Policies & Procedures | GNCS

Document control

• Owner: Quality & Safeguarding Lead

• Approved by: Managing Director

• Version: 1.0

• Review cycle: At least annually or sooner if legislation or practice changes

• Related standards: NDIS Act & Rules, NDIS Practice Standards & Quality Indicators, Aged Care Quality Standards, Privacy Act 1988 (Cth), Work Health & Safety laws (VIC)

How to read this page

Each topic includes:

• Policy (our commitment and rules)

• Procedure (what we do, step by step)

• Records (what we keep and where)

• Responsibility (who does what)

1) Quality & Safeguarding

Policy

We deliver safe, person-centred supports that protect human rights and promote dignity, independence and choice. Safeguarding is everyone’s responsibility.

Procedure

1. Plan and review: Every participant has an individual support plan with goals, risk controls and agreed routines. Review at least quarterly or when things change.

2. Fit for role: Workers hold required screening/registrations and complete induction and role-specific training before supporting anyone.

3. Observe & report: Concerns about safety, wellbeing or quality are recorded the same day and escalated to a Team Lead.

4. Improve continuously: Incidents, feedback and audits feed a Quality Improvement Plan (QIP) with owners and due dates.

Records

Support plans, risk assessments, training records, QIP.

Responsibility

All workers; Team Leads; Quality & Safeguarding Lead.

2) Participant Rights & Responsibilities

Policy

People using our services have the right to safe, respectful, culturally aware support; to make choices; to access information; to privacy; and to speak up without fear.

Procedure

• Inform: Provide the Participant Charter of Rights and service agreement in plain English (and translated/accessible formats as needed).

• Choice & control: Offer options for workers, times and activities. Record preferences.

• Advocacy: Offer independent advocacy contacts at intake and whenever requested.

• Dignity of risk: Balance choice with safety—use risk assessment and agreed safeguards.

Records

Signed service agreement, consent forms, charter acknowledgement.

Responsibility

Intake Officer; Coordinators.

3) Access to Services & Onboarding

Policy

Access is fair and transparent. We respond quickly and communicate clearly with participants, families and referrers.

Procedure

1. Enquiry received: Acknowledge same business day; book an intake call within 1 business day.

2. Intake call: Confirm goals, funding, risks, consent, communication needs and accessibility (including interpreter).

3. Service agreement & plan: Provide quote and draft plan (who/what/when/where/how).

4. Commencement: Confirm start date; complete safety checks and worker matching; provide contact tree.

Records

Intake notes, risk screens, service plan, roster.

Responsibility

Intake; Service Coordinators.

4) Support Planning & Delivery

Policy

Supports are goal-directed, evidence-informed and delivered within scope of practice.

Procedure

• Assessment & goals: Document goals and outcomes; involve carers/guardians where appropriate.

• Progress notes: Record each shift in plain English; include outcomes and any risks/incidents.

• Reviews: Hold reviews quarterly (minimum) or after major changes.

• Exit/transition: Provide a summary and referrals on exit.

Records

Plans, progress notes, review minutes, exit summary.

Responsibility

Workers; Coordinators; Clinical leads (where relevant).

5) Risk Management

Policy

Risks to participants, workers and the organisation are identified, assessed, controlled and reviewed.

Procedure

1. Identify: At intake, home visits and programme design.

2. Assess: Likelihood/consequence rating; document controls.

3. Control: Apply hierarchy of control (eliminate → substitute → engineer → admin → PPE).

4. Review: After incidents, changes, or at least annually.

Records

Risk register; participant risk assessments; home-visit checklists.

Responsibility

All staff; WHS Officer; Quality Lead.

6) Incident Management & Reportable Incidents

Policy

All incidents are responded to promptly, recorded accurately and used to improve services. Reportable incidents are notified to the NDIS Commission within required timeframes.

Procedure

1. Respond: Make the situation safe; first aid; call emergency services if needed; support the person and witnesses.

2. Report internally: Notify a Team Lead immediately and complete an Incident Report the same day.

3. Notify externally: Where criteria are met (death, serious injury, abuse/neglect, unlawful sexual/physical contact, or unauthorised restrictive practice), the Quality Lead notifies the NDIS Commission within 24 hours (or within 5 business days for unauthorised restrictive practice, unless serious harm—then within 24 hours).

4. Investigate & learn: Conduct an internal review; implement corrective actions; update risk controls; provide updates to the participant/representative.

5. Recordkeeping: Keep all records securely and confidentially.

Records

Incident reports, investigations, notifications, corrective actions.

Responsibility

All workers; Team Leads; Quality & Safeguarding Lead; Managing Director.

7) Behaviour Support & Restrictive Practices (if applicable)

Policy

We prioritise positive behaviour support. Restrictive practices are not used unless authorised, time-limited, least restrictive, and in line with legislation.

Procedure

• Positive strategies first; escalate to behaviour support practitioner where needed.

• Authorisation: Follow state authorisation requirements; maintain behaviour support plans.

• Reporting: Any unauthorised restrictive practice is a reportable incident (see above).

• Monitoring: Debrief; review plans; aim to reduce and eliminate restrictions.

Records

Behaviour support plans, authorisations, monitoring logs.

Responsibility

Behaviour Support Practitioner; Coordinators; Workers; Quality Lead.

8) Complaints & Feedback

Policy

We welcome complaints and feedback and handle them fairly, confidentially and without detriment.

Procedure

1. Receive: Online form, phone, e-mail, in person or anonymous.

2. Acknowledge: Within 2 business days; explain process and timeframes.

3. Assess & respond: Allocate to a Manager; seek to resolve within 30 days where possible; provide updates at least every 10 business days.

4. Escalation: Offer internal review; provide external avenues (NDIS Commission, Disability Services Commissioner, Ombudsman).

5. Improve: Log issues and corrective actions in the QIP.

Records

Complaint register, correspondence, outcomes, QIP entries.

Responsibility

All staff; Complaints Officer; Managing Director.

9) Privacy & Confidentiality

Policy

GNCS complies with the Privacy Act 1988 and Australian Privacy Principles. We collect, use and store personal information securely and only for the purposes for which it was provided.

Procedure

• Collect: Minimum necessary; explain purpose; obtain consent.

• Store: Restricted access; secure systems; retain per legal requirements; safe disposal.

• Use/Disclose: Only with consent or where permitted/required by law (e.g., risk of harm, mandatory reporting).

• Access/Correction: Respond to requests promptly; verify identity.

• Breach response: Contain, assess, notify if required, and prevent re-occurrence.

Records

Privacy notices, consent forms, access logs, breach register.

Responsibility

All staff; Privacy Officer.

10) Records & Information Security

Policy

Accurate records support safe, quality care. Information is protected against loss, misuse and unauthorised access.

Procedure

• Create: Use approved templates; write clear, factual notes; no jargon.

• Access: Role-based access; do not share passwords; lock screens.

• Transmit: Use encrypted channels; no participant data via personal e-mail or messaging apps.

• Back-up: Daily system back-ups; tested restore processes.

• Retention: Keep records in line with legal retention schedules.

Records

Records management procedure; access permissions; back-up logs.

Responsibility

All staff; IT/Admin; Privacy Officer.

11) Workforce: Recruitment, Screening & Training

Policy

Only suitable, screened and trained workers deliver supports.

Procedure

• Recruitment: Merit-based selection; reference checks.

• Screening: NDIS Worker Screening Check (risk-assessed roles); National Police Check; Working With Children Check (where relevant); right-to-work evidence.

• Induction: NDIS Code of Conduct, safeguarding, WHS, incident reporting, infection control, boundaries, privacy.

• Training: Role-specific skills, cultural safety, manual handling, medication assistance (if applicable), high-intensity competencies. Maintain a training matrix.

• Supervision: Regular supervision and performance reviews.

Records

Personnel files, screening results, training matrix, supervision notes.

Responsibility

People & Culture; Team Leads.

12) Worker Conduct & Professional Boundaries

Policy

Workers follow the NDIS Code of Conduct, maintain professional boundaries and avoid conflicts of interest.

Procedure

• Boundaries: No personal relationships, gifts or financial dealings with participants.

• Social media: No posting participant information; seek consent for images; use organisation accounts only.

• Conflicts: Declare and manage any real or perceived conflict.

• Fitness for work: Zero tolerance for drugs/alcohol while on duty.

Records

Code of Conduct acknowledgement, conflict of interest register.

Responsibility

All workers; Managers.

13) Work Health & Safety (WHS)

Policy

We provide a safe workplace and expect safe work practices at all times.

Procedure

• Home/centre risk checks before commencing services; review regularly.

• Manual handling: Use correct techniques/equipment; never lift beyond training/scope.

• Vehicles & driving: Licensed, roadworthy vehicles, seatbelts for all occupants; follow GNCS transport policy.

• Hazards: Report hazards and near-misses immediately.

• Emergency response: Know evacuation routes; carry contact numbers and first aid kits.

Records

WHS inspections, hazard/near-miss logs, vehicle checklists.

Responsibility

All staff; WHS Officer.

14) Infection Prevention & Control

Policy

We prevent and manage infections through standard and transmission-based precautions.

Procedure

• Hand hygiene before/after contact; use PPE as required.

• Cleaning & waste: Follow approved methods; dispose of sharps correctly.

• Immunisation: Encourage recommended immunisations for relevant roles.

• Outbreaks: Follow public health guidance; notify participants; enhance cleaning; consider telehealth where suitable.

Records

IPC training, cleaning logs, incident/breach reports.

Responsibility

All workers; Clinical Lead (where applicable).

15) Medication Management (where GNCS provides assistance)

Policy

Medication tasks are performed only when authorised, trained, and documented.

Procedure

• Assessment: Confirm medication support needs and consent; maintain up-to-date orders.

• MAR: Use a Medication Administration Record; follow the six rights (right person, medication, dose, time, route, documentation).

• Storage: Secure and temperature-appropriate.

• Errors/refusals: Report immediately; seek advice; record; notify guardian/clinician as required; treat as an incident when applicable.

Records

Medication policy, MARs, training/competency checklists, incident reports.

Responsibility

Authorised workers; Coordinators; Clinical Lead.

16) Transport Safety

Policy

Transport is provided safely, legally and with respect.

Procedure

• Before driving: Licence check, vehicle roadworthy, insurance, first aid kit.

• During: Seatbelts/restraints correctly fitted; safe loading of mobility devices; drive to conditions; no mobile use while driving.

• After: Record trip details where required; report any incidents.

Records

Vehicle logs, licence checks, transport risk assessments.

Responsibility

Authorised drivers; Team Leads.

17) Finance, Charges & Statements

Policy

Pricing is transparent and consistent with current NDIS/Aged Care pricing arrangements.

Procedure

• Quotes & agreements show hourly rates, travel and any non-face-to-face charges.

• Statements provided regularly; explain variances on request.

• No cash handling by field workers.

• Debt & hardship processes are fair and respectful.

Records

Service agreements, invoices, statements.

Responsibility

Finance; Coordinators.

18) Cultural Safety & Inclusion

Policy

Services are culturally safe, inclusive and tailored to each person.

Procedure

• Ask and record language, culture, faith and identity preferences.

• Offer interpreters; match staff where possible.

• Provide gender-sensitive and trauma-informed options.

Records

Preferences in support plans, interpreter bookings.

Responsibility

All staff; Coordinators.

19) Emergency & Disaster Management

Policy

We maintain continuity of critical supports during emergencies where safe and practicable.

Procedure

• Plan: Maintain emergency contact lists and priority participant lists.

• Prepare: Backup rosters, telehealth options, communication templates.

• Respond: Follow official advice; check on participants; document service changes.

• Recover: Debrief, review and improve.

Records

Emergency plan, contact lists, service continuity logs.

Responsibility

Leadership; Coordinators.

20) Service Exit & Transition

Policy

Exits are planned, respectful and well-documented.

Procedure

• Notice & planning: Agree dates; communicate with stakeholders.

• Referrals: Provide options and warm handovers where appropriate.

• Summary: Provide an exit summary and copies of key documents on request.

Records

Exit forms, summaries, referral letters.

Responsibility

Coordinators; Team Leads.

21) Telehealth

Policy

Telehealth is used when appropriate, with the same standards of consent, privacy and safety as face-to-face services.

Procedure

• Confirm identity and consent; check technology and environment.

• Document session type and any limitations or risks.

Records

Telehealth consent, progress notes.

Responsibility

All clinicians/support staff using telehealth.