly in pension-plus facilities.
In the outer east of the region, Community Visitors
and staff at facilities have regularly raised concerns
about the limited access to support from health
services, in particular, mental health services,
including Crisis Assessment Treatment Teams,
which can be difficult to access. Staff are often
required to provide extra support to particular
residents whose support needs increase, while still
meeting the needs of the other residents. In one
case, where a resident at a pension-level facility
was self-harming, Community Visitors suggested
that extra supports needed to be put in place,
to assist staff to better manage the behaviours.
In another case, the mental health of a longstanding resident at an outer east SRS deteriorated
significantly. Staff at the facility were frustrated by
the lack of communication with them and failure to
include them in care planning with other services.
Community Visitors in the outer east have also
criticised poor discharge practices. During one
visit, a proprietor talked about the varying quality of
discharge information from hospitals.
case
study
A vulnerable resident at an outer east pensionlevel facility, with a complex history including a
mental health diagnosis, was admitted to hospital
after self-harming. The following morning, the
patient was discharged at 6am; at the time he
was wearing pyjamas and dressing gown, and
given a bus ticket to travel home. Discharge
information did not arrive at the facility until the
next day. On the basis of this information, the
Community Visitors Program submitted a formal
complaint to the health service.
Proprietors report that there is often a gulf between
themselves and other professionals involved in
resident care. Notes from a hospital or referring
service may be limited and inadequate, the quality
dependent on the individual case manager. A referral
summary prepared for a facility by a departmental
case manager consisted of an 81-word history of
the patient, which failed to include anything about
his abusive and threatening behaviours to children
and women or his theft of other residents’ property.
Residents may have medication dosages altered
without consultation with carers, while some do
have thorough and well-written notes, which are
easily accessible to the layperson.
Aggressive incidents involving residents were
reported on a number of occasions in the outer
east; some of these incidents resulted in police
involvement, and occasionally eviction of residents.
Community Visitors believe that a number of
factors contribute to these incidents, including
poor communication skills, inappropriate mix of
residents with high support needs and challenging
behaviours, substance abuse, and inadequate
support from mental health services.
A resident at a pension-plus facility in the outer east
(who had previously lived at two other SRS in the
region) was evicted following a number of incidents
including repeated entry into women’s bedrooms,
as well as sexual harassment, which was also
directed at staff.
New Incident Report books have been introduced
this year to assist staff at SRS to document
incidents more comprehensively. These have been
utilised well in most facilities, although Community
Visitors have highlighted deficiencies in incident
reporting on occasions. At one pension-level
facility in the outer east, Community Visitors were
concerned by their lack of access to documentation,
particularly as they were aware that there had been
reports of aggressive incidents at the SRS.
Personal support
Staff at SRS face multiple demands in caring for
residents; this may limit the type of support that
can be offered. For instance, access to recreational
activities may be impacted. In some cases,
volunteers are able to assist, however, this type
of support is not always readily available. At one
outer east facility, residents were unable to attend
exercise classes offered in the neighbouring church
hall because there was no one to support them.
In another instance, Visitors queried why residents of
a facility rarely accessed activities at the community
centre, which is situated directly across the road.
Staff members have also been accused of bullying
residents. In one case, the staff member accused
of bullying contended that she was misunderstood
due to her cultural background. English is frequently
a second language for support staff, which may
lead to misunderstanding and frustration on the
part of already stressed people.
Concerns were raised by Community Visitors at
one outer east SRS regarding perceived disparities
in Individual Support Packages (ISPs) allocated to
different residents. Community Visitors queried the
role that a support worker allocated under an ISP
performed with a young female resident at an SRS.
Community Visitors felt that there was little structure
or value to the resident with the ISP funding, as it
did not seem as though time spent with the SRS
resident had a targeted achievable goal.
Physical Environment
Community Visitors play a key role in monitoring
the state of the physical environment, particularly
in regards to maintenance issues. In one example
at an outer east facility, Community Visitors drew
attention to the very worn carpet in a part of the
SRS. This was a trip hazard for the residents.
Safety
Community Visitors in the inner east noted that
fire extinguishers had not been serviced for an
extended period. This matter was referred to the
department, which has liaised with the local council
to resolve the matter and ensure compliance with
fire safety regulations.
Community Visitors expressed concerns in relation
to an inner east pension-plus facility, where a large
branch fell from the tree near the front door of the
SRS. There was a significant delay in the landlord
addressing this safety issue, despite the proprietors
arranging for three quotes to be sent promptly for
assessment.
Gippsland Region
There are six SRS in this region: three are
pension-level and three pension-plus. One
caters mainly for frail-aged residents with the
remainder having residents from a wide age
range and with a broad range of disabilities.
Health Care
While most staff are caring, problems occur with
residents’ health. Community Visitors consider the
increased presence of the Royal District Nursing
55
at SRS would assist care and support provided
to residents, as SRS staff do not have nursing
qualifications.
Community Visitors were concerned about the
behaviour of a resident supposedly diagnosed with
Multiple Personality Disorder but whose psychiatrist
had not provided ongoing recommendations for
staff on how to work with her.
Kooralbyn SRS, which has provided excellent
service to 14 frail-aged residents over many
years, is planning to add to its services by offering
palliative care to fee-paying residents.
Abuse and neglect
Community Visitors were concerned about a staff
report of an odour from a resident’s bedroom,
which was mistaken for incontinence. It transpired
that the resident had a serious foot infection. The
resident did not follow required hygiene practice at
the SRS and his condition deteriorated. Staff took
the resident to hospital, which eventually led to the
man’s foot being amputated.
Community Visitors reported that a resident’s
allegation of sexual assault at a pension-level SRS
was fully investigated. Subsequently, an application
was made to VCAT for the appointment of a
guardian for the victim.
Personal support
Community Visitors were concerned that, at a
pension-level SRS, residents were assisting a frailaged resident to and from the dinner table while the
only staff member on duty was involved with meal
preparation and serving.
Community Visitors have generally found that
comfortable accommodation and nutritious meals,
including fresh fruit and vegetables are made
available to residents in the region. There were,
however, two complaints regarding meals, one
regarding poor quality of meals and tough meat.
The other complaint was that meal sizes had been
reduced. However, on enquiry, this resulted from a
dietician’s recommendation.
An instance of an unlocked, unattended medication
cabinet at a pension-plus SRS was noted.
Visitors reported it was positive that a resident, with
extreme weight loss, responded to counselling and
increased her weight.
56
It is pleasing to see residents, with the assistance
of Quantum Community Services, finally access a
community centre directly opposite their home.
Physical environment
Facilities in the region are generally well maintained
with considerable effort in some cases to make
improvements to benefit residents.
However, at one pension-level SRS, Community
Visitors were concerned there was a very damaged
lounge suite, which was a potential safety hazard
for residents that took many months to remove
and replace.
It took many months to fix a shower leak, which
caused a very damp patch in a resident’s bedroom.
Two emergency bells in a bathroom area of a
pension-level SRS were not working and the
department was subsequently notified.
Grampians Region
There are six pension-level and three pensionplus SRS in the region.
Health Care
Some SRS residents attended a local day care
centre where podiatry was provided. Those who
did not attend were disadvantaged when
the podiatrist at an outer region hospital left.
Community Visitors notified the department
when they observed that a resident’s nails were
so overgrown that he could only wear sandals.
Eventually, after some months, the position at the
hospital was filled and the podiatrist service to SRS
residents is now very satisfactory.
A female SRS resident had allegedly been asked
for sex by a male co-resident. The female resident
was moved to another facility and police informed.
It is understood by Community Visitors that SRS
staff informed the male resident that police would
be seeking a statement from him. The resident,
who had a history of depression, committed suicide
within the next 24 hours. Police were contacted
and counselling arranged for staff and residents.
Personal support
Community Visitors reported that SRS in the region
are generally well managed and residents receive
good care.
An SRS resident was regularly losing his money
gambling and, in one month, lost $7000. After
counselling from an outside agency, the resident
signed a contract agreeing that his withdrawals
would be limited. This action involving SRS
management and Centrelink is to be commended.
Safety
Police were also called to an SRS after one resident
threatened to kill staff. However, no action was
required as he calmed down following the police
arriving. Support for the resident was arranged with
an outside agency to provide additional occupation
and activities for residents.
When Community Visitors asked for an Incident
Report book at one SRS, they were told that it was
in the adjoining SRS. At the same SRS, a resident
reported that there was no alarm bell in the shower.
He said he had fallen and had to crawl to the
button in the main room. These matters were raised
with the department.
One SRS became a federally funded aged care
facility during the year, which resulted in a loss of 60
registered beds.
Other issues
Residents were concerned that a day centre
where they had enjoyed the company of others
was to close. The Regional Convener contacted
the Authorised Officer to ascertain whether
residents could attend another centre. Alternative
arrangements were made for the residents involved:
some transferred to another day centre, a younger
resident went back to school and the SRS arranged
day outings in their bus for others.
Community Visitors were pleased to learn of a
number of initiatives at regional liaison meetings
with the department:
• information regarding family violence support organisations and the Mental Health Complaints Commissioner was provided to SRS
• fresh fruit and an oral health program continued again this year as part of the SAVVI program
• risk assessment training for SRS was conducted.
Hume Region
There are two SRS in the region, both
pension-level and operated by one proprietor.
Community Visitors have a positive working
relationship with the department.
Health Care
Community Visitors perceive that the physical
needs of residents are met in a timely manner
however appropriate support for mental health
care remains an issue. Another issue of concern
is access to services for residents under 65 where
their needs are beyond the capacity of the SRS
staff; however they are below the age at which
they can be assessed for an aged care funding
package. A residents’ Individual Support Package
could not be transferred when they moved from
one SRS to another in the region, as the agency
providing support did not operate in both areas.
Verbal abuse among residents is the most common
concern reported to Community Visitors, which
in some cases escalated to physical altercations.
Nicotine addiction is the cause of most of the
complaints. An alleged verbal sexual suggestion
by a visiting tradesman towards a female resident
was reported and investigated. In one SRS, there
have been complaints from female residents about
a male resident continually making unwanted
sexual advances towards them. The male resident
has been spoken to and warned regarding his
behaviour, which has now ceased.
Personal support
Several incidents involving a staff member who
dropped or missed administering medication
occurred. These have now been addressed with
a revised process to ensure medication is passed
from hand to mouth without being dropped.
Confusion continues for staff regarding whether and
how to report incidents and complaints.
57
Physical environment and fabric
Community Visitors have observed that both SRS in
the region provide appetising, nutritious meals that
meet the health needs of residents. The standard of
accommodation is perceived as satisfactory in one
SRS and good in the other.
Activities and social independence
Residential Statements indicate recreational
activities are provided. Several residents from each
SRS go swimming on a weekly basis but only one
SRS has a bus to facilitate activities. Community
Visitors do not see evidence of many other activities
happening at the SRS where transport is limited.
At one SRS, a resident enjoys tending a vegetable
garden and looking after the chickens. Community
Visitors were disappointed to learn that the eggs
and produce grown cannot be used in the SRS
kitchen as it is classed as an industrial kitchen
where only purchased food can be prepared.
There are four pension-level and three pensionplus SRS in the region.
Health care
Community Visitors remain concerned regarding
support for residents of SRS diagnosed with chronic
mental illness particularly in pension-level SRS.
In one case, at a pension-level SRS, a resident
began to experience a deterioration in their mental
health while on a social activity. The person was
transported back to the SRS, where they became
increasingly verbally aggressive. SRS staff spent
two hours preventing the person from running on
to a nearby highway. The proprietor was requested
by Mental Health services to call the police to take
the resident from the facility, as they had no staff
available to assist. Due to higher priorities, mental
health was unable to respond. Ultimately, police
transported the person to acute inpatient mental
health care.
In another case, at the same SRS, a female
resident attempted to hang herself and on another
occasion, asphyxiate herself before being admitted
to acute inpatient mental health care.
SRS proprietors often inform Community Visitors
that they receive inadequate support from mental
58
health services given the severity of behaviours,
including self harm, displayed by SRS residents
with chronic mental illness.
A resident expressed concern to Community
Visitors regarding a fellow resident who made
threats to kill him with a knife. Community Visitors
were informed that the person’s mental health had
recently declined, hence a delusion that his life was
in danger, necessitating a change in his medication.
During a visit, Community Visitors observed an SRS
resident grabbing the clothes of another resident,
lifting him to his feet and forcefully transporting
the resident to the dining room. The resident, who
Community Visitors observed to be manhandled,
was very distressed and crying and informed
Community Visitors that he was very frightened
of further attack. Community Visitors reported
their concern about only one staff member being
on duty at the time of their visit, caring for many
residents with complex chronic mental illnesses.
During this reporting cycle, Community Visitors
recorded nine incidents of resident-on-resident
assault at pension-level SRS. Community Visitors
also reported an incident at a pension-level SRS
where a resident physically assaulted the proprietor,
resulting in the resident’s eviction.
Personal support
Community Visitors often reported there was only
one SRS staff member working with up to 30
residents for the whole day. The staff member’s
duties involved cooking, and personal care, and
they were also expected to attend to resident’s
needs and resolve disputes.
Community Visitors observed one resident was still
wearing urine-soaked pyjamas at 11am. The staff
on duty replied that they have five residents with
serious continence issues and the person would be
attended to when they were able.
At a pension-level SRS, Community Visitors were
told by residents that they do not have access to a
complaints book. When staff were questioned by
Community Visitors, they were informed that resident
complaints were entered into the complaints register
by staff. Community Visitors consider this process
to compound the powerlessness of residents at
pension-level SRS who have very few alternative
accommodation options.
Community Visitors continue to report on serious
maintenance issues such as leaking toilets at SRS.
Community Visitors also reported exposed electric
wiring in the laundry of an SRS, which was
addressed when pointed out to the proprietor.
case
study
An SRS resident, who was diagnosed with an
intellectual disability and a range of medical
conditions, left his pension-level SRS through the
front door between 2am and 3am one morning.
The front door could be opened from the inside,
but there is no access for residents from the
outside back into the SRS at night.
The search for the resident involved police
helicopters, dogs and SES volunteers. Sadly,
the resident died and his body was found after
several days, 1.5 kilometres from the SRS.
Residents were very distressed and had to wait
one month before receiving counselling.
Community Visitors recognise that an SRS
cannot be locked and residents prevented from
leaving as they wish. However, no additional
changes have been made to security at the SRS
and, on occasion, residents continue to leave the
SRS late at night.
Region (North)
There are 12 pension-level and six pension-plus
SRS with no new SRS or closures in the last year.
Health and personal care
Again, this year, Community Visitors note an
increased number of residents with complex needs
and mental illness living in SRS due to a lack of
other accommodation. Problems can arise due
to behavioural patterns related to these residents’
illness or disability.
At one SRS, a resident sleeps on a mattress
placed on the floor without sheets or pillowslips.
There is no bed in his room as apparently is his
wish. Community Visitors are concerned about
the cleanliness of his room and in particular his
mattress which was observed to be heavily soiled.
good practice
At one pension-level SRS, Community Visitors
noted a comprehensive activity program
including active resident participation in the
preparation of a monthly newsletter. The
proprietor had also purchased a mini bus to take
residents on excursions or outings, which is a
great boon to their community engagement.
At a pension-plus facility, food is prepared by an
appropriately uniformed chef and residents are
complimentary about the quality and quantity of
food. Staffing numbers are always well-above
the minimum level and there are many and
varied appropriate activities on offer, such as
indoor games.
No incidents of violence between residents were
reported to Community Visitors this year.
The Advice Service was informed that one
proprietor was allegedly supplying illegal tobacco
to residents and then billing them for the tobacco.
One invoice was over $500. Police were contacted
about this issue.
Homelike environment and safety
Generally, Community Visitors reported good
documentation, though some residents reported
that they were not consulted in the updating of
their support plans. Maintenance issues include
stained or ripped carpets, dim lighting, call bells
not working, furniture and bushes partially blocking
exit doors, hot water service problems, cleanliness
issues and water leaking from a broken pipe.
Finances
Apart from some residents at a pension-level SRS
complaining about not enough disposable cash,
Community Visitors have not noted any adverse
financial issues. However, as a person resident at a
pension-level SRS usually pays 85 per cent of their
pension income as rent, disposable income will
often be an issue for residents.
59
Service provider relationship
There is good rapport between Community Visitors,
department Authorised Officers and proprietors,
which is beneficial to residents, with the exception of
one proprietor who appears to have endeavoured to
intimidate and obstruct Community Visitors carrying
out of their duties to support residents.
Community Visitors have been the target of
verbal abuse by staff at one SRS on at least
two occasions. Once, when Community Visitors
asked to see inside a locked laundry, staff refused
access and Community Visitors reported they
were verbally abused. On another occasion, staff
allegedly abused Community Visitors when they
asked to view the Incident Register. The proprietor
demanded that the Community Visitor leave the
SRS immediately. Staff refused to sign the Record of
Visit and Community Visitors terminated their visit.
case
study
Community Visitors were alerted to a situation
where a woman resident was not happy sharing
a bedroom with a male resident. The proprietor
said there was nowhere for the female resident
to move to and she could not afford to have a
separate room. The Authorised Officer agreed
there were privacy concerns and sorted out the
issue with the SRS, ensuring that the person is
now able to share with another woman. This was
a good outcome.
Region (West)
There are seven pension-level and four
pension-plus SRS, catering to the diverse and
often complex support needs of residents.
Community Visitors, department Authorised
Officers and proprietors collaborate effectively
to identify issues of concern and address
these promptly.
Health care
Community Visitors acknowledge that health care
outcomes for residents have improved.
On a number of occasions, Community Visitors
raised concerns regarding the adequacy of care,
particularly for residents with higher support needs.
60
In one pension-level facility, Community Visitors
queried whether a resident was receiving adequate
care as they had high-level needs including catheter
and wound management. It was also noted that the
room smelt of urine.
In another pension-level facility, Community Visitors
met with a resident who presented as confused,
incoherent and very pale, and whose medication
lay scattered on her bedroom floor. They queried
whether the resident should be managing her own
medication, and suggested that her doctor review
this in consultation with her caseworker and staff at
the facility.
Community Visitors were alerted to instances
of violence in facilities; a resident at a pensionlevel facility described ongoing violence among
residents and frequent visits by police. In another
facility, there were concerns regarding a female
resident and the risk she posed to herself and
others, despite efforts by staff to try to modify her
behaviour. She had acted threateningly, carrying
a knife on more than one occasion, and had
damaged property at the facility.
Community Visitors responded to an OPA
Advice Service request to visit and found the
caller in their room disorientated, confused and
seemingly drug-affected. Community Visitors noted
large quantities of medication scattered across
the resident’s floor and communication with the
resident was very difficult.
This individual has a diagnosis, which is not treated
as a clinical mental illness so accessing services is
very difficult.
The one staff member on duty was unaware of
the resident’s condition and was very slow to
respond to the seriousness of the situation. It took
significant prompting by Community Visitors before
an ambulance was called and the resident taken
to hospital.
Subsequently, the resident was evicted and moved
to another SRS.
A resident with mental health issues at a pensionlevel facility was evicted due to aggressive and
threatening behaviour. The resident’s condition
had been deteriorating leading to an escalation
in behaviours of concern, so they were admitted
and discharged from mental health facilities on
more than one occasion prior to their eviction.
Community Visitors, SRS staff and the department
all agreed that poor mental health management and
discharge planning contributed to this unfortunate
outcome for the resident.
Incident reports provide crucial information about
a range of occurrences in facilities, particularly
incidents of abuse and violence; so these are
regularly inspected by Community Visitors during
visits. In two separate pension-level facilities,
Community Visitors queried whether all incidents
were being comprehensively recorded.
Personal support
After meeting with a resident who appeared
unwell, Community Visitors questioned whether
staff monitoring of the residents was adequate;
they also queried staff qualifications and whether
there were sufficient staff to deal with the complex
support needs of the residents. Community Visitors
later commended the proprietor of this facility for
investing a significant sum of money in mental
health training for staff at their two different facilities
in the region.
Over time, Community Visitors have frequently
raised concerns regarding the adequacy of support
planning for residents. In one case, at a pensionlevel facility, Community Visitors highlighted the
support plan for a resident with complex needs,
including mental health issues. The resident kept a
pet dog at the facility; the Community Visitors were
concerned that the support plan did not address
contingencies when the resident was struggling to
cope and their capacity to care for the dog
was compromised.
Pets can definitely contribute to a more homely
environment for residents; however, pets can
pose challenges to the maintenance of cleanliness
standards. At one pension-level facility, residents
complained about the smell of cats urinating inside
the facility.
Community Visitors have raised concerns
regarding temperature control in facilities over time,
particularly during summer and winter extremes.
At one pension-level facility, Community Visitors
arrived on a cold winter day and noted that the
facility was too cold because the heating had been
turned down too low.
Safety
Community Visitors are mindful of how important
it is for facilities to attend to all aspects of fire
safety, including maintenance of equipment
and emergency/evacuation procedures. At one
pension-level facility, Community Visitors pointed
out the need to have a fire drill, and for evacuation
procedures to be updated. This was partly in
response to resident’s concerns regarding property
they had stored at the facility.
There are 27 pension-level SRS and 15 above
pension-plus facilities in this region.
SRS in this region reflect local socio-economic
factors such as drug, alcohol and associated
violence, particularly in pension-level SRS.
However, some proprietors work effectively with
this disadvantaged client group.
Cooperation between the Community Visitor
Program and Authorised Officers in this region
has achieved good outcomes for residents.
Health care
Community Visitors have reported that the
majority of residents in pension-level SRS have
been diagnosed with a mental illness, as SRS
remain a primary discharge destination for persons
who have no alternative accommodation. However,
many SRS staff have little or no training in dealing
with residents with mental illness, despite the
department offering training in this area.
During a visit to a pension-level SRS,
Community Visitors spoke with a resident who
discussed how his mental illness and associated
behaviours meant that he feared eviction from the
SRS, as had previously happened at another facility.
Community Visitors note that the marginalised
position of people with a chronic mental illness
can be compounded by a lack of suitable
accommodation options.
Community Visitors have continued to report on
the placement of people with complex mental and
physical illness in SRS. At a pension-level SRS in
the inner part of region, a proprietor provided a
Notice to Vacate to a resident, as they could not
manage the person’s incontinence. The person
subsequently collapsed with unassociated lithium
poisoning and was sent to hospital.
61
This incident highlights a mistaken belief of clinical
services that SRS are a suitable step-down clinical
environment for people with chronic mental illness,
which is not the case. A subsequent Notification
to the department from Community Visitors stated
that the resident’s care, support and medical needs
had not been communicated to the SRS by the
referring agency. This is a common situation faced
by SRS proprietors and staff, which makes resident
support difficult. The departmental response
indicated that this matter was outside the scope
of the Act. In this case, the Authorised Officer
questioned why a Notice to Vacate had not been
issued to the resident.
Community Visitors have noted that often residents
at SRS have large supplies of self-managed
psychotropic medications, in unlocked cupboards
inside their rooms. During a visit to a pension-level
SRS , a resident complained to Community Visitors
that she had a large supply of anti-psychotic
medication and was not sure which medications to
take and when.
Community Visitors welcomed the departmental
initiative to supply diabetic and exercise support to
five SRS in the outer part of the region to reduce
the requirement for residents to take diabetic
medications. A further expansion of this program to
improve the general health of SRS residents would
be a positive initiative.
Abuse and neglect
Community Visitors have continued to report on
the use of illicit drugs by SRS residents. This year,
it was noted that a pension-level SRS resident had
died of a suspected drug overdose. This matter has
been referred to the Coroner.
Community Visitors reported that at one pensionlevel SRS, following a physical altercation between
two residents, both were evicted. However,
no formal process was followed, including the
provision of Notices to Vacate. Notification to
the department about this matter resulted in
Community Visitors being informed that, in order
to protect all SRS residents, a formal process of
terminating the tenancies of these two people
should have occurred.
Community Visitors were disturbed to report that
on a visit to a pension-level SRS, they were advised
that no toilet paper had been supplied to residents.
When questioned about this, the proprietor
informed Community Visitors that residents had
agreed to supply their own.
62
Each person residing in a pension-level SRS pays
at least 85 per cent of their Centrelink pension and
rent allowance, leaving them only 15 per cent or
less for all other expenditure like clothing, toiletries
and activities.
A Notification to the department was made about
this issue and Community Visitors were assured that
this would be rectified and monitored in future to
ensure that residents were supplied with toilet paper.
Personal support
Community Visitors remain concerned about the
placement of people with more complex physical
care support needs, such as incontinence within
SRS; as such issues are generally better dealt with
by professionally qualified staff in other sectors like
aged care.
Community Visitors notified the department about
a smell of urine at SRS on five occasions and at
one pension-plus facility on four occasions. The
subsequent unannounced inspections by the
Authorised Officers led to the proprietor agreeing
to have the affected areas professionally cleaned
as well as replacing mattresses and bed linen. The
proprietor also agreed to better ventilation in rooms.
The department also suggested that the
proprietor seek outside professional assistance
from continence services to better manage
resident needs.
Community Visitors notified the department that,
during a visit to a pension-plus SRS in the outer
part of the region, they had been ordered to leave
the facility by the proprietor. The proprietor alleged
that Community Visitors were only allowed to visit
the facility between 10am and 11am and between
2pm and 3pm and not around meal times. The
proprietor also alleged that Community Visitors
were not allowed to speak to residents.
Volunteers reported that they felt threatened and
intimidated by the proprietor of the facility, who was
exceedingly hostile in his demeanour.
Community Visitors were appreciative of
departmental support when they offered to do a
joint visit to the facility to ensure that the proprietor
understood that there were no restrictions on
when Community Visitors could attend a facility.
At the subsequent joint visit, Community Visitors
were treated with respect as the Authorised Officer
pointed out the legislative requirements of SRS
proprietors with regard to Community Visitors.
At another pension-level SRS, the proprietor refused
to sign the Record of Visit as required under the
Act. Community Visitors perceived the proprietor
as hostile towards them due to their report
documenting matters, which required rectification.
The proprietor did not agree with their report.
Following Notification to the department, an
Authorised Officer pointed out to the proprietor
the statutory requirement to sign the Community
Visitors Record of Visit. Visitors reported that, as a
consequence, they were treated with due respect.
The most reported issue in this region has been the
poor state of buildings and maintenance of SRS.
A primary issue in rectifying SRS building fabric
problems is when the proprietor is not the building
owner and it requires negotiation between the
parties to determine who is to be responsible for
the work needed.
Community Visitors reported defective or unsanitary
conditions at SRS on 11 separate occasions.
Issues with the unsanitary state of bathrooms
predominated, including leaking pipes and toilets,
broken tiles and serious mould observed on
multiple occasions.
The majority of the maintenance issues were
resolved following Notification to the department.
Fire and other resident safety
which would be included in a ‘Compliance
Instruction’ to the SRS proprietor for their urgent
attention. The Authorised Officers also agreed to
refer the matter to the local council, as the stairs in
question form part of a designated fire exit.
During another visit to an SRS in the inner part of the
region, Community Visitors observed access to fire
extinguishers being blocked by ladders. Community
Visitors were informed that the proprietor of the SRS
had been counselled regarding the inappropriate
and dangerous consequences of blocking fire
extinguishers and that the department would
continue to monitor this matter.
While visiting in the outer area of the region,
Community Visitors noted, on two occasions, a
lack of lighting on landings. Following Notification
to the department, the matter was rectified.
Community Visitors have been repeatedly thanked
for bringing maintenance issues of concern to the
attention of the department, including a trip hazard
on a set of stairs.
Community Visitors also reported on a collection
of refuse in the garden of an SRS in the outer area
of the region and the dirty and blocked state of an
air conditioner.
The marginalised nature of the SRS resident group
and the number of issues reported means that it is
most concerning that current resource constraints
mean that Community Visitors are only able to
visit pension-level SRS monthly and pension-plus
facilities quarterly.
At one SRS in the inner part of the region,
Community Visitors reported twice on the
dangerous state of an outside staircase, which is a
designated fire exit. Community Visitors observed
that steps and the handrails were loose. When
Community Visitors informed the proprietor that
the fire exit was dangerous, they replied that
the physical fabric of the building was “not their
responsibility”, as they did not own the building.
Subsequently, Community Visitors were informed
by the proprietor that building fabric issues required
them to contact the estate agent, who must then
pass the request for maintenance issues onto the
building owner before any repairs can occur.
This information was conveyed to the department
as part of the Notification process regarding the
SRS fire exit. Subsequently, Community Visitors
were informed that this matter had been partially
addressed but that further repairs were required
63
Recommendations
Recommendations
Disability Services
The Community Visitors Disability Services
Board recommends that the State Government:
9.
mandate that all disability residential staff are
trained to a minimum of Certificate IV standard, receive annual professional
development relevant to their role and regular supervision support, not only to provide
the necessary support to residents but also to make the sector an attractive place to work
10.
ensure that residents with complex communication needs have a
communications assessment conducted by a speech pathologist and develop a detailed implementation plan to guide staff providing this support to residents
1.
provide full public reporting on all incidents and allegations of abuse and neglect, as well as the outcomes of these reports and
any investigations
2.
formally recognise resident to resident aggression and assaults in disability residential settings as violence, rather than the minimisation of it as resident incompatibility
3.
develop applicable needs assessment tools, a compulsory code of practice for responding to violence, and professional development for 11. finalise the audit of housing fabric in order staff managing violence in residential settings
to develop a priority list for replacement or major refurbishment and provide sufficient review the Notification Protocol for serious funding to enable these priority needs to
and/or unresolved issues between OPA and be met
DHHS to speed up the resolution of issues, and provide all notifications and responses
12. request the Auditor-General to review the to the Minister
disability resident financial management systems in both DAS and CSOs to ensure
review all of the case studies, notifications effective processes are in place to protect and referrals set out in this report to ensure residents’ money and assets
that it is completely satisfied that all have been dealt with appropriately and are resolved 13. continue its commitment to ensuring the strengths of Victoria’s current system of fund the provision of counselling support for
quality and safeguards, of which the
victims of abuse and emergency Community Visitors program is a fundamental accommodation with intensive support and protection, is retained in the NDIS
behavioural support for alleged perpetrators of violence who are evicted or need to be 14. increase the recurrent funding for the moved from disability residential settings
Community Visitors Program to engage sufficient numbers of specialist and as a matter of urgency, address the needs administrative staff to support the work of the of people with disability living long-term in volunteers, and to recruit and train the number
facility based respite and those that are of Community Visitors required to visit all unable to access these respite facilities
designated facilities on a regular basis and
liaise effectively to address the issues provide new accommodation options identified on visits.
to address the unmet need for
disability accommodation
4.
5.
6.
7.
8.
Disability Services
65
Statewide
Report
The Community Visitors’ role is to visit,
observe, inquire and report into the care and
conditions for the residents they visit. Much
of their focus is on ensuring that residents
have meaningful lives with opportunities for
personal growth and community engagement.
Community Visitors do not have formal
investigatory or regulatory powers however; the
Board has the power to make referrals to other
agencies and to report to the Minister and the
Public Advocate. Last year, the Board exercised
its powers in recommending the need for an
independent inquiry into abuse and neglect so
have welcomed the range of inquiries launched
this year into these serious issues.
The Board can report a matter to the Public
Advocate under section 32 (3) (d) of the Disability
Act 2006 so a process of Notifications to the Public
Advocate from Community Visitors was implemented
in 2010-11. This is to ensure that sexual assault,
serious abuse and other serious matters get the
attention they deserve. Serious abuse is defined
as any incidence of abuse that involves police or
admission to a hospital as a direct consequence.
Since the process of Notifications to the Public
Advocate was introduced in 2009-10 to the end of
the last financial year, there were 87 notifications
relating to disability residential services. Serious
violence (resident to resident) is the highest
category of these Notifications whilst staff to
resident violence is the second highest category.
This year there were a further 21 disability
Notifications to the Public Advocate relating
to disability residential services. The Board is
concerned about the department’s response to
notifications. In one response, the department
acknowledged 28 incident reports of violence yet
determined that Community Visitors concerns
about resident compatibility were unsubstantiated.
Number
293
50
38
557
595
Sexual assault - resident to resident
8
East Division
360
83
53
903
956
Inadequate care
8
South Division
273
74
34
735
769
Sexual assault - staff to resident
5
West Division
259
55
27
715
742
Other
8
262
152
2910
3062
Total
87
Total
1185
Total visits
North Division
Division
Scheduled visits
Requested visits
Issue
No. of CVs
Disability
Services
Stream
In previous years, the Board has taken the
view that the exercise of its referral powers was
a last resort because the need to use them
pointed to a level of inaction by government
and community service agencies that was
unacceptable. However, inadequate responses
and lengthy delays in responding to issues raised
by Community Visitors have led the Board to
the view that it will be pro-active in exercising its
referral powers in the future.
Referrals to the Public Advocate
Table 7: Total visits Disability Services Stream 14/15
66
Violence - resident to resident
31
Violence - staff to resident
18
Unexplained injuries
9
Table 8: Disability notifications to Public Advocate 2010–2014
Disability Services
Abuse and neglect
There continues to be direct abuse of residents,
however, there is a clear trend emerging of
neglect because of the incompatibility of
residents. Sometimes this is caused by poor
placement and transition of residents, however,
it is likely to be multi faceted. It can arise from
resident age differences, such as placing older
more frail residents with younger stronger ones.
Alternatively, it may occur because of staff
inability to manage the challenging behaviours
of residents. Community Visitors have noted
situations where a resident with more difficult
behaviours receives much greater attention than
other residents in the house to the detriment
of those other residents. Community Visitors
question the fairness of these situations.
Resident incompatibility resulting in abuse
may be because of insufficient resources and
inadequate staff training. This lack of staff
training to deal with problems and conflict
is often exacerbated by casualization of the
workforce. The employment engagement
process with intermediaries makes it difficult to
hold people responsible and accountable in the
event of serious incidents.
Community Visitors have observed that stable
staffing and a positive staff culture does lead
to better interaction and relationships between
residents and staff, as well as between residents.
by Community Visitors as emerging issues
also impacting on compatibility that make
the task of providing care and support even
more complex.
This year, Community Visitors have noted that
abuse is being reported either to management
or to the Department to deal with it. Sadly,
what is also often reported is that abuse and
neglect is not being prevented nor dealt with
in an appropriate and timely way.
The exposure of any abuse in houses is
applauded by Community Visitors. However,
its existence presents a workforce picture of
significant cultural problems. This combined
with issues like high casualisation, inadequate
training, challenging rosters and demanding
workloads created by insufficient staff numbers,
are disincentives to work in the sector.
The reports of Community Visitors and
consequent notifications clearly show that
residents in all parts of Victoria still suffer
abuse (including sexual abuse) and neglect.
The Board’s opinion is that this is likely to
continue unless some drastic reform occurs.
Effective reform of the current system is
urgently needed to ensure these failures are
not carried into the NDIS, as that would
severely compromise its effectiveness.
160
147
140
120
100
111
104
80
60
40
20
0
12/13
13/14
14/15
reporting year
Residents presenting with multiple disabilities
including mental health problems and disabilities
like dementia and Alzheimer’s disease are seen
Figure 8: Disability Services Stream abuse, neglect and
violence 12/13 to 14/15
Disability Services
67
case
study
Community Visitors expressed serious concerns
about the impact of the behaviour of a young
resident, with mental illness and intellectual
disability on five older more profoundly disabled
residents and staff. They report escalating and
increasingly physical assaults and the impact
of violence on the dignity, rights and lifestyle of
residents. The older residents were described as
having an extremely impaired ability to defend
themselves from the alleged perpetrator’s attacks.
In November 2014, the Regional Convenor
described her fear of a potential death at this
CSO house to Local Connections and the
DHS Service Manager. The Community Visitors
Program did not receive a formal response until
2 January 2015. In December the residents
were reported to be remaining in their rooms
after return from day programs, and eating and
urinating in their rooms. On 17 December the
CSO Operations Manager of the service stated
that the perpetrator had lit two fires within the
building whilst holding staff at bay. She reported
that a frail co-resident who used a walking frame
was told by the alleged perpetrator ‘I am going
to gut you out’ and that staff subsequently
found a knife under a bed. The CSO Operations
Manager described assaults on one older
resident that included headlocks, pushing and
punching walls near his head.
On 4 January, police attended the house and a
resident was capsicum sprayed twice. He had
been agitated, running around the house biting
himself and spitting blood at staff and other
residents. The behaviour was apparently a result
of the aggression directed towards him. The
younger resident was subsequently charged
with assault after punching one of the older
residents twice in the head.
Following a Notification by the Public Advocate
the Assistant Director indicated that she
had attended a care team meeting and the
Behaviour Intervention Support Team (BIST), the
Senior Practitioner’s Office and the DFATS were
all now involved.
Despite commitments from the CSO and
DHHS to address the significant violence and
related issues between residents at this house,
incidents continued to occur. The resident
allegedly perpetrating the violence was issued
a ‘notice to vacate’ in June 2015, however they
remain at the house.
68
Abuse inquiries
Community Visitors responded to the
Ombudsman’s investigation into disability abuse
reporting including a very worthwhile consultation
session between members of the investigation
team and disability Regional Convenors (team
leaders). The Board welcomes and endorses
the NDIS safeguards framework included in the
Ombudsman’s interim report.
Subsequently, OPA made a submission to the
Parliamentary Inquiry into abuse in disability
services that drew heavily on the work of
Community Visitors. The Board was also pleased
to have the opportunity to present in person to
the Family and Community Development
Committee of the Victorian Parliament that is
conducting this inquiry.
The work of disability Community Visitors was
reflected in the OPA submission to the Senate
Inquiry into disability abuse and the response to the
NDIS Safeguards consultation paper. In addition,
the Board, the Program Manager and a number
of Regional Convenors attended the Melbourne
NDIS Safeguards consultation where they made
a substantive evidence-based contribution on
almost every issue raised. At that consultation,
it was pleasing to hear resident families express
support for Community Visitors. The Program was
well represented at the Barwon NDIS Safeguards
consultation where Community Visitors provided
similar input.
The key tenet of the submission and the Board’s
oral presentations was the importance of a
Community Visitor program and that the Victorian
model had substantial advantages. These include
the use of volunteers who are motivated by altruism
towards residents. Many of these residents have no
family contact so Community Visitors are the only
people they see regularly who are not paid workers.
The value of that should not be underestimated.
The capacity to reflect on how the sector is
operating, as well as recommend much needed
changes in the annual report, is another important
feature of the Victorian model.
Incident reporting
Community Visitors remain very concerned about
incident reporting, as they are regularly unable to
access these documents and routinely highlight
underreporting of incidents that are recorded in
diaries and daybooks, but not formally written up
in incident reports.
Disability Services
issue types
upkeep of buildings and fittings
fire and emergency safety
health care
person-centred planning
incident reporting
staff training and support
environmental safety
inadequate staffing
aids and equipment
external presentation and outdoor areas
behaviour support
compatibility
choice and decision making
social inclusion
transport
awareness of cv protocol
planning and completing action plans
financial management
medication administration
unmet need in accommodation
information provision
emotional wellbeing
abuse and neglect
personal development
key worker reports
individuality
resident outcomes focus
aging
weight management
building design and structure
dignity and respect
communication
building unsuitable
heating and cooling
provision of services in accord with principles specified in the act
privacy
appropriate staff communication
restraint
resident complaint
nutrition
social networks
positive family contact
respite
physical activity
substitute decision-making
other provisions of the act
identity
civic responsibility
seclusion
congregate care and institutions
number >
161
144
131
122
104
102
100
99
94
90
79
73
72
68
65
203
196
583
248
61
60
59
58
53
46
46
43
43
42
40
37
29
28
23
19
19
15
15
14
14
12
12
12
12
9
8
7
6
5
1
0
100
200
300
400
500
600
700
Figure 9: Disability Services Stream number and types of issues identified 14/15
Disability Services
69
Healthcare
In addition, they report that some group homes
when faced with incidents of abuse and neglect
categorise these incidents as either serious or
less serious. This can create a perception of
staff attempting to downgrade incidents to avoid
blame or failing to properly investigate and resolve
incidents. Community Visitors strongly argue
all incidents of abuse and neglect are serious
and inadequate reporting does not adequately
reflect what is happening in the sector. The Board
welcomed the Ombudsman’s investigation and
hopes it will lead to significant improvements in
incident reporting across the sector.
This year the department engaged KPMG to do
a review of incident reporting. The project team
attended a Regional Convenor meeting to hear
firsthand about the volunteers’ experience of how
this system operates and its deficiencies. Regional
Convenors identified a broad range of problems
including underreporting, miscategorisation,
agencies sanitising reports by rewriting them or
not following the required procedures, as well as
insufficient follow-up or analysis of incident reports.
The Board is yet to hear the outcome of this review.
One of the most concerning trends reported by
Community Visitors this year is the practice of
keeping incident reports at CSO head offices rather
than in the house where they occurred. There
is an organisational need to have a knowledge
of all incidents and to use the data they provide
for quality purposes, however incident reports
fulfil many functions. A key one is to review local
practice and pick up patterns that need to be
addressed. In addition, they provide staff with a
picture of what occurred when they were absent
from the facility and often point to issues affecting
resident behaviour so that staff are better equipped
to manage any challenging situations that emerge.
None of these aims will be fulfilled if incident reports
are treated as mere paperwork to be filed at a
remote head office location.
Community Visitors have reported many incidents
of missed medication or the wrong medication
being given to residents and question if staff, in
particular on-call and casual staff, have sufficient
training in medication administration.
This year, the Auditor General requested
Community Visitors’ assistance with their audit
of palliative care services. They were seeking to
understand the volunteers’ experience of palliative
care provision to people in residential services.
They were particularly interested in whether staff
in disability facilities recognised these needs and
could access support and education for their
clients. This session with Community Visitors was
a very fruitful cataloguing of their experience of the
complexities associated with the aging of people
with disability and what, if any, palliative care
supports were available.
Communication and assessments
The ability to communicate with our fellow human
beings is an essential component of a meaningful
life, however for many residents that Community
Visitors see, little has been done to maximise their
opportunity in this area. Capacity to communicate is
essential for these residents to be able to participate
effectively in the planning around their lives and this
will only increase with the rollout of the NDIS.
The Board recommended last year that
everyone with complex communication needs
have a speech pathologist assessment by the end
of this reporting year, Despite, the government
assurances in response to this recommendation
that strategies were in place, Community Visitors
continue to regularly report that residents have
little or inadequate communication support.
There have been few reports of speech pathology
communication assessments occurring this year so
it continues as a Board priority.
Community Visitors also regard good staff
communication skills as essential to understanding
and supporting resident needs. However,
increasingly Community Visitors report that they
have had difficulty communicating with some
staff and that this is likely to adversely affect staff
interaction with residents. The lack of these skills
may increase the risk of behaviours of concern not
being recognised, may lead to health issues not
being identified or generally poor care for residents.
70
Disability Services
Fire safety
Resident finances
Evacuation and fire safety measures are important
issues that in some instances are not provided the
focus they deserve. Aging residents, or residents
with limited mobility and dependent on wheelchairs
and walkers, require fire plans which recognise
these limitations. In some instances, houses were
found to have doorways used for evacuation not
wide enough to fit wheelchairs, and others partly
blocked by laundry appliances.
Community Visitors have reported what they
consider deficiencies, poor oversight and
management relating to finances of residents.
Examples include poor recording of expenditure
or personal belongings including furniture, and
whitegoods and clothing not being recorded in
the resident’s asset register. This is an area open
to abuse that might well be examined by an
independent regulatory agency such as the
Auditor-General.
Respite
Community Visitors continue to report on respite
houses being used for permanent accommodation
as well as concern about the mix of old and young
residents in these houses.
Fabric of facilities
The overall poor standard of houses and
maintenance of houses is still being reported.
Community Visitors acknowledge that there
are finite resources to support this. However, of
particular concern is the very poor condition of
toilets and bathrooms in houses. These conditions
are considered detrimental to the health of
residents and their right to individual privacy and
dignity. The situation of one toilet for six residents is
considered completely inadequate.
Transport
Community Visitors continue to report inadequate
transport at many houses, affecting the access
to day placements for residents, as well as the
engagement in community activities. The cost
of transport to residents and how the cost is
apportioned between residents is uncertain and
most likely inconsistent.
Personal support
While family is extremely important to the success in
the lives of residents, at times, relationships between
families of residents, residents and staff can be
fractious, challenging and may not lead to the best
outcomes. An acceptance of dignity in risk is normal
part of the life of a person without disability, so
Community Visitors ask why this should not be an
accepted part of the life of a person with disability.
Person Centred Plans and individual planning for
residents still presents as a problem. Many plans are
out-of-date, do not reflect the needs and wishes of
residents or are not monitored and updated.
Institutions and congregate care
In May 2013, the State Government announced
that Sandhurst, a large congregate care facility
in Bendigo, would be redeveloped and residents
would move into new homes that would be built
off-site in the community. Planning for the closure
of Sandhurst has continued throughout the
2014–2015 year and the redevelopment is on track
for Sandhurst’s closure in June 2016. Prior to a
change in government the new homes were to be
allocated to an external provider to manage but it
has since been determined that DHHS will provide
the support to residents in their new homes.
VALID, an advocacy organisation funded by the
State Government and Community Visitors have
provided support to residents and their families in
the planning process and assisted in consultations
regarding the design of the residents’ new homes.
OPA welcomes the redevelopment of Sandhurst,
as well as the allocation of funds for the
redevelopment of the Oakleigh Centre in
Melbourne, and the move of some residents at
Colanda in Colac into community-based housing.
Disability Services
71
Regional
Reports
East Division
East Division includes the Eastern Metropolitan
Melbourne area, which is made up of the DHS
areas of Inner Eastern Melbourne and Outer
Eastern Melbourne, and the regional Victorian
areas of Goulburn and Ovens Murray. This year,
83 Community Visitors conducted 956 visits to
360 houses in this division.
There were six notifications to the Public
Advocate regarding group home residents
at serious and imminent risk of harm. These
notifications are detailed throughout this
divisional report.
Melbourne
Abuse and neglect
the same resident being abused, bullied and
disrespected by staff. This house has been the
subject of many incidents since 2010 and there
have been multiple investigations of staff abuse and
misconduct. Residents from this house have since
been relocated and responded positively to the
change in accommodation and support; however,
Community Visitors feel that decisive action in this
case was long overdue.
An anonymous caller to the Advice Service
raised concerns about the redeployment of a
staff member after sexual assault allegations
had been made against him by colleagues at
a former residential service. DHHS investigated
the sexual assault allegations and found that
they were not substantiated.
Abuse and neglect by staff
Community Visitors reported a physical assault of
a profoundly disabled resident by a casual staff
member. The group home contacted the police and
the staff member was stood down. Several other
issues were reported by Community Visitors at this
group home, including the administering of antipsychotic medication that had not been prescribed
to a resident, and the transporting of residents to
the wrong placement.
In September 2014, the parents of a resident
contacted OPA seeking assistance for their
daughter who said she had been the victim of
abuse and assaults at the house by another
resident. In October 2014, an anonymous caller
to OPA’s Advice Service said they had witnessed
72
DHHS contacted the family of a resident to advise
them that digital images of the resident sleeping
naked had been found on a camera belonging to
the group home, and that the images had been
taken by a staff member. The matter was referred
to police, who did not pursue criminal action
against the staff member. DHHS has removed the
staff member from active duty and took disciplinary
action. The staff member had alleged that the
photos were taken as evidence of the resident’s
behavioural problems. However, Community
Visitors checked health, progress and handover
notes but found no behavioural issues relating to
the resident disrobing.
At a CSO house, Community Visitors noted an
incident report stating that a former staff member
had made inappropriate sexual advances toward
a resident. The incident was fully investigated by
the police, and although the staff member was not
Disability Services
charged, the CSO terminated their employment.
The resident was offered counselling, but the
resident and their guardian declined.
At another CSO house, a resident said they
had been sexually and physically assaulted by
staff. Police and the CSO conducted separate
investigations and involved a medical practitioner
and the SOCIT unit. The findings of these
investigations were that there was no sexual assault
and the staff were cleared of any wrongdoing.
Community Visitors were notified of the death of a
resident at a DAS house. Although the resident had
a chronic illness, the death was unexpected. This
death was investigated by the department to look
at how the systemic issues could be improved. The
matter is also being investigated by the Coroner.
Abuse by residents
Community Visitors reported a number of
incidents of resident-to-resident abuse in
group homes in this region.
Community Visitors notified the Public Advocate
of sexual abuse perpetrated by one resident
towards another. The alleged offender had a history
of sexual offending and was on a Supervised
Treatment Order. During the day, the alleged
offender received one-on-one support, but at
night the house only had sleepover staff. The
allegation was that the alleged offender entered
the victim’s room when the victim left it unlocked
to go to the toilet. Following the assault, the victim
was relocated and a revised treatment plan for
the alleged offender was approved by VCAT and
the Senior Practitioner. This included active night
supports, an alarm on the resident’s door linked to
the staff sleepover room, and locks on all external
doors. The Dynamic Risk Assessment Management
System was introduced to inform the treatment
plan and one recommendation was that the alleged
Disability Services
offender be relocated to a house where staff are
experienced in working with sex offenders with
an intellectual disability. Community Visitors ask
why these protections were not put in place earlier
given the alleged offender was known to have
perpetrated sexual assaults in the past. Community
Visitors are continuing to monitor the impact of the
increased level of supervision and restriction, as
well as the possible introduction of new residents.
The OPA Advice Service received a call from the
parent of a resident in a DAS house who feared
for their son’s safety because of the behaviour
of another resident who had punched walls,
thrown objects and displayed inappropriate sexual
behaviours. These concerns have been reported
for years, and while DHHS eventually transitioned
residents to different houses to address the
concerns; Community Visitors felt that DHHS took
far too long to respond.
case
study
At one DAS house, a resident moved out and
was replaced with a new resident with behaviours
of concern. The previously well-run, calm and
stable house changed as residents became
upset at the new resident’s behaviours, which
included continual screaming during the day and
pacing at night. Doors and cupboards had to be
locked, the new resident masturbated in front of
another resident, outings were truncated, and the
other residents became anxious and acted out.
Staff made complaints about occupational health
and safety concerns and appeared to get little
support from management.
Community Visitors question the transition plan
for the resident to enter the home. House staff
did not develop a good relationship with the
new resident’s family in order to address the
behaviours of concern. The resident’s behaviour
has improved and some normality has returned
to the house. DAS management advised
73
Community Visitors that the transition was
completed according to policy, but Community
Visitors feel it was an inappropriate placement
for this group home.
A resident with behaviours of concern, including
assault and verbal aggression, was moved into
a CSO house from another group home. Over a
number of visits, Community Visitors reported that
other residents at the house were frightened by the
new resident’s yelling and other behaviours. The
new resident was then moved to a unit on their own;
Community Visitors were advised that the CSO
and DHHS were discussing this resident’s needs
and seeking more appropriate accommodation.
Community Visitors are concerned about this
resident’s isolation, and have not received a
response about the need for a BSP for this resident.
At one CSO house, a resident told Community
Visitors they wanted to move out of the house
because another resident was following them
around, harassing them and hitting their foot with a
wheelchair. Staff arranged for psychological support
for both residents and behavioural support for the
alleged offender. At a later visit, the resident told
Community Visitors the issue had been addressed.
Community Visitors noted incident reports at a
CSO house indicating one resident had returned
from their day placement with marks on their neck
and thighs. Both a police investigation and an
investigation by the CSO were conducted, including
medical investigations. The CSO reported to DHHS
that ‘being pulled and pinched by another resident
in a taxi’ was considered as one of a range of
possible causes for the injuries. The cause of the
injury could not be confirmed from the investigation.
The CSO has since changed the arrangements so
the two residents travel separately.
Other incidents of resident-to-resident abuse
reported by Community Visitors include:
Response to abuse
Community Visitors report that a CSO responded
promptly to a resident’s allegations of sexual
abuse against family members, ensuring that they
were well supported and the matter appropriately
investigated. The resident was referred to a Centre
Against Sexual Assault and continues to be
supported by a private counsellor. The allegation
was referred to the police, however no charges
have been laid. Community Visitors have had
ongoing contact with senior management regarding
this allegation and all parties will continue to
monitor the issue.
Respite
Over the past 12 months, Community Visitors have
seen a vast improvement in DAS respite care for
children. Staffing has stabilised and some of the
fabric issues have been addressed, in particular
safety issues in order to meet the physical needs of
children. Some children remain in long-term respite
care, but Community Visitors note there are now
some places for emergency and planned respite.
This has been a vast improvement from last year.
Adult respite managed by DAS has also improved in
this area in the past year. Several long-term respite
users were found permanent group homes this
year, including some who had been living in respite
for two, five and seven years. Community Visitors
will continue to monitor long-term accommodation
in respite, as two current users have already been
living in respite for at least six months.
Community Visitors are concerned about one CSOmanaged respite facility that has four beds closed
due to a longstanding dispute with neighbours.
Community Visitors continue to monitor and
advocate regarding this issue to ensure that
the four respite beds are made available to the
community as soon as possible.
• a DAS resident feeling fearful of another resident, Ageing
with no documented strategies in place to address this
Community Visitors commend staff at some DAS
houses for their dedication to supporting residents
• ongoing hostility, intimidation and violence with dementia to remain in their own homes for
between residents at a DAS house, resulting in one resident urinating outside to avoid passing as long as possible. If a resident does move to an
aged care facility, group home residents and staff
another on the way to the bathroom
keep in contact with the former resident.
• tension between residents of a CSO house, which one resident said had resulted in another The transition of one resident from a DAS group
resident pushing people over.
home to aged care this year was handled carefully
and staff and residents visit their friend in aged care.
74
Disability Services
In contrast, a resident of a CSO house was told by
a doctor in hospital, without house staff present,
that they could not return to their home and needed
to move to aged care, which caused the resident
great distress. At another CSO house, one resident
was unable to return to the group home from
hospital, as their high care needs could not be met,
and was placed in residential aged care.
Staff at some DAS houses want to support
ageing residents to stay in their homes, but
Community Visitor feel this may not be what house
management prefers. Community Visitors feel it is
important that management consider what staff
training and support for ageing residents could be
provided, instead of just defaulting to aged care as
the only option.
Community Visitors also raised concerns that in
some CSO houses, aged care was seen as the only
option for residents because there was no funding
to pay for the support they needed.
Upkeep of buildings and fittings
Community Visitors report ongoing maintenance
issues at DAS houses including worn carpet,
damaged walls and paintwork and ‘tired’
bathrooms. Some houses have well-cared-for
gardens, others appear to simply be space that
surrounds the house.
Other issues noted at DAS houses include: lifting
carpet held together with duct tape; old couches
and TVs left in houses and backyards; broken and
cracked tiles, rust marks and damaged bathroom
flooring; houses in need of painting and plastering
repairs; broken whitegoods; carpet in a resident’s
room damaged by a leak from the bathroom;
fences in need of replacing; holes in a kitchen floor,
cupboard doors falling off, and window frames and
furniture in need of repair or replacement.
windows; damaged bathroom flooring and
walls; stained and damaged carpets; a broken
bathroom door and handrail; leaking ceilings; an
ant infestation; garden maintenance; the need
for a new heating system; servicing of a clothes
dryer and dishwasher; a new back fence and
assessment for repair of an uneven concrete path.
At one CSO house, Community Visitors noted that
residents had to use the kitchen sink while they
waited for their bathroom sink to be replaced.
Ongoing maintenance issues at CSO houses that
have not been addressed include: a difficult-toaccess shower with no hand rail; a verandah in
need of replacement; internal painting; a doorway
too narrow for a resident who uses a wheelchair to
easily enter their room, and window coverings that
need to be replaced. At one CSO house, residents
have not been able to use the bath for the past
year because it is too deep for staff to safely help
residents to get into or out of it.
Community Visitors are concerned that one CSO
house does not provide a home-like environment
for residents, as little natural light gets into the
house because broken windows have been
boarded up. Replacement glass and perspex
windows have also been broken by residents,
because cracked window frames do not provide a
secure frame. Boards have instead been secured
to the window frames and painted black, which
makes the house very gloomy.
There has been a recent resolution of a requirement
for internal painting in two adjoining CSO houses,
which was first raised with DHHS in 2012.
Community Visitors have supported the CSO in
advocating to DHHS regarding this issue.
CSOs have generally responded promptly to
maintenance issues when raised by Community
Visitors. Matters attended to include: broken
In 2014, the State Government announced $14
million would be provided to redevelop parts of the
Oakleigh Centre. Following the announcement, a
project team comprising Oakleigh Centre and DHHS
staff was established, along with two advisory
committees, one for residents and the other for
families, to provide input to the project. This year,
five properties were purchased, and another unit
will be added to an existing house. The designs
for each house and unit have been completed,
taking into account the wishes of residents, such
as requests for en suite bathrooms, décor, room
location, and specific support requirements.
Residents have also been asked to nominate which
house they would like to live in and with whom they
wish to share. Families have also been involved in
decision making relating to future support needs of
their family members. This exciting project is due to
be completed by early 2017.
Disability Services
At one DAS house, a kitchen is set to be replaced
after two years of Community Visitors reporting
issues such as missing doors, a broken oven and
hotplate, and a bedside table used for storage.
However, at other DAS houses, Community
Visitors were advised that funding was pending
or not available for work including replacing
carpet, renovating a laundry, painting, flooring
and purchasing new furniture.
75
Safety
Staff support
Community Visitors reported safety issues at
DAS houses including: a potential fire hazard of
a washing machine that spins for hours without
switching off; a manual saw and an electric power
saw left on the floor; a couch with sharp metal
sticking out of it; and a gap in a shower floor that
was a tripping hazard.
Community Visitors reported concerns about the
level of staffing at some houses, including:
maintenance issues at CSO houses that presented
safety issues, such as the need for a sensor light
so a resident coming home after dark on a mobility
scooter could negotiate the entrance. This particular
issue was responded to promptly by the CSO.
Community Visitors report that after two years,
a decision still has not been made about an
occupational therapist assessment and installation
of a handrail in the bathroom of a DAS house.
At a CSO house Community Visitors noted a
number of incident reports relating to one resident
falling in the shower; a manual handling plan and
a falls prevention plan for the resident have now
been completed.
At another CSO house, a resident has repeatedly
fallen out of bed at night and sustained carpet
burns as they move across the floor to the lounge
room. Community Visitors have been advised that a
range of falls management strategies, including bed
rails and rubber matting surrounding the bed, have
now been put into place for the resident.
Residents at a DAS house were distressed by
repeated break-ins involving a former resident when
property was damaged and money stolen. DHHS
ensured that residents had access to counselling
following these incidents and reimbursement of
residents’ funds was also being followed up.
Community Visitors continue to advocate for fire
drill and emergency evacuations to be completed
monthly and documented in an evacuation report
for Community Visitors to view.
Other safety issues reported at CSO houses
include: evacuation packs without residents photos
or spare torch batteries; a house where there was
no information in evacuation packs about new
residents; a house in need of emergency lighting
as noted in a fire safety audit; an evacuation pack
not returned to a house after an evacuation; and a
house where fire and emergency logs were stored
in a locked cabinet which staff did not have access
to in the absence of a house supervisor.
76
• two CSO houses with no active night staff despite constant incidents where residents need support at night
• not enough staff at one DAS house, some staff not turning up to shifts, and regular staff taking on heavy lifting as a result
•
two residents of a CSO unable to go out during the day as there is only one staff member working, contradicting the CSO’s response that two staff work during the day with a coordinator on call.
Community Visitors visited a group home following
calls to OPA’s Advice Service questioning whether
the quality of staff support and staffing levels were
adequate to meet the high care needs of residents.
Staff at the house told Community Visitors that
there was an ongoing issue with ensuring trained
staff were on duty to support a resident who
required PEG feeding. Another resident was left
sitting on the commode for long periods due to
staff shortages. Two staff were needed to transfer
and lift this resident, however between 10.30am
and 1.30pm there was only a single staff member
rostered on. The resident was eventually relocated
to an aged care facility.
One CSO house has two staff to support seven
residents, most of whom have high support needs.
Community Visitors questioned whether this level
of staff support allowed residents to take part in
activities and exercise individual choice. The CSO
responded that there was an adequate level of
staff support, and, if needed, staff could contact a
coordinator or staff at another house for assistance.
The CSO stated staff support residents as far as
possible to visit their families and that “residents
are taken out as much as possible on weekends
but with seven people who all require manual
handling and have health issues, this can
sometimes be difficult.”
A former employee of a CSO made a number
of complaints about four houses it operates.
These complaints related to a variety of matters,
including inadequate briefing of casual staff, poor
Disability Services
cleaning, out of date frozen food, personal hygiene,
behaviour of residents and inability to access
incident reports. Community Visitors visited the
four houses and were unable to substantiate most
of the claims made. The exception was inability
to access incident reports, which has since been
reviewed by senior management.
Community Visitors are concerned about the
high use of casual staff at some DAS houses and
question how casual staff can provide continuity
of care for residents who have high needs and
communication difficulties. It also appears to
take a long time for vacant positions to be filled,
sometimes longer than a year.
Further issues noted include: incident reports at a
CSO house on the poor quality of care provided by
casual agency staff; miscommunication between
DAS staff and taxi drivers picking up residents; a
DAS house supervisor removed from a house for
unknown reasons; and DAS staff unsure of the
procedure to contact a locum doctor.
At one CSO house, Community Visitors reported
concerns with staff attitude toward residents, as
staff were talking about one resident’s behaviour
in a negative and disrespectful way, focussing on
discipline and control rather than identifying the
cause of the behaviour. At a later visit to the same
house, Community Visitors noted that there were
at least four people in the room when this resident
was talking to their psychiatrist, which showed very
little respect for the resident’s privacy.
Community Visitors also reported record keeping
and planning issues at DAS houses that affect
residents, including:
• delays in staff completing action plans or
support plans for residents
• delayed roster reviews and difficulty in filling rosters with permanent staffing
• a house where two separate house diaries
were being kept
• incomplete or inaccessible health notes, progress notes or shift books
•
shift report books not always completed in a way that Community Visitors and other
house staff, particularly casual staff, are
able to clearly follow.
resident would sit in the corner of the room crosslegged on the floor, not interacting with others
or making eye contact. Over time, house staff
supported and encouraged the resident to sit on
the couch, then in the room with other residents,
and to eventually join in activities. At a recent visit,
Community Visitors reported that the resident was
playing the piano, and noticed Community Visitors.
Staff at one CSO have been trained to use the
Hanging Out Program developed by the Centre
for Developmental Disabilities Health Victoria
(CDDH Victoria) for use with people at risk of
social isolation. This program involves a staff
member spending 10 minutes on a regular basis
with a person who has profound communication
difficulties. The staff member is trained to assess
what the person responds to and incorporates
these preferences into the session.
A CSO resident recently presented at a Community
Visitors quarterly regional meeting about living
with disability in the community. The resident
is supported by a CSO staff member when
undertaking a public speaking role.
Individual planning
Community Visitors reported a number of DAS
and CSO houses where residents’ personal
plans were out-of-date or did not reflect changed
circumstances in the house. At one house, outof-date personal plans were not attended to at
three consecutive Community Visitor visits, despite
repeated promises from staff.
At a number of one particular CSO’s group homes
and respite houses, residents’ personal care plans
were either non-existent, out-of-date or failed to
contain resident goals. Furthermore, Community
Visitors have asked that staff receive training
in personal care planning and person centred
active support. Some staff suggest that residents
are engaged in a range of activities, which are
recorded in their daily notes, however these notes
are dominated by a resident’s eating, sleeping
and mood patterns, and are not an appropriate
place to determine and record residents’ life goals.
Community Visitors have reported this issue on
multiple visits, but it has still not been resolved.
Community Visitors were pleased to report
a positive example of staff support that has
transformed one resident of a DAS house.
Previously, Community Visitors reported the
Person-Centred Plans (PCPs) created at some DAS
group homes are broader in scope and encompass
personal development and community involvement
such as going out for dinner, or to a disco, or doing
the household shopping. Plans developed by day
programs tend to reflect a resident’s interests more
Disability Services
77
accurately, for example going to the football at a
local oval. Sometimes there is just one joint plan that
reflects the whole of the resident’s life. There are
also examples of where the two plans complement
each other, such as a resident of a DAS house who
plays in a band at their day placement, and attends
drumming lessons arranged by the house.
Other individual planning issues reported include:
• no holidays planned for residents of some
DAS houses
• a resident of a CSO house who has consistently requested not to have a personal plan
Staff at a CSO respite house told Community
Visitors that they were planning increased
opportunities for respite users to engage in
community activities, which are currently lacking.
The time some residents of DAS houses spend
on transport is excessive. Elaborate bus runs
have been developed to maximise the sharing of
vehicles, but this can mean sometimes residents
spend up to two hours on a bus to or from day
placement. One DAS house was without a vehicle
for a month, which affected residents’ behaviours
and the staff members’ ability to support residents.
At one CSO house, Community Visitors noted
• residents at a CSO house who did not want to go concerns from residents that the house does
to bed at 9pm on Friday night to suit staff rosters
not have a bus to assist residents to access the
community. The CSO responded that there were no
• a resident of a CSO having to change the time plans or funding to allocate a bus or vehicle to the
they get up for work and the time they come
house, and residents are encouraged to use taxis.
home in the evening because of a change in a However if residents cannot afford taxis they miss
staffing roster
opportunities for community engagement.
• no regular resident meetings held at a CSO house.
A resident of another CSO house lives far from their
At a CSO house, a resident asked for a microwave
family and has to rely on costly taxis to visit, as they
to be moved so they could use it to reheat food after do not live near a train line. The resident has asked
coming home late without having to rely on staff, and to move to a house closer to their family.
also asked for more involvement in meal planning.
Funding also presents a barrier to social inclusion
At another CSO house, staff are supporting a
for some residents. Issues reported by Community
resident in determining whether the resident can
Visitors include:
manage their own money and financial affairs. The
CSO sought and followed advice from OPA on this
• a resident of a DAS house with no Individual matter and Community Visitors continue to monitor
Support Package (ISP) funding who relied on
the situation.
staff having time to take them to activities, but missed out when another resident at the house At a DAS house, Community Visitors inquired
became ill
whether sexual education and support services
• a resident of a DAS house who has been without
were required for two residents who were in a
ISP funding for more than three years and has sexual relationship.
little peer interaction
Social inclusion
Community Visitors see residents of DAS houses
interacting with the community in a variety of ways,
such as shopping, belonging to clubs and church
groups as well as the wider community through
visiting galleries and the theatre.
Community Visitors reported that residents of a CSO
house seemed to be staying indoors at holiday time
due to a lack of confidence to go out. However, the
CSO advised that during holidays they had arranged
resident outings and excursions. Community Visitors
will continue to monitor this situation.
78
• a resident of a DAS house whose funding for one-to-one staffing as part of a BSP has, in effect,
prevented their participation in group activities.
Health and wellbeing
Health and wellbeing issues reported by
Community Visitors include:
• a resident of a CSO who had a swollen foot was diagnosed with a hairline fracture, but the CSO could not establish how it occurred
• a CSO resident hospitalised because of bed sores, after which the CSO worked with medical staff to prevent reoccurrence
Disability Services
• broken equipment at DAS houses, including a shower chair and bed
• a lack of equipment in a sensory room at a DAS house, which could be used by a resident with vision impairment
• no exercise plan to support a CSO resident
after surgery, despite the operation occurring months earlier
• residents of DAS houses waiting excessive amounts of time for aids to assist with mobility, sleeping and comfort
• concerns about the mental health of two residents at different CSO houses who refused mental health support
• a lack of fresh food in the fridge and on the menu at one CSO house
•
inconsistent use of weight charts at DAS
houses, which Community Visitors believe could provide an important insight into residents’ health and wellbeing.
Community Visitors also reported a number of
concerns about medication errors at some CSO
houses, including:
•
a house where incident reports noted four occasions when residents missed medication because staff had not administered it correctly or there had been a pharmacy error in medication packs
• a house where Community Visitors noted six medication administration errors
• medication more than two years passed its
use-by date at one house
• poorly organised medication packs at
a house that made it difficult for staff to
administer medication correctly.
In a DAS house where residents are ageing, health
issues are paramount. Community Visitors were
impressed with the extent of detail in records
monitoring each resident’s specific needs.
Community Visitors reported a positive working
relationship between staff at a DAS house and the
family of a resident with ongoing mental ill health.
A change in the resident’s home life caused the
resident to become anxious. House staff promptly
arranged for additional counselling support, and the
resident’s family were able to take the resident to
the appointments with minimal waiting time.
Disability Services
A CSO has been responsive to Community Visitor
concerns about the quality of life for a resident who
has profound communication difficulties and sleeps
for long periods during the day, by proactively
engaging with the resident’s family and organising
for a neurological review for the resident.
At one CSO, staff raised concerns with Community
Visitors regarding a resident’s parents’ expectations
about their adult child’s care requirements. The
CSO has responded by indicating that there will
be a review and clarification of the resident’s health
support plan.
Rights
Residents have a right to live in a safe and
harmonious environment, however, in some DAS
houses, compatibility between residents remains an
issue. Community Visitors observe that there has
been an improvement in the time spent on scoping
out suitable locations for residents to move to,
as well as time and effort spent on individualised
transition planning that meets the needs of residents.
At one CSO house, residents have been disturbed
at night for many years because of one resident’s
behaviour. After many attempts to solve the
problem, the resident has been found more suitable
accommodation in a house that is staffed overnight.
Community Visitors report that staff knowledge and
interpretation of BSPs varies between staff teams
at DAS houses. In some instances, aspects of
residents’ BSPs are not fully implemented or take
substantial time to implement.
For example, Community Visitors asked about the
training staff received regarding BSPs. Community
Visitors were informed that staff are trained at their
induction then as needed to meet the specific
requirements of residents. In one home, Community
Visitors were unable to locate the documentation
about locked doors at their visit, however in a
subsequent response the plan was located and
put on file. Staff seemed unsure and evasive when
Community Visitors asked about these issues in this
particular house.
At one DAS house, Community Visitors reported
that staff were vague in their responses to questions
about resident plan implementation. Community
Visitors were told at a number of visits over
several years that plans were being discussed at
a team meeting, or that a key support worker was
implementing the plan, but was not at work that day.
79
case
study
CSOs continue to reassess whether residents still
require BSPs. In the past year, several residents
have been reassessed as no longer requiring
BSPs, with their behaviour instead addressed using
Behaviour Support Strategies (BSS).
Community Visitors reported concerns about
restrictive interventions, including:
•
a resident of a CSO house found outside in
a distressed state, having come home from day placement with a restraint on their wheelchair and no BSP to support this action
•
lights and windows at a CSO covered in mesh before the arrival of a new resident, despite staff
being told the new resident has shown no signs of destroying lights or windows
•
staff at a CSO complained safety mesh installed in vehicle restricted communication between staff and residents, but were told other houses using the vehicle needed the mesh.
Community Visitors note that asset registers
recording residents’ personal belongings are 12-18
months out-of-date at some DAS houses. In one
DAS house, asset registers could not be located,
in another house they were dated as current but no
new items had been added for the past four years.
Community Visitors reported concerns that a
significant amount of money bequeathed to one
DAS house was reportedly never received. DAS
responded to Community Visitors by stating they
“welcome any further suggestions CVs may have to
solve the mystery as to why the money was never
sent to the Department.”
Community Visitors report residents’ right to privacy
and dignity has been compromised in a number of
instances, including:
A resident of a CSO house reported several
years ago that a male staff member attending to
her personal care had inappropriate contact with
her. Since this time, the resident has requested
that only female staff members attend to her
personal care.
This request was initially complied with by the
CSO, however this year a male staff member
asked to assist the resident with her personal
care because female staff were not available.
The CSO and resident have since signed an
agreement naming the staff that the resident is
comfortable with who will provide personal care
to the resident.
In two instances, Community Visitors reported
that the refrigerator and kitchen cupboards at DAS
houses were locked without evidence of a BSP in
place to warrant restricting residents’ access within
their home.
Community Visitors continue to raise concerns
about the closure of one DAS house and the impact
on residents who may be separated. Community
Visitors learned of the planned closure by chance
after the decision to close had been made, and
could only be reactive in trying to advocate for
the best outcomes for residents. One resident
had already moved to a different home and the
remaining residents were given the option of staying
together or being separated in other nearby houses.
Incident reports
Community Visitors report that the filing of incident
reports can differ between DAS houses, and are
sometimes difficult for Community Visitors to locate.
• a DAS house where Community Visitors had to At some DAS houses, Community Visitors could
request a shower curtain for residents who could not access incident reports as they were stored on
be easily seen from the doorway
a computer, and at others, the non-critical client
event log was used to report incidents.
• a urine odour in a resident’s room at a DAS house
• only one toilet available in a DAS house with four Community Visitors also reported problems
residents who are incontinent
accessing incident reports at CSO houses: in some
instances, they could not be found; were located in
• a female resident bathed by a male staff member, a locked cabinet or on a computer; were incorrectly
despite a female staff member being on duty
labelled; or staff did not know where to locate them.
• a resident of a CSO house who raised concerns Incident reports were not stored on site at some
other residents entered their room at night, houses, and at one house, there was no follow-up
disturbing their sleep
information recorded on incident reports, making
it difficult for Community Visitors to establish if
• a CSO house resident’s urine bag visible from anything has been done to resolve the issues
their wheelchair without any covering to afford detailed in them. Poor quality incident reports at
the resident privacy.
80
Disability Services
some CSO houses also prevented Community
Visitors from seeing how issues were managed and
residents supported.
Community Visitors continue to advocate to CSOs
to ensure that a hard copy of all incident reports is
available to be viewed by Community Visitors.
Goulburn
Abuse and neglect
Community Visitors were informed by staff that
one resident of a CSO had broken a glass, which
shattered, although Community Visitors were unable
to access a specific incident report related to this at
the house. A member of the resident’s family later
took the resident to a doctor, who found a shard
of glass in the resident’s arm. The resident’s family
member has made a complaint to the CSO regarding
this issue. The house now uses plastic glasses.
Community Visitors reported concerns that
a resident with disability, mental illness and
aggressive behaviour was inappropriately placed
in a CSO house with vulnerable residents. The
resident felt frustrated living with others with limited
communication skills. When the resident’s mental
health was unstable, they were aggressive toward
other residents and staff, and displayed unhygienic
behaviours. Staff reported that the resident’s mental
health deteriorated and they were taken to hospital,
but after assessment were not admitted. Other
residents at this house also require a high level of
behaviour support and were negatively impacted by
the new resident’s behaviour. Community Visitors
spoke with the parents of another resident, who
contacted OPA’s Advice Service with concerns for
the safety of their family member in the house.
An application was made to the Disability Services
Register (DSR) in 2014 for the resident to move,
but the resident is still waiting for alternative
accommodation.
At another CSO house, Community Visitors reported
17 incident reports relating to aggressive behaviour
displayed by one resident, who had threatened
both staff and other residents in the house. Police
were called during one incident when crockery was
broken, and a staff member showed Community
Visitors bruising allegedly perpetrated by the
resident. One staff member reported a resident
to police after being assaulted. The resident’s
aggressive behaviour had a negative impact on other
residents; one resident developed incontinence;
other residents began to stay in their rooms, and
Disability Services
residents went on fewer outings. CSO management
agreed with Community Visitors that the resident had
been inappropriately placed, and stated they had
received inaccurate information about the resident’s
behaviour before their placement, including from
the resident’s family. The resident was issued with
a temporary notice to vacate with a view that the
CSO would work with the resident’s family and
DHHS to find more appropriate accommodation.
The resident is waiting on the DSR for alternative
accommodation, and the CSO is arranging specialist
training for staff to positively support the resident.
Community Visitors raised concerns about the
staffing level at one CSO house, where only one
staff member is on duty at a time, and there have
been incidents of assault between residents.
Respite
Community Visitors reported that one respite user
has been waiting for long-term accommodation for
many months.
Ageing
Community Visitors noted that one resident had
moved from a CSO house into an aged care
facility. The resident had multiple health issues and
their occupational therapist care plan stated they
required two staff at all times due to decreasing
mobility. The resident is reportedly enjoying life at
the aged care facility.
Community Visitors reported a number of issues
regarding maintenance at group homes, including:
• a pipe in the garden at a CSO house had been leaking for a month
•
a CSO house with leaking toilets, a blocked drain, a leaking kitchen ceiling and bathrooms in need of re-grouting to stop water damage
and mould
• a kitchen renovation at one CSO house was placed ‘on hold’ for reasons unknown.
Staff support
Community Visitors raised concerns about staff
support for residents at one CSO house after the
house budgie was given away despite residents
81
wanting to keep it. The CSO stated that the budgie
became a “chore” for staff to clean up after, and
after discussing it at a resident meeting, “it was
agreed” that the bird could be given away.
Community Visitors reported that due to a staffing
reduction at one CSO house, staff have difficulty
supporting residents to attend medical and other
appointments.
Rights
Community Visitors reported that at one CSO
house, residents are encouraged not to access
the kitchen because of one resident’s behaviour of
concern relating to food. This restricts residents’
rights to access the kitchen, however, other
residents at this house are frail and ageing and are
no longer as heavily involved in meal preparation, so
they are not as heavily impacted by this restriction.
Ovens Murray
Abuse and neglect
Community Visitors reported that residents at a
CSO were left without support for six hours due to
a misunderstanding with a staff roster. Following
this incident, roster management procedures have
been reviewed with adequate back up procedures
between shifts.
case
study
Five residents of a DAS house had lived
together since moving from a former institution.
After the death of one resident seven years ago,
a new resident with behaviours of concern and
mental illness was placed at the house.
The new resident did not want to live at
the house and demonstrated violent and
destructive behaviours, including assaulting
frail and elderly residents.
An enormous amount of work, skilled care
and specialist expertise has been provided
for the resident, who is now largely happy
and has friendships with other residents.
However, the resident still has occasional
and unpredictable outbursts, and Community
Visitors believe there is still an unacceptable
level of risk for the other residents.
82
While staff support is excellent, Community
Visitors question the original decision to place
the resident at this house.
At a respite facility operated by a CSO, a new
respite-user’s behaviour caused distress to
long-term users of the service. One respite user,
who had lived at the facility for six years, did not
come out of their room for months because they
were intimidated and scared by the new respite
user’s behaviour. The respite provider had to find
alternative accommodation for two long-term
respite users who had been living at the facility
and for short-term respite-users. Staff at the facility
learnt sign language to communicate with the new
respite user and a school placement was arranged.
After repairs to the building and the replacement of
broken furniture, the facility opened again for respite.
Community Visitors noted assaults on both
residents and staff at one CSO house, also property
damage. It was only following the third request
from Community Visitors that incident reports about
these assaults were made available, as staff had
been reluctant to provide them.
Ageing
Community Visitors report that an increasing
number of residents are developing dementia.
There is an aging population with dual disability of
Downs syndrome and Alzheimer’s disease. Most
residents would want to live in their own home for
as long as possible, however there needs to be
appropriate staffing levels at each house for this
to occur. There is also no clear place to go for
residents with disability and Alzheimer’s disease
who can no longer live in a group home.
At one CSO house, a resident with early-onset
dementia is sometimes violent and angry,
frightening other residents who then retreat to their
rooms. In one incident, the resident smashed a
window and injured their arm, and the resident’s
day program reported difficulties supporting the
resident’s behaviour. The resident has health care
support and the CSO is managing the situation
with extra staffing at certain times of the day, but
funding for this staffing is uncertain. Community
Visitors and the CSO expressed disappointment at
the limited assistance available from DHHS despite
submissions from the CSO. There are no suitable
alternative places available within the disability
services network, and the resident is likely to be
placed in an aged care facility when current funding
for staff support runs out.
Disability Services
Community Visitors report houses are generally
in good repair, with maintenance attended to
promptly, however some issues occur when a
CSO manages a group home owned by another
government agency. At one CSO group home,
owned by the Department of Housing, Community
Visitors report ongoing concerns about mould and
damp in bathrooms. Attempts to fix the problem
have been unsuccessful, including the residents
moving to a motel for several days while renovation
work was completed; however, Community Visitors
were disappointed to find fungus again growing on
the floor and walls.
Community Visitors report that some DAS houses
are being replaced with purpose-built homes to meet
residents’ needs. However, one new home is not
an improvement on the house it replaced, with toilet
doors that open onto the dining and kitchen area.
Staff support
Community Visitors report many long-term staff
in this area have developed strong bonds with
residents and house managers closely monitor staff
attitudes and skills.
Positive staff support has included:
• staff at a CSO providing palliative care to a resident over a long period of time
• a CSO staff member bringing their elderly dog to work for the residents to interact with, which residents say they enjoy
•
staff encouraging a resident to shower and change clothes by emphasising the importance of looking their best when they go out to meet friends for drinks.
Staff at one DHHS house have implemented a
communication system that supports residents with
communication difficulties to make choices and
decisions. New and casual staff can read about
each resident’s preferences, routines and dietary
requirements in a matter of minutes.
However, at some CSO houses Community
Visitors reported that staff need more training
and ongoing support, and that understaffing and
use of casual staff had a detrimental effect. Staff
report to Community Visitors that they do not have
the amount of time needed to support residents’
personal development.
Disability Services
Residents at one CSO said they did not want
a particular staff member to work at the house
any longer because they were overly critical and
accusatory. The CSO manager requested the staff
member change their tone and be more ‘upbeat’
with residents. However, the staff member’s
behaviour continued and residents again requested
that the staff member no longer work at the house.
The staff member will now move to another of the
CSO’s programs.
At another CSO house, five residents spoke to
Community Visitors about a staff member who
‘talked down’ or yelled at them, and was generally
unpleasant towards the residents. The five residents
collectively and individually stated the same issues
had occurred and Community Visitors were satisfied
that they had not been pressured to make the
complaint. Community Visitors acknowledged the
strength personally and collectively taken to alert
them to their concerns. All residents agreed that
they wanted the staff member to leave the house.
Individual planning
Community Visitors report that residents’
individual plans are respected, and a lot of effort is
put into supporting residents’ choices, even if they
are problematic.
One resident of a CSO repeatedly stated they
wanted to live independently, despite having limited
independent living skills. The resident lived in their
own unit separate to the main group home. The
CSO began a trial of encouraging the resident
to do their own cooking and cleaning to assess
their independence skills. The resident was also
assisted to lose weight by being matched with a
staff member who had themselves lost a significant
amount of weight. Unfortunately, the trial did not
work as the resident lacked motivation to complete
personal and domestic care tasks, and stated that
they did not want to be ‘pushed’ by staff to clean.
The resident also alleged they had been assaulted
by a staff member, and stated that they wanted to
leave the CSO and live somewhere else.
Social inclusion
Not all houses have a dedicated or appropriate
vehicle to support resident’s access to the
community, which is detrimental to individual choice
and spontaneous activities. Both CSO and DAS
houses without dedicated transport require that
residents use taxis, which have limited availability in
rural areas and are expensive.
83
At some houses, residents have to pay for taxis to
do the household shopping, as well as to attend
any social activities, doctors’ appointments and
day programs. At other houses, the cost of a bus
is included in residents’ board and lodging fees.
Community Visitor’s have asked for a breakdown
of board and lodging fees as well as mobility
allowances for residents to see where the funding
is being spent.
Melbourne
Abuse and neglect
Abuse by residents
Residents are generally very well cared for
and attention is paid to their health care
needs. Community Visitors report residents’
Comprehensive Health Assessment Plans are
usually up-to-date.
Rights
Staff and management are generally respectful of
residents’ rights. However, resident incompatibility
means a number of residents are unable to enjoy
their right to a safe, peaceful home environment.
In some houses, a mix of residents with violent or
threatening behaviours impacts very heavily on
other residents, as described in the abuse and
neglect section of this report.
Incident reports
Community Visitors report that access to incident
reports is not an issue in this area. One CSO has
made a specific incident report book for Community
Visitors for each house, which is always available.
North Division
The North Division includes Northern
Metropolitan Melbourne, which is made up of
the DHS areas of Hume Moreland and North
Eastern Melbourne, and the regional Victorian
areas of Loddon and Mallee.
This year, 50 Community Visitors conducted
595 visits to 293 houses in this division. There
were 12 notifications to the Public Advocate
regarding residents at serious and imminent
risk of harm. These notifications are detailed
throughout this divisional report.
84
Two sexual assaults and two attempted sexual
assaults of a non-verbal resident by a co-resident
allegedly occurred at a CSO house where both
residents were living for an extended period. After
the first couple of incidents, alarms were put on
doors and instructions were issued to staff that
the alleged offender was to be kept in sight at all
times. The police, DHHS and Office of Professional
Practice and the parents of the victim were
contacted by the service. The distressed parents
of the victim sought help from the Minister and
numerous agencies, including OPA. Community
Visitors discussed their concerns with DHHS at
Local Connections liaison meetings.
In the final incident, it appears the alleged offender
sexually assaulted the victim in a bathroom.
It appears from incident reports written at the
time, that the residents may have been left
unsupervised when the only staff member on
duty at the time had locked themselves in the
office and called the police, because the alleged
offender had threatened the staff member with a
weapon. The alleged offender was moved to hotel
accommodation and then a “contingency house”.
The matter is subject to police investigation. The
mother of the victim told the Community Visitor
Coordinator, “the scars will never heal.”
Two notifications from the same house in twelve
months document Community Visitor concerns
about abuse and bullying by one resident
towards their co-residents. In the first notification,
Community Visitors note that an intervention order
was taken out by a family member of the victim
after a physical assault, subsequently the two
residents began to live in separate sections of the
house. The second notification detailed Community
Visitors concerns about constant verbal abuse
perpetrated by the same resident towards another
resident. The parents of the victim reported to
OPA’s Advice Service that the victim had been
Disability Services
wetting the bed, hiding in their room and was too
scared to go to the bathroom. House management
worked to implement behaviour support strategies
and alternative accommodation was sought for
the alleged offender, but the abuse of co-residents
continued for many months.
to protect the residents, and were advised that
behaviour management strategies were in place.
One of the female residents had seen a forensic
psychologist to learn defensive strategies herself,
and alternative accommodation was being sought
for the alleged offender. Community Visitors remain
concern at the risks to residents in this house.
A caller to OPA’s Advice Service reported that their
family member, who lived in a group home, had
been assaulted by another resident. The caller
alleged there were not enough staff at the house,
and was concerned for the victim’s safety as
they had recently run away from the group home
and had been returned by police. A subsequent
Community Visitors report noted further assaults,
verbal abuse and property damage at the house.
A mental health assessment in July recommended
that the two residents, who were the subject of
many altercations, not live together. The Community
Visitor Coordinator wrote to the Area Manager
asking about action to separate the two residents
and reduce the risk of violence. One resident has
since been moved.
Staff witnessed a resident sexually assaulting a
co-resident and intervened. A local GP treated the
distressed victim and police were called. Police
did not formally interview or charge the alleged
offender because of their cognitive disability. The
alleged offender was on a Supervised Treatment
Order (STO) and had a history of sexually assaulting
co-residents. At the victim’s request, the alleged
offender relocated to alternative accommodation.
The STO stipulates that the alleged offender is
to be within line of sight supervision by staff.
Chemical restraint is being considered for the
alleged offender, who is currently living alone under
constant staff supervision.
Community Visitors strongly believe that people
with disability should not have to live with other
people with whom they are clearly incompatible and
where there a real risk of harm. It is very important
that the government creates more housing options,
and that DHHS uses the vacancy coordination
process to ensure that poorly placed residents at
risk of ongoing abuse are not condemned to stay
where they ‘landed’ when they were in critical need
of accommodation.
Community Visitors are concerned about the
volatile environment in a DAS house where a
number of residents have been subjected to
physical and sexual assault and verbal abuse
by other residents. In one case, a male resident
is alleged to have indecently assaulted a female
resident when he was intoxicated. The alleged
offender is the subject of another notification
regarding his sexual advances to another female
resident, who Community Visitors are concerned
may not have capacity to consent. Another resident
at this house has also been violent. Community
Visitors sought written responses on strategies
Disability Services
On a regular visit, Community Visitors noted that one
resident had struck another with an object, which
resulted in the victim requiring stitches. The matter
was reported to police, but no charges were laid.
Community Visitors noted that this was reportedly
because the alleged offender was non-verbal. The
victim told Community Visitors that they wanted
the alleged offender moved, and this was reported
to DHHS. Community Visitors were informed that
the residents were having counselling and that
the counsellor had recommended that the alleged
offender be relocated. On their visit three months
later, the residents were still living together and still
in conflict. In March 2015, DAS advised Community
Visitors that an application to the DSR was being
developed. This was proceeding despite the alleged
offender now being seen by a psychiatrist who had
prescribed new medication which appeared to be
of assistance. In April 2015, Community Visitors
commented that although the application to the
DSR was completed, relocation may not be urgently
required, and requested to be kept informed of
ongoing relationships between the residents.
85
Services appear to have acted responsibly
in suspending staff accused of abuse. One
casual staff member was stood down after
being observed “administering medication
in an inappropriate manner”. Police were
called in relation to this incident.
Two residents were found to have significant
unexplained bruising and abrasions. Community
Visitors were informed at a liaison meeting that a
staff member had been stood down due to the
alleged physical assault of the residents. All other
staff from the house were relocated to other houses.
Police were notified of alleged assaults and further
examination of the bruising was undertaken by a
medical practitioner specialising in forensic medicine.
A new house supervisor and staff team were put
in place at the house and a clinical psychologist
counselled the residents. DHHS Ethical Standards
Unit undertook a Quality of Support Review which
was concluded in April 2015. Community Visitors
understand the police have not pressed charges
against any staff member.
On a regular visit, Community Visitors noted that
a resident had reported that a staff member had
sexually assaulted him. The resident was taken
to police for an interview and to hospital for an
examination. The resident’s family was notified.
The alleged offender was removed from resident
contact until the police investigation was complete.
The DAS manager emailed the Community Visitor
Coordinator to report that the police would not
be progressing their investigation due to lack of
evidence. OPA is monitoring the resident’s situation
and advocating as appropriate.
Ageing
As residents age and their support needs increase,
funding for increased staff is not always available.
When Community Visitors queried why one house
with ageing residents had its staffing hours reduced,
they were advised “the staff roster currently exceeds
the ‘core’ funding allocation and is not financially
86
viable”. This was despite the current resident group
changing and an increased complexity in needs.
Declining health requires more intervention and
support, including more visits to doctors. Some
residents who need wheelchair-friendly transport are
also not able to access this easily.
At one CSO house, residents are all ventilatordependent and have high support needs. The
house has had an age limit of 64, requiring
residents to move to aged care once that age
is reached. Community Visitors have advocated
throughout the year for this age limit to be removed.
Respite
In last year’s annual report, Community Visitors
called for an analysis of respite services in the
region, as there were insufficient respite places,
but to date, little has happened. Some CSO
houses have age limits (up to 18 or 25 years of
age) and there appears to be a lack of respite bed
coordination across the region.
Active night shifts were reportedly reduced at one
respite service, requiring families to travel further if
their family member required overnight support.
One CSO respite house has a resident who has
been living there for almost two years. Staff have
worked hard to increase the resident’s skills,
which were being affected by the frequent resident
turnover at the facility.
case
study
A person with disability has been living in a
DAS respite house since May 2013. For more
than a year, Community Visitors have asked
what is being done to find a permanent place for
this person, as their accommodation in respite
is using one of six respite beds allocated to
approximately 80 respite users. DHHS advised
that they had found an alternative place for this
person, however their family were unhappy with
the proposed option.
Staff report that the person’s behaviour was
worsening, and they often have to seclude the
person in one half of the house to keep them
away from other respite users. As a result, one
desperately-needed respite bed is permanently
occupied and half the house cannot be utilised
by the other respite users.
Disability Services
One older CSO respite house was replaced by a
new house. The new location means some respite
users need to travel further. Community Visitors
continue to advocate for a comprehensive regional
respite review. While this has not occurred, the
different DHHS teams responsible for DAS and
CSO respite have had some discussions.
Community Visitors have reported a variety of
maintenance issues at DAS houses, including
broken fixtures such as kitchen cupboards, doors,
gates and curtains; problems with decking; airconditioning faults; and painting and plastering
issues. Some of these present potential health
hazards to residents, and they seem to take an
inordinate amount of time to be fixed. Renovation
funding has been approved for some DAS houses.
At one DAS house, a rear fire escape poses a risk
because of broken and rotting floorboards, and it
needs to be demolished or replaced. Community
Visitors were told there has not been a wheelchairuser at the house for 14 years, and noted there is a
concrete ramp leading to the garden.
In January 2015, Community Visitors noted a
hole in the wall at a house that exposed electrical
cabling. On their June visit to this house, they
identified over 20 areas where the plaster has
been damaged, as well as two areas where
electrical wiring was exposed. DHHS has informed
Community Visitors that the plastering has been
repaired and the wiring is no longer exposed.
Community Visitors have repeatedly reported privacy
issues in a bathroom that contains a toilet. One
resident stated that they were frightened to use the
toilet in case they was attacked by another resident.
Community Visitors were advised that the second
bathroom, being exclusively used by staff, was to
be made available for resident use. In February
2015, a departmental response advised that the
house supervisor would request Housing Choices
Australia (HCA) assess and recommend alternatives
to the current situation regarding privacy in both
bathrooms. Community Visitors have now been
advised that a request has been placed for a minor
renovation to separate the toilet and shower facilities.
At one DAS house, two residents have been
sharing a small bedroom since 1987. One of the
residents is very dominant, which makes it difficult
for the other to use the bedroom, and they are
forced to keep some belongings in the corner of a
shared living room.
Disability Services
At another house, a new hydrotherapy bath
was installed more than a year ago, yet residents
have not been able to use it because there is no
hoist installed. A response in March 2015 advised
this “was awaiting a funding response from the
DAS Manager”.
Some of the most serious maintenance problems
are in facilities owned by HCA. These houses,
which operate as both DAS and CSO group
homes, are old stock with some longstanding
maintenance issues that have been reported
in previous years. At one house, two residents
continue to share a bedroom, and the parent of
another resident is unable to visit as there are stairs
and no ramps at both entrances.
In another HCA house, two large gas wall heaters,
unused since 2006, are in the hallway obstructing
corridors that are already narrow. One resident has
a severe vision impairment, and another uses a
walking frame to get around the house. Community
Visitors have continually been told that HCA is
looking into this issue, but nothing has been done.
There are longstanding maintenance issues at one
house due to its age and foundation problems. This
house is being assessed for improvements by HCA.
Community Visitors are pleased an audit of HCA
properties has occurred and hope this leads to
property improvements.
At Plenty Residential Services (PRS), several
residents are living on their own (with 24-hour
staffing) in three-bedroom houses because of their
complex behaviours that may pose a risk to others.
Some of these houses could be renovated to
provide additional safe accommodation for others.
Funding has been allocated to PRS to proceed with
renovations of eight kitchens, five bathrooms, and
one living room.
Many CSOs do not own the houses they use; this
delays or inhibits repairs and upgrades. Bathrooms
in particular are often mouldy and needing repairs.
Community Visitors regularly report that carpets in
these houses need cleaning or replacing Community
Visitors have also found building materials in outdoor
areas that have not been tidied, and pathways and
fences that were unsafe.
87
good practice
A new CSO facility opened in 2014 providing
a new accommodation model with four single
self-contained units and a double unit under
one roof. Each unit has a bedsitting room with
a small kitchen, a bathroom with washing
machine, and a secure courtyard. Staff are
centrally located and available to support
residents as required. The units are within
walking distance of shops and parks, and
residents are encouraged to access these with
staff, or alone if appropriate. Public transport to
day placement is located nearby; alternatively
residents are transported by bus. Three staff
work during the day and there is an active night
shift worker.
Staff support
Many houses have staffing vacancies, resulting in
a high usage of casual and agency staff. Staff with
limited training are often required to manage very
difficult situations arising from the conflicting needs
of clients with challenging behaviours. Community
Visitors have been distressed to observe the
constant verbal abuse and intimidation of some
residents by co-residents in their homes, and note
the physical assaults that some staff have suffered
in the course of their work. Some houses have had
high staff turnover, and casual and agency staff
employed in these situations sometimes struggle to
handle very challenging situations.
DAS undertook a major recruitment drive in the
Northern Metropolitan area and established their
own casual pool. However, it appears there is a
lack of people applying for jobs in the disability
residential services sector generally. Community
Visitors question whether there needs to be a
concerted public recruitment campaign, as the
situation affects the quality of life of many residents.
Roster reviews have occurred at some houses,
and concerns about the impact of reduced hours
have been raised. Last year, Community Visitors
reported the case of two residents in a DAS house,
who require two staff to assist them to bed; these
residents are obliged to go to bed before 9pm,
when the last day-shift staff member finishes. This
situation continues.
At another DAS house, where six residents require
a high level of support, Community Visitors were
told by a staff member that they were expecting to
lose four staff from the roster over the next month,
88
despite some of the previously vacant lines being
filled. This presented a huge occupational health
and safety risk, as there were six residents with
complex medical needs all requiring washing,
changing, lifting, and assistance with eating and
medication. This was being managed to a large
degree by casual staff. There has been a shortage
of staffing for years in this house.
At some CSO houses, staff are not adequately
trained to support residents with complex needs.
Use of casual staff who do not know residents also
presents a problem. This may result in restricted
access to activities for residents. At one respite
house, staff were unable to access resident records;
hence staff could not refer to plans when working
with individual residents. Recruitment is a challenge
for some CSOs; and managers or house supervisors
often affect the quality of staff. Generally, Community
Visitors observe many excellent examples of staff
support, where residents are encouraged to be
independent and engage in tasks as they are able.
good practice
When Community Visitors visited a DAS house
in August 2014, it was a very unhappy house.
Staff morale was very poor, and the client mix
was not working; one Community Visitor said
it was the most unhappy house they had ever
visited. One of the residents asked Community
Visitors to help them move from the house. This
resident has since moved; subsequently the
client mix was reassessed and the number of
residents at the house kept to four residents. A
new house supervisor was appointed and the
staffing stabilised. Staff are now working more
effectively as a team and, achieving positive
results, while still managing very challenging
resident behaviour.
good practice
The house supervisor at one DAS house made
considerable effort to ensure rostered staff were
proficient in signing skills, to effectively support the
residents. They have lived together in this house
for over 20 years, and all have hearing difficulties.
Despite this, residents have regular one-to-one
outings, and are supported to be as independent
as possible in all aspects of daily living.
Disability Services
Community Visitors have been pleased to see an
improvement in the care provided to residents
at Life Without Barriers’ houses in the past year.
Stable, consistent staffing and proactive responses
to resident needs have ensured that the home
environment is calm and interesting in these homes.
Previously, some houses did not have pictures on
walls, or display menus or programs. The improved
quality of staff assistance has impacted positively
on the health and wellbeing of residents.
At PRS, the staffing review process, underway
for the past two-and-a-half years, has resulted in
some changes to the rosters. Besides the additional
house supervisor and Disability Development and
Support Officer Level 2 (DDSO2) or second in
charge positions, changes were made to ensure
that rosters more appropriately catered to the
needs of residents. The former institutional practice
of having staff working 12-13 hour shifts for twodays-on two-days-off created additional difficulties.
Unsuccessful negotiations with unions have limited
the capacity for change in these areas. As at 30
June 2015, not all house supervisor positions have
been filled on an ongoing basis, whilst the filling
of DDSO2 positions has also been problematic.
Additionally, due to the number of investigations into
abuse and neglect in a number of houses, and the
amount of time these take to resolve, many houses
at PRS experience constant staffing changes.
In the 2012-13 Annual Report, Community Visitors
reported that communication assessments, many
paid for by residents, were not being implemented.
Management had advised that action was being
taken to ensure these were completed and put into
effect. Community Visitors continue to report on
deficiencies in this area, including delays in reviews
of assessments, and a failure on the part of house
staff to implement the recommendations or actions
identified. The DHHS Residential Services Practice
Manual states that staff should be familiar with
any non-verbal communication strategies used by
residents, regularly discuss and review these as
well as ensure they are implemented.
In January 2014, one resident paid $2000 for
a communication assessment; as of 30 June
2015 this had still not been implemented, despite
Community Visitors repeatedly advocating for it. A
response from DHHS in March stated that the house
supervisor would follow-up on recommendations.
Subsequently, management stated that a strategy
was needed to ensure communication assessment
recommendations were being implemented,
and suggested that communication goals be
documented in PCPs with input from relevant
parties. Community Visitors reported that this
Disability Services
strategy had not been successful; and argued for
more effective management. As PCPs are only
reviewed annually, Community Visitors fear it will be
another 12 months before residents will receive the
dignity of being communicated with effectively.
Individual planning
Community Visitors frequently comment on the
poor quality and availability of PCPs and key worker
reports. Many PCPs lack content and clarity.
Furthermore, progress and action is not reflected in
progress notes and key worker reports; the latter
are frequently not available in client files. Too often,
they do not reflect what is actually happening in
the lives of residents, despite a special regional
project to improve the standard of documentation
in DAS houses. For example, at one house, the
PCPs and activity folder clearly stated that three
residents went swimming on a particular night of
the week. However, discussion with staff revealed
that this no longer happened as the vehicle was
used for another activity. After further queries by
Community Visitors, one of the residents now
attends swimming at an alternative time.
In almost all of these houses, client documentation
is either poorly or inconsistently completed. This is
of real concern when the documentation relates to
the authority to use restrictive interventions, or where
realistic and achievable life objectives for clients are
not in place. In general, Community Visitors could not
determine when a PCP was developed and needed
review and there was limited monitoring and recording
of the progress that residents were making towards
their goals. This is unacceptable and contravening
both the letter and spirit of the Disability Act.
Community Visitors noted that at two DAS
houses, there were no BSPs detailing the use of
PRN medication provided to residents displaying
behaviours of concern.
At CSO houses, Community Visitors find that many
PCPs are out of date and do not relate to resident’s
wishes or detail how goals are to be achieved.
One CSO successfully brought about change by
introducing a ‘paper trail’ to show where goals are
recorded, as well as evidence of activities that work
towards these goals. Another has attempted this
by producing multiple forms for monitoring specific
goals including household skills development and
community access.
Community Visitors visiting respite houses identified
that it can be difficult negotiating resident issues
with the staff, as PCPs are kept at the day service.
89
Social inclusion
Unfortunately, there are a number of DAS and
CSO houses where residents are unable to
attend a day program. Often Community Visitors
observe that the television is on in a house, but
no other activities are occurring. There was also
little evidence of regular activities in client files.
One resident indicated he would like to go for
a walk however, staff said this would occur
“only on weekends”.
Inadequate transport is still a frequently recorded
issue. Vehicles are regularly shared between
houses, rather than every house having a
dedicated vehicle. One house with ageing
residents, one of whom use walking frames, has to
share a vehicle with two other group homes. Two
other homes without a permanent vehicle have
residents who use wheelchairs, and as they cannot
walk to the shopping centre, medical appointments
or community activities, considerable planning is
required to share a bus or organise maxi-taxis.
Community Visitors are seriously concerned about
a resident at a DAS house. The resident was
attending day placement five days a week upon first
moving into the house, but was then transferred to
another placement with block funding to attend four
days per week, and no funding allocated for the fifth
day. Community Visitors were told that, because
of the resident’s behaviour, the day placement was
cut down to three days per week. The resident now
has two days per week without funding for any
activity. The resident is young and highly capable
with significant behavioural issues, which are
exacerbated by not being sufficiently engaged.
good practice
One DAS house is home to residents with
complex behaviours of concern that would
significantly affect co-residents if not properly
managed. Community Visitors observed a
very creative and positive environment that
responds to these behaviours in a way that
ensures residents are impacted minimally,
retain as much control as possible, and are
supported to access the community often for
activities of their choice. Although this could
be a confronting house, it is actually a pleasure
to visit, as the staff are energetic, resident
focussed and very knowledgeable about and
committed to client outcomes.
90
Due to insufficient government vehicles being
allocated to the PRS site, the ability for residents to
access the community on a one-to-one basis or in
small groups is very restricted. Community Visitors
have reported difficulties with accessing vehicles
in six different houses. Management has created a
roster for sharing the limited vehicle fleet amongst
the houses. To assist, staff accompany residents
to medical appointments in taxis. This is reported
to be advantageous and cab charges provided by
DHHS are used.
Community Visitors have seen up to 11 buses
parked on-site on weekends. This is probably
due to the 12-13 hour shifts that PRS staff work,
resulting in only one staff being in each house for
two hours over staff lunch breaks. This leaves
inadequate staff support to accompany residents
into the community in the middle of the day.
At a DAS house, Community Visitors observed
bruising on a resident’s right eye. Documentation
revealed that the client, who has Alzheimer’s
disease, had had more than 50 falls during the
previous two months. An occupational therapist
subsequently assessed the resident, and a
wheelchair was ordered as a result.
Community Visitors could not see anything
advising visitors and casual staff of infection control
procedures applicable to a DAS resident with an
antibiotic resistant infection. In another DAS house,
no medication reviews appear to have taken place
since 2010.
At CSO houses, Community Visitors often
report a lack of medication reviews or errors
in administration. Concerns around aids and
equipment were also raised, including the need for
upgraded hoists in rooms, repairs to wheelchairs,
and the need for extra aids in some houses due to
the increasing support needs of ageing residents.
case
study
One PRS resident was moved to an aged care
facility following a broken hip. The resident had
been institutionalised most of their life and had
no family contact. The aged care facility did not
want the resident’s possessions (including his
clothes) being transferred with them. House staff
told Community Visitors they were not allowed
to visit the resident, stating that this was the
Disability Services
aged care facility’s decision. Considering that
this resident had no-one in their life, Community
Visitors were concerned that staff familiar with
the resident were unable to have contact and
ensure the resident’s wellbeing.
Community Visitors reported at a liaison meeting
in March 2015 that staff in the house had later
told them the resident was not their concern;
their responsibility was with the residents now
living at the house where they worked. It was
also stated to Community Visitors that none of
the residents had a friendship with the resident,
and that they did not want to visit him, which
may be correct as the resident had previously
assaulted other residents.
One resident at PRS complained of back pain. The
service provider responded saying that the resident
had been medically assessed and it was believed
the pain was behavioural. At a liaison meeting,
Community Visitors queried whether the resident’s
diagnosed scoliosis was causing the pain, and the
operations manager agreed to follow this up.
Community Visitors noted the weight gain of
another PRS resident. They were informed that this
is a result of many casual staff not referring to the
‘specific health management plan’ written by the
resident’s doctor. This plan addressed the resident’s
high cholesterol levels, amongst other things.
In responding, DHHS stated the regular staffing
compliment has enhanced awareness of this plan
and the strategies that need to be implemented. The
plan will be copied and placed on the refrigerator
as a prompt for staff, according to DHHS. The last
referral made to a dietician will be reviewed.
Rights
Since 2009, Community Visitors have reported that
the office space at one DAS house encroaches
upon the residents’ lounge area. The office space
has expanded over time, rather than being reduced
as promised, despite the availability of storage
space in the sleepover room.
case
study
When Community Visitors first visited a DAS
house more than 18 months ago, every door
in the house was locked, including bedrooms,
bathrooms, toilets, kitchen and even the fridge
Disability Services
door. Residents had to ask staff for access to
food, drink, toilets and their own bedrooms.
One resident effectively had control of half of
the house and spent most of their time at home
naked. All client documentation was out-ofdate and this highly restrictive intervention of
locked doors was not authorised by the Office
of Professional Practice. In addition, DHHS
management did not appear to know that such
restrictive practices were used in the house.
The situation at this house has completely turned
around, with every part of the house now open
and accessible to all residents at all times. The
resident who controlled half the house now freely
moves around the whole house, as do the other
residents. Also new strategies mostly ensure this
resident wears clothes in common areas. This is
a fantastic outcome as residents now enjoy full
use of their own home and they appear to be
happier and more engaged with each other and
staff. It is a credit to both the house supervisor
and operations manager, who have put so much
work, time and skill into developing positive
behaviour strategies and plans that focus on the
skills and opportunities of the residents, rather
than on challenging behaviours.
At one DAS house, bedrooms are locked because
one resident is constantly on the move and likely to
resist being prevented from entering other people’s
bedrooms. Community Visitors have been advised
that the bedrooms are opened when people arrive
home, however they have observed them to be
locked on several occasions.
case
study
A resident at a DAS house has expressed
interest in going overseas to see the set of
a favourite television series. The resident’s
family member, who is also their administrator,
disagrees and is reluctant to spend the amount
of money required; which has distressed the
resident. Staff reported that this issue had been
unresolved for approximately five years. The
administrator reportedly rejected the proposal
despite there being sufficient funds. The house
supervisor wrote to the administrator, but at last
report, the issue had not yet been resolved.
One resident who moved from a HCA house to
another house appears to have never been repaid
their equity share of the property, despite other
91
residents receiving their share back in 1998. Staff
followed up this issue with State Trustees, while
HCA conducted an audit in relation to the matter.
Incident reports
An increasing number of CSOs are not keeping
paper copies of incident reports in houses. CSOs
may also have reporting systems where information
is held centrally at the organisation’s main office. It
is imperative that Community Visitors are able to
access reports, including incident reports, however,
this does not always occur, particularly when
casual staff are working. Visits can sometimes
become frustrating and counter-productive in
these circumstances.
Plenty Residential Services (PRS)
The PRS precinct has a site area of 10.39 hectares
and comprises 29 purpose-built group homes.
DHHS North Division acknowledges the culture and
ethos of service delivery, in a large-scale cluster
model of on-site homes, has some practices more
akin to institutional settings.
In June 2015, Community Visitors were informed
that DHHS North Division would undertake an
independent service review of PRS to identify issues
and risks related to safety and wellbeing outcomes
for people with disability living there, and to provide
improvement strategies to ensure the safety and
prevention of abuse and neglect. The review will
be undertaken by a specialist consultant with
experience in disability services, and be overseen
by a steering committee comprising representatives
from DHHS’ central Service Design and Operations
Division, North Division and the Office of
Professional Practice. The review will be overseen
and managed by the Client Outcomes and Service
Improvement branch of the North Division.
The review will focus on:
• the resident experience
• resident safety
Disability Forensic Assessment and Treatment
Service (DFATS)
DFATS is a statewide disability forensic service
delivering time-limited treatment and support in a
secure residential facility for people with intellectual
disability who have displayed high-risk anti-social
behaviour and are subject to an order under s152 of
the Disability Act. Many of these people have dual
disability. There are currently eight residents living at
DFATS and one resident residing at a PRS house.
Some very serious incidents at DFATS have caused
residents, staff and Community Visitors concern.
These involved high levels of interpersonal conflict
between residents as well as extensive property
damage and abuse towards staff. Police have
attended on several occasions and units were put
in ‘lockdown’ with restrictions on resident leave and
community access, following security breaches in
January. Seclusion appears to have been frequently
used in behaviour management.
More positively, all residents have the opportunity
to participate in an on-site program being run
on weekdays by Parkville College. The program
includes sports, gardening and a range of activities
to develop literacy and numeracy skills. Most
residents choose to participate in these classes
or other aspects of the treatment program, which
aims to teach residents independent living and
interpersonal skills as well as reduce their likelihood
of re-offending when they leave DFATS.
A large amount of maintenance work has been
undertaken at DFATS during the year, including
electrical work, repainting, repairs to windows,
kitchens, bathrooms, air-conditioning, tiles,
verandahs, and carpets.
A smoking ban at DFATS was introduced in
November 2014. Overall the introduction of the
policy went relatively smoothly.
Loddon Mallee
Abuse and neglect
• service quality.
The review will provide a report outlining the
findings and providing recommendations to
improve the experience and safety of PRS residents
as well as enhance service quality. It is anticipated
the review will be concluded in September 2015.
92
OPA’s Advice Service received a call from a
resident’s mother who stated her son had been
assaulted by other residents on multiple occasions.
Community Visitors visited and reported that there
was systematic bullying by two residents. The victim
Disability Services
was offered alternative accommodation but there
did not seem to be suitable alternative placements
for the other residents. The Community Visitor
Coordinator wrote to the DAS manager to ask what
actions were being taken to ensure the safety of
residents. A written response was received detailing
a number of strategies that were being undertaken.
Community Visitors reported in March that one of
the alleged offenders had been relocated, and the
other would be relocated within 4-8 weeks.
Safety
At a CSO house, Community Visitors were told
that a resident frequently woke at night to make
an evening snack, but would often lean on the gas
stove and accidentally turn the gas on. The service
took immediate action and remedied the problem
with a safety barrier to prevent this occurring. The
resident is able to continue accessing the kitchen at
night without posing a risk to residents or staff.
Staff support
case
study
Community Visitors learnt of a new resident
who was hastily transitioned from a CSO
house to a DAS house. The CSO house, where
the resident had lived for some years, faced
financial difficulties and the resident was evicted
with just six days notice. DHHS implemented
emergency contingency arrangements for the
resident, locating alternative accommodation
and appointing additional staff to assist with
the transition.
Community Visitors were concerned and
disappointed to learn that the CSO withheld
critical medication belonging to the resident,
so the resident was forced to move without it.
Community Visitors commend DHHS staff for
their swift action in supporting the resident with
arranging medical appointments to organise
replacement medication. Community Visitors
also commend DHHS management and staff
for undertaking a review of all life areas with
the resident to identify new goals, plans and
associated support needs.
Community Visitors have reported on the poor
condition of a CSO kitchen for at least 12 months.
The service had secured funding from DHHS to
upgrade the kitchen, however, the planning and
approval process has been delayed for a number
of reasons including the need to have fire sprinkler
system approvals. Several other maintenance and
furnishing issues were identified in houses managed
by the same CSO – some of which had been
outstanding for long periods of time. Community
Visitors understand that funding has been allocated
for maintenance, repairs, painting and furniture so
that these issues can be resolved.
Disability Services
Staff retention appears to be an increasing
challenge for service providers. Community Visitors
raised this issue when meeting with agencies and
DHHS to ascertain if this was a regional issue, or
something experienced by the disability sector
more broadly. The consensus was that it could
be difficult recruiting people to support worker
roles, and that there were considerable resources
invested in recruitment and training for new staff.
On one visit, Community Visitors discovered that
a staff member was working alone because a
second staff member had failed to show up for their
shift. The staff member, assisting two residents
with significant needs, was expected to work the
afternoon shift and sleepover shift alone.
Social inclusion
good practice
iPads are now being used by all residents at a
DAS house. Community Visitors observed how
residents use iPads to tell their individual stories.
These stories reference individual support plans.
One resident uses their iPad to communicate
with family members. This resident can also use
the iPad to go shopping in the township, and the
local shopkeepers are now finding it easier to
communicate and actively participate in helping
the resident make choices. This has helped
reduce feelings of frustration for the resident
around communication, accompanied by a
reduction in incidents and behaviours of concern.
At a CSO house, concerns were raised regarding
the implementation of a new ‘open pantry’ policy;
Community Visitors felt that it did not support
93
residents adequately to ensure that the focus
was on healthy choices at appropriate times.
Community Visitors were also concerned that
staff could not provide active support in other life
areas whilst the focus remained consistently on
eating food from the pantry. The agency decided
to continue with the new policy as a trial, with the
hope that the residents’ focus will slowly move
away from the pantry.
Incident reports
Access to incident reports is an ongoing concern
for Community Visitors. Incident reports are often
not available, or cannot be located by staff. These
issues are raised at quarterly meetings with CSOs
and DHHS with some success. One CSO has
initiated a process whereby incident reports and a
summary sheet are provided at the start of each
month to ensure Community Visitors are able to
access each incident report.
South Division
The South Division includes the DHS areas of
Bayside Peninsula, Southern Melbourne, Inner
Gippsland and Outer Gippsland. This year, 74
Community Visitors conducted 769 visits to 273
houses in this division.
There was one notification to the Public
Advocate regarding a resident at serious and
imminent risk of harm, the details of which are
included in the Statewide report.
Bayside Peninsula
Abuse and neglect
Abuse by residents
Community Visitors have reported a number of
incidents where residents have been abused by
other residents in their group home.
At one CSO house, a resident has been repeatedly
and increasingly physically assaulting and intimidating
other residents, as reflected in incident reports. Staff
advised the CSO management the alleged offender
needs to move to a more suitable house without frail
residents; however, the alleged offender has already
been waiting on the Disability Support Register (DSR)
for two years for new accommodation.
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At another CSO house, a strong resident was
repeatedly abusing a frail resident, despite the
efforts of house staff and specialist staff. The frail
resident’s family asked the CSO to remove the
resident from the home and began legal action to
this end. The CSO then moved the alleged offender
to a new home where Community Visitors report
they appear to be settling in well.
In two different CSO houses, Community Visitors
have been reporting for the past two years about
resident conflict and behaviours of concern that are
detrimentally affecting other residents.
At one of the CSO houses, a resident refused
to come back to the group home after visiting
family because of an ongoing conflict with another
resident. Community Visitors had reported for two
years on the emotionally abusive behaviour of the
other resident, and the potential for escalation to
physical abuse, but efforts to find a more suitable
group home had been unsuccessful. The resident
who refused to return to the group home later
suffered a fall, and after attending hospital and
completing rehabilitation, chose to live in aged care
rather than return to the group home.
In the second CSO house, part of a complex of
units, Community Visitors noted 49 incident reports
relating to one resident’s intimidating and disruptive
behaviour, which has affected several residents. The
resident has been offered other accommodation but
has refused to move. Community Visitors are advised
that the situation does not meet the conditions
required for the resident to be relocated. Community
Visitors are concerned about the wellbeing of other
residents who live with ongoing anxiety while a
satisfactory solution is being developed.
Community Visitors have reported a number of
incidents of resident-to-resident abuse that have
occurred following the placement of a young
person with behaviours of concern in a group home
with ageing and often frail residents. The behaviour
support needs of the new resident are often greatly
different to existing residents, and their behaviour
can cause other residents stress, unhappiness, fear
and, in some cases, compromise their safety.
case
study
inappropriate placement
Community Visitors visited a CSO house where
a young resident with complex medical and
behaviour support needs had been placed with
older, frail residents.
Disability Services
The new resident displayed behaviours of
concern including hitting residents, pulling the
hair of one resident, and telling others to ‘shut
up’. Staff were unsure how to manage the
new resident’s behaviour, and had difficulty in
managing the resident’s health care needs.
Responses to abuse
Other residents began to spend more time in
their rooms to escape the new resident, and
one resident suffered a suspected heart attack,
which was reportedly attributed to stress.
Community Visitors were asked to visit a CSO
house after a service manager contacted OPA’s
Advice Service to ask what procedures they should
follow as a resident had said they had been sexually
abused by another resident. While Community
Visitors were encouraged that the service manager
contacted OPA for advice, it was concerning that
the CSO did not have clear procedures in place for
staff to follow. Following investigation by police, the
resident withdrew the allegation.
Community Visitors noted many incident reports
relating to the new resident’s behaviour, and
questioned whether the house was appropriate
for them. Staff stated they wanted to give the
resident time to settle in, as it was their first time
away from home, and support strategies needed
to be tried.
One month later, the resident’s behaviour was
still an issue, but had significantly improved.
Staff applied good practice, guided by a capable
house supervisor, the other residents had
advocates, behavioural specialists were advising,
and the CSO received funding for more staff.
However, staff and Community Visitors agreed
that alternative accommodation may still be
needed for the new resident.
Ten months after the issue was first reported, the
new resident’s behaviour had improved to the
point where staff and residents had agreed they
should stay. Staff and an independent advocate
had worked with residents to resolve any issues,
behaviour support strategies were in place,
and the Royal District Nursing Service were
managing the resident’s medical care.
Community Visitors have reported a number
of concerns about the way service providers
respond to allegations or investigations of abuse
against residents.
In investigations into alleged abuse of residents,
if the victim has communication difficulties,
Community Visitors believe it is essential that
they have an independent assessment of their
communication needs. Communication support
should be provided so that residents with
communication difficulties can take part in any
investigation and report their concerns. Community
Visitors reported one instance where a resident with
limited speech had returned from a day placement
with unexplained bruising on both arms. A DHHS
internal quality of support review was undertaken,
in which the resident was deemed unable to
communicate, so no cause was established for the
bruising and the police were not contacted.
Community Visitors feel that staff demonstrated
good practice in addressing the situation, but
question whether this was a suitable placement
or whether sufficient information was provided
about the resident’s medical and behaviour
support needs at the time of placement.
Community Visitors are concerned about the care
provided to residents at day placement or travelling
to it. Community Visitors have reported instances
where residents have been assaulted by others at
their day placement, received bruises, or arrived
home soiled. In one incident, a resident fell at
their day placement and broke a bone, but was
sent home in a taxi rather than sent to hospital
straight away. Community Visitors have observed
incident records and communication between day
placements and group homes to be minimal.
Ageing
A staff member at a DAS house was stood
down while an allegation of abuse against two
residents was investigated. Other staff were
interviewed as witnesses, and the residents’
families were notified. Police were also notified
about the incident and the staff member’s
employment was subsequently terminated.
Community Visitors have identified a number of
issues in both DAS and CSO houses relating to
supporting ageing residents, including:
Disability Services
• a lack of clear policies to address the needs of ageing residents
• the need for greater staff support and funding so residents can age in place
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• the need to review day placement participation for ageing residents who may no longer have the energy or desire to attend
• appropriate staff support and activities for residents no longer attending day programs
• lack of staff training in supporting residents
with dementia
• the need for policies to support residents with end-of-life decision making.
Community Visitors have received a limited response
from service providers and DHHS about ageingin-place policies. Community Visitors note there
appears to be a reactive approach to addressing
the needs of ageing residents with disability living in
group homes. Staff need to be up skilled or re-skilled,
policies and procedures developed, and adaptations
made to many of the houses to meet these needs.
The following Good Practice case study illustrates
how advocacy, negotiation and the willingness of a
service provider to support a resident, can enable
ageing-in place.
good practice
ageing in place
A resident of a DAS group home was preparing
to return from hospital after a fall. The resident
was assessed as a candidate for aged care,
despite not being observed at home. The DAS
manager was concerned about the resident
falling in the future, but proposed moving the
resident to a group home, with active night staff,
instead of to an aged care facility.
The resident’s sister raised concerns that moving
the resident from their home of 20 years would
be detrimental, as the resident had routines
and regular outings, was well-liked by staff,
and was very happy there. The resident’s sister
was concerned it was not in the resident’s best
interests, and that active night staff may not
prevent future falls.
When the resident returned home from hospital,
staff proactively assisted them to regain walking
skills, and sleepover staff voluntarily monitored
their movements at night until active night staff
were put in place. The resident’s sister, GP and
occupational therapist suggested changes at the
house to support the resident, who responded
well to rehabilitation.
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As the resident’s walking improved, active night
staff were no longer needed and the prospect
of the resident moving to aged care or another
group home diminished. The resident was able
to remain happily in their home with the support
of dedicated staff and a good support team.
A resident with dementia was transferred from a DAS
group home to an aged care facility. Community
Visitors only became aware of this move when one
volunteer Community Visitor met the resident in the
aged care facility in which they worked.
The Community Visitor informed the Community
Visitor Coordinator that the move to aged care
had been traumatic for the former group home
resident, as their dementia affected their ability to
understand why they had moved. The Community
Visitor observed the former resident was ‘lonely’
in aged care, as they had previously lived with five
others and a settled staff group. However, in aged
care, the former resident lived in new and confusing
surrounds with more than 30 other people and only
three staff on duty.
Respite
One respite service in this area specifically supports
children with autism and their families. The respite
service currently supports 40 families and has
a waiting list of 111 families. There are eleven
specialist schools which use the respite service,
and families travel long distances to access
the expertise of this service. This service offers
overnight, weekend and school holiday stays, as
well as catering for emergency respite.
The respite service staff and management have told
Community Visitors that it is a constant juggling
act to meet respite needs of families. Targeted and
specialised respite services of this kind are vital for
families, and more services are urgently needed as
the waiting list continues to grow. DHHS response
to Community Visitors’ concerns about the unmet
need for respite was that the service had been
contacted and asked to limit the amount of respite
offered to families currently supported, so that
families on the waiting list could be accommodated.
The respite service responded that families were
only receiving the minimum respite entitlement so
there was no leeway to reduce this further.
In November, a CSO opened a purpose-built
respite house in the region supporting people with
disability. Community Visitors report the respite
house is of an exceptional quality and already has a
Disability Services
reputation for assisting families that have previously
found it difficult to access respite services.
Community Visitors report transitioning residents
from respite to group homes is often not well
planned. One resident with behaviours of concern
was placed at a CSO group home after a year in
respite, with no transition period, no behaviour
support plan, and little supporting information.
The resident’s arrival and behaviours seriously
disrupted a previously orderly and tranquil home.
DHHS funded four months of one-on-one support
on a reducing basis, to enable staff to support the
new resident while maintaining care for the longstanding residents.
Many group homes are old and in need of
maintenance, repairs or rebuilding, but this work
can take considerable time to schedule and be
completed, if it occurs at all.
Maintenance is reactive and dependent on funding;
minor maintenance is usually done but larger work
is rarely funded.
Issues reported include mould in residents’
bedrooms, water under flooring in bathrooms,
water damaged ceilings, lifting vinyl flooring,
unclean bathrooms, rooms in need of painting and
old furniture in need of replacement. Community
Visitors have reported some CSO houses have
been more responsive to issues regarding the need
for new carpets and fittings.
There are numerous maintenance issues at older
DAS houses; built following deinstitutionalisation
which are now no longer adequate to meet the
needs of residents. These include uneven flooring,
leaking roofs, mould and long-term water leaks
in bathrooms, worn carpets, urine and blood
stained carpets, broken fences and gates, and
a house infested with spiders and cockroaches.
By comparison, some CSO houses are new and
purpose built.
Staff members at a CSO children’s respite house
held four sausage sizzles to raise money to pay for
paint for the interior of the house and to purchase
a special swing, canopy bed and sensory objects
and toys for the children. A group of volunteers and
staff members painted the interior of the house and
improved the backyard playground.
maintenance issues to be addressed. Community
Visitors believe this house may need to be rebuilt or
replaced in order to meet the needs of residents.
A number of houses requiring renovations do not
appear to have funding for work to be completed.
Residents at one CSO house were told for many
months that they were moving temporarily and their
belongings were packed in readiness for the move
and renovation. Residents told Community Visitors
the situation was “like living a nightmare” and were
concerned about where the house dog would
live. Eventually everything was unpacked and no
renovations were completed.
Renovations are also needed at four DAS houses
and one CSO house with only one bathroom
in each house for up to six residents. This is
particularly a concern in houses where residents
are incontinent or ageing. Community Visitors
believe that these situations have arisen, as houses
are not being updated to meet the changing needs
of residents. Each of these houses has a second
bathroom that is solely for staff use.
Safety
Community Visitors raised concerns about the safety
of a frail resident at a CSO house, who often fell in
the bathroom after falling asleep on the toilet at night.
Community Visitors asked that an occupational
therapist assess what could be done to prevent
the falls, but 10 months later Community Visitors
reported no assessment had been done. After
raising the issue again, Community Visitors received
a response stating there were already 5-6 residents
awaiting an occupational therapist’s assessment
ahead of this frail resident, and it would take another
1-2 months for the assessment to be scheduled.
Community Visitors believe that a 12 month wait for
the situation to be assessed is unsatisfactory.
In a number of DAS and CSO houses, Community
Visitors recorded issues with fire safety and
emergency procedures, including evacuation packs
in need of updating and staff unable to access
evacuation drill records kept on computers. At
one house, fire safety checklists were in a locked
cabinet, to which only the absent site manager had
access. Community Visitors were told the cabinet
contained sensitive information and to “visit at a
time the supervisor was present”.
For the past 10 years, one DAS house has needed
painting. This house also requires numerous other
Community Visitors raised concerns that one CSO
has a policy not to include residents’ names and
room locations on evacuation plans, as they say
doing so can cause confusion in the event of an
Disability Services
97
emergency if names are not updated or removed
when required. Consequently, Community Visitors
are concerned that emergency responders would
be severely hampered.
Staff support
Community Visitors in this region report that the
quality of staff support for residents is relatively good
and that staff are committed to supporting residents.
However, Community Visitors have identified issues
including:
• a need for staff training in aged care and palliative care
• staff employed without a certificate 3 or 4
level training
• unclear policy around how regularly staff should have a police check
•
a need for clear sexuality and relationship policies in group homes, and sex and relationship education programs for both
vulnerable residents and residents displaying inappropriate sexual behaviour
• difficulty securing funding for active night staff when only one resident needs support for increasing health needs
• insufficient permanent staff, and the high use of casual staff, which negatively affects residents.
Community Visitors regularly see that the attitude
and experience of the house supervisor significantly
influences the culture and atmosphere of a group
home. Casual, inadequately trained or unsupported
staff may go about their work reactively, instead of
engaging proactively and inclusively with residents.
At a CSO house, staff requested shutters above a
kitchen bench to stop one resident from climbing
over it. However, an experienced interim house
supervisor thought it more appropriate to introduce
behavioural strategies, rather than restrict kitchen
access for all residents.
Community Visitors reported concerns about staff
at one CSO house who were not working as a team
to follow behavioural strategies to support residents.
Two residents were displaying increasing behaviours
of concern toward each other, one of whom
assaulted the other and staff. The resident who was
assaulted told Community Visitors in a distressed
state that living in the house “was like walking on
eggshells”. Community Visitors reported concerns
about staff support and the impact on residents.
Staff changes are now taking place at this house.
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Community Visitors report an ongoing concern at
one CSO house where a staff member, for religious
and cultural reasons, refuses to feed residents
meals containing meat, garlic or onion. As a result,
these residents must wait to be fed by one staff
member. Community Visitors consider this practice
incongruent with the provision of a residentfocussed service.
Community Visitors commended staff at one
respite facility where positive behaviour support
was provided to a long-term respite user with
behaviours of concern. The respite user was
highly anxious and disruptive, assaulting staff
and displaying complex hygiene behaviours. Staff
showed patience and perseverance in addressing
the behaviour, which subsequently improved
and resulted in a calmer and more harmonious
environment for all respite users.
At one DAS house, a staff member resigned
during a serious misconduct investigation for not
completing and maintaining paperwork, which
placed residents at risk.
Individual planning
Community Visitors report that person-centred
planning is lacking in some houses, where there is
no documentation of resident goals or updates on
the progress of residents achieving these goals.
Many Person Centred Plans (PCPs) are out of
date. Some give lip service to the concept through
a vague or general goal to be reached over a
long period, for example, ‘to go on a holiday by
December 2015’, or ‘to manage fluid intake’.
Community Visitors are of the opinion that specific
goals are needed in PCPs.
Without regular review, PCPs become stagnant,
instead of becoming ‘living plans’. For example,
one resident‘s goal was to join a choir, but after
one attempt by a staff member to arrange this,
no further progress was made.
The better plans detail the incremental goals
and support needed for a resident to achieve a
personal aspiration or independent living skill. At
one house, a resident was supported to take small
steps toward making their own cup of coffee, and
upon succeeding in this skill, now makes coffee
for fellow residents.
Residents at one house decided they would like to
stay up later at night, and asked whether staff hours
could be extended to facilitate this. Sleepover staff
Disability Services
subsequently came on duty later at the house. The
result of this routine change was that some residents
now wake later, which allows staff to spend more
time with those residents who are early risers.
Community Visitors raised concerns about a lack
of planned holidays for residents and activities
for residents while on break from day placement.
Residents who do not attend day placement should
be able to use their funding for holidays or activities.
Examples of this include a resident who could not
afford to visit their family for Christmas, reports of no
holidays planned for any residents in a house, and
one resident having their holiday cancelled at the last
minute for a reason unrelated to their support needs.
One resident at a CSO house told Community
Visitors about an interest in taking up swimming,
but house staff told Community Visitors the resident
was already going out four days a week and was
too busy to attend swimming. However, the house
supervisor spoke with the resident about which
activities they would like to attend, and the resident
agreed to think about taking up swimming after
finishing computer lessons.
Social inclusion
Community Visitors report the social inclusion of
residents at one house was impeded, due to the
lack of a house bus. Community Visitors report
that this has restricted the independence of the
residents and their ability to attend day placement,
shopping and regular outings.
Community Visitors report lack of funding is also
a barrier to social inclusion for some residents,
including:
• a resident of a CSO house who missed out on weekly sporting lessons because they did not have funding to cover the cost of a taxi
• a resident with declining health waiting for an Individual Support Package for activities that are
not dependent on the current staff availability.
Community Visitors have observed that general
health of residents has been consistently good,
and staff are completing all relevant documentation
as well as attending to the physical wellbeing
of the residents in their homes. Preventive and
acute health care needs of residents are generally
well met through annual medical reviews, dental
checks, dietary reviews, mobility aids and assistive
Disability Services
devices. Staff and fellow residents support and
visit hospitalised residents. Repairs of mobility aids
could be timelier.
As the population ages, it appears that there are
an increased number of resident deaths. However,
not all service providers notify Community Visitors
when a resident passes away, so this is difficult to
monitor effectively.
Community Visitors raised concerns about the diet
of three young residents living at a CSO house who
all have diabetes, obesity, mental health issues,
and reduced cognitive ability. Community Visitors
observed residents eating large amounts of junk
food, which they had purchased and brought
back to the house to eat before their main meal.
Community Visitors asked whether a dietician could
help assist residents choose healthy meals and
snacks. The CSO did employ a dietician to work with
residents at the house, however, at subsequent visits
poor food choices continued to be documented.
One of the residents with a poor diet refused for
many months to go to a day program and slept
for much of the day. Community Visitors asked
whether a medication review was needed, and this
was organised with a new doctor, but there was
little improvement in the resident’s motivation.
In many homes, weekly or fortnightly menus are
displayed, residents actively choose their meals and
participate in preparation where practicable. In other
homes the variety and standard of meal is limited by
the staff members’ lack of cooking experience.
availability of mental health support for a resident
of a CSO house. The resident made escalating
threats of self-harm and harm to others, and staff
contacted a hospital’s Crisis Assessment and
Treatment Team (CAT), as they had previously been
instructed to do by the resident’s psychologist.
However, staff were told there was no doctor
available to assess and treat the person. House
staff were informed by a CAT team nurse that they
could bring the resident into hospital, however, all
mental health services would be able to provide
was sedation and containment. Community Visitors
are concerned that disability service staff are not
equipped to support residents’ mental health if
emergency services are not available, particularly in
cases like this where the resident’s behaviour had
previously placed them at risk.
The family of a resident at a CSO house requested
Community Visitors visit to address concerns
about side effects from a change in the resident’s
99
medication. The resident had been taken to a
different GP who changed the resident’s medication
at the direction of house staff. Community Visitors
visited and spoke with the resident and one of their
family members, and asked house staff to ensure in
future that the resident’s wishes were followed, and
that the resident only see their regular GP. House
staff agreed to this, with the exception of a medical
emergency or unavailability of the resident’s GP.
A resident of a CSO house waited for more than four
months to have a replacement shower chair and
wheelchair made. The delay was caused in both
securing State-wide Equipment Program (SWEP)
funding for the items and in manufacturing them.
At one CSO house, Community Visitors sighted
many incident reports for missed medication
and medication errors. One resident had seven
medication errors over four months. The CSO
brought in a nurse educator to raise staff awareness
and medication errors declined. Subsequently,
residents were supported to self-manage their
medication, with all but one resident able to do so.
Rights
In all houses, Community Visitors have ensured
that residents, advocates and staff are aware
of the rights of people with disabilities. Contact
information about OPA and Community Visitors is
usually clearly on display and, if not, Community
Visitors have provided signs, pamphlets and
business cards. Twice this year, residents have
contacted the OPA Advice Service to request visits
by Community Visitors. This is positive, as it means
residents trust that their privacy will be respected
and their concerns acted on.
Community Visitors reported concerns that
residents’ rights and dignity were being breached at
one CSO house, where a new resident continued
to bang on other residents’ bedroom doors and the
toilet door. Extra funding was allocated for staff to
work on a one-to-one basis with the new resident
to address the behaviour. The resident no longer
attempts to enter the other residents’ rooms and
their behaviour is more settled.
A female resident, who lives with four male
residents at a CSO house, asked Community
Visitors if a vacant room at the house could be
offered to another female resident. Community
Visitors passed this request on to the CSO, who
asked DHHS, however, only three male residents
were offered as possible new housemates.
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Community Visitors report that residents’ right
to dignity and privacy are being breached in some
houses where institution-style bathrooms are still
in place. Bathrooms in some CSO houses now
have screens for privacy, however this is not the
case in one DAS house. This is an ongoing issue,
which has been reported in previous years by
Community Visitors.
At one CSO house, Community Visitors reported
they were unable to access residential statements,
asset registers and key worker reports. The response
from the CSO was that items in residents’ rooms
would be added to equipment lists for each resident
and that residential statements had been completed
and were awaiting signing by residents’ families.
rights of a resident who had been repeatedly
moved between group homes. The resident
appeared to be happy in a new home, but their
family wanted them to move to a house with
residents with similar abilities. Despite advocacy
by the staff, and the resident assuring Community
Visitors they were happy at the new house, the
resident was moved again.
Community Visitors noted that a staff request to
increase the height of a CSO house fence was an
unnecessary restrictive intervention. The request
was prompted by one resident throwing objects
over the fence into neighbouring properties.
Following discussions with Community Visitors,
the CSO agreed a higher fence would be restrictive
and a Behaviour Support Plan (BSP) for the
resident would be investigated.
Incident reports
Community Visitors continue to have problems
viewing incident reports, with issues reported
including:
• reports stored on computer systems that Community Visitors were unable to access
• reports taking a long time to download
• staff unable to access incident reports on
house computers
• incident reports stored at CSO head offices
• illegible reports, including one about a resident’s unexplained bruising.
In response, some houses are now ensuring that
incident reports are available in hard copy in the
office, either in a folder or in residents’ files. Other
Disability Services
houses have been asked to provide a summary of
incidents to Community Visitors.
Community Visitors report an ongoing issue with
one CSO where no records of incident reports are
held at the houses, but are sent to the CSO’s head
office. Staff told Community Visitors there had been
no incident reports uploaded to their online system
for the past seven months nor were non-critical
incident logs maintained. The CSO agreed their IT
system needed to be improved and had requested
that either a register of incident reports, or a hard
copy of incident reports, be available at houses for
Community Visitors to view.
Community Visitors also report that casual staff at
houses managed by this CSO could not access
records on the house computer. At one house,
Community Visitors were told that the staff member
submitting an incident report on the intranet was
the only person able to access it, which appears
to be incorrect information.
Community Visitors feel this method of record
keeping is not clear and transparent, and question
how all staff in the house can be aware of incidents
and actions to be taken to support residents when
the records are inaccessible.
When incident reports can be viewed, Community
Visitors report that the way staff categorise
incidents is variable, with some incidents being
downgraded inappropriately. At a CSO house, a
case of shingles was categorised as non-critical
‘because the resident didn’t need to go to hospital.
Non-critical logs, where available, may describe
incidents as ‘known behaviours’ when analysis
may indicate a pattern of unaddressed behaviours.
Southern Melbourne
Abuse and neglect
Community Visitors have long reported concerns
about resident incompatibility at one house
operated by a CSO, where one resident displays
behaviours of concern. The resident is waiting on
the DSR for alternative accommodation.
Community Visitors reported an instance of the
physical abuse of a resident by a staff member.
This matter is being investigated by DHHS’s Ethical
Standards Unit.
At one respite house, Community Visitors reported
that a respite user caused damage to the house by
breaking chairs and pulling pictures from the wall.
Disability Services
Police were called to intervene. Community Visitors
raised concerns that they could present a danger to
more vulnerable service users.
Ageing
Residents in a number of group homes require
additional support from staff as they age,
particularly those that have dementia or age-related
illnesses. Community Visitors believe staff should
receive aged care training so they can support
residents to age in place, a concept to which
DHHS is committed.
It is not always appropriate for residents to move
to an aged care facility, as aged care staff may not
understand the support a person with disability may
need. Training disability workers to support ageing
residents would enable them to remain in their own
homes as long as possible.
Community Visitors believe ageing residents
should also be supported to reduce the time they
spend at day placement, and be able to spend
more time at home.
maintenance issues at group homes including
water damage, exterior fencing repairs and
broken white goods.
Residents at one CSO house have been advocating
for an additional bathroom, as there is only one
toilet for five residents and the other toilet is
locked for staff use. Residents have reported to
Community Visitors that they are frustrated by the
situation, especially in the morning when they are
getting ready for work. The CSO is negotiating with
DHHS, the property owner, to address this.
Safety
Community Visitors reported a number of concerns
related to fire safety. At seven houses operated by
both DAS and CSOs, Community Visitors were
unable to access records of evacuation drills.
Community Visitors also report that on average, fire
safety checks are only completed twice monthly,
instead of each week as required. At one CSO,
Community Visitors report that a resident continues
to smoke in their room, which presents a fire safety
issue for all residents.
101
case
study
resident safety
Community Visitors have repeatedly raised
concerns about the safety, wellbeing and dignity
of residents in a DAS group home. All residents
have significant personal support needs, and all
but one resident are wheelchair users.
Built to accommodate the residents when they
were younger and used smaller wheelchairs,
the house is now no longer suitable. Visit
reports continue to raise serious issues such as
fire safety, personal safety, inadequacy of the
physical environment and inconsistent staffing
often due to unfilled vacancies. Other issues
raised include:
• the driveway and the backyard are too steep for wheelchairs
• the house not comfortably accommodating four residents using wheelchairs
• mobile hoists pose a safety risk for residents when bathing
Most concerning are the fire safety issues.
Community Visitor reports documented outdated
information in the fire evacuation pack though
this has recently been addressed. The house
has an automatic fire sprinkler system however,
Community Visitors remain concerned about the
evacuation of residents in the event of a fire. In
response to this issue the department wrote:
“In the event of a fire … if all clients are in their
wheelchair[s] the evacuation is very quick and
easily managed, however, if in the night, or if
clients in bed, this (sic) would be impossible to
get all residents out and have all clients and staff
safely evacuated. In the case of fire in the night
emergency services would be called immediately
and all doors closed to inhibit smoke and heat
distribution through the house.”
Community Visitors will continue to monitor the
safety of these residents.
Staff support
Community Visitors reported the need for a change
in night staffing at one house in order to support
residents with increasing health needs.
behaviours of concern. In situations where residents
have become abusive or threatening, staff withdraw
until the resident is calm and requests assistance.
At one CSO house, Community Visitors noted a
single staff member performing a number of tasks
for nine residents, some of whom have profound
disabilities. Consequently, Community Visitors
questioned whether an additional staff member
was required.
There was also an inadequate level of staffing at
one CSO house to support a new resident with
behaviours of concern. The CSO reported to
Community Visitors that there was not sufficient
information from DHHS at the time of accepting the
new resident into the house. The CSO has applied
for funding for active night staff and additional staffing
hours in the afternoon to support this resident.
At another CSO house, an application to the DSR
was made to move a resident whose behaviours
are affecting other residents. Community Visitors
report staff and DHHS have been working hard
to address this situation, and have provided extra
staffing to support all the residents.
Community Visitors report that several CSOs are
attempting to support residents with drug, alcohol
and sexual behaviour issues. Generally, staff are
not trained in how to help residents understand the
consequences and risks associated with drinking
alcohol or having sex. In addition, the situation in
relation to resident drug use is dire as there are
no policies, training or support to guide staff in
such situations. Residents may be at risk without
appropriate support, and their behaviour may also
adversely affect other residents in their house.
Community Visitors also questioned what training
was in place for staff to help them support residents
with dual disabilities, as these residents require
specialist care.
Community Visitors raised concerns about one
house where staff were unable to convince a
resident not to leave the property at night as per
their bail conditions.
Individual planning
At one house, Community Visitors reported that all
residents’ PCPs were overdue for review.
Community Visitors have reported positive and
stable staff support at one CSO where staff provide
a consistent approach to supporting residents with
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Disability Services
Social inclusion
Ageing
Community Visitors have raised concerns that a
number of residents in this area are not actively
engaged in the community, which appears to be
because staff are not proactive in supporting their
social inclusion.
Forward planning and extra funding is required
to support ageing residents so that they can stay
at home rather than go to day placements. One
CSO house has asked DHHS for funding to assist
a resident to stay at home on some days with
support, and other houses would no doubt be in a
similar situation with ageing residents.
There are also three houses in this area, which
do not have dedicated transport, which affects
residents’ ability to attend activities in the community.
Incident reports
For several years, Community Visitors have
reported concerns about being unable to access
incident reports at a number of houses in this area.
The Disability Act 2006 and DHHS policy both state
that Community Visitors are entitled to inspect any
document except medical records relating to any
resident which includes incident reports. It is vital
that Community Visitors have access to residents’
records in order to undertake their role effectively.
At two houses, Community Visitors reported that
they were unable to access incident reports as staff
could not locate the reports on the computer, and
there were no hard copies available.
Gippsland
Abuse and neglect
Community Visitors report that assaults have
occurred between residents, and that staff need
more training and strategies to help them support
residents with challenging behaviours. BSPs need to
be developed, monitored and reviewed regularly to
help ensure more positive outcomes for residents.
At one CSO house, a resident had been continually
assaulting another resident, however there was no
BSP in place to address the resident’s behaviour.
Despite the assaults, which continued over a number
of months, the CSO stated that there were no
issues of concern. Community Visitors were told this
resident experienced sleeping problems, which was
being closely monitored. Community Visitors hold
concerns about the staff training, record keeping and
planning strategies in place at this house.
Respite
Community Visitors report that respite users in
the area can be disadvantaged by not having
appropriate equipment available at respite facilities to
support their needs. At one respite facility, a special
chair was delivered to a house, however it was
not suitable for a respite user and an occupational
therapist was required to assess the situation.
The appropriateness of buildings and fittings
in group homes continues to be of concern,
as both houses and residents age. Funding for
renovations and maintenance is tight, and houses
that are inappropriate for residents’ needs affect
their daily routines as well as the support they
receive from staff.
The institutional feel of some houses continues to
be an issue. Community Visitors raised concerns
about the starkness of one CSO house. The CSO
state they understand the issue and are attempting
to improve the feel and homeliness of the house,
despite the difficulty of one resident’s behaviour. The
same CSO has another house, which has a threemetre high internal wire fence designed to prevent
a former resident from ‘absconding’. A gate in the
fence has been removed to allow access to a shed
that can be used for games or celebrations, however
the fence remains a stark reminder of the past.
Staff support
Generally, the quality of staff support throughout the
region is excellent, however, the support needs of
residents are affected by out of date records and
plans, and a lack of appropriate strategies in place
to assist with behaviours of concern.
At another CSO house, Community Visitors
reported an incident where a resident’s behaviour
became so severe the police were called to assist.
Staff have since addressed the resident’s behaviour
and are monitoring it closely.
There are a few houses where training is needed
in order to assist staff with strategies to support
residents with challenging behaviours.
Disability Services
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Individual planning
Incident reports
Updating, reviewing and creating support plans
continues to be problematic at some houses,
especially CSO houses. Staff failure to update plans
is of particular concern to Community Visitors, as
documentation of residents’ support needs must
remain current and relevant.
Community Visitors report that incident reports
are often not kept on residents’ files. At one CSO
house, there were no incident reports kept on
residents’ files, rather they were stored on the
house computer. This issue was rectified after it
was raised by Community Visitors.
In one CSO house, planning had been neglected
and was out of date. This was rectified after
Community Visitors raised the issue, however the
delay in this taking place could have affected the
quality of support given to residents.
West Division
The West Division includes Western Metropolitan
Melbourne, which is made up of the DHS areas
of Brimbank Melton and Western Melbourne, and
the regional Victorian areas of Barwon, Central
Highlands and Western District.
Community Visitors report the health care needs
of residents increase, as they get older. As
residents age, additional funding is required to
make the necessary modifications in bathrooms
and bedrooms to support residents to stay in their
homes for as long as possible.
This year, 55 Community Visitors conducted
742 visits to 259 houses in this division. There
were two notifications to the Public Advocate
regarding residents at serious and imminent
risk of harm. These notifications are detailed
throughout this divisional report.
There have been instances where disagreements
with service providers and residents’ families have
resulted in the appointment of guardians to help
negotiate positive outcomes for residents.
Melbourne
Community Visitors report that three residents in
separate houses are experiencing difficulties with
weight and eating issues, which are affecting their
health and wellbeing. Medical checks, assessment
and monitoring were all strategies adopted in these
cases. Most houses provide healthy food choices
and physical exercises where appropriate. Day
programs also provide these strategies to assist
residents maintain a healthy lifestyle.
Rights
Community Visitors report that residents’ rights
to make their own choices and decisions may
be compromised because of communication
difficulties between staff and residents. At one
house, a resident expressed concern about their
lack of choices and decisions with regard to
food and spending on outings, and indicated an
interest in assistance from an advocate. The matter
was resolved through negotiation and positive
communication.
Residents’ assets are sometimes not recorded
in asset registers. It is very important that this be
done, so a resident can take their belongings with
them if they move.
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Abuse and neglect
Community Visitors continue to report incidents of
abuse in houses that have affected the welfare of
residents and staff. In one CSO house, Community
Visitors viewed multiple incident reports relating to
a particular resident whose behaviours included
destruction of property and throwing of objects at
staff, causing great deal of distress and disruption
to other residents. When the resident displayed
heightened behaviours and needed to be isolated in
one part of the house, other residents were not able
to access their bedrooms or communal spaces.
One resident was so unhappy with the situation they
decided to live alternate weeks with their parents.
In another CSO house, a resident was kicked
by another resident who had recently moved
in. Community Visitors were informed by other
residents that they were intimidated by the new
resident. The service provider responded to
concerns raised, undertaking to work proactively
with all residents around anger management, social
interaction and conflict resolution. Community
Visitors subsequently observed a significant decline
in incidents of aggression; the new resident began
to settle into the house and develop positive
relationships with staff and other residents.
Disability Services
Ageing
Most houses appear to have adequate training and
resources in place to support older residents.
case
study
A resident of a CSO house retired from
supported employment and wished to participate
in a day program. Community Visitors were
concerned that, twelve months later, there
appeared to have been no progress regarding
this matter. Staff supported the resident at home
Monday to Friday, but had not linked the resident
into a formal day program. A staff member at the
house told Community Visitors that an application
to the DSR was submitted and they were waiting
for DHHS approval for the funding. Further
investigation revealed this was not the case; the
house coordinator had requested the application
forms from the DHHS Intake and Response
Team on two occasions (in March 2014 and April
2015), however these had not been submitted.
Community Visitors referred the matter to
the DHHS Agency Connections Team, who
contacted management at the CSO and queried
why there had been no action on this issue. They
also requested that an application to the DSR be
submitted immediately.
In DAS houses, maintenance problems are referred
via a number of different pathways for resolution,
depending on the issue. Sometimes repairs are
completed promptly, however on other occasions
there can be delays. Community Visitors were
disappointed at the length of time it took for a
handrail to be installed at the entry to a house, which
was to assist a resident considered a falls risk.
Community Visitors visiting CSO houses noted that
maintenance issues were not always addressed
in a timely manner. At a DAS house, a bedroom
shutter overlooking a laneway was not repaired
for more than a year. The service provider
commissioned reports recommending different
levels of work to repair it; however, no action has
been forthcoming. At another DAS house, repairs
were partially completed including plastering that
was not repainted. Recently, Community Visitors
were informed that repainting of the house would
begin soon.
Disability Services
In one case, ongoing tension between the Office
of Housing and a CSO regarding responsibility
for maintenance issues, including repair of a
boundary fence was apparent. Community Visitors
were concerned that the safety of residents was
compromised, as a fence on the property required
replacing where a neighbour’s dog would jump up
and act in a threatening manner.
Cleanliness continues to be a significant issue in
one CSO house; Community Visitors identified a
range of concerns, including dirty floors, stained
bed linen, and mould in the shower recess.
Community Visitors have raised these issues with
the service provider over repeated visits.
Community Visitors visited a house where the only
toilet, located in the bathroom, was left unrepaired
for seven days. The toilet could not be flushed
during this time and Community Visitors noted a
lingering unpleasant smell and were concerned
about hygiene. Another house was noticeably cold
when Community Visitors visited in September,
due to faulty heating. Residents of the house had
been ill, which added to their concerns. Staff told
Community Visitors that the broken heating was
reported and residents were given extra blankets
while awaiting the repair of the system.
Safety
Over the past year, Community Visitors in this region
prioritised the inspection of evacuation packs and
first aid kits. In a number of cases, they found that
items in these packs and kits were out-of-date.
Staff support
The quality of report writing and the maintenance of
up-to-date documentation is a problem in a number
of houses. Community Visitors noted this was
particularly evident in houses reliant on agency and
casual staff where resident profiles and key worker
reports were not completed comprehensively or in
a timely manner. Community Visitors believe staff
need further skills development in this area, and
practice leaders may need to allocate more time
to administration to bring all paperwork up to an
acceptable standard.
Staff shortages remain an issue. Community
Visitors felt one resident was receiving insufficient
one-to-one support, due to high staff turnover and
a reliance on agency and casual staff. Community
Visitors are aware that service providers may
struggle to fill staff vacancies.
105
Individual planning
Community Visitors noted some Person-Centred
Plans (PCPs) were not current and were concerned
about the process used to review them. One house
had reviewed PCPs with the residents, their families
and day programs, but these had not been filed
for five months. At another house, two plans were
completed, but still had not been filed two months
later. Casual staff are sometimes unaware where
such plans are kept. Community Visitors have
queried the extent to which staff refer to residents’
plans to inform their work with residents. At DAS
houses, a new standardised folder system has
been introduced that will make such important
information more readily available.
At one DAS house, Community Visitors highlighted
a need to engage residents more meaningfully
when developing PCPs, with a greater focus
on setting short and long-term goals, as well
as documenting them effectively and recording
outcomes more thoroughly. DHHS acknowledged
this, indicating that staff were reviewing PCPs to
ensure that goals were realistic and achievable.
At a number of houses, concerns were raised
about key worker reports – these were not up-todate or not easily accessible. In some cases, it was
not clear whether key worker reports were being
utilised at all. One CSO does not have a key worker
model in place, although Community Visitors have
been informed that planning and reporting systems
are currently being reviewed.
Social inclusion
Community Visitors want to ensure that every
opportunity is taken to maximise residents’
communication abilities so they regularly enquire
whether communication assessments have been
completed. Staff attention to this issue is variable.
At one house, Community Visitors were told a
request for a communication assessment would
be completed in four weeks; on the following visit
several months later, they found that this had still
not been done.
good practice
Lack of identification documents for residents
can mean that they cannot easily arrange internet
connections. One staff member at a DAS house
put significant time and effort into accessing
residents’ birth certificates (not a simple task,
due to the complex histories and institutional
backgrounds of some residents), so they could
obtain Key Passes, which serve as acceptable
identification for internet services. Residents now
have iPads and are learning to use them at a
local community house.
Errors in the administration of medications continue
to occur. Community Visitors have argued that the
use of colour photos of residents on Webster packs
may assist with this issue.
Pressure sores are a serious and painful problem
for some residents who have limited movement.
In one case, Community Visitors queried
whether a resident’s pressure sores had been
appropriately responded to – the resident was
clearly experiencing discomfort, which had been
documented for a number of months. DHHS replied
promptly and in detail to Community Visitors’
queries, allaying their concerns.
At another house, Community Visitors observed
that one resident had lost a significant amount of
weight. They were told the resident was vomiting
frequently, and this was thought to be behaviour
related. However, additional tests demonstrated that
the cause of the vomiting was intolerance to certain
foods. Since this has been identified and the resident’s
diet modified, the vomiting episodes have reduced.
Aids and equipment such as slings and hoists
need to be checked periodically for safety reasons.
In three houses, Community Visitors identified
equipment that was either overdue for checking, or
that was not appropriately tagged to indicate when
checks had previously taken place.
Rights
Prior to the Victorian State election, DAS houses
were provided with a DVD and information in
easy English on how to vote. Some residents
were pleased to have their right to vote actively
supported in this way. DHHS is to be congratulated
on this initiative.
106
Disability Services
While the understanding of the Community Visitor
role amongst staff in houses is good overall,
issues do arise. Community Visitors frequently
need to remind staff in houses to file visit reports
and responses in the Community Visitors folder in
keeping with the Community Visitors Protocol. It is
also apparent that agency staff in houses do not
always understand the role of the Community Visitor.
Incident reports
Community Visitors reported immediate risks to
safety of staff and residents at a group home,
due to the violent behaviours of a resident. These
include punching a staff member in the face,
wielding knives and damaging furniture. Community
Visitors were concerned that residents remained at
risk while staff members locked themselves in the
staff room during these violent incidents.
Access to incident reports can be difficult on
occasions as these are not always available in hard
copy and they may not be accessible on computer.
Community Visitors would also like to obtain
more comprehensive information on responses
to incidents; in particular, what actions have been
taken to prevent reoccurrence of incidents.
DHHS responses to these behaviours included
increased staff coverage, further training, and an
independent review of the group home by the
Senior Practitioner. The review concluded that the
alleged perpetrator should be relocated to more
appropriate accommodation. This was fast-tracked
when there was a further violent incident between
the alleged perpetrator and another resident.
Barwon
The transition to alternative accommodation has
now taken place and Community Visitors will monitor
how the resident settles into the new surroundings.
Abuse and neglect
Community Visitors have monitored some serious
abuse involving group home residents.
During a National Disability Insurance Agency
(NDIS) planning meeting, a resident at a DAS
house revealed to an OPA advocate that he was
being regularly physically assaulted and subjected
to threats to kill by another resident. The OPA
advocate and Community Visitors sought to clarify
how DHHS and NDIA would protect the victim from
further abuse. This process revealed a lack of clarity
between the two agencies regarding responsibility
for the abuse. In addition, there were concerns
that incidents of abuse were not being adequately
recorded by DHHS staff. When DHHS proposed
that the victim be relocated, OPA advocated
strongly against this, as the victim had been a
resident at the house for many years and did not
wish to move. The victim, with assistance from
Villamanta Legal Service, sought and obtained an
intervention order against the alleged perpetrator,
who was subsequently moved to a temporary
respite facility.
Disability Services
Respite
There are ongoing concerns regarding the use of
respite facilities for long-term accommodation –
particularly where respite users display behaviours
of concern. A DAS children’s respite house has
been accommodating two respite users on a longterm basis.
The use of respite services in the region is affected by
a number of factors relating to the National Disability
Insurance Scheme (NDIS), including inadequate
planning, poor information provision to families, and
insufficient funding. Some families are being offered
in-home respite when their preference is to have outof-home respite for their family member. The number
of respite days available to families also appears to
have been reduced under some NDIA plans.
Issues with bathroom and toilet facilities in houses
figure prominently in reports from Community
Visitors. At a CSO house, facilities in the second
bathroom are not accessible to residents in
wheelchairs; while at a DAS house, a raised shower
base poses an access issue for some residents. At
another DAS house, concerns regarding unsuitable
bathroom and toilet facilities have been raised for
more than eight years. Community Visitors were
107
concerned about the length of time residents would
be unable to access the bathroom at a CSO house
while a hole in the wall was repaired that necessitated
residents and staff using a portable toilet.
Community Visitors were concerned about a
resident in a CSO house who is unable to travel on
the train, due to the type of wheelchair they use.
Community Visitors also highlighted maintenance
issues in external areas, including fencing and
garden areas. Funding is being sought for an
outside area for residents at a CSO house that will
make it more comfortable in winter.
Rights
Community Visitors were concerned about the
opaque glass window in one resident’s bedroom.
They felt that this type of glass compromised the
resident’s view outside.
Staff support
Understaffing was an issue at some houses.
Community Visitors are keen to ensure that staffing
levels are adequate in houses, so that residents
can be supported with goals such as community
access. Staffing levels were also queried at
Colanda, particularly as residents age in the facility
and their support needs increase.
While understanding of the Community Visitor role
is generally good across the region, there have
been occasional issues. At one CSO house, staff
seemed unaware of key aspects of the Community
Visitors Protocol, including the process for
escalating and resolving issues.
Incident reports
Incidents reports can be difficult to access,
particularly if they are available on computer only.
This problem is exacerbated when casual staff
are working and have no access to reports on the
house computer. Community Visitors took this issue
up with one CSO, asking why they did not provide
hard copies of reports available in their houses.
Central Highlands
Individual planning
Abuse and neglect
Some concerns were raised in relation to the
introduction of NDIS plans. During one CSO visit,
Community Visitors spoke at length to a resident
who was dissatisfied with the NDIS planning
process. The resident’s paperwork had been lost
several times and their plan had required rewriting
each time. At another CSO house, Community
Visitors were not able to access NDIS plans during
a visit, and were even unsure whether the residents
had plans at all.
A resident at a DAS house physically assaulted
another resident, who sustained a broken
collarbone. The incident was reported to police and
the alleged perpetrator was referred to their GP who
prescribed medication to address their escalating
behaviour. The resident who perpetrated the assault
has responded well to changes in medication
and the behaviours of concern have decreased.
Community Visitors are still keen to ensure that the
other residents feel safe in their own home.
There have been some issues relating to aids and
equipment. A resident at one CSO house was
sleeping on an old orthopaedic mattress in poor
condition, which Community Visitors felt was long
overdue for replacement. At the same house,
Community Visitors felt another resident required
assessment for a more suitable chair, as they
appeared to be experiencing some discomfort.
In another CSO house, concerns were raised
regarding the faulty remote control for a hoist – this
was seen as a safety issue for staff and residents.
Community Visitors have queried whether the
transition to the NDIS has delayed the replacement
of equipment in some cases.
108
A client was given a sedative before arriving at
a respite service as an emergency client. His
behaviour escalated when the medication wore
off and he started physically abusing people and
property. The police were called and on exiting the
building, he assaulted community members and
was taken to the police station. On return to the
facility, his behaviour escalated and police were
again called. The next day, one of the client’s parents
was contacted; the client was taken for assessment
and given PRN medication. Subsequently, oneon-one supervision was provided. For Community
Visitors, this incident raised questions about the
procedures for emergency respite when other
clients are threatened.
Disability Services
At one house, a male resident who was subject
to a Supervised Treatment Order vocalised sexual
thoughts about other residents in the house and
expressed concerns about being able to control
himself. One resident was relocated to another
house for their safety.
A CSO house was reported as having serious mould
issues in the bathrooms over the past year. In this
house, mould was still found, even after a certificate
had been issued stating that no mould was present.
Management at the house acted promptly and
thoroughly checked the facility, inviting Community
Visitors to inspect the premises with them.
Ageing
Insufficient toilet facilities at DAS and CSO houses
remain an issue. For instance, concerns were
raised at a DAS house where there is only one toilet
for residents to use, some of whom are aging.
Aging in place with palliative care is now happening
in this region. Residents are able to retire from day
placement if they wish as retirement transition plans
are in place.
good practice
At a DAS house, roses have been planted
for all the residents (and a pet cat) who have
passed away. A list of these residents and the
corresponding roses is visible in the office.
Residents of the house are aware of this memorial,
and visit the graves of the former residents at the
cemetery. As this house was purpose-built for
residents in their later years, it is pleasing to see
this sensitive approach to ageing and death.
Respite
Concern was expressed by Community Visitors
regarding the mix of respite users at a CSO house
accommodating two adults and two children.
The service provider acknowledged the concern,
advising that this mix of respite users may occur
in an emergency, and that respite users were
assessed as to whether they pose a risk to others
at the facility.
Community Visitors are still concerned that two
respite houses are underutilised. Despite the
demand for respite services, they are closed for two
days each week.
Community Visitors continue to report issues
across the region, in both DAS and CSO houses,
relating to bathroom and toilet areas. Issues include
inadequate ‘patch up’ repairs and where water
problems are reoccurring; flooring hazards (including
lifting linoleum and the absence of non-slip
surfaces); and concerns around poor ventilation.
Disability Services
Community Visitors question the adequacy of lighting
in some houses, especially in work areas such as the
kitchen, eating areas, entrances and passageways.
Staff support
Community Visitors have reported concerns
about quality of staff support. At one CSO house,
Community Visitors reported that a resident’s
behaviours of concern seemed to be displayed only
when casual staff were on duty.
At a DAS house, a resident was being bathed and
one side of the bath had not been secured; when
the resident was asked to roll over to have their
backed washed, they fell on the floor. The resident
was taken to hospital and discharged with no
diagnosis of injury, later they were found to have
fractures to their ankle and hip.
good practice
Community Visitors believe staff at a DAS house
have excelled as a team in managing a highly
complex situation, which they and DHHS were
not adequately prepared for. A new resident
with extremely complex and challenging support
needs was introduced to the house suddenly
and with minimal transition planning. The
resident initially displayed aggressive behaviours
towards staff and other residents. Staff
established clear boundaries and challenged the
resident’s inappropriate behaviours, and positive
changes occurred. They were also supported by
the local police in their efforts. The resident now
has a support plan that is reviewed each month
and changed if necessary.
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Individual planning
Community Visitors report that it is sometimes
difficult for some staff to locate documents; key
worker reports, for example, are not always readily
available. Without access to these documents,
Community Visitors find it difficult to monitor
planning processes and the achievement of
goals identified in plans. However, some houses
organise and manage their records extremely well,
and staff at these houses are commended for
their efforts.
At one CSO house, there were four incident
reports, involving different residents, related to
respiratory issues - some involving hospitalisation.
Residents of this house have ongoing health issues,
but it was noted that mould was present in the
house and there were concerns about its impact on
residents’ health.
Social inclusion
A resident of a DAS house likes to watch cars
and trucks go by the house. The resident has
mobility issues and shade is required for them
to be able to be outside; umbrellas have been
utilised and quotes for a gazebo obtained. As the
cost of a permanent structure was considered too
expensive, the new house supervisor is looking
into whether materials and labour may be donated
to facilitate the building of a pergola.
A new resident at a DAS house, where all
other residents have mobility issues, is being
encouraged to extend their independent living
skills by using public transport, participating
in a cooking class weekly and doing their own
washing and cleaning with minimal assistance.
good practice
An occupational therapist’s assessment
indicated a resident at a DAS house had
sensory deprivation. A sensory diet was trialled
by staff to support the resident in better selfregulating their behaviour. As the diet was
working, a staff member was encouraged to
apply for a Promoting Dignity Grant, through
the Office of Professional Practice. The aim of
this grant application was to reduce restrictions
and improve the dignity and quality of life of
residents with high support needs.
During the last year, this resident has been able
to move from living alone with staff support
in an isolated location, to a purpose-built unit
attached to a group home. This transition was
made possible through many dedicated staff
members who have travelled on this resident’s
challenging journey.
110
Community Visitors noticed a strong urine
odour when visiting a DAS house and they were
informed that over an extended period, a resident
had been coming home from day placement
with incontinence issues. It is expected that an
incontinence plan, as well as action on some
related issues, will occur with the day program in
order to resolve these matters.
A resident at a DAS house has been waiting a
very long time for a new wheelchair. Funding has
been a problem, with many avenues pursued
unsuccessfully. Community Visitors are concerned
that the resident’s current wheelchair may be
causing posture problems, as the resident is still
young and developing physically. According to
DHHS, the new wheelchair is currently in production.
Rights
The storeroom at a CSO house was being
accessed through a resident’s bedroom.
Assurances were given that this practice was to
cease; however, on the next visit, Community
Visitors observed that this practice had not
changed. Community Visitors remain concerned
that the resident’s privacy is not being respected.
Western District
Abuse and neglect
Community Visitors were approached by a
resident at a DAS house who expressed serious
concerns about the behaviour of another resident
who had recently moved in. Although there had
been no physical assaults, the new resident’s
violent and destructive outbursts were frightening
and upsetting other residents. Community
Visitors queried the decision to record a number
of incidents in a behavioural log rather than
documenting them as incident reports, as they
appeared to meet the criteria for incident reports.
The resident’s BSP had also not been updated
and it was clear that the strategies for addressing
the behaviours of concern needed review. In
Disability Services
subsequent visits, Community Visitors noted that
the issues were being addressed with the resident.
DHHS Specialist Services had been engaged and a
new BSP implemented, yielding positive results.
Community Visitors received a request for
assistance from a CSO resident alleging abuse
by staff. Although the allegations could not be
substantiated, Community Visitors observed
disturbing evidence of sub-standard care,
inadequate staff training, and lack of management
direction at the house. Only one of the five residents
attends day programs. Discussions have been held
with the CSO management and DHHS regarding
these concerns.
Ageing
Staff in group homes are increasingly dealing with
issues around ageing and dementia, reflecting
trends in other regions.
Community Visitors were pleased to view a PCP
for an older resident that reflected the resident’s
changing needs; these included exploring
alternatives to day placement, and adjusting daily
routine that allowed the resident to ‘sleep-in’ when
they preferred.
One DAS house continues to cater specifically
for ageing residents, providing a varied program
to cater for individual interests. There is also an
advanced health plan in place to assist with the
care of a resident whose health is deteriorating.
Respite
Respite houses for children are well managed and
cater appropriately for their needs. The atmosphere
in these houses is positive; children appear
enthusiastic about their stay. Communication books
are well utilised to facilitate continuity of care. One
CSO respite house is investigating opportunities
to use the facility during weekdays to provide
alternative activities for ageing residents no longer
wishing to attend day placements. Community
Visitors were impressed by this innovative thinking.
After many years highlighting concerns regarding
outdated respite facilities, Community Visitors were
pleased to report the closure of a respite facility
in a regional town and its replacement with a new
facility. Community Visitors look forward to visiting
this house in the near future.
Disability Services
Upkeep of buildings and facilities
There continues to be a range of maintenance
issues in a number of houses, with delays in repairs
being a concern. Frequently, maintenance issues
are left until the end of the financial year, when
there is some flexibility in the budget, which allows
some works to be approved. Community Visitors
feel bathroom and toilet issues, such as broken or
cracked tiles, sewerage odours, blocked drains and
issues with hot water services should be attended
to promptly.
Improvements have been noted in regards to
upgraded fencing, outdoor areas, blinds, gardens
and kitchen appliances at some facilities. In general,
Community Visitors have found houses to be well
presented, with staff and residents contributing to a
homely feel.
Staff support
Community Visitors have noted the caring and
professional work of staff. High standards are
evident, and quite often staff go beyond what is
expected to enhance the lives of the residents.
Several staff in CSO houses have expressed the
need for more training around issues such as
ageing, dementia and Down syndrome. At both
DAS and CSO houses, Community Visitors have
also observed that staff find it challenging to
discuss relationships and sexuality with residents –
an area where staff should receive more training.
At one DAS house, Community Visitors were
pleased to observe how staff contributed to
creating the sense of ‘home’ that the residents
felt; the interaction between residents and staff
during a photo session was celebrated as a ‘family
get-together’. Staff in a number of houses have
introduced equipment and activities specifically to
assist with the fine motor skills of some residents.
A CSO house introduced a pet bird, which had an
extremely positive effect on one particular resident,
who talked regularly to the bird. In doing so, the
resident spoke of matters not previously shared
with other residents and staff. This same house
now has a cat, which has also had a positive effect.
Individual planning
Community Visitors have found PCPs to be
generally of a high quality, with staff engaging
residents well in the planning process.
111
Social inclusion
case
study
For more than five years, Community Visitors
have had concerns regarding a DAS resident
who did not have access to a formal day
program, as a suitable program was not
available. An appropriate ISP package has now
been implemented enabling the resident to be
supported by non-DAS staff in a supervised
program of activities. The resident no longer lives
alone and has responded positively to the three
new residents who moved to the house during
the year. It is hoped that, in time, this person can
enhance their social skills, with the benefit of the
support provided.
The scope and range of physical activities offered
to residents is impressive, from the many sporting
endeavours through to more leisurely pursuits.
Residents are actively encouraged to participate.
medication errors. None of the errors had a
serious impact on residents but it is an area of
some concern. One CSO house uses a coloured
vest worn by the worker issuing the medication.
Residents understand the strict procedures to be
followed when the vest is being worn.
Overall, Community Visitors have found that
the health care needs of residents are very well
managed. Residents have regular appointments
with doctors, dentists, nutritionists and other health
practitioners. This includes annual flu injections.
Incident reports
Access to incident reports continues to vary from
house to house. In one case, a CSO keeps all
incident reports at its head office. Currently, the
Community Visitor Regional Convenor receives a
monthly summary sheet of any incidents; if followup is necessary, the relevant incident report can be
requested from head office.
112
Disability Services
Disability Services
113
Community Visitors 2014–2015
OPA acknowledges and thanks Community Visitors in all streams who stood
up for the rights of people with a disability or a mental illness during the year.
Susan Aarons
Amanda Abbruzzese
Marta Acton
Chanelle Adam
Deanne Ades
Ian Alexander
Priya Alexander
David Allen
Jo Allen
Arthur Apostolopoulos
Shirley Armitage
Mary Armstrong
Lyn Arnold
Beth Atkins
Karina Au
Tad Bakko
Joyce Ball
Anne Bambrook
Rajashree Banerjea
Rati Banga
Christine Barbuto
Ennio Bardella
Jan Barker
Andrew Baugh
Nyamka Bayanmunkh
Jane Beard
Suzanne Beaton (RC)
Cheryl Beatson
Vicki Bechaz
Anne-Marie Beckett
Nada Bendall
Judith Bink
Marion Blythman (RC)
Margaret Bodenham
Roger Boey
Dominic Boland
Sally Bolton
Michael Boucher
John Bowen
Kathleen Bragge (RC)
Jenny Broughton (RC)
Jeanise Brown
Robyn Brown
Geoff Brown
Marc Brubacher
Cheryl Brunton
Ian Buckles (RC)
Ronald Butler (RC)
Rick Byrne
Teigen Bywater
Lyn Campbell (RC)
Kevin Campbell
114
Jacqui Campbell
Paul Campobasso
Eve Caplan
Christine Carder Rice
Cheryl Carnio
Suzanne Casserley
Ken Castanelli
Joan Castledine
Julie Cesal
Chris Chapman
Melissa Chapman
Patricia Cheary
Daniela Cherie
John Chesterman
Siok Chew
Peter Chiang
Pamela Clarke
Tania Cleary
Jo Cohen
Terry Collison
Ronitte Collyer
Sandra Cooper (RC)
Christine Cooze
Erin Cowley
Bryan Crebbin
Patricia Cross (RC)
Graeme Crutchfield
Stephen Culhane (RC)
Robert Cull
Robyn Cunningham (RC)
Shruti Dahal
Peter Dalgleish
Doreen Dalrymple
William Daly
Linda Dare
Margaret Davidson
Wendy Davies
Pat Davison
Susan Dedes Bonneau
Sonia Di Ilorio
Graham Dickinson
Christine Dimer
Carly Dober
Diane Doherty
Diana Donohue (RC)
Audrey Downing (RC)
Robert Drayton
Majella Dryden
Liz Duell
Jan Dunbar
Ian Dunn
Jennifer Dunn
John Dunn
Aileen Eames
Rosalie Edge
Tony Ellis
Marilyn Faiman
Eveline Fallshaw (RC)
Fred Falvo
Mark Feigan
Ruth Felbel
Miguel Feliciano
David Ferguson (RC)
Trudy Firth (RC)
Max Fletcher
Maureen Fontana (RC)
Debbie Fowler
Paulette Fraser
Janis Fregon
Joseph Fung
Dale Furey
Gemma Furtado
Allan Fyffe
Suzette Gallagher
John Garland
Peter Gauld
John Gleeson
James Glenn (RC)
Una Gold
Karyn Golumbeck
Piers Gooding
Audrey Grace
Eddie Graham
Bernie Graham
Brian Granrott
David Grant
Avril Green
Jarrod Greenhalgh
Kay Gregory
Alison Gribble
Alan Grigson
Susanne Grosser
Judi Groves
Alan Gruner
Mark Gunn
Wendy Guy
Michael Hadley (RC)
Ghassan Haidar
Rachel Hansford
Alexander Hardy
Susan Harraway (RC)
Lynette Harris
Rowena Hart
Cliff Hawkins
Lynette Hayes
Elizabeth Haylock
Carol Haynes (RC)
Coral Heazlewood
Lyn Hedger
Jennifer Henry
Anne Hickerton (RC)
Robyn Hickey
Bill Hickey (RC)
Colin Hinckson
Karen Hitchen
Barbara Hocking
Ruth Hoffman
Wendy Holland
Ash Hosseini
Mary Howlett
Chia-ming (Ken) Hsu
Carolyn Hutchens (RC)
Paul Iles
Chris Ingram (RC)
Dallas Isaacs
Beverley Jacob
Thomas Jambrich
Robert Jeffree
Angus Jessel
Raymond Johnson
Lyn Johnson
Catherine Jones
Taffy Jones
Catherine Joyce
Lynda Judkins
Donald Juniper
Peter Kadar
Soula Katsaros
Liam Kershaw-Ryan
Sarah Khor
Brian Kiley
Joan Kincade
Katrina Kincade-Sharkey
Sean Koerner
Alan Kohn
Ashanthi Kuluskera
Tineke Lagerwey
Pauline Lavars
David Lawrence
Anna Lee
Debra Lee
Briar Leece
Beverley Libbis
Margaret Lippold
Vashti Lloyd
Ken Locke
Kathleen Loxton (RC)
Graeme Luke
Jennifer Lush
Desma MacDonald
Brian MacIntosh (RC)
Helen Mahar
Carole Maher
Vicki Mahony
Andrew Majiga
Kaye Manners (RC)
Heather Marmur
Annette Marrington
Neville Marriott
Jenny Martin
Sandra Martin
Nikita Matchado
Beth Matthews
Julian Maugey
Ian McBeath
Maura McCabe
Debra McCann
James McCarthy
Ailsa McCarthy
Stan McCredden
Megan McDonald
Jamie McDonald
Carole McElvaney
Irene McGrath
Deborah McLachlan (RC)
Shaun McLaws
Heather McLeish
Claire McLinden
Pamela McMillan
Brenda McMinn (RC)
Louise McPhee (RC)
Hilary McVey
Jan Meiklejohn
Laurie Messenger
Neil Michael
Jan Middleditch
Frank Miragliotta
Irene Meredith Morgan
David Morris
David Morrison
Carol Morse (RC)
Marj Munro (RC)
Aneeka Munshey
Bruce Murray
Pauline Musgrave (RC)
Danielle Neal
Judith Newman
Paul Newman
Craig Ng
Donna Ng
Connie Ngu
Philippa Nichol
Judi Nicholson
Edwina Nutt
Paul Nykios
Sue O’Brien
John O’Connor
Kim O’Donoghue
Audrey Orr
Karleen Osborne
Joanne Page
Izabella Pankowska
Christian Papadopoulos
Olga Paramboukis
Faye Pargetter
Sonia Park
Dave Parker (RC)
Wendy Patchett (RC)
James Paterson (RC)
Judith Pauwels
Loes Pearson, (JP)
Roman Peldys
Peter Penry-Williams
Jennifer Perry (RC)
Claire Peschel
Wendy Pfeifer
Lyn Phelan
Aldo Pitre (RC)
Sally Polack
Patrick Poon
Cherie Poulter
Pauline Powell
Denise Poynter
Nancy Price
Margaret Purves
Maria Isobel Quiceno
Anna Raicevic
Jose Ramirez
Judy Rattray
Helen Rawicki
June Rea (RC)
Harvey Reese
Keren Reeve
Brian Reeves
Sue Rewell (RC)
Fay Richards (RC)
Norman Richardson
Dawn Richardson (RC)
Dany Roberts
Julie Robottom
David Roche
Vivienne Roche
Stephanie Rock
Jo Rodger
Mick Rosier
Ainsley Rozario
Linda Rubinstein
John Russell
Jeanette Santowiak
Liane Schuhen
Bill Scott
Raymond Scrace
Brenda Seavers
Kyrstie Sebastian
Debra Sevastianov
Robert Shafar
Zahan Shafeeg
Lois Shallow
Rosemary Shaw
Yvonne Sherlock
Margaret Shoebridge
Colin Shoebridge
Eileen Sholl
Perundevi Sinnasamy
Jocelyn Sinton
Puvana Sivakumar
Mike Slattery
Rhiannon Smith
Jenny Smith
Tanya Smith
Moira Somerville
June Soutar
Michele Sproule
Glenn Staunton
Raymond Steadman (RC)
Emma Steele
Erlinda Sterlus
Margaret Stevenson (RC)
Evan Stewart
Graham Stickland (RC)
Loraine Stone
Bernadette Sullivan
Robert Swiger
Tanjila Tayeb
Margot Thimm
Pauline Thomas
Kathryn Thomas
Mark Thompson
Jim Thornley
Rosslyn Thurrowgood (RC)
Cherie Titman
Julia Tivendale
John Trevillyan
Helen Tribe
Julie Trompf
Jessica Tsoulsoulis
Marion Tune
Merrill Tunstall
Gary Turner
Gail Upton
Malcolm Urqhart
Bryan Valionis
Helen Vallance
Luke Van Den Dikkenberg
Tina Veliscek
Bethany Veysey
Alexa Viani
Christine Volk
Connie Vukotic
Peter Waldron
Colin Wales
Emma Walker
Brian Wallace
Lynn Wallace-Clancy
Sebastian Waluk
Elizabeth Warren
Betty Waters
Anita Watt
Taryn Webb
Joy Webster
Marion Wellwood (RC)
Wendy Wereta
Jan Wiebe
Davina Wijesinghe
Dianne Wilde
Carole Williams
Lauren Williams
David Williams
Johanne Willoughby
Elaine Wilson
Bryon Winn
Sheila Winter (RC)
Jessica Wong
Rhonda Woodrow
Ted Woollan
Junia Wraith
Trudy Wyse
Susanna Young
Susan Zammit
Lewis Zammit
Ignatius Zanetidis
Saul Zavarce
Tony Zdravkovski
Elizabeth Zinn
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Facilities eligible to be visited by Community Visitors 2014–2015
Supported Residential
Services
Aaron Lodge
Absalom
Acacia Gardens
Acacia Place
Achmore Lodge
Acland Grange
Adare Supported Residential Care
Airlie
Alexandra Gardens
Allbright Manor
Alma House
Arnica Lodge
Ascot House
Balmoral
Bamfield Lodge
Belair Gardens
Bella Chara
Bellden Lodge
Bentleys Aged Care
Berwick House
Bignold Park
Blue Willows Residential Aged Care
Brooklea Lodge
Brooklyn House
Browen Lee Home - Ballarat
Brunswick Lodge
Burwood Lodge
Camberwell Manor
Carrington Court
Caulfield House
Caulfield Manor
Chatsworth Terrace
Chesterfield
Chippendale Lodge
Coorondo Home
Corandirk House
Covenant House
Cranhaven Lodge
Crofton House
Crosbie Lodge
Crystal Manor
Darebin Lodge
Delany Manor
Doncaster Manor
Dorset Lodge
Dunelm
Eagle Manor
Edwards Lodge
Elgar Home
Eliza Lodge
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Eliza Park
Eltham Villa
Fermont Lodge
Ferntree Gardens
Ferntree Manor
Finchley Court
Footscray House
Galilee
Glenhaven Special Care Facility
Glenhuntly Terrace
Glenville Lodge
Glenwood Assisted Living
Golden Gate Lodge
Gracedale Lodge
Gracevale Grange
Gracevale Lodge
Grandel
Grand Villa Mentone
Greenhaven
Greenslopes
Hamble Court
Hambleton House
Hampton House
Harrier Manor
Hawthorn Grange
Hawthorns Victoria Gardens
Hazelwood Boronia
Heathmont Lodge
Hillview Lodge
Hollydale Lodge
Home Residential Care
Homebush Hall
Iris Grange
Iris Manor
Jasmine Lodge
Kallara Residential Care
Karinya
Kilara House
Kooralbyn Retirement Lodge
Kyneton Lodge
L’abri
Landora Care
Lilydale Lodge
Manalin House
Mayfair Lodge
Meadowbrook
Melton Willows
Merriwa Grove
Milford Hall
Mont Albert Manor
Mornington House
Mt. Alexander
Mulvra Aged Care
Mulvra Place
Nepean Gardens
Northern Terrace
Oakern Lodge
Parkland Close
Peninsula Residential Care
Pineview Residential Care
Princes Park Lodge
Raynes Park Court
Reservoir Lodge
Rosewood Downs
Rosewood Gardens
Royal Avenue
Sandy Lodge
Seaview House Residential Care
Sheridan Hall - Caulfield
Southcare Lodge
St James Terrace
Stewart Lodge
Strabane Gardens
Sunnyhurst Gardens
Surfcoast Supported Accommodation
Sydenham Grace
Themar Heights
Trentleigh Lodge
Vermont Gardens
Viewbank House
Viewmont Terrace
Warranvale Gardens
Warrina Retirement Village
Wattle-Brae
Westley Garden
Whitehaven
Windermere Retirement Lodge
Woodford Gables.
Mental Health
Providers
Albury Wodonga Health
Alfred Health
Austin Health
Ballarat Health
Barwon Health
Bendigo Health
Break Thru People Solutions
cohealth
Eastern Health
ERMHA
Forensicare
Goulburn Valley Health
Grampians
Inner West Area Mental Health
La Trobe Regional Hospital
Melbourne Health
Mercy Health
MI Fellowship
Mid West Area Mental Health
Mildura Base Hospital
MIND
Monash Health
Neami National
North East and Border Mental Health Service
Northern Area Mental Health
North Western Mental Health
Orygen Youth Health
Peninsula Health
Royal Children’s Hospital
Royal Melbourne Hospital
SNAP Gippsland Inc
SouthWest Health Care
St Vincent’s Mental Health
Stawell Regional Health
West Wimmera Health Service
Disability Services
Providers
ABLE Australia
Accomodation Care Solutions
AGAPI
Alkira Centre - Box Hill Inc.
Amicus
Annecto Inc.
Araluen
Ashcare Incorporated
Asteria Inc
ACSO.- Australian Community
Support Organisation Inc
Australian Home Care Services
Autism Plus
Bayley House
Care Beyond Measure
Carinya Society
Central Access Ltd
Colac – Otway Disability Accommodation Inc.
Community Connections (Victoria) Limited
Community Living and Respite Services Inc.
ConnectGV
Cooinda-Terang Inc.
Department of Health & Human Services
Epworth Foundation
EW Tipping Foundation Inc.
Family Plus Inc.
Focus
Gateways Support Services
Gellibrand Residential Services Inc.
Golden City Support Services Inc.
Golden Valley Centre
Haven
Healthscope Limited
Independence Australia
Ivanhoe Diamond Valley Community Centre Inc.
Jesuit Social Services Limited
Jewish Care (Victoria) Inc.
Karingal Inc.
Kirinari Community Services Inc.
Knoxbrooke Inc.
Kyeema Support Services Inc
Life Without Barriers
Lifestyle Solutions
Maccro, Mansfield Adult Autistic Services Limited
Mallee Family Care Inc.
Marillac Ltd
McCallum Disability Services Inc.
McKillop Family Services
Melba Support Services Inc.
Melbacc
Melbourne City Mission Inc.
Melbourne Health
Merriwa Industries
MIND
Mirridong Services Inc.
MOIRA Inc.
Monkami Centre Inc.
Multiple Sclerosis Limited
Murdoch Community Services Inc.
Murray Human Services Inc.
Nadrasca
Nepean Centre for Physically Handicapped Inc.
Northern Support Services
Noweyung Limited
Oakleigh Centre For Intellectually
Disabled Citizens Inc.
ONCALL Personnel & Training
Ozchild
Plenty Valley Community Services Inc.
Providing All Living Supports (PALS)
SCOPE Victoria Ltd
Southern Way Direct Care Services Inc.
St John of God Services Victoria
Statewide Autistic Services Inc.
STAY - Residential Services
Association Inc.
Sunraysia Residential Services Inc.
The Salvation Army (Victoria)
Property – Trust Western
Uniting Care Harrison Community Services
Victoria Deaf Society
Villa Maria Society
Vista
Wallara Australia Ltd
Wesley Mission Victoria
Wimmera Uniting Care
Woodbine Inc.
Yooralla
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Acronyms
AAU Adult Acute Unit
OPP Office of Professional Practice
ABI Acquired Brain Injury
PACER Police Ambulance Crisis and Emergency Response
ACSO Australian Community Support Organisation
PARC Prevention and Recovery Care
BSP Behaviour Support Plan
PCP Person-Centred Plan
CAG Consumer Advisory Group
PDRSS Psychiatric Disability Rehabilitation Support Services
CALD Culturally and Linguistically Diverse
PEG Percutaneous Endoscopic Gastrostomy
CAT Crisis Assessment and Treatment
PRN Pro Re Nata (Medication Provided as Needed)
CCU Community Care Unit
PRS Plenty Residential Services
CDDHV Centre for Development Disability Health Victoria
SAVVI Supporting Accommodation for Vulnerable Victorians Initiative
CHAPS Comprehensive Health Assessment Plans
SECU Secure Extended Care Unit
CRP Community Recovery Program
SOCIT Sexual Offences and Child Abuse Investigation Team
CSO Community Service Organisation
SRS Supported Residential Services
DAS Disability Accommodation Service
STO Supervised Treatment Order
DFATS Disability and Forensic Assessment and Treatment Service
VCAT Victorian Civil and Administrative Tribunal
DDSO Disability Development and Support Officer
VDDS Victorian Dual Disability Service
DH Department of Health
VEOHRC Victorian Equal Opportunity and Human Rights Commission
DHS Department of Human Services
VIHMS Victorian Incident Health Management System
DHHS Department of Health and Human Services
VSA Victims Support Agency
DSR Disability Support Register
VSDP Victorian State Disability Plan
ECT Electroconvulsive Therapy
Y-PARC Youth Prevention and Recovery Care
ED Emergency Department
GP General Practitioner
HCA Housing Choices Australia
HDU High Dependency Unit
IGUANA Interagency Guideline for Addressing Violence, Neglect and Abuse
IHBOS Intensive Home-based Outreach
ISP Individual Support Package
LGA Local Government Area
MHRB Mental Health Review Board
NAMHS Northern Area Mental Health Service
NDIS National Disability Insurance Scheme
NPU Northern Psychiatric Unit
NUM Nurse Unit Manager
NWMHS North West Mental Health Service
OPA Office of the Public Advocate
118
Office of the Public Advocate
Level 1, 204 Lygon Street, Carlton, Victoria 3053
Local call: 1300 309 337 TTY: 1300 305 612
Fax: 1300 787 510 DX 210293
www.publicadvocate.vic.gov.au

Community Visitors Annual Report 2014–2015 Mental Health

Transcription

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