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OCR re-coding of report obtained through the Freedom of Information act. Original pagination indicated [thus].

REPORT OF THE

INVESTIGATION INTO

WANDIN SPRINGS PRIVATE

TRAINING CENTRE

 

Report compiled by the Investigators appointed by the Director General, Community Services Victoria.

January 1992


CONTENTS

 

                                                                                                                                                        Page No .

 

PART A - INTRODUCTION                                                                                                           1

 

 

 

1.                                                     Background                                                                                  2

 

                       1.1                             Historical Perspective                                                                  2

 

                       1.2                             Current Service                                                                             2

 

 

2.                                                     Current Investigation                                                                  5

 

                       2.1                             Appointment of Investigators                                                   5

 

                       2.2                             Investigation Timelines                                                               5

 

 

3.                                                     Previous Investigations                                                               7

 

 

4.                                                     Framework of the Investigation and Basis                              12

                                                        for the Findings

 

 

 

PART B - RESIDENT CARE AND MANAGEMENT PRACTICES                                         13

 

 

5.                                                     Issues relating to the Service Provision in                              14

                                                        the Least Restrictive Environment

                                                        (Section 23 (3) (a) I.D.P.S Act

 

 

                       5.1                             Restricted Opportunity for Residents                                      14

 

                       5.2                             Medical Issues                                                                            15

 

                       5.3                             Guardianship Aspects                                                                18

 

 

6.                                                     Issues relating to Service Provision to                                    20

                                                        enable Persons receiving the Services to

                                                        participate in its Planning, Operation

                                                        and Evaluation (Section 23 (3)) (b)

                                                        I.D.P.S. Act

 

                       6.1                             Resident Transfers                                                                      20

 

                       6.2                             Resident Participation in Decision Making                             22

 

7.                                                     Issues relating to Service Provision to                                    24

                                                        ensure that restrictions on the rights, dignity

                                                        and self respect of the persons receiving

                                                        the service are kept to the minimum

                                                        (Section 23 (3) (c) I.D.P.S. Act

 

                       7.1                             Inadequate Investigation of Allegations                                24

                                                        of Abuse of Residents

 

                       7.2                             Privacy Issues                                                                             26

 

                       7.3                             Residents left Unattended when Ill                                          27

 

                       7.4                             Financial Matters                                                                        28

 

 

8.                                                     Issues relating to adequate mechanisms                                 30

                                                        for assessment (Sections 23 (3) (d)

                                                        I.D.P.S. Act

 

                       8.1                             Resident Assessment to Access Programs                            30

 

                       8.2                             Resident Communication                                                           30

 

 

9.                                                     Issues relating to services provided in                                    32

                                                        accordance with General Service Plans

                                                        and Individual Program Plans

                                                        (Section 23 (3) (e) I.D.P.S. Act

 

                       9.1                             Individual Program Plans/General                                            32

                                                        Service Plans

 

 

10.                                                   Issues relating to Management Practices                               34

 

                       10.1                           Staff Recruitment and Selection                                                34

 

                       10.2                           Staff Dismissals                                                                           35

 

                       10.3                           Staff Discrimination/Manipulation/                                          36

                                                        Harassment

 

                       10.4                           Staff Turnover/Emergency Staff/                                              39

                                                        Volunteers

 

                       10.5                           Staff Training                                                                               40

 

 

11.                                                   Issues relating to General Management                                  42

                                                        Practices

 

                       11.1                           Medical and Medication Concerns                                          42

 

                       11.2                           Communication Issues                                                               43

 

                       11.3                           On-call Service                                                                             44

 

                       11.4                           Assaults on Staff by Residents                                                45

 

                       11.5                           Children of Staff Members at Work -                                       47

                                                        in Duty Hours

 

                       11.6                           Committee of Management                                                        48

 

                       11.7                           Unorthodox Practices                                                                 50

 

                       11.8                           Policies and Procedures and records                                       51

 

 

 

PART C - REPORT ON FINANCIAL INVESTIGATION                                                           52

 

 

12.                                                   Details of the Accounting Records,                                         53

                                                        System and Period of Financial

                                                        Investigations

 

                       12.1                           Accounting Records at Wandin Springs                                53

 

                       12.2                           Accounting System in Operation at                                         55

                                                        Wandin Springs

 

                       12.3                           Previous Audit Reports                                                            55

 

                       12.4                           Period of Financial Investigation;                                            56

                                                        Verification of CSV Funding

 

 

13.                                                   Findings of Financial Investigation                                         57

 

                       13.1                           Possible Misuse of Committee of                                             57

                                                        Management Office-Bearers Signatures

                                                        to Impose a Levy on the Families of

                                                        Clients at Wandin Springs

 

                       13.2                           Taxation Implications of the Levy                                            58

 

                       13.3                           Management of Client Funds                                                    58

 

                       13.4                           Other Financial Issues at Wandin Springs                             60

 

 

PART C - CONCLUSIONS

 

 

                       14.1                           The Conduct and Framework of the                                         68

                                                        Investigation

 

                       14.2                           Matters Substantiated in the                                                     69

                                                        Investigation

 

                       14.3                           Failure to meet Legislative                                                         73

                                                        Requirements

 

 

APPENDIX - SUMMARY LIST OF ISSUES RAISED                                                               76

 


[1]

 

 

 

 

 

 

PART A

 

 

 

 

INTRODUCTION

 


[2]

1.        BACKGROUND

 

Wandin Springs Private Training Centre (hereinafter referred to- as "Wandin Springs") is registered as a residential and a non-residential service under Section 23 of the 'Intellectually Disabled Persons Services' Act 1986 (I.D.P.S Act).

 

Wandin Springs is sited on a rural property of approximately 26 acres at Wandin East. The service is conducted in accordance with the anthroposophical principles of the late Dr. Rudolf Steiner, specifically curative education and social therapy which is an area of his teaching.

 

Wandin Springs is registered for 29 residents and currently has 27. The centre receives block funding from Community Services Victoria in excess of $1.1 million per annum. Under Section 24 of the IDPS Act an interim Funding and Service Agreement was entered into by the Director-General of CSV and Wandin Springs. This agreement expired on 31 October, 1988. A more detailed Funding and Service Agreement has yet to be developed by both parties.

 

 

1.1      Historical Perspective

 

Wandin Springs was formed by a group of parents of residents of Kindilan (a Rudolf Steiner home, established in Balnarring in 1971). This group of parents established what is now known as Wandin Springs, due to dissatisfaction with the service provided by Kindilan. In 1975 this group established a centre at 'Mayport', in Mount Martha and in the same year purchased the property at Wandin. This was known as the Wandin Rudolf Steiner Curative Home and was registered under the Hospital and Charities Act 1958.

 

In 1986 the service's name was changed to Wandin Springs: "A Rudolf Steiner community for people with Special Needs".

 

 

1.2      Current Service

 

Wandin Springs is a centre that provides both residential and vocational services for the 27 intellectually disabled adults aged up to 60.

 

Wandin Springs comprises three dwellings which are divided into 6 units. Each unit accommodates up to five clients.

 

The residences are uniform in design and are aesthetically pleasing, blending well into the surrounding environment.

[3]

These are known as:

 

Miranbeena "Welcome" (formerly Pine Lodge) which is known as a transitional house for residents who have- low support needs.

 

Carinya "The Happy Home" (formerly the Yellow House) comprises two units, Amura and Kaliva.

 

Wandarra "The Meeting Place" (formerly the Red House) comprises three units; Giraween, Cowaree and Gilbulla.

 

There is also a cottage known as "Cwinganna Cottage" which provides on-site accommodation for staff and one client in a co-residency situation.

 

The office administration area is housed in the Wandarra building.

 

Wandin Springs is managed by a Committee of Management, comprising parents and other interested parties who are contributors. Reporting to the Committee of Management for the overall functions of Wandin Springs is a Chief Executive Officer, who has an executive structure which includes the Residential Superintendent and the Vocational Director. Each Unit is staffed with a House Supervisor and Direct Care Staff and a number of emergency staff.

 

This structure manages 30 staff for 27 residents, plus 7 vocational staff who work on site at Wandin and 9 who work off site in a setting called Fire and Clay.

 

Vocational programs are conducted on site, apart from the federally funded 'Fire and Clay' which is a ceramics supported employment venture operated from Factory 2, Lot 2 Beresford road, Lilydale.

 

Vocational programs include; Bakery, Nursery, Farm, Behaviour Intervention, Life Skills. Residents do the same vocational program for a 12 month period, reviewed annually.

 

The residents access a 24 hour residential program but return home every third weekend and during school holidays.

 

The profile of the adults at Wandin indicates that a majority of the people are independent in self help skills but require supervision. Others require direct assistance with basic self help skills. A number of residents have associated disabilities and exhibit some challenging behaviour.

[4]

The centre has a commitment to social therapy based on the principles and methods of the late Dr. Rudolf Steiner. According to a pamphlet distributed by the Committee of Management, Social Therapy attempts to provide the disabled adult with environments, circumstance and opportunities that are the right of every other member of the community. Social Therapy is the recognition that        the development of the friendship is the starting point in empowering the person with an intellectual disability to develop and learn.

 

Curative education, on which social therapy is based, is the healing or nourishing of the soul or person through techniques such as homoeopathic medicine, correct nutrition via biodynamic farming, music therapy, painting and eurhythmy. The aim is to create a self sufficient village and an environment of tolerance for those 'never likely to become normal members of society.' (Man and World in the Light of Anthroposophy, Easton, 1972, p. 429).

 

The Committee of Management is dedicated to this philosophy and prefers to employ staff who support this view. Committee of Management representatives have indicated that the Steiner influence has diminished significantly in recent times as a result of the implementation of the current administrative structure and minimal direct care staff training in the Steiner approach.

.

 

 


[5]


2.        THE CURRENT INVESTIGATION

 

 

2.1      Appointment of Investigators

 

In May 1991 two former staff members of Wandin Springs raised a number of allegations in relation to the service with CSV.

 

These allegations were made on a confidential basis to C.S.V. The allegations included abuse of residents, inappropriate care including medical care, dubious program activities, poor management practices and financial irregularities.

 

As a result of the seriousness of the allegations, the broad ranging nature of the allegations and the fact that several complaints were directed at senior management staff, it was determined that CSV would appoint an investigation team pursuant to the provisions of section 55(1) of the Intellectually Disabled Person' Services Act 1986. This section of the legislation deems persons appointed for the purpose of any investigation in connection with the administration of the Act to exercise the powers conferred on a community visitor under the Act.

 

Ms. Denise Harrison, Manager, Direct Care Services, Kew Cottages and Ms. Ann Henderson, Discipline Consultant, Discipline Consultancy Unit were appointed by the Director-General, Dr. John Paterson an 13th August, 1991.

 

Mr. Jim King, Manager, Financial Investigations and Mr. John. Hutchinson, Financial Investigator from the Institutional Investigation Program were appointed on 13th September, 1991 to investigate the financial affairs at Wandin.

 

 

2.2      Investigation Timelines

 

The investigation formally commenced on 19th August, 1991 and Denise Harrison commenced on 26th August, 1991, full time for three weeks and then on a part-time basis. Jim King instigated initial enquiries into the financial affairs of Wandin in early September and John Hutchinson examined "Fire and Clay", in October, 1991.

 

A meeting was arranged at Wandin Springs with representatives of the Committee of Management, John Leatherland, Regional Director, Outer East Region, Denise Harrison and Ann Henderson on 30th August, 1991. The purpose of this meeting was to outline the process for the investigation and the procedures that would be undertaken.

[6]

A range of factors impacted on the length of the investigation and these included:

 

-       The significant complexity of issues and allegations raised

 

-       The time involved in taking formal statements

 

-       Following the initial three weeks, Denise Harrison returned to her operational line position and was only able to provide limited time to the investigation.

 

-       The need for a comprehensive investigation due to the nature of the allegations and those of previous investigations.

 

 


[7]


3.        PREVIOUS INVESTIGATIONS

 

 

The current investigation into Wandin Springs is the fifth that has been conducted in a relatively short history.     The last two of these investigations were conducted jointly with representatives of the Committee of Management. This current investigation has been conducted independently of Wandin Springs Committee of Management and CSV Outer East Regional Team.

 

What is strikingly clear is that many issues/ concerns/ allegations which are the subject of this investigation have been the subject of previous investigations. It needs to be noted that many of the key players have remained constant.

 

A synopsis of the previous investigations is provided in the following pages.

 


DATE

CONDUCTED BY

COMPLAINANTS

MATTERS INVESTIGATED

INVESTIGATORS CONCLUSIONS

RECOMMENDATIONS

DEPARTMENTAL ACTIONS

PRACTICE CHANGES AT WANDIN

1981

Mr. Bob Cavill

Health Department (Preliminary Investigation)

Parent members of Committee Management raised concerns about financial misappropriation.

Financial records to ensure they complied with generally accepted accounting practices

Financial reords maintained by employees on behalf of the Committee Management

All financial arrangements made with persons at the centre by the committee of Management in respect to the ongoing operations of the centre

Constitution and associated by-laws to ensure that business undertaken by the COM and staff meet with these requirements

Determine if any assistance should be provided by the MRD to enable the COM to operate on a daily basis.

Report submitted on 28/1/82

Staff on a number of occsions had been underpaid

Staff had provided large amounts to the organisation, either by donation/requirement.

Staff rostering/recording of entitlements was not in accordance with the normal principles of management or the Award.

Duties of the administrator are not consistent with standards expected by Division

the activities of the COM have failed to comply with it's constitution

Accusations of financial irregularities, however difficult to substatniate without sworn statements

No information available to suggest that funds have been misappropriated from Wandin

 

 

 

MRD adopt specific guidelines and conditions for the funding, operation and control of Private Training Centres

Wandin be further investigated to ascertain the precise nature of its activities and financial arrangements by the COM

A special meeting of contributors be called for the purpose of permitting the present COM to stand down

The position of the Administrator be utilised for the employment of a suitably qualified for Wandin

The secretary of the Health Commission, Mr E Cocks on 15/2/82

The Committee of Management at Wandin has failed to:

Implement and maintain appropriate financial records

Utilise all staffing facilities appropriately

Conduct themselves in a manner consistent with the organisations constitution

The COM were informed of the finding and given assistance of two officers to attend COM Meetings and for ensuring the ongoing operations of the home

On 26/3/82 the Principal of the Home was forced to resign by the committee of Management

The now Chief Executive Officer, Mr Stuart Spackman was placed in the position of Acting Principal until a replacement could be found.

On 6/7/82 Mr David Baldwin was appointed as Principal.


 

DATE

CONDUCTED BY

COMPLAINANTS

MATTERS INVESTIGATED

INVESTIGATORS CONCLUSIONS

RECOMMENDATIONS

DEPARTMENTAL ACTIONS

PRACTICE CHANGES AT WANDIN

1982

Mr. Bob Cavill

MRD

Mrs Margaret Waspe Principal Ð Wandin

Mr Stuart Spackman Wandin Staff

The family

Allegations of maltreatment of ................. by

Initial investigation was conducted by Margaret Waspe and Stuart Spackman. Mr Bob Cavill interviewed .............who denied any mistreatment of

A meeting was held between Dr Maginn and Mr Bob Cavill MRD, Margaret Waspe, Stuart Spackman, ...........

It was decided allegations could not be substantiated and if the family wanted further investigation they would have to contact the police.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No further action taken.

Resignation of

sought

 


 

DATE

CONDUCTED BY

COMPLAINANTS

MATTERS INVESTIGATED

INVESTIGATORS CONCLUSIONS

RECOMMENDATIONS

DEPARTMENTAL ACTIONS

PRACTICE CHANGES AT WANDIN

1984

Mr. Tibor Bakos Assistant Director Ð Client Services

and

Mr Rob Gordon President Wandin Committee of Management

Allegations were specifically related to client abuse, but during the course of investigation a number of management issues were raised

Inadequate staffing levels

Poor communication practices

Inadequate staff training and expertise in the senior staff

Resolving disputes and staff dissatisfaction

Lack of medication in addressing behavioural issues

Client abuse involving inadequate techniques to manage behaviour

Evidence of concerns in all areas listed in matters investigated

Recommended termination of one staff member and the counselling of three others (including the Principal and his wife)

Supervisory staff need to access staff training and behaviour management techniques to instruct junior staffs

Management condoning actions of staff handling clients with difficult behaviour

Principal requires counselling in behavioural techniques, staff supervision, appropriate safety standards for staff and clients

Committee of Management to negotiate with MRD for assistance with staff training and management of difficult behaviour and training of staff in the basic knowledge of mental retardation

Appears likely that MRD will seek funding (up to $5000) for training in Curative Education. This issue to be further investigated and is top priority

The Committee of Management to ensure that the Principal and the Home Committee conduct an extensive review of internal management practices with the Home both in regard to staffing and rosters and assist the Home Committee establish realistic, effective methods for dealing with such problems, and the planning of behaviour management. A comprehensive set of policies, procedures and practices should be developed and accessible to staff

 

On 15/1/85 the finding of the report were presented to the Committee of Management.

On 18/2/85 Secretary of the Committee of Management advised that the Committee would be asking to resign and was requesting that the licence be transferred to Mr Les Heath who had been appointed to the position of Administrator on 1 July 1984

 


 

DATE

CONDUCTED BY

COMPLAINANTS

MATTERS INVESTIGATED

INVESTIGATORS CONCLUSIONS

RECOMMENDATIONS

DEPARTMENTAL ACTIONS

PRACTICE CHANGES AT WANDIN

1987

Steering Committee

CSV

John Mc Lennan

Tibor Bakos

Tony Feain

Inge Carr

Dorothy Wee

David Hampton

John Jenkins

Tim Fisher

WANDIN SPRINGS

Henk Bak

Janet Fox

Alan Truett

Stuart Spackman

Current staff of the centre and the parent of a resident raised complaints ranging from inefficient administration, organisational difficulties to allegations of resident abuse and inappropriate medical care. These issues had been raised with OIDS Head Office, the Minister's Office and the Office of the Public advocate

Organisational Structure

Allegations of resident abuse

Personal and Industrial Practices

Residents rights and privacy

Residents medical care

Financial management

Relationship with OIDS Outer East Regional Team

Some issues were substantiated and rectified, other issues were found to be without substance

Adequate internal accounting control mechanisms

Employees to pay their share of running costs for power, electricity, gas (cottage rented by staff on premises)

Implement new management structure and roster alterations

Resident abuse not substantiated

Policy and procedure manual to be established

Wandin to access medical officer service and document role of homeopath

Extensive in-service training be available to residential staff

Creation of the position of Chief Executive Officer

The creation of an additional 5.2 Child Care Worker (or Assistant) positions and downgrading of other positions

The reclassification of Residential Superintendent position

Phase out the position of Administrator and reclassify clerical position

In-service training on behaviour management and medical issues

Incident reporting guidelines be developed

Document of clients rights be prepared

Parents be notified re preference to homeopathic/allopathic treatments

Initially action by the Department was to appoint an Administrator and to establish a Steering Committee to address the issues.

Inge Carr was appointed Administrator July until November 1987 and John Jenkins from November 1987 to April 1988

The Steering Committee believes it has adequately addressed the issues, some of which have been found to be without substance, and where necessary has introduced measures to rectify deficiencies. The major outstanding issue was the provision of 4.7 additional residential staff without which there will be continual staffing and resident management difficulties.

Funding was provided for the extra positions

 

 

 

 

 

 

Stuart Spackman was appointed in the newly created position of Chief Executive Officer


[12]

4.        FRAMEWORK OF THE INVESTIGATION AND BASIS FOR THE FINDINGS

 

As Wandin Springs is registered as both providing a residential and non-residential service under the Intellectually Disabled Persons Services Act (Section 23 (4)), all issues were examined in the context of relevant sections of.that Act.

 

Sections 5-9 of this report present findings using the framework of. principles specified in Section 23 (3) in accordance with which.a registered service is required to operate.

 

During the course of the investigation the investigators spoke to staff, ex staff, parents (individually and in parent groups), committee of management representatives, senior management, community visitors, CSV regional team and external agencies. On 12th September, 1991 the investigators met with a group of 17 parents.      The overwhelming view of the parents in attendance at the meeting was one of support for the service provided for residents and the work undertaken by management and staff. Community visitors interviewed raised concerns about the organisation, which were documented in the 1990 Annual Report of Community Visitors. These included difficulty in gaining access to documentation, divisions and communication difficulties between groups of staff, limited training in communication skills. 25 people formalised concerns in the form of either statements or reports. These comprised 7 parents, 10 current staff and 8 ex-employees. A total of 222 pages of documentation was obtained from statements and reports. A significant amount of further documentation was also obtained.

 

The statements have been made to C.S.V on a confidential basis and therefore cannot be appended to this report. They have been examined in detail not only by the investigators but by senior C.S.V. staff.         

 

Several persons providing statements displayed considerable anxiety about the possibility of their information being released to the Committee of Management or management staff of Wandin Springs. Two parents expressed concern in -writing as to whether their son would receive unfavourable treatment if it became apparent that they had spoken to the investigators. Several staff expressed the fear of losing their jobs and alleged that other staff had been forced to resign having conflicted with management. Some former staff feared retaliation. One former staff member experienced significant damage to her car and an object thrown through her loungeroom window shortly after the investigation commenced. While there is no evidence that these actions were linked with Wandin Springs investigation, they added to the anxieties of the

person concerned.

 

 


[13]

 

 

 

 

 

 

 

PART B

 

 

 

 

FINDINGS:

 

RESIDENT CARE AND

 

MANAGEMENT PRACTICES

 


[14]

5.        ISSUES RELATING TO SERVICE PROVISION IN THE LEAST RESTRICTIVE ENVIRONMENT (SECTION 23(3) (a) I.D.P.S ACT)

 

 

 

5.1      Restricted Opportunities for Residents

 

An objective in the Wandin Springs Constitution is "to continuously carry on and maintain a property or elsewhere in Victoria a residential community and occupation for life for intellectually handicapped persons". This objective implies a "whole of life" philosophy, which, coupled with the isolated location of Wandin Springs has created a situation where the service is largely isolated from the local community.

 

It is understood that some parents support the isolation preferring vocational services to be on site and wanting nursing home accommodation to be planned on site. Other parents have expressed major objections to the current service and seek to establish houses in the community and expand vocational possibilities.

 

Several parents, staff and former staff have raised concerns about the isolationary aspect of Wandin Springs and have indicated that this has resulted in poor outcomes for many of the residents. Examples given include the following.

 

-       Some residents have little opportunity to interact in the wider community. More effective integration into the community should be possible given the staffing resources available for the organisation.

 

-       Some residents undertake a minimal day activity work resulting in poor progress. An example given was a resident who works in the garden wandering around aimlessly, dribbling all day. Productive day time activities should be able to be provided for all residents.

 

-       One resident was barred from a weekly outing for 2 years due to a behavioural problem. Lack of access to the outside community is said to have aggravated his behavioural problems.

 

-       High functioning residents living in a transitional house - Miranbeena and having a co-residency with staff on-site have not progressed to off-site housing options.

 

-       Very few if any residents have been relocated to alternative accommodation apart from a small number who have exhibited behaviour management difficulties and have relocated to C.S.V. training centres. A senior manager indicated that plans to develop offsite accommodation were not able to be implemented given that a submission to CSV for additional resources was not successful.

 

-       An observation that some residents have regressed rather than progressed during a 4 year period. Residents were not given a challenging environment or permitted the dignity of risk but, in one staff members terms "wrapped up in cotton wool and kept safe".

 

-       As recently as October, 1991 dental treatment was provided through an on-site visit of a dental van.

 

A senior manager indicated that attempts were made to overcompensate for the isolation issue by focussing on activities outside Wandin Springs for residents.

 

Issue:                 The relative isolation and insulation of the service results, in some instances; in restricted opportunities being provided which leads to poor outcomes for residents.

 

 

 

5.2      Medical Issues

 

A number of medical issues raised in the 1987 investigation were raised again in this investigation.

 

Concerns highlighted in the 1987 investigation included:

 

-       inadequate access to medical services for residents

 

-       the need for each resident to nominate their preference for either allopathic (traditional) or homoeopathic treatment       .

 

-       the need to access medical services from the Outer East Regional Team in terms of the provision of basic medical training for staff, consultancy and advice from medical staff

 

The administrator in the 1987 investigation established and implemented a comprehensive Health and Medical Policy that was accepted by the Wandin Springs Committee of Management.

[16]

In 1991 several current staff, former staff and a number of parents have expressed the view that residents have not received adequate access to medical attention. Examples of this include the following:

 

-       As recently as 1990, residents were not able to use simple remedies such as aspirin for pain relief.

 

-       Limited choices in selecting a medical physician. Residents are either treated by a homoeopath or by a general practitioner, nominated by Wandin Springs management.

 

-       On the 29th November 1991, a resident was diagnosed with advanced chicken pox, after being. taken to a doctor by their parents. The resident had previously been taken to a chemist by an administrative staff member and was, being treated for a heat rash.

 

-       According to a staff member some residents do not have regular comprehensive check ups.

 

-       Limited access by residents to specialist treatment for psychiatric, gynaecological and epilepsy conditions. A number of current and former staff expressed concerns about the limited access to professional and.psychiatric advice, especially for those residents that exhibit challenging behaviour. On one occasion when a second opinion was requested for a resident who was experiencing behavioural problems, a senior manager organised a visit to a doctor who was a gynaecologist and home birth practitioner, who altered the medication prescribed by a treating psychiatrist. The doctor is one preferred by Wandin Springs management.

 

-       An administrative staff member has authority to make medical decisions relating to residents. An example of this person's inappropriate authority is her decision that the female residents do not require pap smears, the rationale being that the women are not sexually active (this is supported by documentation made available to the investigation).

 

-       The homoeopath had almost exclusive service rights in the provision of medical services to residents at Wandin springs prior to 1987. This practice ceased following the implementation of a range of medical recommendations after the investigation of a resident death in 1986. Since 1990 residents attend homeopathic services off site at a clinic managed by the same homoeopath. As of 19th November 1991 this homoeopath was listed as one of the preferred doctors' at Wandin Springs.

[17]

-       Parents complained that a senior manager had insisted that their son have homoeopathic as well as allopathic treatment. Parents corresponded with the C.S.V. Regional Team to highlight their concerns which offered no real support in relation to this issue. A senior manager finally indicated that their son might have to leave Wandin Springs if they did not agree with the decision on this issue. This complaint was eventually addressed through the General Service Plan process, with the outcome that ­this person only access allopathic treatment.

 

-       A similar issue was raised by other parents who were not informed that their daughter was being given homoeopathic drops. They had insisted that she not be treated homoeopathically, as the resident had an allergic reaction to belladonna drops. This request was ignored by certain residential staff who instructed other staff to give the resident drops three times a day. Staff were instructed not to advise the mother of this. This issue was finally rectified by means of the General Service Plan where it was clearly stated that any change in the medication could be made only with the consent of the two named people.

 

-       It is alleged that residents are still being given limited choice of medical treatment. In cases where contentious issues arise often a senior manager or the parents make the decision. The option of formalising the decision through the Guardianship Board or an independent third person is not utilised.

 

-       Parents not always being informed about problems which had occurred.

 

The following example was given:

 

The parent rang to see how her daughter was. The daughter was extremely upset and complained that she felt ill, had a headache and had vomited during the day. The parent alleged that the staff member on duty stated 'there was absolutely nothing wrong'. When questioned whether a doctor had been called, the staff member stated that one had attended twice during the week and since her daughter's symptoms seemed to be the same as on the other: two occasions there was no reason to get a doctor to examine her daughter.

 

The parent was later informed by a senior manager that her daughter had exhibited self injurious behaviour {bashing head on concrete for approximately 30 minutes) the day before the mother had spoken to her.

[18]

The parents concern was that her daughter was denied medical attention for possible concussion.

 

-       A resident death in 1986 was never reported to the Coroner. Several former staff allege that the resident was not given access to proper medical care prior to her death even though it was clear her health was deteriorating. Concerns were also raised about this resident being subject to restraint (tied to a chair with bandages, restrained at night in a sack fastened to bed). While this matter is fairly old it demonstrates medical inadequacies in the service which appear not to have been fully addressed

 

Issue:      The significant numbers of cases referenced suggest that residents do not at all times access adequate medical support and attention. In fact some residents appear to have been placed at risk due to poor decisions and inadequate practices.

 

Where contentious issues arise relating to either choice of medical treatment of whether a resident accesses medical services, appropriate advocacy guidelines and processes were not in place to ensure that right decisions are made.

 

While there are policy and procedural documents on medical matters especially from the 1987 investigation, a significant concern is that staff interviewed indicated minimal knowledge of these policies and procedures and in many instances, had not followed set guidelines.

 

It is apparent that the relevant information on medical issues required by direct care staff has not been disseminated throughout the organisation.

 

 

5.3      Guardianship Aspects

 

A pattern has emerged that residents at Wandin Springs are limited in what choices and decisions are made regarding major life areas. Management has not implemented policy or procedures that ensure residents access to independent panels/bodies that would assist in determining appropriate decisions where contentious issues are raised.

 

Examples provided by current staff and parents indicate that some Wandin Springs staff and parents exercise inappropriate control and authority- over issues related to resident finances and medical interventions.

 

This is of concern where in some cases residents are capable of making some informed decisions in these areas.

 

[19]

Generally staff interviewed were concerned about the lack of control of residents over their own lives. The following examples are given:

 

-       A few parents are opposed to orthodox medical treatment and prefer that their son/daughter use homoeopathic remedies and appear to authorise this form of treatment through the GSP process. An independent person/panel is not utilised to determine whether this is in the best interests of the resident or represents the resident's view, taking into account all relevant considerations.

 

-       The majority of parents/ siblings directly administer resident funds. Monies are allocated to residents based on requests from staff and management.

 

-       Most resident funds are held in bank accounts held off site by relatives. One current and two former staff allege that funds are expended on behalf of residents without residents consultation or consent. In one case, one resident had a large sum of money spent on a classroom computer and the purchase of 30 prints for general use. The rationale for these purchases by her trustee was that the person would lose the pension if she had too much money.

 

-       According to one current staff member, one resident's request for the personal purchase of a television set was refused by Wandin Springs management, until the Public Advocate intervened. At the time of the investigation a senior manager did not allow residents of another unit to purchase a television set.

 

Issue:            Parents/siblings and staff have significant control in a range of life areas for residents over 18 years of age. Indications are that some residents have capacity to make an informed decision in relation to certain aspects of their life and are not being enabled to do so. In some instances one person may override choices selected by a resident or those determined by a consensus process.

 

Under current guardianship legislation parents have limited authority to determine how resident funds are expended. Administrators should be appointed for residents that have in excess of $5,000 in their accounts.

 

 

 


[20]

6.        ISSUES RELATING TO SERVICE PROVISION TO ENABLE PERSONS RECEIVING THE SERVICE TO PARTICIPATE IN ITS PLANNING AND OPERATION AND EVALUATION (SECTION 23(3) (b) I.D.P.S. ACT)

 

 

6.1      Resident Transfers

 

Significant concerns have been raised by current and former staff and parents about resident relocations to other units at Wandin Springs. On a number of occasions it is alleged that residents were relocated without reference to the residents best interests or to the impact of the transfer on other residents in the unit. It is alleged that this has resulted in skill regression in some residents.

 

In one example, where a resident was relocated to another unit in late 1990, it is alleged by several staff and parents that other residents, in the unit experienced direct negative impacts. These included:

 

-       A resident being assaulted by the transferee, which caused the resident to become distressed and have a grand mal seizure. According to two former staff this residents epileptic episodes increased and he developed compulsive eating habits and bit his fingernails down to the flesh. On examining the case file, the incident was cited as well as notations related to changes in his medication.

 

-       Another resident who had resided there for six years was moved. The resident's parent was not happy about the move and commented to a staff member about becoming legal guardian so as they could have more say in his lifestyle. According to staff this resident was unhappy about this new unit. This resident kept packing his bags and returning to the unit and was found on the road running away from Wandin Springs.

 

-       Another resident who was non-verbal indicated that he did not like the new transferee, in that he would shake his head and point to the resident and refused to go to work if he had to work with that individual. A former staff member who had worked with the resident for 12 months prior to the new resident relocation, also noted a general deterioration in the residents behaviour in that he would keep staff awake all night and bash on the new residents door.

[21]

-       The resident who had transferred into the unit assaulted a significant number of staff (addressed elsewhere in the report). Both former and current staff requested assistance from management in the development of appropriate strategies to reduce the residents behaviour.

 

Protracted staff meetings on the issue occurred, followed by an unsuccessful intervention by a psychologist who had known the resident for a number of years previously. No behaviour intervention for the resident eventuated until a program was devised in October, 1991.

 

According to one current staff member, four former staff and four parents, favouritism was shown to residents whose parents are prepared to monetarily support Wandin Springs. Specific examples of this involve the following:

 

-       According to a former staff member, a senior manager presented an offer on behalf of the parents and resident to the cost of $12,000 towards the building of a residential unit on the premises or in the community, if their son was moved. Reference to this was cited in Committee of Management minutes.

 

-       Following numerous requests one resident was finally given his own room. This was of concern as a number of other residents had been given their own rooms on admission.

 

Several direct care staff interviewed raised concerns related to the fact that the residents in the house required counselling following some resident transfers. Some staff felt patronised by management when these issues were raised. The specific resident concerns have never been addressed.

 

-       The Individual Program Plan (Ι.Ρ.Ρ) format was not utilised and both staff and parents had minimal input into the relocation exercise. The inappropriate transfer of residents was often related to one resident exhibiting challenging behaviour and the relocation was the management solution to the demonstrated problem.

 

-       In mid 1991 a person placed on respite care for a four week period was placed in residents bedroom. A current staff member raised concerns that:

 

                                     i.)           This was contrary to the resident's General Service plan where it is documented that he does not share their their room, due to his severe behaviour difficulties.

[22]

                                       ii.)           Information supplied by management on the person in respite care was incorrect. Information indicated that the person was non violent, toilet trained and could communicate by signs. Staff found this was not the case.

 

                                        iii.)           Friction developed between the resident and the person in respite care.

 

Issue:      It is concluded, from several different examples, that residents have had minimal input in any relocation. Often the rationale for the relocation was not known, by staff or parents. Some relocations resulted in major disruption, distress and regression in other residents. The opportunity for residents or for parents to give consent or to have parents and/or staff to advocate was minimal. An independent third person to act on behalf of the resident was not viewed as an option.

 

Management has not put into place avenues for staff to address concerns raised about resident placement. The placement of residents is not achieved via any formal procedure, in consultation with all parties concerned. As a consequence significant disruption to resident care occurred.

 

 

 

6.2      Resident Participation in Decision Making

 

A number of current and former staff interviewed have indicated that residents had minimal participation in deciding on issues that affect them directly, either through the Individual Program Plan (Ι.Ρ.Ρ) process or on a daily basis.

 

Example include:

 

-       Residents had no choice as to whether they attended a disabled rally as management selected which residents were to attend. In addition residents had to participate in a 'walk against want' rally and .were photographed for publicity purposes for Wandin Springs. This is a supported in diary entries in the house report.

[23]

-       Management has refused to allow the residents of one unit (Gilbulla) to have their own T.V. This unit is the only unit at Wandin Springs without their own T.V. The residents, staff and parents have agreed to the purchase of a T.V. set which has been overridden by management. The rationale is that the television would be utilised as a 'baby sitting' device.

 

-       A former staff member alleged that an administrative officer bulk purchased manchester, as a result residents did not participate in selection of linen. This is a significant issue given the level of functioning of some residents in being able to make decisions. The Staffing resources and I.P.P programs should facilitate individual shopping

 

-       Staff interviewed have commented that the residents do the same vocational programs all year, whether they like them or not.

 

A senior manager commented that if the residents preference was in another vocational area this would be facilitated. However, current staff have commented on the unsuitability of certain work for particular residents. One example, being one resident who works in the garden and has been described as 'wandering aimlessly, dribbling all day". In another case, a resident's vocational program was reduced to 4 days and according to his parent 'left to wander Wandin each Friday'. Appeals to the CSV Regional Team were referred back to the Wandin Springs committee as it was deemed an internal matter.

 

Issue:            It is apparent that opportunities for residents input in determining daily life choice have not been maximised.

 

 

 


[24]

7.        ISSUES RELATIVE TO SERVICE PROVISION TO ENSURE THAT RESTRICTIONS ON THE RIGHTS, DIGNITY AND SELF RESPECT OF PERSONS RECEIVING THE SERVICE ARE KEPT TO THE MINIMUM (SECTION 23 (3} (c) Ι.D.Ρ.S. ACT

 

 

7.1.1               Inadequate investigation of allegations sexual abuse of residents.

 

A former and a.current staff member have made allegations of instances of sexual abuse of residents by staff and a volunteer which they claim were not adequately investigated. The following are some examples:

 

-       In July 1988, a female alleged sexual assault against a former male staff member via assisted communication. Wandin Springs undertook an investigation and resolved that no sexual abuse took place following a medical examination and interviewing staff.

 

-       A further allegation was raised against the same employee in late 1988 by another female resident. A current staff member reported this matter to a senior manager. No management investigation occurred. The staff member who was alleged to have sexually assaulted residents resigned following a complaint of sexual harassment was made by a female staff member in early 1990.

 

-       In March/April 1990 a former staff member alleged that a male staff member- sexually touched a female resident. The same former staff member alleged that the male staff member on separate occasions kissed the resident; carried her naked through unit, and sat on the floor with the resident who was semi-­naked. The male staff member was allowed to take this resident out on several occasions all day. All these concerns were reported to senior management who allegedly took no steps to investigate the matter. The person who observed the alleged abuse took the action of ensuring that the male staff member was excluded from intimate contact with residents by stopping him taking part in bathing situations, and vetoing a request that he take the resident home over the weekend. Noting the change of duties the staff member approached management with a view to resigning. It was at that time he discovered the allegation was made. (These allegations were handed to CSV during the course of the investigation, to the police for investigation. Police have subsequently advised that the brief of evidence for prosecution was not approved.)

[25]

-       In 1990, a female resident with low support needs alleged that she was sexually assaulted by a volunteer who touched her on the breast and genital area. No investigation was conducted despite the fact that the resident was capable of co-operating with one. The volunteer was simply sent a letter indicating that currently there was no employment available at Wandin Springs.

 

 

7.1.2               Inadequate investigation of allegations physical abuse of residents

 

Two former staff have made allegations - that instances of physical abuse of residents by staff were not adequately investigated. The following are examples:

 

-       According to our former house supervisor, a resident arrived home from his vocational placement in January, 1991 with bruising to his neck. The bruising was noted in the shift report and a senior manager informed. The next day it was discovered that an incident had occurred on the bus the previous afternoon.

 

A staff member who was under suspicion for other resident assaults was accused of assaulting this resident as she had supervised the resident on the day the bruising was noted.

 

No incident report was filed, although parents have requested a copy of all incidents relating to their son. When questioned by parents, a senior manager informed them that an incident report was not warranted as police were investigating.

 

The House Supervisor expressed concern that the incident had not been fully investigated by management.

 

-       A former staff member raising concerns about harsh treatment of residents received from certain staff. Examples of pushing, slapping and smacking were given. A further allegation related to a resident being forced to stand on the table holding a chair in each hand while the rest of the residents had their meal. These matters were reported to the House Supervisor who did not forward the information to management.

[26]

-       In early 1991 allegations relating to resident abuse by a now former staff member were, on the advice of C.S.V reported to police for investigation. These allegations were withdrawn after the staff member tendered her resignation and after C.S.V advised that it was not able to fund an ongoing suspension.

Subsequent enquiries raise serious doubts about the validity of the allegations. In relation to one of the allegations, three other staff were subject to disciplinary action. One of these staff accepted a 'redundancy' package being paid from 11/2/91 to 29/5/91 without being on duty. No further action was taken against the other two staff members.

 

Issue:            A number of serious allegations of sexual abuse and physical abuse have been made. Many of these allegations do not appear to have been investigated by management.              .

 

 

 

7.2      Privacy Issues

 

Following the 1987 investigation privacy issues have again been raised. Staff interviewed highlighted a lack of privacy afforded to residents.

 

According to a Steering Committee Report, a document as part of the investigation in 1987 on Resident Rights and Privacy was to be presented to the Committee of Management for adoption in May 1988.

 

Current and former staff interviewed are unaware of the existence of- this document or of any Policy and Procedures in relation to this, and the investigators were not furnished a copy. In August 1991, this issue was being reviewed in response to 'Minimum outcome' Questionnaire by the Commonwealth Department of Health and Community Services as noted in a letter to parents from a senior manager.

 

Three former employees highlighted specific incidents where residents were not afforded appropriate privacy considerations. Examples included:

 

-       A staff member walking in on another staff member who was changing an incontinent client.

 

-       Male staff entering bathrooms where female residents were toileting.

 

-       A senior staff member entered a bathroom where the residents were naked and proceeded to hold a conversation with a staff member.

[27]

-       A male staff member being employed in a female unit to provide a one to one ratio for a severely disabled resident, against the wishes of a House Supervisor.

 

Issue:            Policy and Procedures had not been distributed to minimise the possibility of breaches of privacy incidents occurring and to create an accepted standard of privacy for residents in all units at Wandin Springs.

 

 

 

7.3      Residents Left Unattended When Ill

 

Staff are not rostered on duty whilst residents are at their day placement. Wandin Springs has delegated the responsibility of supervising ill residents when house staff are off duty to the Assistant to the Residential Superintendent. Staff and former staff have alleged specific incidents where residents were not directly observed and management provided no alternative arrangement.

 

-       Two former staff cited an incident where a resident with high temperature and vomiting was left unattended all day.

 

-       One current staff member and one former staff person stated that a severe epileptic was left alone for extensive periods of time. The resident had returned from hospital with sutures in his head and was returned to his unit after he had a grand mal seizure.

 

-       Another two current staff confirmed that this same resident was regularly left in unit for 2 hours each day, unsupervised, even though he was known to fit in his sleep.

 

-       Two current staff complained that some residents are left alone with only intermittent visits from the administrative officer.

 

-       A former staff member stated that one resident had a wisdom tooth extracted and was found in bed in the afternoon by residential staff. The resident had apparently, vomited on a number of occasions and had blood all over the sheets. Prescribed mouthwashs had not been administered.

[28]

-       According to a former staff member, in January 1991 a resident was left unsupervised in a unit, she received no lunch, was left unshowered and medication was not dispensed. As the house staff were off duty, the administrative staff member was responsible for supervision of this resident. The doctor in this case had supplied a certificate to say that the resident needed constant supervision, due to severe coughing attacks. This was sighted by the investigators. In one fit of coughing, the resident had stopped breathing and had been transported to hospital by house staff.

 

A note in the residents file stated that the house staff believed that 'someone should be with the resident at all times' and requested that if the administrative staff member was unable to be there all day, that someone be brought in to stay with her.

 

A current staff member complained that a resident suffering from glandular fever was left alone with only intermittent visits by staff.

 

A number of staff have indicated that since the investigation commenced, all ill residents have adequate supervision.

 

Issue:            While staff resources are limited due to budgetary considerations, management should initiate alternative options to leaving ill residents unattended. One such option could be to establish a sick bay in a central location where on duty staff could monitor the residents more closely. This initiative in the past has been canvassed with management.

 

 

 

7.4      Financial Matters

 

The staff practice of accessing residents monies to subsidise other residents in the short term is a frequent occurrence. This practice, according to currently employed staff, is condoned by management. Generally resident ownership of their monies is not adhered to, in one case, as mentioned earlier, the resident subsidised the purchase of thirty prints for distribution throughout the houses. These purchases were made with the permission of her trustee.

[29]

In January 1991 a staff member collected $10 from each resident to fund a staff resident party. In addition the houses had to provide supplementary food. Staff complained about this issue and as a result staff also had to contribute. Records do not indicate whether the residents' money was refunded or not.

 

In late 1990 a staff member was counselled for taking $10 from a resident's funds. This resident was at the time on a 'home weekend' and could not have been taken out for a meal. The staff member was counselled for this, but never requested to pay the $10 back.

 

Issue: Management has not implemented a comprehensive local policy and procedure or any appropriate monitoring system to ensure residents funds are correctly expended.


[30]

8.        ISSUES RELATING TO ADEQUATE MECHANISMS FOR ASSESSMENT (SECTION 23 (3) (d) I.D.P.S. ACT)

 

 

8.1      Resident Assessment to Access Programs

 

A number of residents have presented with challenging behaviour and staff often experience difficulty in managing these residents. Management has not facilitated access to generic service agencies according to former and current staff. Multi disciplinary assessments were not regularly available to assist in determining which programs were suitable for residents.

 

Staff frequently requested support from Wandin Springs management to develop programs that would reduce the risk of injury to both residents and staff.

 

Minimal assistance was provided by management in terms of accessing professional support or the development of appropriate strategies through the IPP process. One resident was involved in a minimum of 25 violent outbursts in an 18 month period before the resident accessed an appropriate behavioural strategy.

 

Another resident was involved in numerous incidents before a behavioural management strategy was recently implemented.

 

Issue:            Staff are experiencing difficulty in managing residents who exhibit challenging behaviour. Staff have initiated and implemented some basic behaviour programs with minimal effect. It appears that management does not provide appropriate ongoing in-service training or support to address this difficult issue.

 

Management has not ensured provision of quality assessments to enable residents access to appropriate program options, nor has it implemented monitoring systems to guarantee a reasonable standard of service delivery.

 

 

8.2      Resident Communication

 

Resident access to communication aids and/or systems appears to be restricted in that management, following an incident in 1986 where a non-verbal resident alleged sexual abuse, implemented a communications policy that limited the use of communication mechanical aids to the following:

 

-       Everyday conversation and questions and responses re food, clothing participation in an activity etc.

[31]

-       Everyday interaction/conversation necessary for participation in vocational and residential activities.

 

-       Conversation re personal news, i.e. what happened during the day; where did you go out for dinner etc.

 

-       Conversation specific to educational program development.

 

As a result of the above policy a number of former staff and parents are concerned that management is reluctant to facilitate communication in that,

 

-       One former staff member initiated the introduction of COMPIC communication aid to residents in one house. Management supplied minimal support and co-operation in establishing this program. Minimum planning was undertaken to further develop this initiative.

 

-       Although the COMPIC system has further developed, residential staff have complained that staff in the vocational area do not utilise the system consistently.

 

-       Senior management appears reluctant to establish appropriate communication programs.

 

-       No adequate explanation was provided to interested staff and parents when an assisted communications program conducted by DEAL, organisation was terminated.

 

Community visitors, in the 1990 Annual Report raised concerns regarding communication programs at Wandin Springs.

 

Issue:            It appears that resident access to communication aids and/or systems has been restricted by management. A major program priority should be to increase and improve the residents ability to communicate.

 


[32]

9.        ISSUES RELATING TO SERVICE PROVIDED IN ACCORDANCE WITH THE GENERAL SERVICE PLANS AND INDIVIDUAL PROGRAM PLANS (SECTION 23(3) (e) I.D.P.S ACT)

 

 

9.1      Individual Program Plans/General Service Plans

 

 

A significant number of complaints have been alleged by both former staff, current staff and parents in relation to GSP/IPP documentation, development and implementation. These include the following;

 

-       On occasions ΙΡΡ's were held without the resident, parents or advocates being present, contrary to Policies and Procedures. An example highlighting this practice is where a parent received a copy of an ΙΡΡ with their name listed as attending. The parent had been notified of an impending meeting but not the time or date and had not attended.

 

-       According to a former staff member a senior manager allegedly altered two IΡΡ's to reflect 1989 goals which had already been achieved and stated "we have to keep CSV happy and I don't believe in the programs". In addition, programs documented were often not forwarded on to house staff to ensure implementation.

 

-       A former staff member alleges that following a letter from CSV to Wandin Springs requesting copies of ΙΡΡ's, a senior manager had an administrative staff officer type new schedule 3's and added their name in the attendance section. A house staff member complained about the managers non-­involvement and the name was then removed.

 

-       Former staff have indicated that on occasions house staff were denied access to the GSP process, especially when those, staff intended to address specific concerns. House staff often had limited. input into the ΙΡΡ process, especially when a senior manager chaired the meeting. A senior manager attended IPP meetings for selected residents only.

 

-       According to former staff, one senior manager hindered ΙΡΡ goals implementation by bringing in personal laundry which residents had to hang out prior to doing their own washing programs.

[33]

Parents of a resident stated that a senior manager had told them not to discuss past events of an ??? -meeting as the speech therapist from the Regional Team was present and Wandin Springs did not want to go over past incidents. These parents expressed concern at the presumption of authority of the manager to ban any point of discussion concerning a resident.

 

One current and one former staff member stated that in one instance when professional advice was sought by staff for a resident exhibiting difficult behaviour, the result was more of a counselling session for staff than program development for the resident concerned.

 

According to two parents and two current staff, some current and some former house staff have neglected to implement IPP goals, in not supporting residents to undertake the identified task. One senior manager was unable to provide the investigation with any formal process of how he monitored or evaluated resident ΙΡΡ achievement. Some staff consider that a data collection format, developed by a senior manager is inadequate. A number of residents on restraint have not been documented formally by the Authorised Program Officer and notification has not been forwarded to the Intellectual Disability Review Panel as required by the I.D.P.S. legislation.

 

One resident has documented in his GSP that he is to have his own bedroom. This was disregarded by management who placed a resident on respite care in the persons room for a four week period, (as previously outlined).

 

Issue:            A significant number of different concerns have been raised pointing to inadequate GSP/ΙΡΡ documentation and implementation with resultant negative impact on residents.

 


[34]

10.         ISSUES RELATING TO STAFF MANAGEMENT PRACTICES

 

 

10.1    Staff Recruitment and Selection

 

Staff recruitment and selection are conducted by an interview panel, with the Chief Executive officer having final authorisation.

 

Supervisors are represented on some selection panels for direct care staff, but one current and two former supervisory staff complained that their opinions were ignored in the final selection of house staff.

 

One example cited was the employment of a male with no previous experience in the field of intellectual disability to work directly with a severely disabled female resident and as part of the direct care role required to toilet and bathe resident. The Supervisor in the house concerned was included in the interview of two male applicants, and were advised that- these were the only applicants. Another staff member stated that there were a number of female applicants who were interviewed without the involvement of the supervisor for the same position.

 

Initially the CSV Regional Team was involved with the selection process, but his ceased following the introduction of the CEO management structure in 1988. The Regional Team is still involved in the selection of management personnel.

 

One current staff member and two former staff members.and a parent interviewed have stated that anyone with an Anthroposophical leaning would be given preference to other applicants. Additionally, experience within the field of intellectual disability is not necessarily regarded as significant. Comments made suggested that management tended to employ new staff with no experience in the field, the rationale being that these staff would be more easily managed.

   .             .

Another complaint by two current and three former staff is these staff who had been employed in a temporary capacity in positions, were either not granted an interview or overlooked for someone with minimal or no field experience, when the position was substantively filled.

 

According to one former staff member: "People employed were not asked their background half the time. There were people who had nervous breakdowns. Emergency staff would come in and they had no idea what to do, they had no experience working with the handicapped .and wouldn't know what to do. They employed weird people and could see the effects on the residents".

[35]

Issue:            The overriding principle in staff selection, the merit principle, appears not to have been adopted in some staff selections. ManagementÕs responsibility to ensure an equitable selection and interview process appears not to have been exercised in several instances.

 

 

 

10.2    Staff Dismissals

 

A number of serious issues were raised in relation to the termination of staff.

 

-       According to two current staff -and two former staff an incident occurred where one staff member was apparently coerced into resigning in February 1991 after her involvement in an incident with a resident. In a. meeting between the union, management and two staff members, it was intimated by management that if this staff member resigned, no disciplinary action would be taken against two other staff members. This person was offered a 'redundancy' package of salary until May plus six weeks pay. Salary was paid from 10/2/91 the date of the meeting, until 29/5/91, although the. employee did not return to work after this meeting. This person was not suspended, and did not submit any medical certificates for the period of absence. Time sheets were sent to staff members home and were duly returned, completed and signed. This person was paid their normal rate, less sleepover allowance. A total amount of $9026 was paid to this employee. Although this employee resigned after discipline procedures had been implemented, the employee was still furnished with a reference which was sighted by the investigators.

 

Two current staff interviewed have confirmed that time sheets were sent home to this employee to complete and this employee was paid regularly. In fact, a senior manager commented in approximately June 1991 "That's the last time we have to pay".

 

The circumstances surrounding the resignation of this staff member involved an issue of resident abuse where the use of aversive therapy was alleged. No further- discipline action was taken against either of the two other staff members.

 

This appears not to be an isolated incident or method used by Wandin Springs management to terminate an employee.

[36]

-       According to former staff member, a staff member who left early one morning to attend a course incorrectly completed his time sheet. The staff member was stood down for a period of four weeks and negotiated with management for an additional six weeks 'redundancy payment' plus a reference. This was agreed to by the Committee of Management.

 

-       According to a former staff member a staff member was given a verbal warning after being reported for verbal abuse of other staff. Later this staff member was given a written warning. After this warning the staff member returned to his unit and advised another Supervisor that he was going off duty, sick. Senior management then asked this Supervisor to put in a report regarding this staff member who left early. Management was not happy with .the contents of the report and the Supervisor was asked to alter the report. The Supervisor refused. Management approached the staff member with the time-sheet for the day they had gone home early and this staff member was forced to resign immediately. Prior to resigning the staff member agreed to resign as long as she was provided with a reference.

 

-       According to a former staff member, another former staff member, with previous allegations of inappropriate behaviour with female residents was not forced to resign until after he made an improper suggestion to a female staff member. A staff member interviewed stated that a senior manager commented "He was given the option to resign with a reference or have the matter investigated." The staff member commented that they thought the matter should be investigated.

 

Issue:            Wandin Springs has 'paid out' staff in preference to implementing appropriate disciplinary processes. If staff have acted improperly, management should initiate investigations into the incident and determine the appropriate outcome.

 

 

10.3 Staff Discrim’nation/ Manipulation/ Harassment

 

Generally, former and current staff interviewed have indicated a fear of losing their employment if they disagree with the directions of Wandin Springs Management.

[37]

Examples of alleged actions are as follows:

 

-       Inferences reportedly made by a senior manager to staff were that if issues of concern were raised with CSV they may lose their jobs.

 

-       A current staff member alleging that a senior manager retrospectively examined the communication book of a house, attempting to find an issue to inculpate a specific staff member who had made adverse comments regarding a co-worker staff member, in the house communication book (this allegation is supported by written documentation made available to the investigators). On locating an issue where the staff member borrowed a pair of track suit pants from a resident, the page was removed and the section whited out and this photocopy returned to the book. The original was retained by a senior manager and the staff member was rebuked for placing sensitive comments in a public document. Further consequences resulted in the 'favoured' staff member contacting the parent of the resident concerned, explaining that the resident had no clothes to wear. According to the parent the whole incident had been blown out of proportion by management.

 

-       Inappropriate sexual comments being made to a staff member by a senior staff member.

 

-       One former and current staff member and a parent have further alleged that requests have been made by management to put in negative reports on staff members as an aid in the dismissal process. An example was given of a staff member who attempted to manipulate parents into mailing a complaint against fellow employees.

 

-       According to four current staff members, a 'favoured' staff member making verbal threats and inferences to junior staff about losing.their jobs. This particular staff member is alleged to have written spurious shift reports, intimating that other staff are unable to handle the behaviour of a certain resident.

 

-       A staff member and a parent interviewed complaining of the retaliatory behaviour of Senior Management. For instance, a current staff member was requested by senior managers to incriminate a fellow worker. The implication was that if the staff member inculpated another worker, she would not be disciplined for the same act. A number of current staff have alleged that senior managers have requested staff to 'spy' on fellow workers.

[38]

-       Favoured staff being allowed flexible hours, even if it affected resident care and in turn affected ­workloads. It has been alleged that a senior manager in fact spent inordinate amounts of time with a particular staff member both in a house and in the administration area. This also affected the running of the houses and the distribution of workloads.

 

-       As confirmed by documentation a current staff member involved in an internal dispute having her status changed from Temporary to Part-time to casual following her submitting a report to the Committee of Management. Altering her status resulted in her losing leave benefits. When this case was lodged with the Industrial Relations commission, management reverted her to her former status on 7/11/91.

 

-       Two former staff also alleging that a staff member, after being assaulted by a resident was made a 'floating relief'. The resident was transferred to another house. Management then placed the staff member in a situation where they would have to work directly with the resident who had assaulted her. After the union representative approached the management, the staff member was placed back in their original Unit.

 

-       One current staff member has been in the position of Acting supervisor since February 1991. The staff member was interviewed for the position in August and in September she was given a developmental program to complete prior to being substantively appointed. This staff member is the only person who has been instructed to complete a developmental program to be used in appraisal for permanent employment. The content of the program is cause for concern in that the staff member has accessed limited training.

 

The staff member is required to write a report on PRN medication for one resident and also devise a behaviour management program for another. This staff member is untrained, with no formal qualifications and management provided inadequate level of support for this staff person to complete the set task.


[39]

-       In another instance, a resident with challenging behaviours has assaulted a number of staff. One former staff member was reluctant to work with this resident alone, was assisted by another staff member working a tandem sleepover on a voluntary basis. This was approved by senior management on the proviso that the staff member acting, in a voluntary capacity could make no claims against Wandin Springs if injured.

 

A senior manager commented on the inappropriate actions and favouritism of another senior manager, who allegedly countersigned the signature of staff member who had signed on and off for the next morning. Previously, the senior manager who allegedly took this action had cited this type of action as a 'sackable' offence.

 

Issue:            There is clear evidence that management in effect operates a system of staff favouritism and retaliations to achieve its own goals. This has resulted in widespread distrust and conflict and some staff fearing loss of their employment.

 

.

10.4    Staff.Turnover/Emergency Staff/Volunteers

 

Four parents, one current and one former staff member interviewed have raised concerns about the high staff turnover at Wandin Springs, and the direct affect this has had on the residents.

 

-       One resident with high support needs has had four support workers since March, 1989 resulting in some skill regression. In the unit in which this resident is placed, there have been a total of 28 staff move through the unit in the period December 1989 to October 1991.

 

-       On examination of wage records for the financial year 1991/1992 it was evident that 25 different emergency workers had been employed for various period ranging from one fortnightly pay period to eight. The significant utilisation of emergency staff      and volunteers does certainly compound the concerns raised by parents and staff interviewed.

 

 

A senior manager indicated that the staff turnover was comparable to similar organisations and that the staff situation has stabilised in the last year.

[40]

A number of former and current staff interviewed complained that there was no comprehensive orientation/program training. According to these staff has had a direct effect on resident care. A senior manager stated that emergency staff were used as volunteers for two or three days, to see how they get on. Another senior manager commented that there is in fact an orientation program offered to new employees, however people acting as volunteers may never reach this status.

 

-       In one instance, a staff member interviewed had complained to management about the use of four different emergency workers in a three week period.

 

Issue:            The high turnover and use of untrained emergency and volunteer staff impacts directly on resident behaviour/care and it is management's responsibility to minimise staff turnover implementing strategies that address the identified causes

 

 

.

10.5    Staff Training

 

In the final report of the Steering Committee in 1988 following a previous investigation, it was recommended that both residential and vocational staff be given in-service training in behaviour management of difficult residents. In May 1988 this recommendation was initially implemented.

 

A number of staff and senior managers interviewed indicated that the majority of staff at Wandin Springs have received minimal in-service training. There is a lack of management support for staff wanting to complete courses related directly to their occupation, and lack of training in behaviour management.

 

There is a preference for Anthroposophical training. Other staff training has included first aid, stress management and orientation courses. Staff access to TAFE training for the ACRACS course is limited due to staff coverage and under the Residential Award there is no automatic entry. If staff intend to undertake such courses, they have to do such privately.

 

Wandin Springs has recently availed themselves to ΙΡΡ training conducted by Outer East Regional Team. Unfortunately, at this two session course, the same staff did not attend both sessions, hereby reducing its effectiveness.

[41]

Wandin Springs management has currently allocated a total of $3,000 to fund in-service training. According to a senior manager;

   .

-       The two line managers establish training priorities. To date these priorities have included sessions on stress management, duty of care, first aid, leadership, ΙΡΡ/GSP procedures and a local orientation program.

 

-       Training such as Everyday Interactions and Everyday Behaviour Management for direct care staff has been presented once, the priority is for vocational staff to access these programs in preference to the residential staff.

 

-       Wandin Springs, has received $10,000 from the Australasian Steiner to fund a Steiner conference for all staff. This conference has been delayed due to this investigation.

 

Some staff questioned the appropriateness of the little training they received. One staff member referred to his attendance at a symposium where topics covered included "Karma, reincarnation, etheric bodies, astral bodies, astral travelling and as part of a. workshop one person put in that he had been in contact with 'the other side' ... Also covered were colour therapy, speech therapy and, eurythmy workshops.." This staff member indicated that his attendance at the symposium was a waste of time.

 

Issue:            Despite recommendations from a. previous investigation, staff are not given adequate in-service training in behaviour management of difficult residents. Training priorities do not appear to reflect the needs of staff.


[42]

11.      ISSUES RELATING TO GENERAL MANAGEMENT PRACTICES

 

 

11.1 Medical and Medication Concerns

 

Parents and both former and current staff interviewed have raised a number of concerns alleging inaction by management in following up on medical and medication issues. The follow’ng are examples:

 

-       Two former staff stated that missing medication from one of the residents dosettes was reported to management. The management comment made to the staff member on reporting the incident was that it was "just one of those things" and this issue was not investigated further or strategies put in place to minimise the possibility of the incident recurring.

 

-       One current staff and one former staff member interviewed were concerned that there were no PRN Guidelines for Wandin Springs in dispensing medication in case of emergency. Management has in some instances established PRN guidelines for individual residents.

 

-       A significant complaint by 2 current staff and 3 former staff was the lack of access to client files, medical histories and the poor quality of these files. Staff encountered a problem in accessing resident files outside office hours which would include medical histories, allergies, current medication. According to current staff, since the commencement of the investigation an administrative staff member has been duplicating these files.

 

-       The decision as to whether residents access a general practitioner appears in some instances to be left to the discretion of an administrative officer, the Assistant to the Residential Superintendent. This staff person had made decisions such as:

 

-       Whether female residents have pap smears

 

-       Whether or not a resident attends a doctor. In one instance, according to a senior manager, this staff person refused to take a resident to the doctor after being directed by a senior manager. This staff person apparently viewed the issue as not being urgent. This issue was addressed by the parents of the resident by attending the doctor when the resident was on weekend leave.

 

-       Whether a resident would require services of optometrist after the resident read an eye chart.

[43]

When requested case files were provided by Wandin Management on all residents, an examination of the information revealed a lack of historical data. On questioning a senior manager about the information in the files, another set of files was produced that contained ­historical data.

 

Issue:            Senior Management at Wandin Springs indicated that guidelines on medical issues were available to staff. However, it was evident that direct care staff lacked knowledge in areas of administration of PRN medication, dispensing of medication and the reporting of issues concerning medication. House staff operate on the premise that guidelines were non existent resulting in incidents occurring or staff concerns which often were brought to the attention of management.

 

The resident files examined at Wandin Springs were particularly inadequate in the medical area. The files were incomplete and information on individual residents had to be collated from a number of sources. Medical data was not sequential and the information was generally ad hoc. From the presentation of the files, vital medical information could be overlooked.

 

 

11.2    Communication Issues

 

There was a general concern among former and. current staff and parents who were interviewed about the inadequate communication between management and staff. Issues range from the changing of staff rosters and shift times without consultation, to inaccurate information about working conditions, terms of employment, time in lieu, conditions and general information on temporary admissions.

 

Inadequate communication links between vocational and residential areas has also been raised as a significant concern. This lack of communication can undermine the work of both residential and vocational staff and their reaction to, for example, challenging behaviours displayed by residents.

 

A senior management staff member complained of lack of participation in decision making at the Executive level and the fact that there were no Executive meetings.

 

Community visitors have reported communication problems in their 1990 Annual Report. Internal communication at Wandin Springs between designated work areas appears to be unstructured and in some cases non-existent. One senior manager suggested that the poor communication was exacerbated by the lack of clear authority given to individual managers and supervisors.

[44]

The hierarchical management structure of Wandin Springs appears to cause some communication and management problems. For example, a direct care worker in a house has to report through three management levels to reach the Committee of Management. Changes in the management structure could improve the accountability and lines of communication for staff.

 

Issue:            The inadequate communication linkages between designated work areas has caused disruption to some of the operations of Wandin Springs in both facilitating resident programs and ensuring that all staff have relevant information. This coupled with the hierarchical management structure in the residential area has caused direct care staff to receive misinformation and function in an organisational environment which exacerbated communication problems.

 

 

 

11.3    On Call Service

 

One current staff member and a former employee expressed concerns about the availability of staff rostered on call.    These staff alleged that a senior manager would quite often not answer his pager when rostered on call.

 

Examples include:

 

-       On 19/1/91, unable to be contacted by house supervisor as additional support was required for a resident exhibiting challenging behaviour.

 

-       On occasions a. senior manager while on call was not within range of the beeper. He had informed staff he would be unavailable prior to the weekend. When queried by a staff member he left a telephone number for contact purposes, although this was not a direct line to him.

 

-       Staff were particularly concerned about the adequacy of the on call support, given the insufficient in-service training provided. For example, administrative typist or casual staff members with minimal direct care and management experience would be rostered for on-call. This has been confirmed in documentation. Given that the advice sought was often related to medical emergencies, staff considered this particularly inappropriate.

 

Issue:            The after hours on call service does not appear to operate as an effective back up system. It is evident that some staff are not confident in the service and advice provided.

[45]

11.4    Assaults on Staff by Residents

 

Two current and four former staff raised concerns about the frequent incidents and/or assaults on both residents and staff by a particular resident and the inaction of management in minimising the incidents by implementing appropriate strategies.

 

Incident reports cited relating to this one resident indicated:

 

-       25/4/89 - Resident suffered a grand mal seizure. After seizure became aggressive and punched staff member in abdomen twice and pinched on upper arm leaving a bruise.

 

-       29/8/89 - Incident reported that resident had been verbally abusive on this day and the staff member at the conclusion of the report commented that to place this resident and another resident in another unit without adequate staffing arrangements would be a great error of judgement.

 

This comment was proven to be correct when on 12/9/89 the resident assaulted a female staff member. The staff member was kicked and punched in the face and over the head several times. A cup of hot tea was then thrown over the staff member. Thinking the resident had calmed down, staff member told resident not to hit again. At this stage, staff member was grabbed by hair, dragged to ground and kicked in the head. Staff member was dragged approximately 15 feet across the floor. A female staff member was unable to restrain resident off and a male member eventually released residents hold.

 

Injuries claimed to have been received as a result of the assault were evidence of a hairline fracture to the skull, both cheekbones and jawline. The staff member also had an operation on a tooth at the Dental Hospital and was billed $36.00. The staff member was advised that this should be covered by WorkCare. The employee states management refused to supply WorkCare forms when requested.

 

-       15/1/90 - Resident physically attacked female staff member around the head and face, the moved away and returned to reading the newspapers. When asked what the problem was, the resident repeated the attack and told her to go home.

 

-       18/1/90 - Resident was asked to do the dishes. He yelled at another resident and then squirted dishwashing liquid on her and the table. He then picked up the electric jug and attempted to hit here with it. Resident then ran outside and spoke to male staff member. He was confused as to why he did it.

[46]

-       18/10/90 - Resident hit female staff member (who was pregnant at the time) in the stomach. This occurred at 3.45 p.m. in the afternoon. As a result of this attack, this staff member claimed she suffered vaginal bleeding and was bedridden for one week. A WorkCare claim was submitted to support this injury.

 

-       22/10/90 - Resident was directed to put dishes away. He became verbally abusive and ran out of the unit. He ran back inside a minute or two later and threw a piece of wood at a female staff member missing her narrowly. Resident then went and saw a male staff member. From 4 p.m. onwards resident was verbally abusive towards female staff member. There were no witnesses to actual incident.

 

-       4/11/90 - Resident picked up an empty milk carton and hit female staff member over the shoulder. This was seen to be an act of aggression as he had to walk across the room to go and get the carton.

 

-       8/11/90 - Resident was verbally abusive to another resident and female staff member. He hit resident over the face, ran out and broke a pot plant.

 

-       21/1/91 - Resident refused to eat his evening meal at the table. After 15 minutes he picked up his meal and went into the lounge room. Staff member asked him to return to table. He then threw his plate onto the floor scattering the food. He ran out of the house, then picked up rocks and threw them with force at the window of the lounge area (perspex). Staff member went to talk to him and he picked up more rocks and threatened to throw them at staff member. Staff member went inside and resident again threw rocks at the side window.

­

-       29/4/91 - Resident in socks walked up behind female staff member. She turned around not aware of his presence and he punched her in the nose. He asked to leave. He ran through Gilbulla, returned, grabbed the electric frypan and ran to Warrandah lounge and hid the frypan.

 

-       Another staff member came to assist with resident as he did not wish to talk to staff member he had punched. Resident punched this staff member in the left causing her to fall. She left the area to attend to the other male residents. On her return she found that resident had smashed the kitchen window. Reason for attack: resident not happy with the change at the bakery.          Resident apologised.

[47]

-       8/8/91 - Resident hit female staff member very hard with a flat hand to the left side of the face, flinging off her glasses. Staff followed him outside where he threw a clay pot and a lemon at a car. The reason for this outburst was that staff member would not give resident the keys to her car to get the milk out.

 

One current staff and one former staff member highlighted management's failure to provide staff training to assist in the management of residents displaying challenging behaviour. Apart from those incidents already documented in this report, other residents have exhibited similar behaviour. In one case in the months between January 1988 and June 1989 there had been a ­­minimum of 25 violent outbursts by this resident. Staff had refused to work with this resident on the grounds of Health and Safety. Management implemented a backup sleepover and PRN medication. Staff agreed to return to the unit if other more far reaching changes were affected to ensure staff and resident safety. The resident was transferred to CSV Training Centre after he severely damaged a car with 3 people inside one of whom was pregnant.

 

Issue:            Given the numerous incidents and assaults relating to an individual resident, management had not implemented on-going strategies to minimise the inappropriate behaviour and risk to both residents and staff. Had such been implemented injuries to staff and risks to other residents would have been minimised.

 

 

11.5 Children of Staff Members at Work - in Duty Hours.

 

Following the 1987 investigation, a policy was distributed instructing staff not to bring children to work during duty hours. In 1990 it was evident that the practice was recurring. Examples alleged by a former staff member include:

 

-       Several staff members consistently brought their children to Wandin Springs for the day during the weekend shifts or the duration of sleepover periods.

-       One senior manager brought his children into Wandin Springs during school holidays. The children remained in the manager's office, one wandering freely. This was confirmed by a parent as on one occasion they were in a meeting with a senior manager whose son was allowed to play on the blackboard. A child of a senior manager was observed mowing a lawn unsupervised.

 

[48]

One former staff and two parents stated that one married couple had an arrangement with the Committee of Management to work opposite shifts so that the non-working partner could care for the baby. This effectively meant that a resident in the husband's unit was left alone in that unit while he slept in the adjoining unit. Parents complained that some families stayed and dined in the units, although they did pay for their meals.

 

It has been reported by another former staff that a staff member left her baby with another staff member while she went on the bus run, effectively reducing the direct care to the residents.

 

According to a former house supervisor, casual staff often brought in their children including babies.

 

Issue:            Management on establishing policy following the 1987 investigation that children of staff do not attend Wandin Springs during duty hours, disregarded this policy in some instances. There is implication of legal liability of a child is injured or assaulted by a resident whilst on the property. Resident care received a low priority in several instances.

 

 

 

11.6    Committee of Management

 

The Chief Executive Officer is responsible to the Committee of Management, but in discussions Committee representatives agree the C.E.O had delegated authority.

 

The Committee of Management's membership is restricted to contributors who financially support Wandin Springs. This has limited the Committee's skill base.

 

The Committee of Management has also recently experienced a period of internal turmoil, including insufficient committee members to make a quorum at some meetings, and the resignation of key office bearers such as the Treasurer and President.

 

Parents interv’ewed stated that some parents perceived their role as subservient to and protective of senior management and to promote whatever the Steiner faction dictates and believe in the exclusiveness of the Steiner name at any cost. Some parents have complained that if you do not belong to this group, you have extreme difficulty in having issues addressed and in fact tend to be ignored.

[49]

Significant concerns have been raised about the Committee of Management. The following are examples of issues raised:

 

-       During the course of the investigation, C.S.V was approached by concerned staff and parents who had lodged a complaint with the Committee of Management. This dispute involved all of the staff of one of the houses, the relationship between a senior manager and a co-worker from the house, and the effect on both staff and residents.

 

Staff in this unit were denied the right of instituting formal grievance procedures as a senior manager was directly involved in the incident. They had no confidence in another senior manager to handle their complaint and waited until the involved manager was on leave before lodging complaint.

 

These staff complaints were handled initially to the person acting in the position who made a synopsis for the Committee. The manager on leave returned prematurely and was the main orator when all staff were interviewed. The complainants felt intimidated and that they were denied natural justice.

 

The outcome of this meeting was to place the 'aggrieved' staff member in another unit. Unfortunately staff from this unit refused to work with this person.

 

This employee had been placed in yet another unit in a tandem sleepover situation. Effectively, since bans .were put in place on 14 November, this continued until the supervisor in this unit went on maternity leave and this staff. member was placed there as deputy.

 

The Committee chose to insist on a reconciliation of all parties. During the ensuring months, no resolution was reached.

 

-               Under the Wandin Springs constitution, Section 7.14 it states "No member of the Committee shall directly or indirectly supply services to the home where such goods or services can be satisfactorily obtained elsewhere locally."

 

The wife of a committee member has in the past been used almost exclusively to cater for the medical needs of the residents. Until 1990 she attended at Wandin regularly and residents still attended at her home clinic.

[50]

-       Staff have limited access to the Committee of Management, in that severe restrictions were put in place, and they were able only to comment on issues such as leisure and recreation. Reports would be censored if management wished to control an issue and did not want the Committee of Management to be informed. One senior manager complained of this practice. A former staff member commented on limited access to the Committee of Management members, stated that the only regular committee member who attended Wandin Springs was the former Treasurer.

 

Issue:            Minor industrial issues have been exacerbated by the Committee of Management's inability to effectively resolve issues or direct senior managers to undertake a specific course of action.

 

The Committee of Management has not provided the organisation with a strong direction and ensured effective communication linkages with all staff levels.

 

 

 

11.7    Unorthodox Practices

 

During the course of the investigations various unorthodox practices were allegedly undertaken. These include:           

 

-       A senior manager brought personal laundry to work on a regular basis (including his family's clothing) and uses the machine in Miranbeena. This washing was left for the staff or residents (who think it is their job) to hang out. A memorandum was circulated about this issue instructing staff not to do personal laundry, however a senior manager did not adhere to this direction.

 

-       During that initial week of the investigation staff have alleged that a senior manager went through his office to clean out certain documentation. One staff member had seen brand new document files/archive boxes in the senior managers office at different times since the inception of the investigation. A senior manager was observed on three separate occasions during the week 26 August to 30 August 1991 loading boxes of papers into his vehicle.

[51]

-       Current staff members indicated that in 1990 staff had been seen smoking marihuana in front of residents. The matter was reported to a senior manager who issued a memorandum regarding the practice. No formal investigation was instituted. No copy of the memorandum was located and staff claimed it had disappeared from their files.

 

 


11.8    Policies and Procedures and Records

 

As a result of the 1987 investigation, new policy and procedures were developed and endorsed by the Committee of Management. These did not incorporate all areas and further policies needed to be developed by the .organisation.

 

On examining the policy and procedures document provided by Wandin Springs management, it was evident that further work needed to be undertaken in this area. The policies examined were not comprehensive. The majority of policies/procedures were not dated, signed/authorised and in no sequential order. A senior manager commented that all policy and procedures at Wandin Springs were under current review and that management had obtained copies of policies from other organisation.

 

The two former and two current staff interviewed stated that procedural guidelines were not readily available or non-existent. Personnel records and records or residents were of a poor standard.

 

Issue:            Management has not provided comprehensive policies and procedures despite recommendations and work undertaken following 1987 review. Direct care staff are not given guidelines to follow on specific issues.

 

During the course of the investigation it became apparent that the personnel files maintained were of a very poor standard and that a range of documentation was missing or located in other areas of the facility. Files examined had minimal content and could not be used to obtain a clear picture of the employees history. Records of residents were inadequate and non-sequential.

 

 


[52]

 

 

 

 

 

 

 

PART C

 

 

 

 

REPORT ON THE

 

FINANCIAL INVESTIGATION

 


[53]

12.      DETAILS OF THE ACCOUNTING RECORDS SYSTEM AND PERIOD OF FINANCIAL INVESTIGATION

 

 

12.1    Accounting Records of Wandin Springs

 

Bank Accounts

 

Wandin Springs utilises the services of the ANZ bank, Lilydale and the bank accounts operated via this branch can be broken up into three categories as follows:

 

(1)       Day to Day Operations of Wandin Springs

 

A total of 4 bank accounts are used as follows:

 

General Account (Account No. 3042-41313)

 

-       account used for the payment of all operating accounts and to reimburse the ΑΝΖ Bank for the fortnightly wages service provided via the ACCESS PAYROLL system.

 

-       all cheques drawn on this account are signed by a panel made up of the Committee of Management with two signatories being required to sign after sighting of relevant supporting documentation.

 

General Account - No. 2 Account (Account No. 86-86502)

 

-       account used for the payment of emergency type payments and to reimburse petty cash expenditure including the purchase of food for houses.­

 

-       all cheques drawn on this account are signed by a panel comprising the CEO of the Administrative Officer plus one other, usually a staff member.

 

-       reimbursement of expenditure via this account is made via the GENERAL ACCOUNT.

 

Building Fund (Account No. 3042-43781)

 

-       this account has been established to receive various donations and fund-raising proceeds.

 

-       expenditure from the account covers a range of items including building maintenance, hire of fund-raising consultants, transfer of funds to the General Account, various capital/equipment purchases and transfer of funds to the Cash Management Account.

 

-       the account is operated via the Committee of Management with two signatories being required to sign after sighting of relevant supporting documentation.

[54]

Cash Management Account (Account Νο. 3042-87805)

 

-       this account was opened in March 1990 and is used as a holding account for funds not immediately required for use.

 

-       deposits into the account emanate from the General Account and the Building Fund

 

-       the account is operated by the Administrative officer and is, by its nature, an account which attracts a higher rate of interest on credit balances held.

 

 

(2)       Client Accounts

 

All clients at Wandin Springs have an individual ACCESS ACCOUNT opened in their own name at. the ΑΝΖ Bank, Lilydale.

 

Each client's mobility allowance is automatically deposited into the account and client parents or family can deposit funds into these accounts to enable additional expenditure. E.g. clothing, furniture, spends via outings/holidays etc.

 

The Administrative officer is the primary signatory for these accounts however, several clients are able to sign their name and therefore can operate their account as required.

 

 

(3). "Fire and Clay" Accounts

 

For some years a pottery operated on the property of Wandin Springs as part of the Vocational Program available to clients.

 

Around August/ September 1988 the pottery operation was relocated to a factory site in Beresford Road, Lilydale.

 

In April 1991, following several Federally funded grants for specific purposes, the Federal Department of Community Services and Health gave a funding approval to "Fire and Clay" in the vicinity of $160,000 per annum.

 

From this date "Fire and Clay" has operated as a separate entity but is still accountable to the Wandin Springs Committee of Management.

 

It is known that at least two bank accounts are operated by "Fire and' Clay" via the ΑΝΖ Bank, Lilydale.

 

 

[55]

12.2    Accounting system in operation at Wandin Springs

 

As can be seen by the various bank accounts in use at Wandin Springs the day to day operation of these accounts is split between the Administrative officer and the Committee of Management C/- the Treasurer.

 

Wandin Springs utilises a KALAMAZOO system as its principal bookkeeping record and as such payment entries are recorded at the time a cheque is written.

 

In relation to receipts a standard Newsagent purchase receipt book is used for the General Account and the No. 2 Account.

 

The Building Fund receipt is a specifically designed and printed receipt which gives the following information:

 

-       Wandin Springs formerly Wandin Rudolf- Steiner Curative Home

 

-       Registered with the Hospitals and Charities Commission

 

-       Building Fund Account

 

-       Donations of $2.00 and over are Tax Deductible

 

All bank accounts in operation are reconciled with relevant bank statements on a monthly basis and adequate supporting documentation exists to enable verification of receipts and payments.

 

In addition to the bank accounts a petty cash advance of $1,500 is maintained which is used to provide office petty cash and advances to the houses of Wandin Springs for housekeeping money.

 

These advances are made at the rate of $38.00 per week per resident which covers groceries, meat, toiletries etc.

 

Receipts are insisted upon by the Administrative Office to fully account for moneys advanced and a cash book is maintained in each house recording such expenditure.

 

Service and utility accounts relating to each house are paid via the General Account and the Petty Cash float is reimbursed via the No. 2 Account.

 

 

12.3    Previous Audit Reports

 

The accounting records of Wandin Springs Private Training Centre are maintained on a financial year basis (ie. 1st July to 30th June) and the Committee of Management has appointed PRICE WATERHOUSE as Auditors.

[56]

An. examination of the Auditors Reports for 1988/89 and 1989/90 revealed that the accounts were prepared on a cash basis and included the following qualification:

 

"As an audit procedure, it is not practicable to extend our examination of donations, fund-raising and opportunity shop receipts beyond the accounting for amounts received as shown by the books and records of Wandin Springs".

 

An examination of the draft auditors report for 1990/91 reveals that the accounts were prepared on an accrual basis for the first time.

 

The main difference between the accounts being expressed on a "cash" basis compared to an "accrual" basis is via the "cash" method of accounting receipts are reflected in the year they are actually received and payments are reflected in the year they are actually paid, whereas via the "accrual" method of accounting receipts are brought to account when the right to receive them comes into being and payments are accounted for as and when incurred rather than "on payment".

 

Enquiries were made on the 6th September 1991 with Mr. Anthony Dale C/-Price Waterhouse regarding the final audit of the 1990/91 accounts and the expression of an "Audit Opinion". Advice was given that in view of the current CSV investigation, Price Waterhouse did not wish to issue an audit opinion.

 

 

12.4    Period of Financial investigation; Verification of CSV Funding

 

As a result of information gathered in the preliminary stages of the investigation and in view of the fact that the 1988/89 and 1889/90 audit reports were accepted by CSV, the period of the financial investigation for the day to day operations of Wandin Springs was restricted to the 1990/91 financial year and the current financial year.

 

In relation to the "Building Fund" the investigation period was extended to include 1987/88 to date.

 

Committee of Management operations for all of 1990 and 1991 from a financial perspective, were also included, in particular the operation of the Finance Sub-Committee.

 

During the 1990/91 f’nanc’al year an amount of $1,110,677.92 was paid by CSV to Wandin Springs as grants or reimbursements for expenditure incurred (WorkCare, mileage etc).

 

As a starting point of the financial investigation this amount was traced to cash receipts and bank of Wandin Springs with all cheques being adequately accounted for.

 


[57]

13       FINDINGS OF THE FINANCIAL INVESTIGATION

 

 

13.1          Possible inappropriate use of Committee of Management Office-Bearers Signatures to Impose a Levy on the families of clients at Wandin Springs

 

In May 1990 a number of letters    were forwarded to parents, brothers, sisters and guardians of clients detailing various financial concerns and highlighting the current debt problems of the centre.

 

This culminated in a letter dated 29th May, 1990 being sent in which claims that the CSV funding system had "forced us into overdraft" were made and requesting that in order to reduce the immediate debt level an amount of $100,000.00 needed to be raised.

 

The letter proposed "A TEMPORARY TIME LIMITED LEVY" of. $5,000.00 per resident family spread over a 2 year period and stated that "this amount would be recognised as a DONATION and you would be receipted thus and gain considerable tax advantage".

 

The letter also suggested other ways of assisting the financial situation including building a network of support for donations and the payment of fees in advance.

 

In all a total of four letters were sent regarding the financial situation as follows:

 

                     9th May 1990   -             signed by C.E.O

                  10th May, 1990   -             signed by President and Treasurer

                   18th May,1990   -             purportedly signed by President and Treasurer

                  29th May, 1990   -             purportedly signed by President

 

The letters of 18th and 29th May bear the signatures of the stated office bearers of the Committee of Management. However there appears to be evidence to suggest that the signatures of office-bearers shown on the letters were taken from another document and placed on the letter which was then photocopied. This is considered to be inappropriate. It is unclear whether the signatures were used with their specific authority or not.

 

As a result of the letter of the 29th May 1990 a total amount of $95,525.01 was raised up to the 7th October 1991. Reference to the levy and the response by families has been referred to in the minutes of the Committee of Management

 

A total of 24 families have responded to the request and 3 have not.

 

From the records examined it is not apparent what action the Committee of Management proposes to take in relation to those families who have not paid any part of the levy.

 

 

[58]

13.2    Taxation Implications on Levy

 

Wandin Springs Private Training Centre is recognised as a. public benevolent institution under the provisions of Section 78 (1) (a) (ii) of the Income Tax Assessment Act and therefore gifts of $2.00 and over would be allowable deductions.

 

Advice received from the Australian Taxation office suggests that a levy imposed by an organisation would not and could not be construed as a donation as it is not an unsolicited charitable act on the part of the giver.

 

Of the $95,525.01 received as levy payments $91,794.96 has been deposited into the Building Fund and "official" Building Fund receipts issued to those contributing thus enabling a taxable deduction to be claimed.

 

The balance of $3,730.05 has been deposited into the General Fund with unofficial receipts being issued to those contributing thus no taxation deductibility status applies.

 

On the face of the facts available it appears that Wandin Springs may be in breach of the Income Tax Assessment Act in that official receipts were given for a levy purportedly imposed by the Committee of Management but recorded in the books of account as "donations".

 

This may well have implications for the individual taxpayers involved.

 

              .

13.3    Management of Client Funds

 

The 27 clients at Wandin Springs have ANZ Access Accounts opened in their name. These accounts are operated at the ANZ - Lilydale Branch.

 

Client mobility allowances are directly credited into these accounts and any monies received on behalf of a particular client can also be deposited into their respective account.

 

The Wandin Springs Administrative Officer, is the sole signatory for the clients access accounts although some clients are able to sign their name and thus operate their own account.

 

Amounts are withdrawn from the accounts on a fortnightly basis for pocket money, etc, or as required for the purchase of other items of a personal nature.

[59]

Cash withdrawn is handed to the respective House supervisor who maintains a handwritten record of each clients balance on hand and is required to account by way of receipts those amounts spent by the client or on a clients behalf.

 

A total of two clients have their financial affairs managed by Administrators - one being the State Trustees Office the other family members.

 

Client files and records relating to the management of client funds were examined during the course of the investigation and the following shortcomings were noted:

 

(1)       client files were found to be, in some cases, haphazardly kept with a number of folders having to be referred to in order to obtain the full picture of a clients record.

 

(2)       It was noted that the family who administer one client's financial affairs is continually concerned about personal income tax implications should she accumulate what the Trustees consider too much personal wealth and as such they encourage the CEO at Wandin Springs to request funds as required.

 

This request has been met on a number of occasions.

 

The wisdom of administering Trust funds in this manner is open to question.

 

(3)       an examination of transactions from the State Trustees Office in relation to a resident revealed that there appears to be no unwarranted claims being made on behalf         of her by Wandin Springs. All furniture bought for her by Wandin Springs and charged to her account at the State Trustees was sighted during the investigation.

 

(4)       overall the procedures used within each House to account for the expenditure of cash withdrawn from clients ACCESS ACCOUNTS were found to be lacking several areas including:

 

-       evidence that records were written up in a block and not on a day by day basis.

 

-       evidence that cash withdrawn from ACCESS ACCOUNTS was not always recorded in the relevant clients record of cash held in the respective house.

 

-       in a number of cases the record of cash held was in arrears.

 

-       use of white out was noted to be a common practice.

[60]

-       entries were sighted where it was apparent that cash sums had been borrowed from staff members and other clients, then repaid at a later date when a cash withdrawal had been made on behalf of the relevant client.

 

-       there is no apparent system to independently check the adequacy of the procedures being used in each House.

 

A summary of the balances held in ACCESS ACCOUNTS and in CASH at Wandin Springs on behalf of each client indicated that minimal balances are held - 50% of clients with less than $100.00 in total.

 

The fact that such minimal balances are maintained would create problems when planning day to day activities for clients and it is therefore recommended that a more realistic balance be established for each client thus eliminating the need for monies to be borrowed from other sources.

 

It was also apparent during the examination of the records maintained by each house that revised procedures which incorporate a regular monitoring role are required to satisfactorily account for the expenditure of client cash which emanates from the ACCESS ACCOUNTS.

 

Accordingly it is recommended that a card system be implemented to account for cash expended.

 

This proposal was discussed with an administrative officer on the 5th December and it was agreed that by introducing such as system internal controls in relation to the handling of client funds would be significantly strengthened as follows:

 

-       only one card would be issued per client

 

-       when card completed it is returned to the administrative area with relevant receipts attached thus enabling verification of entries

 

-       when the new card is issued the balance carried forward would be recorded by administrative staff after verification of the previous card

 

-       used cards and receipts would be retained and stored in the administrative area

 

13.4    Other Financial issues at Wandin Springs

 

These include the following:

 

13.4.1       Apparent Breaches of By-Laws by the Committee of. Management

 

The overall operation of Wandin Springs is under the control of the Committee of Management which is elected in accordance with the by-laws of the organisation.

 

 

[61]

The by-laws state that the Committee shall:

 

(a)       manage the funds and manage the provision of the facilities, amenities and requisites for use by the home.

 

(b)      be responsible for the employment and dismissal of paid officers and staff.

 

(c)       control the admission to or discharge of residents from the home.

 

(d)      control the acquisition, use and disposal of real and personal property by the home and the building programs of the home, including the raising or securing of funds for such purposes.

 

The by-laws also determine the composition of the Committee as being 9 members, comprising contributors, elected from among their number.

 

The by-laws draw on the Hospitals and Charities Act to define a contributor and provided these provisions are met the person is eligible to be elected on to the Committee of Management at the Annual General Meeting.

 

Further relevant by-laws in relation to the Committee include:

 

7.9      the Committee shall at its first meeting after the AGM in each year appoint from its members a President, two Vice-Presidents, a Secretary and a Treasurer.

 

7.10    the President, Vice-Presidents, Secretary and Treasurer shall hold office for one year, and shall retire from these respective offices on the day-of the next AGM, but may be reappointed.

 

7.13    no member of the Committee shall be appointed to or retain any paid office of the home whilst that person is a member of the Committee.

 

7.14    no member of the Committee shall directly or indirectly supply goods or services to the home where such goods or services can be satisfactorily obtained elsewhere locally.

 

9.1      the Committee shall meet once each month.

 

10       the Committee may at any time appoint any Sub-Committee they may think fit and may prescribe the functions and procedures of any such Sub-Committee.

[62]

In addition to the financial records minutes of the Committee of Management and the Finance Sub-Committee were examined for the 1990 and 1991 period and the following possible breaches were noted:

 

-       for the year 1990 it appears that two Committee of Management members could not be deemed as financial members as they had not paid the required donation to qualify them as contributors until prior to being re-elected in 1991. Both persons paid the fees required under the Hospitals and Charities Act - definition of a contributor, on the 5th September, 1991, which qualified them to be elected at the AGM on 12th.September, 1991.

 

-       By-law 7.14 appears to have been breached as medical services have been provided to clients by the wife of a former member of the Committee of Management.

 

 

 

 

 

13.4.2.      Use of the Building Fund

 

As previously indicated Wandin Springs has established a Building Fund into which various funds are deposited, including donations via several trusts, donations received via the Opportunity Shop which operates at Prahran, levy payments as previously identified and other general donations.

 

As the name suggests it would be anticipated that the majority of payments from this fund would be related to building programs, however this is not the case as a range of capital and operational expenses have been met from this Fund. These are set out below

Financial records relating to the Building Fund for the period 1987/88 to 07/10/91 were examined and the following points were noted:

 

(a)       TABLE No. 1 - DONATIONS FOR WHICH OFFICIAL RECEIPTS HAVE BEEN ISSUED

 

                              EX PARENTS/              OPPORTUNITY                    TOTAL

                               TRUSTS ETC                        SHOP

 

1987/88                        7,508.53                        33,500.00                       41,008.53

1988/89                        7,615.26                        33,000.00                       40,615.26

1989/90                      78,266.00                        25,000.00                       98,266.00

1990/91                      69,371.16                        33,000.00                     102,371.16

1991/92                        4,579.60                            NIL                               4,579.60

(@ 07/10)

 

TOTALS                $162,340.55                    $124,500.00                   $286,840.55

 

Of the amounts recorded for 1989/90, 1990/91 and 1991/92 $91,794.96 relates to the Levy, whilst $124,500.00 is attributed to the work of the Opportunity Shop for the four and l/3 year period.

[63]

This leaves a balance of $70,545.59 which relates to direct donations to Wandin Springs via various trusts, parents and general donations as follows:

 

TABLE No. 2 - SOURCE OF DONATIONS TO WANDIN SPRINGS

 

                     TRUST/CO                INDIVID.                     FEES                       OTHER                     TOTAL

 

1987/88               NIL                         7,257.01                      NIL                            251.52                    7,508.53

1988/89               NIL                         6,010.00                      NIL                         1,605.26                    7,615.26

1989/90          11,000.00                    2,475.00                    3,400.00                    1,386.00                  18,261.00

1990/91          28,406.00                    3,585.20                      NIL                         1,570.00                  33,561.20

1991/92               320.00                       645.00                    2,334.60                       300.00                    3,599.60

 

                     $39,726.00                $19,972.21                  $5,734.60                  $5,112.78                $70,545.59

 

 

(b)      TABLE No.3 - PAYMENTS FROM THE BUILDING FUND VIA CHEQUES DRAWN

 

Payments from the Building Fund via cheques drawn from the 1987/88 financial year onwards are reflected as follows :

 

 

                      TRANSFER               BUILDINGS                  ASSETS                     OTHER                     TOTAL

                      GEM/CMA­

 

1987/88        120,000.00                  22,352.95                    9,082.51                    2,155.50                153,590.96

1988/89               NIL                         2,517.95                  43,331.20                       NIL                      45,849.15

1989/90          73,000.00                    2,935.69                  29,654.34                  23,823.10                129,413.13

(@ 07/10)       75,000.00                    9,431.52                  15,717.53                    6,265.00                106,414.05

 

1991/92               NIL                             NIL                          NIL                         1,120.00                    1,120.00

 

TOTALS       268.000.00                  37,238.11                  97,785.58                  33.363.60              $436.387.29

 

 

**       Represents amounts transferred to the General Account or the Cash Management Account.

 

NOTE      1 -       "Asset" figure for 1988/89 includes $31,222.87 for pottery equipment.

 

                 2 -       "Other" figures for 1989/90, 1990/91 and 1991/92 include an overall amount of $10,201.80 for the services of fund-raising consultants. This service can be attributed with the figure raised under "trusts/ companies" in TABLE No. 2

 

                 3 -       "Asset" figure for 1989/90 includes the purchase of a vehicle for the Chief Executive Officer at a cost of $17,565.00 and the "Asset" figure for 1990/91 includes the changeover cost for the vehicle of $1,986.00

 

[64]

 

13.4.3       Specific Matters in Relation to "Fire and Clay"

 

Throughout the investigation it was apparent that CSV funds had been used for the operation of "Fire and Clay" both when located on-site at Wandin Springs and when at the current site in Lilydale.

 

As this had occurred it was evident to the Investigating team that the operation of "Fire and Clay" would need to be examined thus the Federal Department of Health and Community Services was contacted, and asked to assist in a preliminary visit to the "Fire and Clay" site in Lilydale.

 

As a result of this visit and subsequent enquiries with staff and parents of clients attending the service a number of financially related concerns are listed hereunder, however it should be noted that full access to the financial records of "Fire and Clay" was not possible and comments made are based on a copy of the cash book.

 

(a) the financial records of "Fire and Clay" prior to May 1991 are incorporated in the books of account at Wandin Springs. Since May 1991 a Federal funding arrangement has applied and several bank accounts have been opened to receive and draw on funds provided.

 

An examination of the cash book for the period May to August 1991 revealed that minimal revenue was being generated from the sale of product lines ($2,017.71) compared- to wages paid for the corresponding period totalling $36,909.62

 

(b)      from the records available it would appear that bank reconciliation of the cash book to bank statement has not been performed since the account was opened (5/91) and the account may have been overdrawn on a number of occasions.

 

(c)       associated records which would be expected to be kept would be of interest especially a record on items produced.

 

(d)      it appears that considerable use of the facility is made by a number of potters who are renting studio space at what appears to be a very minimal rental rate.

 

(e)       other areas of interest would be reasons for the ­high staff turnover, payments to a Wandin Springs contractor which are shown as wages, personal taxation implications for the potters who are renting studio space, and whether the strategies per the "Fire and Clay" business plan are being met.

[65]

It is accordingly recommended that an independent audit be made of the "Fire and Clay" operation to ensure that the project is meeting its stated and anticipated objectives and. that no CSV funds can be used for the ongoing expenditure of the project.

 

 

 

13.4.4       Initial Acquisition and Replacement of CEO's Vehicle

 

On the 16th February 1990 a submission was put to the Committee of Management by the Chief Executive Officer requesting that a vehicle be provided for that persons business and personal use.

 

Grounds cited in support of the request included:

 

(a)       as compensation for inadequate wage levels in the context of the beyond reasonable time commitment and energy expenditure allied to such positions.

 

(b)      recognition of the value of the position and its incumbent

 

(c)       an investment by the organisation to ensure quality persons are attracted to such positions

 

(d)      an inducement for such persons to remain long-term with the organisation

 

The Committee of Management considered the matter at its meeting on 16th March 1990 per the minutes of that meeting gave approval to this in principle.

 

Subsequent meetings of the Committee of Management did not ratify or refer to this matter and the vehicle was purchased on 27th April 1990 at a cost of $17,565.00 sales tax exempt

 

This Purchase occurred at a time when the Committee of Management was concerned with various financial problems including the appointment of fund-raising consultant, letters to parents explaining the current financial situation including the imposing of a time limited levy, and noting of a financial concern "proper financial management is urgently required" Ð meeting of the 18th May 1990.

[66]

The timing of the vehicle purchase and the outright approval of the Committee of Management is open to question.

 

On the 14th May 1991 the vehicle purchased in 1990 was traded in on a replacement vehicle.

 

As with the first vehicle no specific Committee of Management approval could be sighted in the minutes approving the trade-in on a replacement vehicle in fact an appendix to the Financial Statement for-April 1991 under Vehicle Replacement noted:

 

"although this month we are in debt there will be no other replacement vehicle this financial year."

 

 

 

 

 

 


[67]

 

 

 

 

 

 

PART D

 

 

 

 

CONCLUSIONS

 


14.1    THE CONDUCT AND FRAMEWORK OF THE INVESTIGATION

 

Between August, 1991 and November 1991 the investigators appointed by Director General of Community Services Victoria pursuant to the provision of Section 55(1) of the I.D.P.S Act gathered information from a wide variety of sources. These included an analysis of records, the taking of statements, and discussion with staff, former staff, Committee of Management representatives, community visitors, CSV Regional Team and external agencies.

 

It is recognised that many persons who spoke to the investigators raised concerns about the operation of Wandin Springs. There were other persons who were very satisfied with the operation of Wandin Springs. It is also recognised that some persons making complaints were aggrieved about decisions taken by Wandin Springs management in relation to their own situation. These factors have been considered carefully and taken into account.

 

A constraint of the investigation is that it has not been possible, during the conduct of the investigation to put allegations/concerns to the Committee of Management as the management body of the organisation or to senior managers. This was due to the fact (as outlined in Section 4) that information and statements were made to CSV on a confidential basis and persons providing statements displayed considerable anxiety about the possibility of the information being released to the Committee of Management or management staff at Wandin Springs.

 

As stated in Section 4 of this report, the issues analyzed by the investigators were examined in the context of relevant sections of the I.D.P.S Act given Wandin Springs status as a registered residential and non-residential service.

 

Principles in accordance with which a requested service is required to operate are specified in Section 23 (3) of the I.D.P.S Act.

 

These principles are:

 

(a)       that the service is provided in the least restrictive environment; and

 

(b)      that provision is made or persons who are receiving the service to participate in the planning, operation and evaluation of the service; and

 

(c)       that restrictions on and the interference with the rights, dignity and self respect of persons receiving the service is kept to the minimum necessary in the circumstances; and

[69]

(d)      that there are adequate mechanisms for the assessment and review of persons receiving the service; and

 

(e)       that services to eligible persons are provided in accordance with the general service plans and individual program plans; and

 

(f)       that the service provided is accessible and flexible to meet the individual rights and needs of eligible persons.

 

The principles specified in Section 23 (3) are referred to in Section 25 (1) of the Act:

 

Section 25 (1): Where in the opinion of the Minister a registered residential service or a registered non-residential service:

 

(a)       is inefficiently or incompetently managed; or

 

(b)      has failed to provide an effective service in accordance with the principles specified in Section 23 (3); or

 

(c)       has breached or failed to comply with any provision in a funding and services agreement -

 

The Governor in Council may on the recommendation of the minister made after complying with Sub-Section (3), by Order in Council published in the Government Gazette appoint a fit and proper person as administrator of the registered residential service or registered non-­residential service.

 

 

14.2    Matters Substantiated by the Investigation

 

During the course of the investigation a large number of complaints and allegations were made by current staff, several former staff, a number of parents and other individuals. Only those concerns that have been documented in statements in records have been referred to in the report. Careful analysis of material in the statements has been undertaken as well as an examination of relevant records. The majority of complaints and allegations have been made by more than one person apparently acting independently.

 

In assessing all the material provided to the investigation, substantial concerns have resulted from, firstly, the consistent and cumulative content of the issues raised and secondly, the similarity between issues raised in this investigation and many matters raised in previous investigations.

[70]

These concerns fall into 3 broad areas:

 

(1)       Care of Residents

(2)       Management Practices

(3)       Financial Aspects

 

Care of Residents

 

Some of the most critical concerns relate to the following issues:

 

-       Lack of access to appropriate medical attention including simple remedies for pain relief not being available; a resident being treated for heat rash who had advanced chicken pox; the lack of choice in some instances between traditional and homeopathic medical treatment. These concerns were highlighted in the 1987 Investigation. Policies and procedures developed at that time have not been followed and are not known by direct care staff. Several other recommendations of the 1987 review in relation to residents medical care have apparently not been implemented.

 

-       Inappropriate use of resident funds. Some residents who have the capacity to make an informed decision about the use of their funds and other matters are not being enabled to do so.

   .             .

-       Inappropriate transfer of residents between units without effective consultation with residents, their advocates or staff, resulting in major disruptions, distress and regression of other residents.

 

-       Allegations of sexual and physical abuse of residents by staff not being adequately-investigated or followed up by management. A significant number of allegations of physical abuse were made in the 1987 investigations. It was concluded at that time that they lacked supportive evidence.

 

-       Lack of resident participation in decision making on issues effecting the daily- living (eg. whether they should have their own television.)

 

-       Lack of privacy afforded to residents despite this being a significant issue raised in the last investigation. Policies and procedures relating to privacy were to have been presented to the Committee of Management in May 1988 following the 1987 investigation. Staff interviewed were unaware of the existence of any such documents.

 

-       Instances where residents were left unattended when ill including a resident with a high temperature who was vomiting; a resident with epilepsy who had returned from hospital with sutures.

[71]

-       Instances of lack of adherence to and implementation of Individual Program Plans resulting in lack of progress and skill development in some residents.

 

A clear pattern emerges that residents are more limited in terms of choice and participation in decisions concerning major life areas that should be the case given the resources available to Wandin Springs and its comparatively small scale. What emerges is a clear lack of management endeavour to provide professional input, policy and program support. This coupled with the direct care staff's limited access to training has led to residents being exposed to inappropriate management techniques and actions. In some cases skill regression is apparent. The large number of serious incidents including alleged assaults by residents on staff and allegations of abuse by staff of residents raises major concerns about the wellbeing of residents.

.

It should be noted that while some staff have engaged in inappropriate and bad resident care practices, many other staff have endeavoured to provide quality care often in difficult circumstances.

 

 

Management Practices

 

Specific concerns related to the following issues:

 

-       staff selection and recruitment practices. Staff have not always been selected on merit and according to a fair process

 

-       staff dismissals. It is apparent that some staff have been 'paid out' in preference to an appropriate disciplinary process being implemented. Some staff appear to have been forced to leave on inappropriate grounds.

 

-       staff discrimination and manipulation. It is apparent that some staff have been favoured while others have been discriminated against. A climate of fear and distrust exists between many staff and management. This adversely affects resident care.

 

-       inadequate support and staff training of staff by management in relation to failure to provide support when staff are dealing with challenging behaviour. This concern was highlighted in the 1987 investigation. Failure to communicate effectively with staff on resident and working conditions matters; failure to provide an effective after-hours support service.

[72]

-       lack of adequate, complete and sequential client files. Of particular concern was the fact that in several instances, medical records were incomplete. Reports of several incidents either had not -been prepared or were unable to be accessed.

 

-       lack of comprehensive policies and procedures. For example, the 1987 review report indicated that a Personnel and Industrial Practices Manual was being prepared for presentation to the Committee of Management in May 1988. This manual, if it was prepared is not available.

 

-       Mishandling of a specific staff complaint and other resident/staff issues by the Committee of Management.

 

During the course of the investigation it became apparent that major tensions and bitter divisions are occurring between groups of staff, staff and management, groups of parents and the Committee of Management.

 

It is considered that the Committee of Management has failed to provide effective leadership. It has a precarious membership following the recent resignations of the Treasurer (following a major conflict with the committee members) and the resignation of the President. It has difficulty managing the service and delegates inappropriately many of its responsibilities to senior management. The committee's membership needs to be broadened and it its skill base increased.

 

Following careful analysis of an extensive amount of data provided to the investigation, it is concluded that a senior manager operates in an inappropriate manner when outcomes do not reflect that managers preferred outcome. There        is insufficient delegation of appropriate responsibilities to other senior managers and unit supervisors are allowed limited access to decision making. This manager does not have the confidence or trust of several parents and many staff. These parents consider that the Committee of Management protects the manager at all costs and condones some of the behaviour which they consider has been the root cause of the problems.

 

The structure of the management of Wandin Springs appears to be overly cumbersome and bureaucratic. There needs to be a simpler and more direct line relationship between the resident and the Chief Executive Officer. A revamping of the management structure of the organisation is warranted to enable a more direct relationship between the resident and the C.E.O and a stronger focus on the development of standards and quality assurance procedures.

[73]

A number of staff have confirmed that they were unskilled and required training input to improve services. Staff raised concerns about the service provided and resident outcomes and the inaction of management in addressing these issues. Several staff held grave concerns about formally reporting to CSV due to either a perceived or a real threat of losing their employment.

 

Certainly, since the commencement of the investigation, management has responded by addressing shortcomings in areas such as staff recruitment, staff training, resident programs and policies and procedures.

 

 

 

Financial Aspects

 

As a result -of the financial investigations several concerns were identified:

 

 

-       taxation implications of a levy imposed on residents (on the face of the facts it appears that Wandin Springs may be in breach of the Income Tax Assessment Act in that official receipts were given for a levy purportedly imposed by the Committee of Management but recorded in the books of account as 'donations')

 

-       shortcomings in relation to the administration of resident funds

 

-       the use of the Building Fund

 

 

 

14.3    Failure to Meet Legislative Requirements

 

In view of the above concerns, it is concluded that the Committee of Management has failed to meet certain legislative requirements.

 

Failed to provide an effective service in accordance with the principles specified in Section 23 (3)

[74]

The Wandin Springs Management has failed to provide a residential service in accordance with the I.D.P.S legislation Section 23 (3) particularly in the following areas:

 

23 (3) (a)                Medical issues

23 (3) (a)                Guardianship aspects

23 (3) (b)                Resident transfers

23 (3) (c)                Inadequate investigation and allegations of abuse to residents

23 (3) (c)                Residents left unattended when ill

23 (3) (e)                Individual Program Plans

 

 

 

 

Inefficient and/or Incompetent Management

 

The Wandin Springs Management was incompetent and/or inefficient as a registered service under Section 25 (1) ( a ) in relation to the following matters

 

Staff dismissals

Staff discrimination/manipulation

Medical and Medication concerns

Financial Management

 

 

As previously stated the current investigation is the fifth in a ten year period.

 

In previous investigations several complaints which were found to be substantiated (in the 1984 and 1987 investigations in particular) are similar to present complaints. Examples of such complaints are poor communication practices; inadequate staff training; inadequate means of resolving disputes; inadequate handling of residents behaviour problems and the medical care of residents; .inadequate attention to resident privacy issues, lack of documentation and personnel and industrial practices. In several instances recommendations of the 1987 review have not been implemented in that some policies and procedures have not been adhered to and in some cases have not been developed.

 

Outcomes of previous reviews have included the termination of various management staff; the provision of funding for additional staff positions; a revised organisation structure; appointment on a short term basis of CSV administrators who would in conjunction with the Committee of Management assist in the adoption of policies and procedures.

[75]

Despite reforms instituted as a result of previous investigations, practices which are antithetical to a healthy organisational climate and quality resident care have re-emerged. Reforms and improvements appear to have been shortlived.

 

Substantial reform of the management of Wandin Springs Private Training Centre is considered a necessary prerequisite for addressing the specific issues of concern raised in this report.

 


[76]

APPENDIX

 

 

SUMMARY LIST OF ISSUES RAISED

 

 

Resident Care

 

Restricted Opportunities for Residents

 

The relative isolation and insulation of the service results, in some instances, in restricted opportunities being provided which leads to poor outcomes for residents.

 

Medical Issues

 

The significant number of cases referenced suggest that residents do not at all times access adequate medical support and attention. In fact some residents appear to have been placed at risk due to poor decisions and inadequate practices.

 

Where contentious issues arise relating to either choice of medical treatment of whether a resident accesses medical services, appropriate advocacy guidelines and processes were not in place to ensure that right decisions are made.

 

While there are policy and procedural documents on medical matters especially from the 1987 investigation, a significant concern is that staff interviewed indicated minimal knowledge of these policies and procedures and in many instances had not followed set guidelines.

 

It is apparent that the relevant information on medical issues required by direct care staff has not been disseminated throughout the organisation.

 

 

Guardianship Aspects

 

Parents/siblings and staff have significant control in a range of life areas for residents over 18 years of age. Indications are that some residents have capacity to make an informed decision in relation to certain aspects of their life and are not being enabled to do so. In some instances one person may override choices selected by a resident or those determined by a consensus process.

 

Under current guardianship legislation parents have limited authority to determine how resident funds are expended. Administrators should be appointed for residents that have in excess of $5,000 in their accounts.

 

[77]

Resident Transfers

 

It is concluded, from several different examples, that residents have had minimal input in any relocation. Often the rationale for the relocation was not known, by staff or parents. Some relocations resulted in major disruption, distress and regression in other residents. The opportunity for residents or for parents to give consent or to have parents and/or staff to advocate was minimal. An independent third person to act on behalf of the resident was not viewed as an option.

 

Management has not put into place avenues for staff to address concerns raised about resident placement. The placement of residents is not achieved via any formal procedure, in consultation with all parties concerned. As a consequence significant disruption to resident care occurred.

 

 

Resident Participation in Decision Making

 

It is apparent that opportunities for residents input in determining daily life choice have not been maximised.

 

   .

Inadequate Investigation of Allegations of Abuse to Residents

 

A number of serious allegations of sexual abuse and .physical abuse have been made. Many of these do not appear to have been investigated by management.

 

 

Privacy

 

Policy and Procedures had not been distributed to minimise the possibility of breaches of privacy incidents occurring and to create an accepted standard of privacy for residents in all units at Wandin Springs.

 

 

Residents Left Unattended When Ill

 

While staff resources are limited due to budgetary considerations, management should initiate alternative options to leaving ill residents unattended. One such option could be to establish a sick bay in a central location where on duty staff could monitor the residents more closely. This initiative in the past has been canvassed with management.

 

 

Financial. Matters

 

Management has not implemented a comprehensive local policy and procedure or any appropriate monitoring system to ensure residents funds are correctly expended.

 

 

[78]

Resident Assessment of Access Programs

 

Staff are experiencing difficulty in managing residents who exhibit challenging behaviour. Staff have initiated and implemented some basic behaviour programs with minimal effect. It appears that management does not provide appropriate ongoing in-service training or support to address this difficult issue.

 

 

Resident Communication

 

It appears that resident access to communication aids and/or systems has been restricted by management. A major program priority should be to increase and improve the residents ability to communicate.

 

 

Individual Program Plans/General-Service Plans

 

A significant number of different concerns have been raised pointing to inadequate GSP/IPP documentation and implementation with resultant negative impact on residents.

 

 

 

Management Practices

 

 

Staff Recruitment and Selection

 

The overriding principle in staff selection, the merit principle, appears not to be been adopted in some staff selections. Managements responsibility to ensure an equitable selection and interview process appears not to have been exercised in several instances.

 

 

Staff Dismissals

 

Wandin Springs has 'paid out' staff in preference to implementing appropriate disciplinary processes. If staff have acted improperly, management should initiate investigations into the incident and determine the appropriate outcome.

 

 

Staff Discrimination /Manipulation /Harassment

 

There is clear evidence that management in effect operates a system of staff favouritism and retaliations to achieve its own goals. This has resulted in widespread distrust and conflict and some staff fearing loss of their employment.

 

[79]

Staff Turnover /Emergency Staff/Volunteers

 

The high turnover and use of untrained emergency and volunteer staff impacts directly on resident behaviour/ care and it is management's responsibility to minimise staff turnover implementing strategies that address the identified causes.

 

 

Staff Training

 

Despite recommendations from a previous investigation, staff are not given adequate in-service training in behaviour management of difficult residents. Training priorities do not appear to reflect the needs of staff.

 

 

Medical and Medication Concerns

 

Senior Management at Wandin Springs indicated that guidelines on medical issues were available to staff. However, it was evident that direct care staff lacked knowledge in areas of administration of PRN medication, dispensing of medication and the reporting of issues concerning medication. House staff operate on the premise that guidelines were non existent resulting in incidents occurring or staff concerns which often were brought to the attention of management.

 

The resident files examined at Wandin Springs were particularly inadequate in the medical area. The files were incomplete and information on individual residents had to be collated from a number of sources. Medical data was not sequential and the information was generally ad hoc. From the presentation of the files, vital medical information could be overlooked.

 

 

Communication Issues

 

The inadequate communication linkages between designated work areas has caused disruption to some of the operations of Wandin Springs in both facilitating resident programs and ensuring that all staff have relevant information. This coupled with the hierarchical management structure in the residential area has caused direct care staff to receive misinformation and function in an organisational environment which exacerbated communication problems.

 

 

On Call Service

 

The after hours on call service does not appear to operate as an effective back up system. It is evident that some staff are not confident in the service and advice provided.

 

[80]

Assaults on Staff by Residents

 

Given the numerous incidents and assaults relating to an individual resident, management had not implemented on­going strategies to minimise the inappropriate behaviour and risk to both residents and staff. Had such been implemented injuries to staff and risks to other residents would have been minimised.

 

 

Children of Staff Members at Work - in Duty Hours

 

Management on establishing policy following the 1987 investigation that children of staff do not attend Wandin Springs during duty hours, disregarded this policy in some instances. There is implication of legal liability of. a child is injured or assaulted by a resident whilst on the property .Resident care received a low priority in several instances

 

 

Committee of Management

 

Minor industrial issues have been exacerbated by the Committee of Management's inability to effectively resolve issues or direct senior managers to undertake a specific course of action.

 

The Committee of Management has not provided the organisation with a strong direction and ensured effective communication linkages with all staff levels.

 

 

Policies, Procedures and Records

 

Management has not provided comprehensive policies and procedures despite recommendations and work undertaken following 1987 review. Direct care staff are not given guidelines to follow on specific issues.

 

During the course of the investigation it became apparent that the personnel files maintained were of a very poor standard and that a range of documentation was missing or located in other areas of the facility. Files examined had minimal content and could not be used to obtain a clear picture of the employees history. Records of residents were inadequate and non-sequential.

 

 

[81]

Financial Aspects

 

 

Taxation implications of a levy imposed on residents (on the face of the facts it appears that Wandin Springs may be in breach of the Income Tax Assessment Act in that official receipts were given for a levy purportedly imposed by the Committee of Management but recorded in the books of account as donations).

 

Shortcomings in the administration of resident's funds.

 

Use of Building Fund for other than building programs.

 

Certain other matters (See Section 13)