Service Standards Resource Kit
Introduction:
The Community Legal Service Standards were developed following discussions between
practitioners, centre coordinators and volunteers, together with the Australian Government's
Attorney-General's Department, State/Territory Program Managers and NACLC. The standards are
also reflected within the National Association of CLCs (NACLC) Accreditation Scheme requirements.
Clauses 7 and 12 of the Service Agreement relating to the provision of community legal services
provides that the Funding Body may undertake a Service Standards Audit with the organisation and
monitor performance of the organisation during the term of the agreement to ensure compliance with
the service standards.
There are ten standards:
1) Information and referral
2) Provision of advice
3) Casework
4) Community Legal Education
5) Law Reform and Legal Policy
6) Accessibility
7) Organisational Management
8) Management of Information and Data
9) Assessing Client Satisfaction and Managing Complaints
10) Aboriginal Cultural Safety Standard
Standard 10 is a new service standard on Aboriginal Cultural Safety that has been introduced into
the Service Agreements for 2015-16 and is expected to be mirrored in the next phase of NACLC
Accreditation requirements and workplans. This standard was developed in consultation between
NACLC and the Aboriginal Legal Access Program (ALAP) Co-ordinator and Regional Accreditation
Coordinator (RAC) at CLCNSW, the NSW CLC Aboriginal Advisory Group (AAG) and Legal Aid
NSW. The standard provides 7 key requirements to ensure cultural safety within CLCs, specifically:
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Documented procedures to ensure cultural safety across all services and activities and at all
levels of the organisation;
Formal and informal processes are in place to identify and understand legal and social needs
of communities within the catchment area;
The organisation is connected to the local Aboriginal and Torres Strait Islander communities,
families and people, with formal consultation processes functioning to inform strategic
planning and service delivery;
Employment and retention strategies for Aboriginal members of staff;
Regular training and professional development in the areas of Aboriginal Cultural Awareness
and Cultural Safety for all Management Committee members, staff and volunteers;
The internal areas of the Centre, and the outside of the building and surrounds, where
possible, are welcoming, culturally sensitive and create culturally safe environments for
clients and staff; and
Evaluation of cultural safety and responsiveness strategies.
As Standard 10 is a new requirement it is appreciated that CLCs will need to work towards full
compliance during the 2015-16 period. It is expected that Centres demonstrate adequate progress
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against the requirements of this new Standard by 15 April 2016. The CLC Program will be assessing
each Centre’s progress against this standard, with an expectation that Centres will be able to
demonstrate compliance with Aboriginal Cultural Safety Standard requirements from 1 July 2016.
Under each of these requirements the standard outlines ‘evidence indicators’ against which CLCs
can demonstrate compliance. The requirements of this standard are incorporated within the Service
Standards Audit Checklist.
Structure of the Standards:
The Standard is a statement of principle or practice required.
Each standard is broken down into attributes and elements.
'Attributes' are the concrete evidence required to show compliance with that Standard.
'Elements', or 'processes', of each set of Attributes are the individual bits of evidence.
Steps in Documenting Procedures:
Do you already have procedures manuals?
You should plan to start compiling documentation for a Service Standards Audit several weeks in
advance of the audit date. The Service Standards Audit Checklist can help you with this.
You may already have one or more procedures manuals. Alternatively, you may operate a service
where staff know the procedures but nothing, or very little, has been written down. Procedures need
to be documented for Centres to be able to comply with the Service Standards.
In order to work out what you already have written down and what is missing, you can carry out a
Preliminary Centre Self-Audit. By using the Service Standards Audit Checklist you can record the
location of procedural documentation that you already have and indicate what, if anything, is missing.
If not, document what you do in relation to each standard
If you have ascertained that some procedures are not yet documented these will need to be
documented. Note that some procedures may relate to more than one standard/attribute/element.
Writing up polices/procedures:
Each piece of documentation should indicate:
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title of Procedure e.g. - 'Referrals to other Community Legal Services'
Service Standard & Attribute number to which it applies e.g. '1.1.3'
a description of the task or process
staff/organisation position responsible for the task or process, including supervision if
applicable, and
timeframes, checks and/or controls as relevant.
Set an Audit Date:
Audit Dates must be set by agreement between the Centre and the SPM.
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The Audit Process:
The Audit process will vary slightly according to whether the SPM is participating in the audit or it is
a Centre Self-Audit.
The following steps provide an overview of the steps required to conduct an Audit.
The Centre Self-Audit Overview:
For a Centre Self-Audit, it is recommended that you appoint a person within your organisation to
coordinate the Audit. This 'Audit Coordinator' will instigate and organise the Audit including:
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Ensuring that all documentation is readily available
Making staff and volunteers aware of the Audit
Making sure key staff are available to be interviewed on the Audit Date
Making a room or an area available to conduct the Audit
Locating documented procedures and noting them on the Service Standards Audit Checklist
Identifying relevant members of staff/volunteers/management committee who are
responsible for each procedure on the Service Standards Audit Checklist
7. Analysing documents to see whether or not they comply with procedures and then recording
results on the Service Standards Audit Checklist
8. Conducting Staff Awareness Interviews and recording results on the Service Standards Audit
Checklist
9. Recording findings within an Audit Report.
10. Forwarding a copy of the Audit Report to the State Program Manager within 30 days of the
Audit Date.
11. Undertaking actions to ensure future compliance.
The SPM Participant Audit Overview:
For an SPM Participant Audit, it is recommended that:
1. A person is nominated to coordinate the audit with the SPM and/or SPM delegate.1
2. The Audit Coordinator negotiates a day for the SPM centre visit and a due date for materials
to be provided to SPM. Note that the day the SPM visits the Centre will be deemed to be the
audit date.
3. The SPM will send a confirmation letter to the Centre, including a request for interviews with
a sample group from administrative staff, those providing legal services (employed and/or
volunteer) and members of the management committee (categories and minimum numbers).
4. The Audit Coordinator will ensure that the following materials are provided in advance to the
SPM (to be received at least 10 working days before the audit date):
a. The Service Standards Audit Checklist with the name of the Audit Coordinator, document
references and staff responsibilities completed, and
b. Documented procedures.
5. The Audit Coordinator arranges for relevant staff/management committee members to be
available for interviewing on the Audit Date
6. The Audit Coordinator ensures that staff to be interviewed are aware of the existence and
location of particular procedures
7. The SPM will conduct interviews at the Centre and may wish to clarify some of the
documentation with the Audit Co-ordinator
8. The SPM will analyse the results and, if required, seek further information
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The SPM may appoint a delegate to undertake the SPM audit on their behalf.
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9. The SPM will provide a report to the Centre within 30 days of completion, and
10. If applicable, the Centre will undertake actions to ensure future compliance and provide a
plan to the SPM for achieving full compliance.
Assessing the Documentation:
Centres need to meet two requirements in order to comply with Service Standards:
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Documentation - possess documented procedures which demonstrate the attributes, and
Staff Awareness - that people in the organisation (including employees, volunteers and
management committee members) are aware of procedures referred to in the attributes.
The Service Standards Checklist:
During the audit process the Service Standards Audit Checklist can be used for either a Self-Audit
or SPM Participant Audit, to determine:
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whether a documented procedure exists, and
whether staff (i.e. relevant legal/para-legal/volunteer/management committee members) are
aware of those procedures. The Service Standards Audit Checklist can also be used earlier,
during the Preliminary Audit, and as a reference when writing up procedures.
All Service Standards are listed in the Service Standards Checklist, together with necessary
attributes and elements for each standard.
The column headed Documented Evidence, is used to record the location of the relevant procedure.
This may not be just a page number, but a section number and/or chapter heading. A Yes, No or
question mark in the next column indicates whether the procedure or documentation exists, does not
exist, or is unclear.
The column headed Staff Awareness, is used to record the staff position responsible for the
procedure. A Yes, No or question mark in in the next column indicates whether the interviewee has
shown awareness of the procedure, is not aware of the procedure, or whether it is unclear.
The column headed Auditor's Comments, is used to make notes as required.
Staff Awareness Interviews:
At this stage the Auditor should have a reasonable understanding of the Centre's procedures.
Questions can now be prepared for the Staff Interview. The Auditor should interview a range of
people, from different areas across the organisation, based on who is responsible for a particular
procedure. Interviews can be performed either one to one, or with a cross section of staff. In terms
of staff awareness of the procedures, the Auditor will want to carry out brief interactions with some
staff and, where relevant, interested volunteers, to gauge the level of awareness of the procedures.
This does NOT mean that staff require a capacity to memorise all the procedures. This interaction
can occur in the context of some brief discussions with the use of a simple survey process.
Questions should be of a general nature, to allow staff to provide a full explanation. Questions that
elicit an explanation are better than those that get a 'yes' or 'no' response. For example, 'what do you
do if someone comes in asking for some information' requires the interviewee to provide an
explanation. A question such as 'do you do conflict checks?' will likely draw out a response of, 'yes'.
In essence, the best questions start with 'how', 'who', 'what' and 'when'.
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Audit Report Summary:
In the case of a Centre Self-Audit results of the Audit are to be provided to the SPM within 30 days
of the Audit.
In the case of an SPM Participant Audit the SPM will provide an Audit Report to the Centre within 30
days of the Audit outlining whether an Attribute is fully met, partially met with completion of work
underway, or not met. This is determined by considering whether or not polices/procedures are
observable, understandable and staff in the organisation are aware of them.
What to do if you are not fully compliant:
If the results of the Audit show that your Centre has not complied with, or is not fully compliant with,
one or more of the Service Standards, they must include:
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reasons for non-compliance
a proposal for actions, and
a timetable to achieve full compliance within a timeframe either outlined, or agreed to, by the
SPM.
The Audit Coordinator should discuss, with relevant staff, the aspects that require attention. It may
be a good idea to assign the work to an individual or group. It is recommended that the people
assigned to address the shortfall in compliance are clear on what is required.
Where the Centre is unable to achieve compliance within the proposed timeframe, the SPM will
assist the Centre to achieve full compliance and may participate in subsequent audit processes until
such time as the Centre becomes fully compliant. Alternatively, the SPM may seek to take other
action outlined within the Service Agreement including, but not limited to, actions under Clauses 12,
22 and 24 of the Agreement.
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