NDIS Policies and Procedures Manual – Core Module
Document Number: CM-POL-005
Document Control
This table shows a record of significant changes to the document.
| Legal Name: | Holistic Healthcare Management Services |
| ABN: | 20695058096 |
| ACN: | 695058096 |
| Primary address/head office: | 15 Agasse Way, Tapping WA 6065 |
| Document Name: | NDIS Policies and Procedures Manual – Core Module |
| Document Number: | CM-POL-005 |
| Approved by: | Director |
| Date Approved: | February 2026 |
| Version No: | 1.0 |
| Comments: | Initial Release of the Policies and Procedures Manual |
| Next Review Date: | May 2026 |
Introduction and Purpose
Holistic Healthcare Management Services is committed to safeguarding participants by ensuring that all supports and services provided are free from violence, abuse, neglect, exploitation, and discrimination. This policy outlines the principles, procedures, and practices aimed at preventing, addressing, and resolving such issues in alignment with the NDIS Practice Standards and Australian legislative requirements.
This policy provides a framework to uphold the dignity, rights, and safety of participants, ensuring any allegations or incidents are handled effectively, transparently, and with the utmost care to prevent recurrence. It also empowers participants to access advocacy services and participate in decisions about their care and safety.
Scope
This policy applies to all Holistic Healthcare Management Services staff, including permanent and casual employees, contractors, volunteers, and third-party service providers.
It also applies to all participants accessing supports and services through Holistic Healthcare Management Services, ensuring their rights to safety, dignity, and respect are upheld.
Definition
| Term | Description |
|---|---|
| Violence | Refers to the use of physical force or coercion intended to harm a participant or their property. This includes but is not limited to physical assaults, threats, or intimidation that compromise the participant’s safety. |
| Abuse | Encompasses any act or behaviour that causes harm, distress, or exploitation of a participant. This may include physical abuse (hitting, slapping), emotional abuse (verbal insults, manipulation), sexual abuse (unwanted or coercive sexual contact), or psychological abuse (intimidation, threats, controlling behaviour). |
| Neglect | The failure to provide necessary care, supervision, or services to a participant, leading to harm or risk of harm. Neglect may be active (intentional) or passive (unintentional due to lack of awareness or resources). |
| Exploitation | Involves taking advantage of a participant for personal or financial gain. This includes actions such as coercing participants into giving money or property, forcing them to perform unpaid work, or manipulating them for personal benefit. |
| Discrimination | The unfair or unequal treatment of a participant based on their race, gender, age, disability, religion, cultural background, or other protected characteristics. Discrimination may be direct (overt exclusion or mistreatment) or indirect (policies or practices that disproportionately disadvantage certain groups). |
| Advocate | A person or organisation chosen by the participant to represent their interests and ensure their rights are upheld. Advocates play a critical role in supporting participants through complaints or decision-making processes. |
| Incident | Refers to any event or situation involving violence, abuse, neglect, exploitation, or discrimination that negatively impacts a participant’s safety, rights, or well-being. Incidents may include both witnessed events and reported allegations. |
Outcomes and Indicators
| Term | Description |
|---|---|
| Each participant accesses supports free from violence, abuse, neglect, exploitation or discrimination. |
|
Guiding Principles
- Zero Tolerance for Harm: All forms of violence, abuse, neglect, exploitation, and discrimination are strictly prohibited. This principle underpins Holistic Healthcare Management Services’s commitment to creating a safe and supportive environment for all participants.
- Participant-Centred Safeguarding: Supports and services are designed and delivered with the participant’s safety, preferences, and rights at the forefront. Participants are encouraged to voice their concerns, provide feedback, and be active collaborators in ensuring their own protection.
- Empowerment and Advocacy: Participants are informed of their rights, including the right to access advocacy services. Advocacy is facilitated as an integral part of safeguarding to ensure participants can effectively assert and defend their rights.
- Transparency and Accountability: Allegations and incidents are addressed promptly and effectively, with open communication between participants, staff, and advocates. Transparent processes are implemented to ensure accountability at all levels of service delivery.
- Continuous Improvement: Policies and procedures are subject to regular reviews and updates to incorporate best practices, participant feedback, and lessons learned from past incidents. Continuous improvement ensures the ongoing effectiveness of safeguarding measures.
Policy
Holistic Healthcare Management Services ensures that participants receive supports in an environment free from violence, abuse, neglect, exploitation, or discrimination. This commitment is reflected in all aspects of service delivery, from policy development to day-to-day practices.
To achieve this, Holistic Healthcare Management Services will:
Prevention and Awareness
Develop and implement comprehensive policies, procedures, and training programs to actively prevent harm. This includes raising awareness among staff, participants, and the wider community about the importance of safeguarding (Indicator 1).
Participant Advocacy
Provide participants with clear, accessible information about their rights and the availability of advocacy services. Participants are encouraged to engage advocates to represent their interests, particularly in cases involving allegations or concerns of harm (Indicator 2).
Incident Management and Response
Establish robust procedures for reporting, investigating, and resolving allegations and incidents. Participants affected by harm are provided with emotional and practical support throughout the process, and corrective actions are taken to prevent recurrence (Indicator 3).
Staff Training and Development
Ensure all staff members are trained to identify and respond to signs of harm. Training programs include modules on safeguarding principles, mandatory reporting, and ethical practices to equip staff with the knowledge and skills needed to uphold participants’ safety and dignity.
Collaboration and Feedback
Engage with participants, families, advocates, and external stakeholders to foster a collaborative approach to safeguarding. Feedback mechanisms are used to identify areas for improvement and ensure participants’ voices are central to policy and practice development.
Procedure
Prevention Strategies
Holistic Healthcare Management Services employs proactive measures to prevent violence, abuse, neglect, exploitation, or discrimination. These include comprehensive staff training on safeguarding, mandatory reporting, and ethical practices. Training modules are designed to equip staff with the skills to recognise early warning signs of harm, address concerns sensitively, and uphold participants’ rights.
A robust risk management framework identifies and mitigates risks associated with service delivery. This includes regular reviews of participant care plans, environmental assessments, and consultation with participants to address any concerns they may have. Prevention strategies also extend to embedding a culture of respect and inclusivity across the organisation, ensuring that staff model appropriate behaviour at all times.
Participants are encouraged to provide feedback and raise concerns without fear of reprisal. Clear, accessible communication channels, including anonymous reporting mechanisms, are made available to all participants and their support networks.
Supporting Dignity of Risk
Participants are provided with clear, detailed information about their right to access advocacy services. This includes independent advocates who can support them during investigations or reviews of incidents involving violence, abuse, neglect, exploitation, or discrimination.
Staff are trained to facilitate timely access to advocacy services by identifying local advocacy organisations, assisting with referrals, and arranging meetings. Participants are encouraged to involve advocates in all aspects of their care, particularly when making complaints or decisions about their safety.
Advocates are integrated into the support process as valued partners. Staff are trained to collaborate respectfully with advocates, ensuring their input is considered in decision-making and support planning. Records of all advocacy involvement are meticulously maintained, ensuring transparency and accountability.
Responding to Allegations and Incidents
When an allegation or incident occurs, it is addressed with urgency, sensitivity, and a participant-centred approach. Staff must immediately report the incident to their supervisor, who ensures appropriate actions are taken, including notifying relevant authorities if required by law.
Participants affected by the incident are provided with emotional and practical support. This includes arranging medical care, counselling, or alternative accommodation if necessary. Staff are trained to handle such situations with compassion, ensuring participants feel safe and supported throughout the process.
An internal investigation is conducted to establish facts and identify areas for improvement. The investigation process is documented thoroughly, including actions taken to address the incident and prevent recurrence. Lessons learned are incorporated into policy reviews and staff training programs to enhance organisational practices.
Supporting Participants During and After Incidents
Participants involved in incidents receive continuous support tailored to their specific needs. This includes regular check-ins, counselling services, and updates on the outcomes of investigations. Support plans are reviewed and adjusted to address any risks or vulnerabilities identified during the incident review process.
Participants are informed of their rights throughout the process, including their right to escalate concerns or seek external reviews. Staff are trained to provide clear, compassionate communication and ensure participants remain informed and involved at every stage.
Roles and Responsibilities
| Ref No | Roles | Responsibilities |
|---|---|---|
| 1 | Qualified Health Practitioners |
|
| 2 | Workers |
|
| 3 | Management |
|
Record Keeping
Documentation of Safeguarding Policies and Procedures
All organisational policies and procedures related to safeguarding are thoroughly documented and regularly reviewed to ensure compliance with current legislation and best practices. These documents provide a clear framework for preventing and responding to harm.
Incident Reporting and Management Records
Detailed records of all incidents, allegations, and investigations are maintained. These include:
- Date, time, and nature of the incident.
- Actions taken to support the participant and mitigate risks.
- Investigation findings and outcomes.
- Any changes made to policies or practices to prevent recurrence.
These records are securely stored to ensure confidentiality and are accessible only to authorised personnel.
Participant Advocacy Records
Documentation of advocacy services provided to participants, including:
- Details of the advocate involved and their role.
- Records of interactions between participants and advocates.
- Feedback from participants on the effectiveness of advocacy support.
These records demonstrate the organisation’s commitment to empowering participants and ensuring their voices are heard.
Training and Competency Records
Comprehensive records of all safeguarding-related training sessions are maintained, including:
- Training content, attendance records, and participant feedback.
- Competency assessments and results for workers.
- Refresher training schedules and evidence of ongoing professional development.
These records help ensure all staff have the required skills and knowledge to uphold participants’ safety and rights.
Audit and Review Records
Records of safeguarding audits, reviews, and quality improvement initiatives are maintained, including:
- Audit findings and recommendations.
- Documentation of actions taken to address identified gaps or risks.
- Evidence of continuous improvement in safeguarding practices.
Confidentiality and Data Protection
All safeguarding-related records are handled in compliance with Australian data protection legislation and organisational privacy policies. This includes:
- Secure storage of physical and electronic records.
- Restricted access to authorised personnel only.
- Use of encrypted systems for digital record management.
Related Documents
- Risk Management Policy
- Participant Complaint and Feedback Policy
- Advocacy Support Policy
- Incident Reporting and Investigation Procedure
References
- NDIS Practice Standards and Quality Indicators
- Australian Privacy Principles
- Disability Discrimination Act 1992
- National Standards for Disability Services
Policy Review
This policy will be reviewed annually to ensure alignment with best practices, legislative requirements, and feedback from participants, staff, and advocates. Updates will be made as needed to enhance its effectiveness and relevance.