Residential Services Practice Manual 3rd Edition – Part 6
In this section
6
Records and procedures
6.1
Introduction to public records
6.1.1
Records kept by residential services
6.1.2
Client Relationship Information System (CRIS)
6.1.3
Personal information privacy and access
6.1.4
Freedom of information
6.1.5
Storing, maintaining, moving and archiving files
6.2
Accountability of money
6.3
Handling funds in respite services
6.4
Critical client incidents and non-critical client events
6.5
Damage caused by people living in residential services
6.6
Missing people
6.7
Responding to physical and sexual assault
6.8
When a person dies
July 2013
6.9
Wills and deceased estates
re-issued
RSPM application to service type
Each instruction has service type and instruction application codes to assist to identify how the specific
instruction applies to supported accommodation by service type.
Service type:
FBR
facility based respite
GH
group homes
STJ
short term justice
LTR
long term rehabilitation program
I
Sandhurst and Colanda
RTF
residential treatment facility (DFATS)
Instruction application:
Y
instruction applies in full
N
instruction does not apply to service type
P
Partial application. Service required to implement principle of instruction but service not generally
directly responsible for planning, monitoring and reviewing components of instruction
LD
Locally determined based on client plans, service model and protocols. Applicable to STJ, LTR and
RTF only
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Residential Services Practice Manual 3rd Edition – Part 6
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Residential Services Practice Manual 3rd Edition – 6.1-1
6.1 Introduction to public records
Issued: August 2012
Applies to all
Contents
What are public records?
Why are public records important?
Public records in residential services
Legislation and policy directs records management
Standards for written records
Resources
What are
public records?
A public record is any record made or received by a public officer in the course of
their duties. Records come in a variety of formats and media including:
 hardcopy documents
 emails
 computer files
 letters
 scanned documents
 web pages
 maps
 plans
 photographs.
Disability Accommodation Services staff are public officers. A public officer includes
anyone employed by any department, branch or office of the Government of
Victoria including permanent, part-time and contracted staff.
Why are public
records
important?
Records demonstrate how the Department of Human Services is accountable for
decisions and actions and how it complies with legal, financial and business
requirements. Records provide proof of services provided to clients, business
practices, communications, decisions and actions.
Records generated in residential services are the collection of information
necessary for Disability Services to provide evidence of the support which has been
provided to residents.
Public records
in residential
services
In the course of a working day, all information which provides evidence of the
work undertaken must be retained as a record. Records must be created whenever
there is a requirement for accountability and evidence of decisions made and
actions taken.
The Accommodation Services File (ASF) is the public record of the support
provided to a resident in a residential service.
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Residential Services Practice Manual 3rd Edition – 6.1-2
Legislation and
policy directs
records
management
There are legal and policy requirements for government departments which places
significant responsibility on all public officers. Based on these requirements, all
records collected or received must be treated in accordance with the provisions of
the legislation which governs practice and the department’s policy on records
management. For disability services the following law and policy applies:
 Victorian Public Records Act 1973
 Information Privacy Act 2000
 Health Records Act 2001
 Disability Act 2006.
 Evidence Act 2008
 Freedom of Information Act 1982
 Residential Services Practice Manual 2011
 Department of Human Services Records Management Policy (10/001)
Standards for
written records
The majority of records created are subject to the Freedom Of Information Act
1982, so all records must be:
 factual and non-judgmental
 legible
 logical and sequential
 signed and dated
 appropriately cross-referenced, for example, if a letter from an administrator is
filed in the finance section of a person’s file, this should be noted in the daily
communication record.
Staff must not:
 use white-out to correct mistakes; mistakes must be crossed out with a line
through the text and initialled
 archive or store documents in plastic sleeves which can cause printed
information to deteriorate
 file faxes or documents on thermal paper as these deteriorate over time; these
documents must be copied onto standard paper before filing
 use jargon. Avoid acronyms or abbreviations to ensure information is clear to
any reader
 use abbreviations or nick-names of staff or residents.
In addition:
 the use of red pen should be avoided as it may become illegible if it needs to
be photocopied for a formal process, such as an investigation by police or the
coroner.
Resources

DHS Business Support Records Management – policy, fact sheets and
resources that describe requirements for records management. Available
on the DHS Hub.
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Residential Services Practice Manual 3rd Edition – 6.1.1 – 1
6.1.1 Records kept by residential services
Issued: August 2012
Applies to all
Contents
Overview
Security of records within residential services
Security of records taken to external appointments
Portable data storage devices
What are resident records?
Electronic documents
How are residents identified in the system?
How do group homes get ASF’s
How is the ASF used?
What are operational records?
How are operational records managed?
Role of staff
Role of supervisor and manager
Resources
Overview
All documents and files created and used within residential services are known as
records. The records kept in residential services relate to both residents and the
general operation of the service site.
The records required to be completed are specified in each part of this manual.
Security of
records within
residential
services
Records must be securely kept in locked storage when not in use to ensure
protection from:
 unauthorised access, see RSPM 6.1.3, 6.1.4
 tampering
 damage or destruction
Security of
records taken
to external
appointments
When information held on a resident’s file is required for an appointment outside of
the residential service, for example, a specialist medical appointment, staff must
ensure that the record is:
 in a secure non-transparent document envelope
 limited to only the specific information required for the appointment
 never saved to an unsecured portable data storage device.
 never transported loose or with information visible
 not left unattended in any place at any time
 kept with the staff member at all times.
A note should be included in the diary or shift report, to identify what records have
been removed from the residential services, and when they were returned. This
should include the date and time the information was taken and returned.
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Portable data
storage devices
Portable data storage devices must only be used for resident records if they
approved and provided by the Information management and technology units.
These devices include:
 USB memory sticks
 personal digital assistants (PDA’s) such as palm pilot and Blackberry
 digital audio players such as iPods and MP3’s
 mobile phones and smart phones
 lap top computers
 removable storage media such as CDs and memory cards.
Resident information must never be saved to staff members’ personal device under
any circumstance. Where portable electronic storage devices such as a USB, may
be required they must be requested via the manager to regional Information
Technology services. The devices supplied will be encrypted to ensure that any
information is secure and only able to be accessed with passwords or codes.
Residents may use personal devices to store personal photo’s or other information
and these are not subject to records management requirements.
What are
resident records?
The official corporate file for resident records is the Accommodation Services File
(ASF). Resident records include, based on resident support needs, but are not
limited to:
 personal profile
 health support
 personal care
 person centred active support and daily routines
 support assessments and plans
 Critical Client Incident reports
 financial plans
These records are documents that:
 describe support needs and services used by department clients
 keep a history of how support is provided to each person.
Electronic
documents
Electronic documents include resident plans written on the computer, emails,
scanned documents and photo’s.
Saving documents to the residential service computer, is not part of the official
client information management system like CRIS.
Documents required to guide support, or that contain information about a resident
(including emails), must be printed and placed in the relevant section of the ASF in
accordance with the department’s records management policy.
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How are
residents
identified in
the system?
There are two official sources which keep client information. One is the Client
Relationship Information System (CRIS), which allocates a number to every person
who is registered for services with the department. This number forms the basis for
all reference numbers relating to the client records and the services which they
receive from the department.
Residential services may not currently use or access CRIS however a resident’s
CRIS number must be on all files to ensure records can be registered to the right
person in the Total Records Information Management (TRIM) system.
When a new ASF is requested, the file folder will have a bar coded label attached
to ensure the system knows the location of a resident’s records.
The two systems, CRIS and TRIM combine records to give the complete resident
history.
How do group
homes get ASF’s
The ASF is the corporate file which is used to record client information in
residential services. All ASF files must have a TRIM label attached to the cover
before information is placed in the file.
To obtain a new ASF for a resident contact either the DAS administration or
regional records unit, as required by the regions process. Regional records staff will
register the ASF to the resident by the CRIS number, on the TRIM system.
The file will be sent to the residential service via the regional process.
How is the
ASF used?
Each resident has an ASF where all records must be kept in the relevant section.
The ASF is the registered corporate file and is to contain one year of records.
Each ASF should not be more than 5cm in thickness. Where a resident requires a
large amount of records to be kept that causes the ASF to exceed the 5cm
thickness, then a new ASF part should be requested. Parts will be used to form a
series of information relating to the resident during the year which should be
maintained in sequential date order.
To manage retrospective organisation of ASF’s, the date range of the contents may
be included as a reference as some of these files may not be sequential.
When information contained in the file is more than one year old but remains
current and required, it is to be transferred to the new ASF. A note that the
document remains current and the date of transfer to the new file, is to be noted
on the top of the document. For example a letter from the neurologist with safety
instructions for a person with epilepsy. This document should be verified as still
being current by notation of date and who verified the information, see RSPM
6.1.5.
Records are to be placed into the relevant corresponding ASF section.
What are
operational
records?
Operational records capture the day to day operation of the residential service that
are not specific to an individual resident. These include:
 diaries
 general shift reports
 staff roster and shift replacement
 household and staff routines
 shopping and menu planning
 household budget and finance information
 minutes of both staff and resident meetings.
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How are
operational
records
managed?
An Administration file (ADF) is the official corporate file that is to be used to
manage operational records. An ADF is requested from regional records
management. Each year, corporate files should be created for each specific type of
information, for example there will need to be a file for house meeting minutes and
a separate file for household budget and finance documents. These files are
registered in the TRIM system.
At the end of each calendar year the documents are to be moved to the archive,
see RSPM 6.1.5.
Role of staff
All staff are responsible to complete and store required documentation on every
shift. This will include but is not limited to:
 shift reports
 diary entries
 resident support including health, medication, Person Centred Active Support
(PCAS)
 shift handover tasks such as cash counts
In addition, staff are required to ensure:
 they adhere to the standards for written documents, see RSPM 6.1
 all records clearly show the date of creation and, where required, a review or
end date
 the name of the staff member who wrote the record is recorded
 document copies or those in draft are marked accordingly as only the most
current and correct information is to be used.
Role of
supervisor
and manager
The records management responsibilities of individual staff and managers are
defined in the Department of Human Services Records Management Policy and
Department of Health Records Management Policy.
The supervisor and manager are required to ensure:
 staff complete all records as required
 information is kept secure and only available to people who have a legal right
to access the information
 ASF’s and ADF’s are updated each year
 the previous years records are managed as required, see RSPM 6.1.5
 staff are trained in records procedures which relate to their work
Resources
 File/health note template – a template to use for recording file notes or health
notes for the resident file. It is available on the DAS Hub.
 Resident profile template – a template to record a brief resident profile. It is
available on the DAS Hub.
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Residential Services Practice Manual 3rd Edition – 6.1.2 – 1
6.1.2 Client Relationship Information System (CRIS)
Issued: August 2012
Applies to all
Contents
What is the Client Relationship Information System (CRIS)?
What information is held in CRIS?
What is information in CRIS used for?
Who enters information in CRIS?
Resources
What is the Client
Relationship
Information
System (CRIS)?
The Client Relationship Information System (CRIS) is the primary electronic file
system used to document client support information required by Disability Services.
All people who are eligible for services and request support must have a CRIS file
created. CRIS is not always used by residential services and the Accommodation
Services File (ASF) remains the formal corporate record for residential services.
What information
is held in CRIS?
CRIS stores information about:
 Critical Client Incidents or significant events
 contact with family or others which may impact on support needs
 changes in resident behaviour or health issues
 support plans
 information which may result in health or welfare risks
 issues which require specific action
 information and copies of legal or formal orders, such as guardianship or
supervised treatment orders.
What is
information in
CRIS used for?
CRIS information is used to provide:
 individualised support
 a summary of data service use, for example, the Federal Government often
requires statistical information to determine on-going funding requirements.
Who enters
information
in CRIS?
Staff with CRIS access may enter their case notes, health information, individual
health plans, Critical Client Incident reports and alerts onto the system based on
regional direction.
Resources
 CRIS, CRISSP, FERIS – client electronic records system. Resources tolls and
information
http://intranet.dhs.vic.gov.au/corporate-service-hubs/technology/cris-crisspferis
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Residential Services Practice Manual 3rd Edition – 6.1.3 – 1
6.1.3 Personal information privacy and access
Issued: August 2012
Applies to all
Contents
What is personal information?
Privacy of personal information
Who can access personal information?
Who has legal authority to access personal information?
Resources
What is personal
information?
Personal information is any information, or opinion, which directly or indirectly
identifies a resident. This includes:
 personal profiles
 plans
 case notes
 file notes
 health information.
This information is held in a resident’s file. This includes the Client Relationship
Information System (CRIS) file and the Accommodation Services File (ASF).
Privacy of
personal
information
Residents have a right to have their personal information remain private unless
disclosure is required, or authorised by law, see RSPM 6.1. Residents can expect
to:
 have personal information provided to others on a ‘need to know’ basis only
 have personal information stored securely
 be informed before any personal information is disclosed in situations where it
is practical and desirable, to do so.
Who can access
personal
information?
Access to personal information held in resident files is restricted to:
 the resident, or their guardian or administrator with authority in the relevant
area, for example, an administrator can only access financial records
 staff working in the residential service (including casual staff) who require the
information to provide support
 other departmental staff with a legitimate business need
 professionals employed to provide services such as health professionals who
need to access or record information to ensure the wellbeing of the resident
 those with legal authority
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Who has legal
authority to
access personal
information?
Resources
Under the Disability Act 2006, the following people can access a resident’s
personal information without their consent.
Community Visitors, who can:
 inspect any part of a residential service and see any resident, at any time,
with or without previous notice
 make enquiries about service provision
 inspect any document relating to a resident which is not a medical record, this
includes:
– financial records
– health files
 inspect any resident medical records, with the consent of the resident or their
guardian, as defined in section 37 of the Guardianship and Administration Act
1986. A medical record is a record created by a treating medical practitioner
for a medical purpose, that is, for medical assessment, diagnosis and
treatment.
The Disability Services Commissioner, who can:
 seek information from any service provider about the workings of their
complaints system
 ask questions about the resident, or their support needs.
The Senior Practitioner, who can:
 inspect and copy any document related to any resident they believe may be
subject to a restrictive intervention or Compulsory Treatment Order
 ask questions about the resident or their support needs.
Victorian WorkCover Authority inspectors who can:
 request any information they require to perform their role, which may include
components of a resident’s file or health records. These requests must be
referred to the regional Disability Accommodation Services manager.
 Corporate Integrity, Information and Resolutions Unit – provides information,
advice, training and tools to support compliance with privacy legislation.
Available on the DHS Hub.
 Disability Act 2006 – provides a legislative framework to strengthen the rights
and responsibilities of people with a disability, see: the Victorian Legislation
and Parliamentary Documents website at: http://www.legislation.vic.gov.au
 Office of the Public Advocate (OPA) – protects and promotes the rights of
people with a disability, see: the OPA website at:
http://www.publicadvocate.vic.gov.au
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Residential Services Practice Manual 3rd Edition – 6.1.4 – 1
6.1.4 Freedom of information
Issued: August 2012
Applies to all
Contents
What is freedom of information?
Freedom of information and disability client records
Records exempt from freedom of information
Resources
What is freedom
of information?
The Victorian Freedom of Information Act 1982 gives people the right to:
 access documents about their personal affairs and the activities of government
agencies
 request incorrect or misleading information about them be amended or
removed.
The Act gives people the right to request information from:
 state government departments
 Ministers
 local councils
 most government agencies and statutory authorities
 public hospitals and community health centres
 universities, TAFE colleges and schools.
Freedom of
information and
disability client
records
Disability client records are subject to the Freedom of Information Act 1982. It is
important staff are aware of this whenever they create a record.
Records exempt
from freedom of
information
Some records are exempt from the Freedom of Information Act 1982 . For
example:
 documents which would involve unreasonable disclosure of information
relating to the personal affairs of a person, including one who is deceased
 health information about a person which would pose a serious threat to the
applicant’s health or safety.
Resources
 Freedom of Information Act 1982 – provides a legal framework which enables
people to access personal information about them held by the government.
Available on the Victorian Legislation and Parliamentary Documents website
at: http://www.legislation.vic.gov.au
 Freedom of information Unit – comprehensive information about freedom of
information for department staff. Available on the DHS Hub.
 Privacy policy – provides the policy and guidelines to meet privacy
requirements in the Department of Human Services. Available on the
Department of Human Services website at:
http://www.dhs.vic.gov.au/disability
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Residential Services Practice Manual 3rd Edition – 6.1.5 – 1
6.1.5 Storing, maintaining, moving and archiving files
Issued: August 2012
Applies to all
Contents
Overview
Why are records retained?
How long are records retained?
ASF in current use
ASF from previous year
ASF is archived after 3 years
Transferring files when a resident moves location
Role of the supervisor and manager
Resources
Overview
Residential services create and keep large amounts of records. Some records such
as a personal profile are actively used over a long period of time, others are used
short term, for example, continence charts. All information forms part of the
department’s records about services provided and business decisions. When this
information is no longer required for regular use or reference it is then managed in
accordance with policy and legislative requirements known as archiving. Archiving
is the process of managing records which are no longer considered to be active but
may need to be referred to in the future.
The Accommodation Services File (ASF) is the official department file for resident
information. A new ASF should be created for each resident each year, and the
previous year’s file can be archived.
Staff and general household records must not be placed in an ASF. This
information is managed in a separate house files and should also be archived on
an annual basis.
Why are records
retained?
Records are created and retained to:
 describe resident support needs
 keep a history of how support is provided to each resident
 provide evidence of actions and decisions in relation to resident support and
the general management of the group home.
Not all information is kept for the same length of time. A statutory document
known as a Retention and Disposal Authority (RDA) specifies how long information
relating to Disability Services needs to be kept.
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How long are
records retained?
All information gathered and used in the provision of disability services funded and
or managed by the department, are managed according to the RDA.
The life span of documents reflects its importance and relevance to both the care
of the resident and its legal or legislative requirement. For example, life spans of
records range from:
 Permanent, known as a state archive
 temporary, only a specified time after the record ceases to be required. For
example, this may range from 1 year after information is no longer referred to
or up to 75 years after death.
ASF in
current use
Each ASF should contain one year of records relating to a client. At the end of each
year a new ASF should be requested from Regional Records Unit and the previous
ASF archived on site for 3 years. The archived ASF’s must be archived by DAS
offsite after 3 years.
All resident information is kept in their allocated ASF – do not place another
resident’s information into some one else’s ASF.
Check that documents are securely attached and the file does not contain items
that should not be in the file, see RSPM 6.1, 6.1.1.
ASF files must be kept in a locked and secured area, preventing unauthorised
access.
Keep
Do not keep
Original information

multiple copies of the same
document
Notes (including sticky notes) related to a
record securely attached to relevant
record.


draft information.
old identification cards such as
pension and health care, library or
other membership cards
Photos taken for support purposes– place
into an a paper envelope and secured in
the ASF.
Note: resident’s personal photo’s are their
personal property.

other information not relevant to
the resident.
items that are not documents, see

RSPM 6.1
Resident information must never be placed into general waste or household
recycle bins. Draft, copies and any other item that has resident, staff or address
details must be placed in secure bins for destruction. These are available at
regional offices.
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Residential Services Practice Manual 3rd Edition – 6.1.5 – 3
ASF from previous
year
The ASF is placed into an archive box. The box must not be directly written on.
The archive box may contain more than one resident’s ASF’s for that year however
it is advisable that residents with a large volume of documentation and multiple
ASF parts use a dedicated archive box containing only that residents’ records.
The archived records must remain on site at the residential service for three years.
During this time, the archive box must be stored in a locked area. After three years
the archive is sent to the regional records unit for processing.
All staff must ensure that boxes are managed in accordance with safe manual
handling practices.
Note: Client finance ledgers will not fit into the archive boxes. The hard covers
should be removed and the ledgers folded over to place into the box. Ledgers and
ASF’s should be kept in a separate archive boxes.
ASF is archived
after 3 years
At the end of three years the records stored in the archive boxes are transferred to
the regional office. ASFs are stored according to regional arrangements. This may
be in the regional office or on an offsite secure storage facility. The TRIM system
allows history, content, location and retention status of records to be easily
identified if required.
The archive boxes should have a completed box contents form placed in the front
of the box which clearly states:
 what is contained in the box
 residential service address
 contact details
date range of information
Note: the boxes must not be directly written on.
Resident information must never be placed into general waste or household
recycle bins. Draft and copies must be placed in secure bins for destruction. These
are available at regional offices.
Operational
records
Records related to the general operation of the residential service are kept in the
Administration file (ADF) and a new ADF should be commenced each year, see
RSPM 6.1.1. The requirements for the management of the ADF content is the
same as the ASF. The ADFs can be placed in the archive box with other
operational records such as communication books and diaries. It is kept on site for
3 years and then transferred to regional records management.
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Transferring files
when a resident
moves location
File transfer occurs when a resident moves from one site to another within the
service. Files are not transferred to external agencies.
The supervisor or manager responsible where the file is located must:
 check prior to transfer to make sure that all information has been filed
appropriately
 make arrangements for the file to be transported securely
 attach the file transfer form to the front of the file
ensure that details are filled in correctly, including details of the person who will
receive the file.
The supervisor or manager responsible at the file’s destination must:
 ensure that file is received intact
 complete details on the File Transfer form
 copy the completed File Transfer form and return a copy to previous location
 attach the File Transfer form to the ASF to ensure that when it is sent in for
archiving that the information can be updated in the TRIM system.
Role of the
supervisor
and manager
Resources
The supervisor and manager are required to have a system in place to ensure
records are:
 managed in accordance with Department of Human Services Record
Management Policy and Disability Services statutory obligations
 stored in a secure location within the residential service
 transferred securely to regional offices:
– at the end of the three year on site storage requirement
– when a resident is deceased or leaves the service.

File Transfer form – a form that must be completed when files are
transferred. Available on the DAS Hub.

Information management – records storage and management
information, policies, procedures and contacts on the DHS Hub.

Information management – security policies, procedures and contacts on
the DHS Hub.

Records education unit resources and guides. Available on the DHS Hub.

Archiving records in Disability Accommodation Services – a visual guide to
managing the packing and management of archive box contents.
Available on the DAS Hub.

Public Records Office Victoria – PROS 08-13 Authority – Retention and
Disposal Authority for Records of the Disability Services Function.
Describes the retention period required for documents and who is
authorised to dispose of documents that are not kept as a permanent
public record. Available at: http://prov.vic.gov.au
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Residential Services Practice Manual 3rd Edition – 6.2 – 1
6.2 Accountability of money
Issued: August 2012
FBR – N GH/I – Y
STJ/LTR/RTF – LD
Contents
Accounting for money
Resident’s who don’t require assistance with money
Staff accountability for funds
Monthly statements of client funds
The financial plan
Unplanned expenses
Resident inclusion
Resources
Accounting for
money
Staff are required to account for all resident and department money expended. The
systems designed to manage and account for money used at the group home are
there to:
 protect the funds of residents who cannot manage their own money
 ensure compliance with departmental financial management and accountability
requirements, see RSPM 6.1
provide reports to financial administrators.
The system is designed to keep a record of:
 all money held on behalf of residents in the Resident Trust Fund
 bank account transactions by staff who hold cards to access accounts on behalf
of clients and the house
 how residents’ money has been spent
Resident’s who
don’t require
assistance with
money
Residents who do not require any staff assistance and independently manage their
own money are not required to participate in the Resident Trust fund processes.
If staff are required to handle any client funds for any purpose they must be
accounted for via the Resident Trust Fund process.
The funds of respite and emergency accommodation service users are managed by a
separate process.
Staff
accountability
for funds
Staff are accountable for all funds they handle so must document all expenditure as
required in the relevant ledger and ensure receipts are provided. Staff must not use
funds or resources intended for use by residents. For example, staff must make a
contribution for meals and pay for private telephone calls, see RSPM 2.1.
Monthly
statements of
client funds
The department must provide residents, or their administrators a monthly statement
of money received and spent. Residential services are provided with monthly
statements which must be reconciled against all transactions for expenditure.
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Residential Services Practice Manual 3rd Edition – 6.2 – 2
The financial plan
A financial plan must be developed and approved for every resident whose money
is managed through the Resident Trust Fund. The financial plan is to be developed
by the:
 resident
 administrator
 supervisor
manager.
The plan allocates the money available to residents and what it may be spent on.
Staff must only expend funds according to the approved financial plan. The plan is
to be kept in the finance section of the ASF.
Financial plans must be reviewed annually.
Unplanned
expenses
Occasionally there may be a need to use funds for a purpose not anticipated in the
financial plan, for example, a resident may need extra money for:
 new clothing
 an unanticipated outing
membership fees of a local sporting or leisure club.
The administrator must approve unplanned expenses, before any purchases can be
made or fees paid.
Resident
inclusion
Resources
Residents should be involved and informed about their financial plan. Where
possible, they should be encouraged to manage their own money independently
especially for small or regular purchases. This requirement can be included in
routines and their financial plan.

Client Expenditure Recording System (CERS) policy manual and tools –
comprehensive instruction and forms for the management of people’s
finances in Department of Human Services disability residential services.
Available on the DAS Hub.

Disability Services - Department managed Residential Charges Policy –
Long Term Accommodation and Facility Based Respite – contains the
current accommodation fees payable in department managed
accommodation services. Available on the Department of Human Services
website at: http://www.dhs.vic.gov.au/disability

Managing utility costs – tip sheet to assist in managing and reducing use
of electricity, gas and water. Available on the DAS Hub

Rights and Accountability: Management of Money Policy – a policy for
disability service providers and their staff on their roles and
responsibilities in relation to managing the money of people with a
disability living in residential services managed or funded by the
Department. Available on the Department of Human Services website at:
http://www.dhs.vic.gov.au/disability
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Residential Services Practice Manual 3rd Edition – 6.3 – 1
6.3 Handling funds in respite services
Issued: August 2012
FBR – Y STJ/GH/I/LTR/RTF – N
Contents
What monies can staff accept?
Process for receiving spending money
When a client holds their own money or valuables
Housekeeping money
Resources
What monies can
staff accept?
Staff can only accept cash as personal spending money for respite service users.
Staff must not accept respite and accommodation charge payments. These are
made by, or on behalf of the person, to regional finance.
Process for
receiving
spending money
When respite service staff receive money, the following processes apply:
 they must check the amount given and immediately provide a receipt to the
family, carer or service user, as appropriate
 if the service user arrives independently, staff must:
– receipt the amount given
– have it countersigned by another staff
– provide a receipt to the family, carer or service user
the amount received must be documented in the Record of Client Expenditure
form.
Cash provided should be secured in a locked tin which must be stored in a locked
safe or cabinet.
When a client
holds their own
money or
valuables
If a respite service user retains their own money or valuables, the following must
apply:
 a Release form must be completed. This form releases staff from responsibility
should the money or valuables be lost or stolen
 a Release form should be signed if a respite service user brings valuable
personal property to the service, or when it is known they are retaining
spending money. The Release form must be kept on file and only needs to be
completed once.
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Residential Services Practice Manual 3rd Edition – 6.3 – 2
Housekeeping
money
Housekeeping money is made up of departmental funds which are provided to pay
for groceries and, in some regions, utilities. This money is department funds and
paid directly to group homes. When using housekeeping money, staff must:
 clearly document cash spent
 provide receipts
complete a Declaration of Expenditure form when receipts cannot be obtained.
All recording forms are pre-printed and available from management.
Resources

Rights and Accountability: Management of Money Policy – a policy for
disability service providers and their staff on their roles and
responsibilities in relation to managing the money of people with a
disability living in residential services managed or funded by the
Department. It is on the Department of Human Services website at:
http://www.dhs.vic.gov.au/disability

Disability Services – Department managed Residential Charges Policy –
Long Term Accommodation and Facility Based Respite. Contains the
current accommodation fees payable in department managed
accommodation services. Available on the Department of Human Services
website at: http://www.dhs.vic.gov.au/disability
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Residential Services Practice Manual 3rd Edition – 6.4 – 1
6.4 Critical client incidents and non-critical client events
Issued: August 2012
Applies to all
Contents
Overview
What is the Critical Client Incident Management Instruction 2011?
Regional responsibility for after hours support
Role of support staff
Completing a critical client incident report
When a manager must be notified immediately (day or night)
Staff actions
When notification to a manager can wait until the next business day
Staff actions
Managing and recording non-critical client events
Types of non-critical client events to record
Additional reports and notifications may be required
Role of supervisors and managers
Resources
Overview
Reporting critical client incidents and non-critical client events that occur in
Disability Accommodation Services form an important part of the ongoing
process of monitoring practice and promoting quality improvement. The process
ensures incidents and events are managed appropriately and all people involved
are adequately supported.
Serious incidents involving a resident are managed according to the
Department’s Critical Client Incident Management Instruction 2011 and this
must be followed by all directly managed services and funded agencies.
Non-critical client events do not fall within the critical client incident
management reporting system but still need to be recorded and captured at a
local level to support and improve service delivery to residents.
Non-critical client events are to be recorded in Department managed residential
services and regularly used by local management to monitor practices and
identify quality improvement strategies. This may reduce the risk of non-critical
client events escalating to critical client incidents as far as possible.
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Residential Services Practice Manual 3rd Edition – 6.4 – 2
What is the Critical
Client Incident
Management
Instruction 2011?
Critical client incidents are those that have or may have a significant adverse
impact on clients, service providers, the community, the department or
government.
Within the Department’s Critical Client Incident Management Instruction 2011
there are two categories of critical client incident:
Category one
These are the most serious incidents. A category one incident is an incident that
has resulted in a serious outcome, such as a client death in unusual or
unexpected circumstances, or severe trauma.
Category two
These incidents involve events that threaten the health, safety and/or wellbeing
of clients or staff.
The Department’s Critical Client Incident Management system ensures:
 appropriate Ministers, the Secretary, Executive Directors, Directors and
Regional Directors are accurately and promptly informed
 the appropriate response and support are provided to all involved
 analysis of critical incidents both locally and centrally to assist and guide:
– identification of gaps in policy and practice
– review and improvement to policy and practice
– practice strategies to reduce the reoccurrence of similar and serious
incidents
Regional responsibility
for after hours support
Regions are to ensure that appropriate management support is provided after
hours. The reporting requirements for critical client incidents do not vary
between business and after hours so regions must ensure that staff who will be
providing this support:
 have sufficient knowledge and experience to provide the required support
 have a good knowledge of the Residential Services Practice Manual and the
Department’s Critical Client Incident Management Instruction 2011
 have a clear understanding of the reporting process and timelines required
for critical client incidents
 are able to provide any immediate supports that may be required at the
location of a critical client incident or provide referral for this to occur.
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Residential Services Practice Manual 3rd Edition – 6.4 – 3
Role of all staff
Staff must follow the Critical Client Incident Management Instruction 2011
requirements and:
 make the required notifications to the manager
 where a manager must be notified immediately, staff must make all attempts
to speak directly to a manager rather than leaving messages
 complete an incident report whenever a critical client incident occurs
 if in doubt whether an issue is a critical client incident or a non-critical client
event, report it as a critical incident
 ensure other staff are informed of the incident and any actions to be
implemented by documenting this in the shift report and resident files, as
required by regional process
 notify the family of incidents that involve injury or hospitalisation of a resident,
according to any agreed prior arrangements
 notify the manager immediately if you are unsure of the category of an
incident, or if the circumstances related to the original report change
 complete any other reports required such as the Disease, Injury, Near Miss,
Accident (DINMA) report.
Completing a
critical client
incident report
Staff must use the Department’s Critical Client Incident Report template. The
report must be written clearly and include all factual information relating to the
incident including:
 the exact circumstances of the incident including what happened, where and
when
 the names and dosages of medications when incidents involve medication
 the names and role of every person involved in, or as a witness to the incident
 actions taken by any person, for example, applied first aid, called fire brigade,
ambulance or police
 any instruction received from the manager or emergency services, stating what
you were asked to do and by whom
actions you took including what you did, when and where.
This is to ensure all required and appropriate actions have been undertaken,
including the provision of supports to residents and staff involved, and to check the
incident is categorised appropriately.
Staff should be aware that incident reports may be used in formal processes such
as investigations into injuries and deaths. The reports are public records, so it is
important that they do not contain comments or personal judgements that cannot
be verified.
Incident reports must be submitted via the regional critical client incident report
lodgement process within the specified timelines.
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Residential Services Practice Manual 3rd Edition – 6.4 – 4
When a manager must
be notified
immediately (day or
night)
If any of the following incidents occur, a manager (the regular line manager
during business hours or the manager providing after hours on-call support),
must be contacted immediately regardless of the time and verbally notified of
(in addition to the completion of the incident report):
 the death of, or serious injury to, a resident or staff member
 allegations of, or actual, sexual or physical assault of a resident or staff
member by a staff member
 physical assault by a resident where the victim requires medical attention
 a fire involving death or serious injury
 a fire involving closure or significant damage to parts of a building or its
contents
 serious property damage that makes the building unsafe or unusable
 injury or deterioration in health that requires urgent medical attention,
hospital admission or attendance by an ambulance (that is not a
requirement of an epilepsy management plan)
 all PRN chemical restraint medication errors
 missed or refused medication or errors in administration where these result
in:
– referral to, or attendance at a hospital emergency department
– loss of consciousness or seizures
– changes in consciousness that reduce a persons physical ability or
normal communication capacity such as sleepiness, unsteadiness on
feet or inability to communicate using usual communication methods
 an event occurs that has the potential to involve the relevant Minister, or
subject the department to high levels of public or legal scrutiny.
Staff actions
The incidents noted above require immediate contact with a manager to notify
them. Staff must:
 speak directly to a manager. The manager receiving notification of the
incident must immediately determine if they should notify the DAS
manager.
 follow any instruction provided by the manager
 ensure, as far as possible, that any person involved in the incident is
adequately supported
 lodge the critical client incident report via the regional lodgement process.
When notification to
a manager can wait
until the next business
day
If any of the following occur the regular manager should be notified. If any of
these occur outside business hours, notification to a manager does not need to
occur immediately and can wait until the next business day. These include:
 serious threats made against residents, staff, visitors or members of the
public
 criminal behaviour resulting in police intervention excluding assaults that
require immediate notification
 sexualised behaviour of a concerning nature that does not involve sexual
assault
 unethical behaviour by staff, particularly if it involves taking advantage of
residents, excluding assaults that require immediate notification.
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Residential Services Practice Manual 3rd Edition – 6.4 – 5
Staff actions
Staff are required to:
 notify the manager
 lodge the critical client incident report via the regional lodgement process.
The manager receiving notification of these incidents is not required to immediately notify
the DAS manager, but should do so if they have concerns about the incident.
Managing
and
recording
non-critical
client events
Non-critical client events are events involving a resident that do not require incident
reporting, but still need to be recorded and used at a local level to identify trends and
develop strategies to prevent future critical client incidents. These are not reported as a
critical client incident.
These events are to be recorded using the Non-Critical Client Event Log to ensure all
events involving a resident can be readily accessed by staff and their line manager at the
local level.
These event logs can be used regularly by key workers and house supervisors to develop
strategies to minimise the risk of these issues escalating to critical client incidents. This
information can also be used for discussion at staff meetings, and to regularly discuss with
line managers the nature and frequency of non-critical client events at a site as part of
regular monitoring and supervision.
Where multiple residents are involved in an event a notation should be made in each
resident’s Non-Critical Client Event Log to describe their role and how they were affected,
to ensure all non-critical client event information for each resident can be considered
together.
Where details of an event are recorded in another location, for example, a behaviour
support chart, a brief notation in the log is adequate with a cross reference to the location
of the detailed event description.
Staff are generally not required to report non-critical client events to the manager either
immediately or the next business day, unless they have concerns about a particular issue.
Similar to other client information, the Non-Critical Client Event Log should be kept in hard
copy on the resident’s current Accommodation Services File and be made available to
Community Visitors on request.
Non-critical events that do not involve specific residents, such as minor neighbourhood
concerns about vehicle parking or general noise levels, the loss of Client Expenditure
Recording System (CERS) bank cards, or accidental withdrawal from the wrong bank
account, do not get recorded as Non-Critical Client Events and can be recorded in shift
reports.
Current policies that include a requirement to complete an Incident Report for issues that
are no longer reportable according to the Critical Client Incident Management Instruction
2011, will be amended to reflect these changes as they are due for review.
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Residential Services Practice Manual 3rd Edition – 6.4 – 6
Types
of
noncritical
client
events
to
record
The following are types of non-critical client events that are to be recorded on the Non-Critical
Client Event Log:
 Health and Wellbeing Concerns (Code HW)
Anticipated deterioration of a known medical condition in a resident, where any contact is made
with NURSE-ON-CALL, a medical practitioner or allied health professional. (Unanticipated
deterioration of a known condition or the onset of an illness, where the resident attends, or
receives treatment from a medical practitioner, is reported as a category 1 or 2 critical client
incident). If doubt exists whether deterioration was anticipated or not, this should be reported as
a critical client incident).

Medication (Code MED)
 Any refused or missed medication or incorrect administration that a Pharmacist, Doctor
or Poisons Information Line has advised does not require medical attention. (Errors
leading to attendance at or treatment by a medical practitioner are reported as a
category 1 or 2 critical client incident).

Accidents/Falls (Code AF)
 Any accident or fall involving a resident, that does not lead to an injury, or the resulting
injury does not require treatment by a medical practitioner. (Injuries requiring treatment
by a medical practitioner, or unexplained or concerning injuries, are reported as a
category 1 or 2 critical client incident).

Concerning Behaviour (Code CB)
 Any PRN medication given for behaviour management that is authorised in a Behaviour
Support Plan. (PRN medication for behaviour management that is not authorised is
reported as a category 1 critical client incident). The focus of the recording in the event
log is to capture the details of the behaviour and what occurred before and after, in
order to identify patterns and ways to prevent events occurring or escalating to critical
client incidents.
All other PRN medication (not for behaviour management) can continue to be recorded
in a resident’s file notes.

Other (Code OTH)
 Any other events that raise staff concerns about the wellbeing of residents that are not
serious enough to be reported as a critical client incident. These should also be raised
with the manager as soon as possible on the next business day, to confirm they should
not be reported as a critical client incident.
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Residential Services Practice Manual 3rd Edition – 6.4 – 7
Additional reports
and notifications
may be required
Role of supervisors
and managers
Some critical client incidents will require completion of additional relevant reports.
For example:
 The incident involved occupational violence:
– Complete the Occupational Violence Risk Assessment Management Tool
(OVRAMT) post incident tool
– Complete a Disease, Injury, Near Miss, Accident (DINMA) report.

A staff member was injured or nearly injured:
– Complete a DINMA report
– The Health and Safety Representative (HSR) must be notified.

Any person on the property including residents, staff, contractors or
visitors, was seriously injured and required medical attention:
– Complete a DINMA report
– Notify WorkSafe immediately by phone and send a completed Incident
Notification form to WorkSafe within 48 hours. See RSPM 3.15, Serious
incident notification to WorkSafe Victoria.

If the incident involves a department vehicle:
– The driver must complete the Lumley Insurance claim form, and a DINMA
report.
– If the vehicle is a bus, the fleet manager must be informed as a Transport
Safety Victoria, bus incident notification may need to be completed and
lodged.

If a resident dies:
– The coroner must be immediately notified of the death of any resident
living in department managed residential services. Only the coroner can
certify a resident’s death and authorise removal of their body.
– The DAS Manager is required to notify the Community Visitors of the death.
See RSPM 6.8.
Supervisors and managers must ensure:
 supports, including debriefing, counselling or advocacy for residents’ or staff
involved in an incident, are available
 all critical client incidents and non-critical client events have been recorded and
dealt with appropriately and as required
 any additional reports and notifications have occurred as required
 communication has occurred to ensure all staff are aware of critical client
incidents and any recommendations or follow up actions required
 implementation of recommendations or follow up actions is documented.
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Residential Services Practice Manual 3rd Edition – 6.4 – 8
Resources

Responding to allegations of physical or sexual assault – a department instruction
that sets out management and reporting requirements relating to allegations of
assault. Available on the DHS Hub.

Critical Client Incident reporting – reporting policy, report templates and guides.
Available on the DHS Hub.

Transport Safety Victoria – Bus safety information and incident notification forms
available at: http://www.transportsafety.vic.gov.au/bus-safety

When a person dies action checklist – a checklist to help ensure all requirements are
met in the event of a person’s death. It is on the DAS Hub.

When a person dies incident reporting guide – a guide to assist in writing the incident
report in the event of a person’s death. Available on the DAS Hub.
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Residential Services Practice Manual 3rd Edition – 6.5 – 1
6.5 Damage caused by people living in residential services
Issued: August 2012
Applies to all
Contents
Procedures to follow if a person causes damage
What is intentional damage?
Who pays for damage?
If the person must pay for the damage
What if the person who caused the damage, or their administrator, is
unwilling or unable to pay?
If the police have decided the damage is a criminal matter
Resources
Procedures to
follow if a person
causes damage
Staff must refer to the Critical Client Incident Reporting Policy to determine what
type of report should be completed when damage occurs. The manager must be
informed immediately if damage:
 is related to property belonging to a member of the public
results in the police being involved.
The report for the circumstances above must contain:
– the name of the person responsible
– the type and extent of the damage and the circumstances of the incident
– if the damage was intentional or unintentional
– the name and address of the person whose property was damaged
– the names of any witnesses.
What is
intentional
damage?
Intentional damage is damage which is deliberate. To be intentional a resident
must understand the outcome of their action. This includes damage to property
belonging to:
 the department
 co-residents
 staff
 a member of the public.
Staff must follow the Critical Client Incident Reporting Policy in conjunction with
this instruction.
Who pays
for damage?
The damage may be paid for by the resident or the department. Responsibility for
costs will be determined by regional management based on considerations
including:
 if the damage was intentional, or unintentional
 if the resident was being supported appropriately when the damage occurred.
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Residential Services Practice Manual 3rd Edition – 6.5 – 2
If the person
must pay for the
damage
The supervisor and manager should determine the cost of the damage according
to quotes or receipts. This information must be provided to the resident’s
administrator. The administrator will decide how the payments will occur. For
example, the administrator can arrange payment by:
 making a direct payment to the person whose property was damaged
 requesting payment be made out of the client funds available at the group
home.
The administrator may suggest replacing or repairing the damaged item.
What if the person
who caused the
damage, or their
administrator, is
unwilling or
unable to pay?
If the resident or their administrator refuses to pay, after it has been determined
they are responsible for the costs, the matter should be referred to the
department’s Legal Services Branch. If the resident does not have sufficient funds
they, or their administrator, should make arrangements to make the payment by
instalments, or when funds become available. This arrangement should be
documented and a copy placed with the resident’s ASF financial information.
If the police have
decided the
damage is a
criminal matter
If the police decide the damage is a criminal matter, client services should be
involved to ensure the resident is represented and understands the proceedings.
The court will determine if the resident is guilty and may provide directions
regarding how the resident must pay. The supervisor and manager are required to
determine the cost of the damage and provide the police with this information.
Resources

Critical Client Incident reporting – reporting policy, report templates and
guides. Available on the DHS Hub.

House maintenance guide – a guide for accessing maintenance and
repairs in group homes. Available on the Department of Human Services
website at: http://www.dhs.vic.gov.au/about-the-department/documentsand-resources/policies,-guidelines-and-legislation/disability-supportedaccommodation-house-maintenance-guide

Singleton Equity Housing Limited and properties owned or managed by
other housing options, follow the maintenance information provided at the
site.
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Residential Services Practice Manual 3rd Edition – 6.6 – 1
6.6 Missing people
Issued: August 2012
FBR/GH/I – Y
STJ/LTR/RTF – LD
Contents
Overview
Confirming if a resident is missing
If a resident is confirmed missing
Informing and reporting
When the resident is found
Resources
Overview
Residential services are generally voluntary and residents have freedom of
movement within their community unless they have an authorised restrictive
intervention or legal order in place. This must to be balanced with reasonable
actions to ensure resident’s who require support to access the community safely
are not placed at unreasonable risk, see RSPM 1.2, 4.2.
The level of support and the resident’s safety risks are to be documented in their
profile and plans to ensure appropriate action can be taken if the resident’s
whereabouts are unknown.
Confirming if
a person is
missing
Staff must take the following steps to confirm if a resident is missing:
If
Then
the resident is
known to wander

the resident will have a response plan in their file (consult
the plan for the steps to follow)
a resident goes
missing from the
residential service

check the diary to see if the resident is at a pre-arranged
meeting or appointment
ask others at the residential service if the resident
mentioned they were going out and where they were going
search inside and outside the residential service and nearby
properties
search the resident’s favourite places



a resident goes
missing on an
outing



a resident does not 
return to the
residential services
at the usual, or

allocated time
search the immediate area
notify staff at the residential service or the manager
seek assistance from the police, or bystanders, if the
resident is at risk when on their own
if the resident was at a particular organisation, contact the
organisation to find out information about the resident’s
whereabouts
if a pre-booked taxi was used, contact the taxi service to
determine if, or when the resident, was picked-up or
dropped off.
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Residential Services Practice Manual 3rd Edition – 6.6 – 2
If a person is
confirmed
missing
As soon as a resident is confirmed missing, staff must notify the manager
immediately and:
If the resident:
Then








has a Supervised
Treatment Order
is at risk to themselves or
the community when
unsupervised


does not have a

Supervised Treatment
Order
is not known to wander
is not a risk to themself or 
the community when
unsupervised
the police do not need to be contacted
immediately (the police must be contacted if the
resident is not found within an hour of being
confirmed missing)
in case the police need to be contacted, compile
a description of the missing resident by
completing the Missing Person Identification form
and have a recent photograph of the resident,
should it be required
has not been found within 
an hour of being

confirmed missing
telephone 000 to report the missing resident
give the police a copy of the Missing Person
Identification form and a recent photograph of
the missing resident
record in the communication book the name,
rank and personal identification number of the
police officer who compiled the report
decide whether to contact the police earlier than
an hour depending on the situation and the
resident involved (management must assist with
this decision, as required).


Informing and
reporting
report the matter to the police immediately and:
provide information documented on the Missing
Person Identification form
provide a photograph of the resident
record in the communication book the name,
rank and personal identification number of the
police officer consulted
Step
Action
Up-date the
manager


management must be informed of the missing resident
if a report is made to the police, the staff member who made
the report must inform their manager immediately
inform the missing 
resident’s family
the manager must inform the missing resident’s family and
develop a plan to keep them up-dated
complete a Critical 
Client Incident
Report

the staff member on duty when the resident went missing
must complete an Critical Client Incident Report
the category of the incident will depend on the
circumstances and the resident involved, see RSPM 6.4
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Residential Services Practice Manual 3rd Edition – 6.6 – 3
When the
person is found
Staff must immediately inform:
 their manager
 other relevant staff
 the family
 the police, if the resident was not found by them.
Staff must ensure the resident’s wellbeing by:
 checking for physical or emotional injuries
 assessing and arranging medical attention, as required.
Resources

Critical Client Incident reporting – reporting policy, report templates and
guides. Available on the DHS Hub:
http://intranet.dhs.vic.gov.au/resources-and-tools/policies-andstandards/incident-reporting-departmental-instruction

Missing person checklist – a list of tasks to complete if a person is missing.
Available on the DAS Hub.

Missing Person Identification form – a form to provide emergency services
with relevant information. Available on the DAS Hub.
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Residential Services Practice Manual 3rd Edition – 6.6 – 4
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Residential Services Practice Manual 3rd Edition – 6.7 – 1
6.7 Responding to physical and sexual assault
Issued: August 2012
Applies to all
Contents
What is physical assault?
What is sexual assault?
Issues that are not reportable as physical or sexual assault
Reporting allegations to the police
If staff suspect a client has been sexually assaulted
What to do when an allegation is made
Supporting victims of sexual assault
Who must report the allegation to the police?
Staff actions
Resources
What is physical
assault?
For the purpose of this instruction, physical assault is defined as the application of
force which causes physical injury requiring medical attention. This definition is not
as broad as the definition provided in the Crimes Act 1958, to exclude some
actions which people with a disability may take due to a lack of social expectation
awareness.
What is sexual
assault?
Sexual assault includes rape, assault with intent to rape and indecent assault.
Examples of indecent assault include:
 unwelcome kissing or touching of a person’s breasts, buttocks or genitals
 forcing a person to watch pornography or masturbation.
Issues that are
not reportable
as physical or
sexual assault
There are some behaviours that do not require a Critical Client Incident Report and
reporting to police. These are treated as non-critical client events and they include:
 minor shoving between residents
 inappropriate touching by a resident who lacks understanding of the behaviour
 exposure in a public place by a resident in some contexts
 a resident does not understand the significance of their behaviour, because of
their cognitive ability, for example, a resident may be unable to distinguish
between the significance of touching someone on the arm, as opposed to
touching them on the breast.
The manager is to be informed, see RSPM 6.4, and an appropriate support plan
implemented and monitored. If staff are unsure as to the nature of the issue they
should seek immediate advice from a manager.
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Residential Services Practice Manual 3rd Edition – 6.7 – 2
Reporting
allegations to
the police
Allegations of physical or sexual assault, are defined in the department’s
Responding to Allegations of Physical or Sexual Assault policy, and must be
reported to the police. Physical and sexual assault includes:
 rape of or by a resident
 rape or indecent assault by a staff member, volunteer carer or member of the
volunteer carer’s household
 the production of child pornography by a resident, staff member or volunteer
 physical assault of a resident by a staff member, volunteer carer or member of
the volunteer carer’s household (regardless of the need for medical attention)
 physical assault of or by a resident resulting in medical attention being
required (treatment by a medical practitioner)
 physical assault of or by a resident involving a weapon, such as a knife,
hammer or other object.
This instruction applies whenever there is an allegation a resident has assaulted, or
been assaulted by:
 another resident
 a staff member
 a volunteer carer
 a visitor to the residential service
 a family member
 a community member.
If staff suspect a
client has been
sexually
assaulted
Some residents may be unable or unwilling to report a sexual assault. Staff
working with people with a disability must be aware of possible indicators of sexual
assault. These include:
 significant behavioural changes which may include:
– self-destructive behaviour
– sleep disturbances
– acting-out
 persistent or inappropriate sexual play
 physical symptoms caused by sexually transmitted diseases or pregnancy
 complaints of physical symptoms, such as abdominal pain.
Staff who suspect sexual assault may have occurred must immediately discuss this
with their manager, or after hours support. A medical review should also occur as
soon as possible with immediate medical attention sought, if a resident displays
physical or emotional signs of assault.
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Residential Services Practice Manual 3rd Edition – 6.7 – 3
What to do
when an
allegation is made
Allegations of assault must always be treated seriously. When there is an
allegation of assault, staff must:
 immediately takes steps to create a safe environment, if the threat remains
 reassure and support the resident and advise them of what will happen next
report the allegation to the police.
If the victim or perpetrator has a cognitive disability, advise the police, an
Independent Third Person (ITP), will be required. If the victim or perpetrator is
less than 18 years of age, a parent, plenary guardian, or Independent Person (IP)
must be present when they give a statement. The police are responsible for
contacting the ITP or IP. Staff must not:
 act as an ITP
 interview the resident about the allegation, as this is a police role.
Some discussion may be required to:
 ensure the resident’s safety
 obtain a basic understanding of what has happened.
If the resident needs to talk about what occurred, listen and show concern.
Depending on the resident’s age and status, notify their next-of-kin, or guardian,
as appropriate. For further information, refer to the department’s policy:
Responding to allegations of physical or sexual assault.
Supporting
victims of
sexual assault
A resident’s feelings may be influenced by their initial reaction to the allegation. If
they sense a negative response, this may cause or reinforce feelings of guilt and
shame. If a sexual assault is disclosed, a helpful response may include:
 letting the resident know you believe them
 making it clear whatever happened is not their fault
 reassuring them disclosing the assault is the right thing to do
 telling them they are not is responsible for the assault.
Sexual assaults reported to police are immediately referred to The Centre Against
Sexual Assault (CASA). CASA provides 24-hour advocacy and counselling and will
support the victim to decide what they want to do.
Who must report
the allegation to
the police?
The allegation must be reported to the police by:
 the most senior staff member on duty at the residential service
 the person who was told of the alleged assault, if a senior staff member was
not on duty at the time.
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Staff actions
Resources
If the alleged perpetrator is present and is continuing to threaten any person, then
staff are to call ‘000’ to seek immediate assistance.

Critical Client Incident reporting – reporting policy, report templates and
guides. Available on the DHS Hub:
http://intranet.dhs.vic.gov.au/resources-and-tools/policies-andstandards/incident-reporting-departmental-instruction

Independent Third Person, Office of the Public Advocate – for
comprehensive information on role and functions of the Office of the Public
Advocate, see: http://www.publicadvocate.vic.gov.au and click on
‘Services’

Responding to allegations of physical or sexual assault – a department
instruction that sets out management and reporting requirements relating
to allegations of assault. Available on the DHS Hub.
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Residential Services Practice Manual 3rd Edition – 6.8 – 1
6.8 When a person dies
Issued: August 2012
Applies to all
Contents
The role of the Coroner
If staff believe a person has died at the residential service
Who can determine if a person has died?
When it is determined a person has died at the residential service
If a person dies in hospital
Role of the manager
Removal of the body when a person dies at the residential service
After the Coroner’s investigation
Responsibility for funeral and burial arrangements
The role of friends or staff in funeral arrangements
Departmental inquiry into a person’s death
Resources
The role of the
Coroner
The coroner may investigate deaths that must be reported to the Victorian Coroner
by law. This includes deaths that:
 are sudden
 are traumatic or unexplained
 occur in people who reside in residential or custodial services that are the
responsibility of government (even if the death occurs elsewhere).
This means it is mandatory to report the death of a resident of a department
managed residential services, even if the person dies while absent from the
service, for example, in hospital, on holiday or an overnight stay with family or
friends. The Victorian Coroner is the only person who can legally certify a
resident’s death and authorise removal of their body from the residential service.
If staff believe a
person has died
at the residential
service
If staff believe a resident has died, they must:
 call an ambulance immediately
 implement relevant first aid procedures, see RSPM 3.12, 5.16
 follow directions provided over the telephone by ambulance personnel
 note the time the resident was discovered
 notify the manager as soon as possible.
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Residential Services Practice Manual 3rd Edition – 6.8 – 2
Who can
determine if a
person has died?




The following people can determine if a resident has died in a residential
service:
a doctor
ambulance personnel
other medical professionals.
When it is
determined a
person has died
at the residential
service
If it is determined that a resident has died at the residential service staff must:
 contact management
 contact police
 document the names, rank and identification numbers of the police who attend
 discuss with management, the most appropriate person to contact the family,
and ensure they are notified
 provide verbal information requested by the police

not provide a written statement to the police at this time.
If a person dies
in hospital
If a resident dies in hospital, staff must:
 inform the manager, or after hours support, as soon as possible.
 check if the hospital has notified the family where the family is not present at
the time the person dies. While the hospital has primary responsibility to notify
next of kin and respond to any queries related to medical issues, a
representative of the department is also required to make contact with the
family. This may need discussion with the manager to determine the most
appropriate staff member to make contact, for example, it would usually be
the supervisor or manager but at times a key worker may have a close
working relationship with the family and may make this contact. The contact
must occur as soon as possible.
 ensure the hospital is aware that the Coroner must be involved
 inform staff coming on shift of the resident’s death.
 follow the Critical Client Incident Reporting instruction, see RSPM 6.4.
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Residential Services Practice Manual 3rd Edition – 6.8 – 3
Role of the
manager
The manager must ensure:
 the family has been contacted by the most appropriate departmental staff
person
 the family is aware of the legal requirement for the Victorian Coroner to be
notified of the death
 the Coroner has been informed (regardless of where the death occurs)
 where another service, such as police or hospital, state they have informed the
Coroner, the manager must confirm this with the Coroners office
 Critical Client Incident reports are completed and the Disability Accommodation
Services manager is informed, see RSPM 6.4
 the resident’s guardian has been informed of their death (orders cease upon
death, but notification should occur as soon as possible).
 support is arranged for co-residents and staff, this may include debriefing from
the Critical Incident Stress Management service, or counselling through the
Employee Assistance Program, see RSPM 2.4
 requirements are completed according to the ‘When a person dies’ checklist
 the Divisional Executive Director or delegate notifies the Community Visitors
Program Manager of a resident death
 the death is noted in the Client Records Information System (CRIS) and
records are archived, see RSPM 6.1.5.
Removal of the
body when a
person dies at the
residential service
When a resident dies at a residential service the Coroner, or their representative,
are the only people who can authorise removal of their body. In the metropolitan
area, the Coroner will arrange for the body to be taken to the Coronial Services
Centre. In rural areas, the resident’s body is usually taken by ambulance to the
local hospital mortuary.
After the
Coroner’s
investigation
After the Coroner has investigated the death, the family, or person arranging the
funeral, must arrange for the body to be collected by the funeral director.
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Residential Services Practice Manual 3rd Edition – 6.8 – 4
Responsibility for
funeral and burial
arrangements
The family is usually responsible for funeral arrangements. If the resident does not
have a family, advice should be sought from the State Trustees. The State
Trustees take responsibility for burial when there is no one to arrange it. In this
case there may not be a funeral service.
The role of friends
or staff in funeral
arrangements
The person arranging the funeral will decide who should be consulted, or asked to
participate in the funeral service. Sometimes a decision is made that a private
service will occur where group home staff and other residents may be excluded
from attending.
Where this occurs, the group home may choose to hold its own memorial or
participate in some other event or ritual to remember the resident, for example by
planting a memorial tree in the garden.
This can be an important part of the grief process. If residents or staff require
support to manage the death of a resident, they should access the Australian
Centre for Grief and Bereavement. Staff may also access the Employee Assistance
Program (EAP), see RSPM 2.4.
Departmental
inquiry into a
person’s death
Resources
The death of a resident is always treated as a Critical Incident, see RSPM 6.4.
Many Critical Client Incidents are reviewed and in some cases the department may
investigate a resident’s death.

Critical Client Incident reporting – reporting policy, report templates and
guides. Available on the DHS Hub:
http://intranet.dhs.vic.gov.au/resources-and-tools/policies-andstandards/incident-reporting-departmental-instruction –incident reporting
policy, report templates and guides. Available on the DHS Hub

State Coroners Office of Victoria – telephone: 1300 309 519. Available at:
http://www.coronerscourt.vic.gov.au

State Trustees – helps people with their financial needs, telephone: 03
9667 6444. The website is located at: http://www.statetrustees.com.au

When a person dies action checklist – a checklist to help ensure all
requirements are met. Available on the DAS Hub.

When a person dies: incident reporting guide – a guide to assist in writing
the incident report in the event of a person’s death. Available on the DAS
Hub.

Australian Centre for Grief and Bereavement – provides information about
counselling and support services. Available at: http://www.grief.org.au
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Residential Services Practice Manual 3rd Edition – 6.9 – 1
6.9 Wills and deceased estates
Issued: August 2012
Applies to all
Contents
Who can make a will?
What is testamentary capacity?
Witnessing a will and making an affidavit
Role of support staff
What if a person dies without a will?
What if the person who died had unpaid bills or debts?
Resources
Who can make
a will?
Anyone who has testamentary capacity can make a will. The Supreme Court can
also make a will on behalf of a person who lacks the capacity to do so.
What is
testamentary
capacity?
Testamentary capacity means at the time of making the will the person:
 understands the nature and effect of what they are doing
 knows in general terms what property they own and can dispose of
 can judge the claims different people may have on their estate.
Witnessing a
will and making
an affidavit
For a will to be valid, it must be signed by two independent witnesses aged over
18 years of age. A person’s partner should not be a witness. Witnesses should also
not be beneficiaries of the will. If there is any reason why a person’s capacity to
make a will may be challenged at a later date, it is advisable to ask a GP or
solicitor to witness the will and swear an affidavit as an attachment. In the
affidavit, the GP or solicitor must confirm the person has testamentary capacity
when making the will.
Role of
support staff
It is not the role of staff to:
 ensure residents have a will. This is the responsibility of the resident or their
guardian.
 be involved or assist with preparing a resident’s will.
Additionally, staff must not:
 assess a resident’s capacity to make a will
 act as an executor for a resident’s will. In situations where staff are made
executors without their knowledge, they must renounce the appointment by
filing an affidavit with the Register of Probates and arrange for the court to
appoint someone else.
 benefit from the estate of a resident they support. In cases where staff are
named beneficiaries without their knowledge, they should renounce this
 knowingly attempt to benefit from the estate of a resident.
Staff can refer residents to an appropriate service such as a solicitor, the
Community Legal Centre or State Trustees if they want to make a will, or their
family requests a will to be made on their behalf.
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What if a
person dies
without a will?
When a resident dies without a will:
 The manager must notify the client services officer at the State Trustees and
arrange for a letter to be written advising them of:
– the person’s death
– details of any known assets and liabilities
– next-of-kin, if known.
The State Trustees are responsible for the estate until an administrator is
appointed. The deceased resident’s former financial administrator is not the
administrator of their estate. The next-of-kin, or interested parties, can apply to
the Supreme Court to administrate the estate. If no one applies to be the
administrator, State Trustees will be responsible for administering the estate. This
includes:
 paying any debts
 distributing the estate to beneficiaries.
State Trustees are responsible for arranging the collection of the resident’s
property and holding it in storage until it can be distributed to beneficiaries. Prior
to the property being collected, the manager should arrange for small items to be
stored in a locked cupboard, or safe at the residential service. Money must be
returned to the Resident Trust Fund. Larger items, such as a chair, table or audiovisual equipment, may remain in the residential service, or be stored in a secure
locked garage or shed, if available.
What if the
person who
died had unpaid
bills or debts?
If the resident has unpaid bills or debts, the organisation or individual owed
money (the creditor) must seek payment from the executor or administrator.
Resources
If
Then
the resident has a
will
there will be an executor managing their estate (refer the
creditor to this person)
the resident does
not have a will
their assets will be frozen until an administrator is appointed
(the administrator will be State Trustees or a person
appointed by the court – refer the creditor to this person).

National Association of Community Legal Centres – has links to local
Community Legal Centres which provide free, confidential advice and
assistance about a variety of legal matters. Available at:
http://www.naclc.org.au

State Trustees – helps people with their financial needs. Available at:
http://www.statetrustees.com.au
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Residential Services Practice Manual 3rd Edition – Part 7
In this section
7
Positive behaviour support
7.1
Reducing and preventing behaviours of concern
7.2
The Senior Practitioner
7.3
Restrictive interventions
7.4
Behaviour Support Plans
7.5
Compulsory treatment
RSPM application to service type
Each instruction has service type and instruction application codes to assist to identify how the specific
instruction applies to supported accommodation by service type.
Service type:
FBR
facility based respite
GH
group homes
STJ
short term justice
LTR
long term rehabilitation program
I
Sandhurst and Colanda
RTF
residential treatment facility (DFATS)
Instruction application:
Y
instruction applies in full
N
instruction does not apply to service type
P
Partial application. Service required to implement principle of instruction but service not generally
directly responsible for planning, monitoring and reviewing components of instruction
LD
Locally determined based on client plans, service model and protocols. Applicable to STJ, LTR and
RTF only
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Residential Services Practice Manual 3rd Edition – 7.1 – 1
7.1 Reducing and preventing behaviours of concern
Issued: August 2012
Applies to all
Contents
Overview
Factors that impact on behaviour
Role of staff
When is an authorised BSP required?
Resources
Overview
Behaviours that impact on an individual and those around them is more than
behaviours defined as behaviours of concern and use of restrictive interventions.
Support strategies that provide opportunities for a resident to develop skills for
meaningful interaction and participation, in conjunction with appropriate health
management will prevent or significantly reduce the risk of behaviours of concern or
withdrawal.
All life areas need to be considered and addressed as far as possible before any
restrictive interventions can be considered, authorised or implemented.
Also see RSPM Preface: Promoting positive practice and RSPM 4.3.
Factors that
impact on
behaviour
All human beings behave according to a variety of factors that include but are not
limited to:
 personal life experiences
 attitudes and expectations of the individual and others
 physical and social environments
 physical, mental and oral health
People with a disability may also be impacted by:
 the cognitive and physical impacts of disability
 medications they take
 discrimination, for example, being denied access to education or employment
 poor access to information, support or physical environments
 exclusion from activities, conversations and decisions.
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Residential Services Practice Manual 3rd Edition – 7.1 – 2
Role of staff
Staff are to follow the Person Centred Active Support (PCAS) method of working with
resident’s and seek specialist advice and assistance as directed by the resident needs,
support plan and related parts of the RSPM. Residents are to be supported to develop
and maximise:
 good health
 communication skills
 relationships and social connections
 choice and decision making
 skills to manage and cope with change
The resident’s support plan, implemented in conjunction with the resident along with
RSPM sections 4 and 5, provide guidance about the information and support activities
required for each individual resident.
When is an
authorised
BSP required?
A Behaviour Support Plan (BSP) may be a useful support tool where a resident has
behaviours of concern that are managed without the use of restrictive interventions. In
this circumstance, the use of the BSP does not require authorisation or reporting to the
Office of the Senior Practitioner as no restrictive interventions are used.
An authorised Behaviour Support Plan is required when a resident has significant
behaviours of concern where supports or interventions require the use of restrictive
practices, see RSPM 7.3, RSPM 7.4.
Staff must not implement any intervention that is restrictive without a BSP that is
developed using the Positive Behaviour Support framework, approved by the Authorised
Program Officer (APO), explained to the resident by an Independent Person (IP) and
lodged with the Office of the Senior Practitioner (OSP).
Resources

Positive Behaviour Support framework- a practice framework designed to reduce
use of restrictive interventions and improve quality of life for people with
behaviours of concern. Available on the Department of Human Services website
at: http://www.dhs.vic.gov.au/about-the-department/documents-andresources/reports-publications/positive-behaviour-support-getting-it-right-fromthe-start
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Residential Services Practice Manual 3rd Edition – 7.2 – 1
7.2 The Senior Practitioner
Issued: August 2012
Applies to all
Contents
Role of the Senior Practitioner
Functions of the Senior Practitioner
What is an Authorised Program Officer?
Role of the Authorised Program Officer
What is an independent person?
Role of the independent person
Resources
Role of the Senior
Practitioner
The Disability Act 2006 states the role of the Senior Practitioner is to ensure:
 the rights of people subject to restrictive interventions and compulsory
treatment are protected
 appropriate standards for restrictive interventions and compulsory treatment
are complied with.
Functions of
the Senior
Practitioner
The Senior Practitioner develops guidelines and standards with respect to
restrictive interventions and compulsory treatment and provides:
 education and information with respect to restrictive interventions and
compulsory treatment
 information with respect to the rights of persons with a disability who may be
subject to restrictive interventions or compulsory treatment
 advice to improve practice in relation to restrictive interventions and
compulsory treatment
directions in relation to restrictive interventions, compulsory treatment and
behaviour support and treatment plans
The Senior practitioner is also to:
 develop links and access to professionals, professional bodies and academic
institutions for the purpose of facilitating knowledge and training with regards
to clinical practice for staff working with persons with a disability
 undertake research into restrictive interventions and compulsory treatment and
provide information on practice options to disability service providers
 evaluate and monitor the use of restrictive interventions across disability
services
 recommend improvements in practice to the Minister and the Secretary
 perform any other functions specified or required by the Disability Act 2006.
What is an
Authorised
Program Officer
An Authorised Program Officer (APO) is any person approved and appointed by the
Secretary of the Department of Human Services, to authorise Behaviour Support
Plans that require the use of restrictive interventions. Authorisation can be revoked
by the Secretary.
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Residential Services Practice Manual 3rd Edition – 7.2 – 2
The role of the
Authorised
Program Officer
The APO must ensure that strict criteria have been met in the development of the
Behaviour Support Plan, including inclusion of least restrictive alternatives
consistent with the Positive Behaviour Support framework. Restrictive interventions
can only be used when a resident displays behaviours which place them or others
at risk, and behavioural change has not occurred with the introduction of nonrestrictive interventions. The APO may only authorise the use of restrictive
interventions where:
 It is necessary to prevent the resident from:
– causing physical harm to themselves or others
– destroying property when doing so involves the risk of harm to themselves
or others. Note; property destruction alone is not sufficient to implement a
restrictive intervention.
 evidence is provided that it is the least restrictive alternative for the resident
and co-residents and the evidence describes:
– the strategies that have already been tried
– why the restriction is necessary
– how the restrictive intervention will be reduced and removed overtime
– how the option places the least restriction on co-residents.
What is an
independent
person?
An Independent Person (IP) assists residents to understand the restrictive
interventions in their Behaviour Support Plan. An IP must not:
 be a disability service provider, or a representative or an employee of a
disability service provider
have any interest in a disability service provider which is providing, or has
provided, disability services to the person with a disability.
An IP toolkit, which contains a range of information for service providers and staff
and persons who may act as an IP, is available from the Office of the Senior
Practitioner.
Role of the
independent
person
The IP must explain to the resident:
 the inclusion of restraint or seclusion in their BSP
 they can seek a review of the decision to include restraint or seclusion in their
BSP
 how the revised BSP will be different, should they already have a BSP.
The IP may report the matter to the Public Advocate if they consider:
 the resident is not able to understand the proposed use of restraint, or
seclusion, as detailed in their BSP
 the requirements of the Disability Act 2006 are not being complied with.
Resources

Office of the Senior Practitioner – oversees, and provides information and
resources on, the use of restrictive intervention and compulsory treatment.
Available on the Department of Human Services website:
http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protectingrights/office-of-the-senior-practitioner
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Residential Services Practice Manual 3rd Edition – 7.3 – 1
7.3 Restrictive interventions
Issued: August 2012
Applies to all
Contents
What are restrictive interventions?
Least restrictive strategies must be tried
Locking of doors and windows
The use of side rails on beds
Chemical restraint
Physical restraint
Seclusion
What interventions are not reportable?
Approval of restrictive interventions
Emergency use of restraint and seclusion
Reporting requirements
The role of the supervisor and manager
Resources
What are
restrictive
interventions?
A restrictive intervention means any intervention used to restrict the right or
freedom of movement of a person with a disability. This includes:
 chemical restraint – a chemical substance used for the primary purpose of
behavioural control
 mechanical restraint – the use of devices to prevent, restrict or subdue
movement for the purpose of behaviour control
 seclusion – the sole confinement of a person where the windows and doors
cannot be opened by the person from the inside, or are locked from the
outside.
Staff should refer to the Disability Act 2006, Part 1 – Preliminary, Section: 3 for
more detailed definitions of the above restrictions. In addition, any action which
impacts on a resident’s rights according to the Victorian Charter of Human Rights
and Responsibilities Act 2006 must be viewed as restrictive, see RSPM Preface.
Restrictions may be physical or psychological. Physical restrictions include, but are
not limited to:
 locking doors, windows and cupboards
 physically holding a resident (physical restraint) or blocking access to a
common area of the residential service, such as the kitchen
 straps or belts on chairs and bed rails used to stop or restrict a resident’s
freedom of movement.
Psychological restrictions include, but are not limited to:
 exclusion from activities
 verbal threats and intimidation
 any action or directive which creates compliance through the use of fear. For
example, ordering a resident to go to their room, or lie on the ground.
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Residential Services Practice Manual 3rd Edition – 7.3 – 2
Least restrictive
strategies must
be tried
Least restrictive strategies must always be tried by following the Positive Behaviour
Support framework. Staff must only apply restrictive strategies that are part of the
authorised Behaviour Support Plan (BSP). Restrictive interventions must be:
1. Part of a resident’s approved BSP
2. Administered in accordance with the resident’s approved BSP
3. Only applied for the period of time which has been approved by the APO
4. Have been explained to the resident by an Independent Person.
To decide if an intervention is restrictive the intent or primary purpose needs to be
determined. To do this staff must ask if the intervention is for behaviour control or
to restrict freedom of movement. Unauthorised restriction may breach duty of
care, see RSPM 1.2.
If the intent or primary purpose is unclear, the intervention should be treated as
restrictive, be authorised before it can be used and must be reported.
The locking of internal or external doors and windows to restrict a resident’s access
in or out of the residential service, or access to internal common areas or facilities,
is a restriction on freedom of movement and is a restrictive intervention. This
includes:
 placing locks on cupboards and refrigerators to restrict access to food
 turning-off the water supply to taps in bathrooms or kitchen, or restricting
access to water.
The approval and reporting processes in these situations is the same as those
required for other restrictive practices. Access restrictions to any area or common
facility must be noted on the Residential Statements of co-residents. The
information must include strategies to reduce the impact on co-residents.
Examples of locked doors and windows not considered a restrictive intervention
include:
 a door being locked from the outside when a resident is absent (to protect
their property from theft)
 external doors and windows (which do not require a key to be opened from
the inside) being locked for the purpose of deterring intruders
 the front door being locked from the inside to ensure the safety of resident
who require constant supervision when outside of the residential service. For
example, residents with little or no understanding of road safety who may walk
onto the road. For these residents the following must occur:
– the safety issue must be noted in their support plan
– the practice must be included in the Residential Statements of co-residents
– written approval for door locking practices to be implemented must be
provided by the Disability Accommodation Services manager
– doors must only be locked when the resident for whom approval is
applicable, is at the residential service
– the approval must be reviewed every 12 months to ensure it:
o remains necessary
o is the least restrictive option for co-residents.
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Residential Services Practice Manual 3rd Edition – 7.3 – 3
The use of side
rails on beds
The use of bed side rails should only be considered in exceptional circumstances.
Chemical
restraint
Chemical restraint medication must be authorised and administered in accordance
with the medication section of the RSPM. Staff should read the medication
information provided by the resident’s doctor and pharmacist and contained in
their BSP to understand the reasons why it is being prescribed. If the prescribing
doctor details specific medication monitoring is required, it must be included in the
resident’s BSP. If additional monitoring, other than observing the resident is
required, the supervisor and manager must determine the capacity of staff to do
this based on the:
 requirements involved
 skills of staff.
Information from the pharmacist and prescribing doctor should be discussed at the
staff meeting to ensure staff have a shared understanding of why the resident has
been prescribed chemical restraint medication. If other medication changes occur,
staff should ask the doctor if these may impact on the prescribed chemical
restraint medication. If the doctor or pharmacist indicates the effect of chemical
restraint medication may be altered, (even if the chemical restraint medication
dose has not been altered), the information must be reported to the APO and the
Office of the Senior Practitioner to determine if a variation to the resident’s BSP is
required. Chemical restraint must be reviewed by the treating doctor at no more
than four month intervals. A review must also occur annually (or more often if
determined during the planning process) by the relevant medical specialist, for
example, the psychiatrist, paediatrician, neurologist or gynaecologist.
For example, consideration should be given to less restrictive interventions such as
lowering the bed to its lowest level and placing a fall-out mat beside it, if there is a
risk the resident may roll-out. Bed side rails represent the most restrictive option
and can only be used where a comprehensive assessment by a qualified
occupational therapist demonstrates they:
 present a lower risk to the resident than not using them
 are not for mechanical restraint purposes.
The same therapist must specify the details of how and when bed side rails can be
used. In this circumstance the APO needs to sight evidence, for example, an
assessment tool, report or recommendation, which states the bedding system has
been prescribed for therapeutic purposes, and not mechanical restraint. Any bed
side rail system which has not been recommended following assessment by an
occupational therapist, and prescribed by them, must be:
 considered mechanical restraint
 approved and reported as a restrictive intervention.
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Residential Services Practice Manual 3rd Edition – 7.3 – 4
Physical restraint
Physical restraint is where a person is physically held by another person to prevent
movement. Physical restraint may only be used in strict accordance with the OSP
Direction on Physical Restraint as it presents a high risk of injury to all involved.
Some forms of physical restraint in conjunction with specific risk issues that some
individuals may have, can cause death so are prohibited.
Applying unauthorised or prohibited physical restraint may be assault. Staff should
never apply physical restraint unless it is part of an authorised BSP they have been
trained to implement.
Safety measures, such as holding a person’s arm for a brief period to stop them
walking onto a road, is not considered physical restraint.
Seclusion
Seclusion is the confinement of a resident to a room or part of a building that is
locked or has a barrier used that stops their freedom to exit. Where seclusion is
part of an authorised BSP staff must ensure:
 the environment is suitable, including appropriate heating and cooling
 clothing, food and medications are available
 access is available to appropriate toilet facilities
The maximum time period allowed for the seclusion must be documented in the
BSP and adhered to.
What interventions There are some restraint exemptions which are not reportable under the Disability
are not
Act 2006. These include:
reportable?
 the use of seatbelts and seatbelt buckles to stop a resident removing the belt
when in a moving vehicle
 support straps to ensure a resident does not fall from a wheelchair
 splints applied for therapeutic purposes
 psychotropic medications prescribed to treat a resident’s psychiatric illness
which has been diagnosed and documented by a psychiatrist.
Prescribed treatment or therapy which is not reportable as a restrictive intervention
must be documented as a specific management strategy in the resident’s health
plan, and be reviewed by the relevant medical or health professional, see RSPM 5.2.
Restrictive interventions cannot be applied without APO approval. The Office of the
Senior Practitioner must be provided with a copy of the approved BSP within two
working days. Staff must not apply any intervention which may cause restriction
without approval from the APO. The BSP guidelines available from the Office of the
Senior Practitioner should be used to assist BSP development.
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Residential Services Practice Manual 3rd Edition – 7.3 – 5
Emergency use
of restraint and
seclusion
Section: 147 of the Disability Act 2006, directs the circumstances whereby
restraint and seclusion may be used in an emergency situation on a resident who
does not have an approved BSP that provides for the use of restraint and
seclusion. For example, doors may be locked in a one-off emergency where a
resident is engaging in behaviour which is placing co-residents and staff at risk.
Locking the doors ensures the safety of the parties involved. Emergency restraint
and seclusion can only be used if the approved disability service provider believes:
 there is imminent risk of the resident causing serious physical harm to
themselves or others and the conditions for use of emergency restraint or
seclusion have been satisfied
 it is necessary to use restraint or seclusion to prevent such risk.
In these cases, the following conditions apply:
 the use and form of restraint or seclusion must be the least restrictive possible,
given the circumstances
 the use of restraint or seclusion must be authorised by the person in charge
 the APO must be notified without delay of the use of restraint or seclusion
 the manager must be notified of the intervention, including after hours.
The Restrictive Interventions Data System (RIDS) is the tool which must be used
to report restrictive interventions. RIDS must be completed monthly and forwarded
to the APO. If interventions are not used, a nil-return must be lodged.
The APO is required to report to the Office of the Senior Practitioner the use and
form of restrictive interventions for the service outlets in which they are
responsible. The APO is also responsible for ensuring returns are completed, as
required, and forwarded to the Office of the Senior Practitioner within seven days
of the end of each month.
Staff should ensure they:
 participate in the development of support plans and BSP’s
 implement tasks and activities outlined in resident support plans including
PCAS
 follow the directions of the approved BSP
 do not apply restrictions which have not been authorised, see RSPM Preface,




1.2, 4.2
attend training to ensure the health and safety of:
– the resident to which the restriction is to be applied
– colleagues
– themselves
document the use of interventions, as required
are familiar with RSPM Section: 1.2: Duty of care in residential services
report concerns to their supervisor or manager.
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Residential Services Practice Manual 3rd Edition – 7.3 – 6
The role of the
supervisor and
manager
Resources
Supervisors and managers must ensure assessments and documentation are
completed. This requirement will assist the APO to determine if the proposed
restraint or seclusion is the least restrictive option. If a resident is subject to
restrictive interventions, supervisors and managers must ensure:
 the approval is current
 the restriction is implemented as per the approved BSP
 the restriction is recorded appropriately, as applied
 the restriction is reported as directed by the Office of the Senior Practitioner
 concerns regarding the use of the intervention are documented
 staff, including casuals, who are required to implement the restraint or
seclusion described by the BSP, are trained in inclusive communication
strategies and have refresher training, as recommended
 staff training needs are referred to regional Learning and Development Coordinators.
Where locked doors are in place, and it is not considered a restrictive intervention
as outlined in this instruction:
 the Disability Accommodation Services manager must confirm it is the least
restrictive option for the resident involved and co-residents
 strategies must be in place to reduce the impact on co-residents
 written approval must be provided and reviewed every 12 months by the
Disability Accommodation Services manager for the locked door practice to
continue
Where the use of bed side rails is in place and is not considered a restrictive
intervention as outlined in this instruction, the APO needs to sight evidence to be
satisfied the bedding system has been prescribed for a therapeutic purpose and
not as mechanical restraint. This evidence may include:
 an assessment tool
 report and recommendations.

Office of the Public Advocate (OPA) – protects and promotes the rights of
people with a disability, see: http://www.publicadvocate.vic.gov.au

Office of the Senior Practitioner – oversees, and provides information and
resources on, the use of restrictive intervention and compulsory treatment.
Available on the Department of Human Services website:
http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protectingrights/office-of-the-senior-practitioner

Senior Practitioners direction on physical restraint – The direction from the
Senior Practitioner on the prohibition of physical restraint. Available on the
Department of Human Services website: http://www.dhs.vic.gov.au/aboutthe-department/documents-and-resources/reports-publications/physicalrestraint-direction-paper-senior-practitioner

Restrictive Interventions Data System (RIDS) – the system for reporting
the use of restrictive interventions. Available on the DAS Hub
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Residential Services Practice Manual 3rd Edition – 7.4 – 1
7.4 Behaviour Support Plans
Issued: August 2012
Applies to all
Contents
What is a Behaviour Support Plan?
What are behaviours of concern?
Developing an authorised BSP
Before lodging a BSP with the APO for approval
To ensure a BSP can be implemented
Review of an authorised BSP
Role of the supervisor and manager
Role of support staff
Resources
What is a
Behaviour
Support Plan?
A Behaviour Support Plan (BSP) is a plan which is developed within the Positive
Behaviour Support framework and:
 specifies a range of strategies when supporting a resident to alter their
 behaviour
 reduces the risk of harm.
The plan includes proactive strategies to build on a resident’s strengths and
increase their life skills.
A BSP which has provisions for the use of restrictive interventions must be
developed and authorised for implementation in accordance with the directions of
the Authorised Program Officer (APO) and Office of the Senior Practitioner (OSP)
and be explained to the resident by an Independent Person (IP). Authorised BSP’s
are only used where a resident has a behaviour of concern that has not responded
to positive behaviour support strategies.
The BSP template provided by the OSP is to be used when restrictive interventions
are proposed, as this format has been developed to assist with positive behaviour
support and compliance requirements.
What are
behaviours of
concern?
Behaviours of concern are behaviours which individuals who have a physical,
sensory or cognitive disability present with, or are at risk of presenting with, which:
 are severe dangerous behaviours
 are not age or culturally appropriate
 cause serious harm to the individual, others or property
 without long-term support and intervention will continue to challenge usual
support services and potentially form a barrier to the resident’s participation
and inclusion in society.
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Residential Services Practice Manual 3rd Edition – 7.4 – 2
Developing an
authorised BSP
An authorised BSP cannot be developed or implemented if the residents’ health and
other life areas have not been addressed as far as possible, see RSPM 7.1. This
includes any changes that may have occurred in the residents’ life or routines being
investigated and appropriate support strategies provided. In addition, a functional
behavioural assessment must be completed if:
 a resident presents with behaviours which impact on their health and safety, or
the health and safety of others
 the known behaviour increases, or alters significantly.
The Occupational Violence Risk Assessment Management Tool (OVRMAT) must also
be completed, or reviewed, as required. Staff and managers should consult the
Office of the Senior Practitioner resources to familiarise themselves with current
behaviour support publications and information.
Requests for specialist services support must be registered with Client Services
Intake, or as per regional processes.
Before lodging a BSP
with the APO for
approval
The BSP form must be completed in full to ensure the OSP is:
 able to register the BSP
 follow-up queries or concerns.
This includes the:
 resident’s name, address, date of birth, gender and CRIS number
 address and name of the service provider, for example, the DHS region and
regional address
 details of other disability services which the resident accesses
 completed and review dates
 name, date and signature of the APO
 name of the Independent Person and their relationship to the resident.
If the resident has an appointed guardian, this person must be involved and be
identified in the BSP as their guardian. Additionally, the BSP must clearly:
 identify the type of restraint required
 state the circumstances for which the approved restraint can be used
 list the least restrictive options to be used first
 explain the benefits of the intervention.
Failure to check and complete these details may result in the BSP not complying
with the requirements of the Act.
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Residential Services Practice Manual 3rd Edition – 7.4 – 3
To ensure a BSP can
be implemented
When implementing a BSP it is important:
 the environment is suitable for the requirements of the plan
 co-residents receive information and support to ensure their wellbeing and
safety, if incidents occur
 managers refer training needs to regional Learning and Development Coordinators to ensure staff have access to learning and development
opportunities which:
– develop communication skills with a focus on augmentative and alternative
communication strategies (if these are recommended in the communication
assessment)
 is part of a positive behaviour support strategy which includes strategies to
address:
– communication issues
– the safety of staff and others.
If the BSP identifies staff require assault response training, this can only occur after
positive behaviour support training has been delivered. This requirement must be
clearly documented in the resident’s BSP.
Review of an
authorised BSP
Authorised BSP’s must be reviewed within a 12 month period, or at intervals as
specified by the APO or OSP. BSP reviews should include those who were involved
in the original planning process. A resident may request a BSP review at anytime.
Staff should review the BSP at on-going staff meetings to ensure it is:
 well understood
 being implemented, as required.
Role of the
supervisor and
manager
The supervisor and manager must ensure:
 authorised BSP’s are in place, as required
 staff understand their role in implementing BSP’s
 staff training needs are included in the support information required to
implement the BSP
 staff have access to identified training and refresher training, as required
 staff training needs are referred to regional Learning and Development Coordinators
 BSP’s are discussed at staff meetings to ensure they are understood and
consistently applied.
Role of all staff
Generally, staff have the primary responsibility for implementing BSP’s on a day-today basis. It is important staff:
 participate, as far as possible, in the development of BSP’s
 raise concerns or queries with the relevant person
 attend training specific to BSP’s
 complete necessary documentation as required by BSP’s
 assist with the reporting requirements of authorised BSP’s
 are familiar with RSPM Preface, 1.2, 4.2.
 do not implement any restriction which is not part of the authorised BSP
 follow the PCAS method of working with residents, see RSPM 4.4.
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Residential Services Practice Manual 3rd Edition – 7.4 – 4
Resources

Behaviour Support Plan format and Practice guide. Available on the
Department of Human Services website: http://www.dhs.vic.gov.au/aboutthe-department/documents-and-resources/forms-and-templates/behavioursupport-plan-template

Occupational violence – policy, implementation guidelines, procedures and
tools. Available on the DAS Hub.

Occupational violence risk assessment and management – an electronic
tool on preventing occupational violence. Available on the DAS Hub.

Office of the Senior Practitioner – oversees, and provides information and
resources on, the use of restrictive intervention and compulsory treatment.
Available on the Department of Human Services website:
http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protectingrights/office-of-the-senior-practitioner

Office of the Public Advocate (OPA) – protects and promotes the rights of
people with a disability. Available at: http://www.publicadvocate.vic.gov.au

Strengthening rights in residential services: Policy statement – an
explanation of the policy expectations of residential service providers in
relation to residential rights. Available on the Department of Human
Services website at:
http://www.dhs.vic.gov.au/__data/assets/pdf_file/0010/599122/dis_act_20
06_residentialrightspolicy_pdf_-0610.pdf
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Residential Services Practice Manual 3rd Edition – 7.5 – 1
7.5 Compulsory treatment
Issued: August 2012
Applies to all
Contents
What is compulsory treatment?
Changes to treatment plans
Resources
What is
compulsory
treatment?
Compulsory treatment, residential treatment orders and security orders can only
be applied if specific requirements are met. People who are authorised under the
Disability Act 2006 to participate in making this determination include:
 the Secretary of the Department of Human Services
 the Senior Practitioner
 Authorised Program Officers
 the Adult Parole Board
 the Secretary of the Department of Justice.
Any resident who is subject to a compulsory treatment order must have an
approved treatment plan. The treatment plan requirements outline the way that
staff must support the resident.
Changes to
treatment plans
A change cannot be made to a treatment plan unless it is approved by the Senior
Practitioner. The Senior Practitioner cannot approve a change to a treatment plan
which relates to an increase in supervision or restriction, except in an emergency.
The Victorian Civil and Administrative Tribunal (VCAT) is the only authority which
can approve a variation in a treatment plan which involves an increase in
supervision or restriction. If the Senior Practitioner approves a change in an
emergency situation, they must immediately apply to VCAT for a variation of the
treatment plan.
Resources

Office of the Senior Practitioner – oversees, and provides information and
resources on, the use of restrictive intervention and compulsory treatment.
Available on the Department of Human Services website:
http://www.dhs.vic.gov.au/for-individuals/your-rights/offices-protectingrights/office-of-the-senior-practitioner

Victorian Civil and Administrative Tribunal (VCAT) – VCAT deals with a
range of disputes, appoints guardians and administrators and has the
power to review certain matters under the Disability Act 2006. Available at
http://www.vcat.vic.gov.au
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Residential Services Practice Manual 3rd Edition – 7.5 – 2
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