Public hearing 32 - Service providers revisited - Day 4

CHAIR: Good morning everybody. Welcome to everybody who is in the Brisbane hearing room today and to everybody who is following the proceedings of the Royal Commission by the livestream. This is the fourth day of Public hearing 32, which is a hearing revisiting service providers. We commence with the Acknowledgment of Country. We acknowledge the Jagera people and the Turrbal people as the Traditional Custodians of Meanjin, that is, Brisbane, the land on which we are today gathered for this hearing. We pay our respects to their Elders past, present and emerging. We also acknowledge First Nations people who are participating in this hearing, including those who are following the hearing either in person or via the livestream. Yes, Ms Eastman. 

MS EASTMAN: Good morning, Commissioners, and good morning to everybody following the proceeding. The Royal Commission will now turn its attention to examining and understanding the way in which service providers address complaints. 

CHAIR: Yes. Sorry to interrupt, I think I have again forgotten to take any additional appearances today. So could I do that and then we will continue. 

MS EASTMAN: I'm sorry. I wasn't aware of that. 

CHAIR: Sorry. Other additional appearances to be announced from any parties who have not previously announced appearances? Yes. 

MS HARRIS: Thank you, Chair. If the Commission pleases, my name is Claire Harris. I appear for Yooralla with Ms Naughton. 

CHAIR: Thank you, Ms Harris.

MS HARRIS: Thank you. 

CHAIR: Yes. Any other appearances? 

MS TAY: My name is Tay. I'm instructed by Corrs Chambers Westgarth for Endeavour Foundation. 

CHAIR: Thank you very much.

MS GARDNER: Commissioner, my name is Gardner and I appear for Northcott Society. 

CHAIR: Thank you. Is there any appearance from any party represented remotely? There may be later on today. All right. Sorry for that interruption, Ms Eastman. Thank you. 

MS EASTMAN: So, Commissioners, we now turn attention to looking and understanding the way in which service providers respond to complaints but also incidents. The plan for today is that we will have three panels which will examine the way in which service providers respond to issues. We want to start this morning with the first panel, to understand whether service providers have policies, how those policies have been developed and the way in which the policies are used within their organisations. 

Our second panel will then have an opportunity of looking at particular policies a little more closely and to understand the way in which those policies might apply in given circumstances. For example, how a complaint or a grievance or feedback might be addressed pursuant to the policies. And then at the end of the day, we will turn our attention to the way in which service providers deal with external processes, so the extent to which the service providers need to report complaints or notifications and the way in which external systems operate with respect to service providers. 

It will be also an opportunity for the Royal Commission to revisit to - two service providers. A representative from Yooralla will tell you about steps taken by Yooralla since Yooralla's appearance at Public hearing 3 in December 2019, and you will also have the opportunity to hear from Ms Robbs from Life Without Barriers. As the Commissioners are aware, the Commissioners have provided a draft report to Life Without Barriers, but the hearing report is yet to be made public. So you will have an opportunity to hear what steps Life Without Barriers has taken following the conclusion of the hearing. 

So I want to turn to this panel, and you will see that we have three members of this panel. We have Sonya Furey, the interim chief executive   is there any change to that, Ms Furey? 

MS FUREY: No, the board has extended my contract and   

CHAIR: From Community and Accommodation Respite Agency, Cara, and I will come back to you in a moment; Mr Swain, who is the CEO of the Endeavour Foundation; and Ms Liz Forsyth, who is the CEO of The Northcott Society. So I think they have all given their oath and affirmations. 

CHAIR: Yes. Thank you very much. Welcome to the Royal Commission. Thank you very much for coming to the Brisbane hearing room to give evidence today. We appreciate the assistance you have provided and will provide during the course of the morning. So if you would be good enough to pay attention to Ms Eastman, she will now ask you some questions. 

<SONYA FURY, CALLED

<DAVID SWAIN, CALLED

<LIZ FORSYTH, CALLED

<EXAMINATION BY MS EASTMAN SC

MS EASTMAN: So, Ms Furey, can I start with you. You have just confirmed that you are the interim CEO of Cara, and there's a process of recruitment underway to find a new CEO. Is that right? 

MS FUREY: No, the board has not commenced a process of recruitment. If I have the opportunity to continue, I would be delighted to do so. And that's the current status. 

MS EASTMAN: And as the interim CEO, your focus is on driving the implementation of Cara's strategic plan 2022 to 2024. Is that right? 

MS FUREY: Correct. 

MS EASTMAN: And you have qualifications in law and accounting, and a wide ranging experience in finance, commercial law, risk management, strategy, mergers and acquisitions. Is that right? 

MS FUREY: Yes, I do. 

MS EASTMAN: In terms of Cara, it's an organisation that commenced its operation in 1995 in South Australia. Is that right? 

MS FUREY: That's correct. 

MS EASTMAN: And Cara supports people with disability in South Australia, not only in Adelaide but in regional areas such as Mount Barker, Murray Bridge, Mount Gambier, Kadina, Port Augusta, Port Pirie, Port Lincoln and the surrounding areas. 

MS FUREY: Correct. Kadina. 

MS EASTMAN: I'm giving away my non South Australian knowledge. That's quite a large area for the service to cover. And are we right in understanding that you provide services to 313 people with disability? 

MS FUREY: Yes. As at December, 313 was the number. 

MS EASTMAN: And the 313 people are across all the different locations? 

MS FUREY: Correct. 

MS EASTMAN: And the nature of the services provided include supported independent living, short term accommodation and home and community support. Is that right? 

MS FUREY: That's correct. 

MS EASTMAN: Cara has 252 full time employees. Is that right? 

MS FUREY: How many employees did you say there? 

MS EASTMAN: 252 full time employees, 676 part time employees and 200 casual employees. 

MS FUREY: That sounds about right, yes.

MS EASTMAN: Rounding up, doing the maths, 782. Does that sound right? 

MS FUREY: Full time equivalent. Yes.

MS EASTMAN: So 782 full time equivalent. Okay.

MS FUREY: I believe so. 

MS EASTMAN: All right. If we need to check that number, can you let me know? 

MS FUREY: Yes.

MS EASTMAN: I will just make sure that my note is correct. Mr Swain, can I turn to you. So you joined the Endeavour Foundation as the CEO in December 2021. Is that right? 

MR SWAIN: That's correct. 

MS EASTMAN: And you are a founding director and immediate past chair of the Community Services Industry Alliance. Is that right? 

MR SWAIN: Yes. 

MS EASTMAN: And current director of Guide Dogs Queensland? 

MR SWAIN: Correct. 

MS EASTMAN: And in terms of your background, you have worked for a number of organisations, and you have qualifications in business, health science and education. 

MR SWAIN: That's correct. 

MS EASTMAN: And you also are a graduate of the Australian Institute of Company Directors. Is that right? 

MR SWAIN: Correct. 

MS EASTMAN: In terms of Endeavour, Endeavour Foundation was founded in Brisbane in around 1951. Is that right? 

MR SWAIN: That's correct. 71 years ago. 

MS EASTMAN: And the origins of the Endeavour Foundation rest with a group of parents who wanted to create more educational opportunities and options for their children with intellectual disability. 

MR SWAIN: That's correct. 

MS EASTMAN: So over the past six decades, Endeavour has provided schools, non vocational day services, employment services and accommodation services for people with intellectual disability? 

MR SWAIN: Yes. 

MS EASTMAN: In terms of the number of people with disability   I think for the notice, it's been described as "service user". That's a little sort of impersonal, but there's 3,700, approximately, service users? 

MR SWAIN: That's correct. 

MS EASTMAN: And in terms of full time equivalent staff, 3,106. That's as at 2020. Have those numbers changed? 

MR SWAIN: I couldn't tell you the exact number of full time equivalent. 

MS EASTMAN: Okay. Ms Forsyth, can I turn to you. You are the CEO of Northcott, and you were appointed to that position in September 2020. 

MS FORSYTH: That's correct. 

MS EASTMAN: Now, you joined Northcott in 2008? 

MS FORSYTH: Yes. Correct. 

MS EASTMAN: And you joined as a family support worker in the Coffs Harbour branch. 

MS FORSYTH: That's correct.

MS EASTMAN: And may I say you are one of the people we have been talking about this week who has had a career path from support worker up to the level of CEO. Would that be a fair summary? 

MS FORSYTH: That would be a fair summary. 

MS EASTMAN: So you have held a range of roles, from area manager, business development manager and then leadership roles in customer experience, supported living and Northcott Innovation. Is that right? 

MS FORSYTH: That's right. 

MS EASTMAN: And in terms of Northcott, it was established in 1929 by the Rotary Club of Sydney. And it was intended, again, to support children with disability. And I think the old fashioned language was the New South Wales Society for Crippled Children. Is that right? 

MS FORSYTH: That's correct. 

MS EASTMAN: So Northcott is now one of Australia's largest not for profit service organisations, and you provide services in metropolitan and regional locations throughout New South Wales and ACT. Is that right? 

MS FORSYTH: That's right. 

MS EASTMAN: You employ over 2,000 staff? 

MS FORSYTH: That's correct. 

MS EASTMAN: And in terms of service users, if I can use that expression, are we right in understanding that there are about 16,700 service users, or thereabouts? 

MS FORSYTH: That's correct. 

MS EASTMAN: And of that group, about 12,500 are children and their families. 

MS FORSYTH: That's correct. 

MS EASTMAN: So in terms of the nature of the services provided to children, what can you tell us about that? 

MS FORSYTH: The nature of the services provided to children primarily fall under a service we offer as a partner in the community for the National Disability Insurance Agency called early childhood supports. 

MS EASTMAN: Right. So have each of you, or someone on your behalf, been following the proceedings of the Royal Commission this week? 

MR SWAIN: Yes. 

MS FORSYTH: Yes. 

MS FUREY: To a limited extent. 

MS EASTMAN: All right. Did you follow a panel yesterday afternoon where I asked this question, and I'm going to ask each of you, in the approach that you take, do you assume that violence, abuse, neglect and exploitation is occurring within your organisation? 

MR SWAIN: Yes, I did hear you ask that question. And, yes, I do assume that it is occurring. 

MS FORSYTH: I did not hear you ask that question. But, yes, I do assume it is occurring. 

MS FUREY: I also did not hear   monitor the panel yesterday. And, yes, we set our systems on the basis that that could be occurring. 

MS EASTMAN: So if we start with the assumption that it either is or could   there's a little bit of a distinction between "is" and "could", would you agree? 

MS FUREY: Yes. 

MS EASTMAN: So assume it is occurring in the organisations. Then when it comes to having a process in dealing with incidents of violence and abuse that occurs, you all agree that you need to have robust and effective complaint handling processes? 

MS FUREY: Yes. 

MS FORSYTH: Yes. 

MR SWAIN: Yes. 

MS EASTMAN: And a way of measuring and understanding why incidents of violence and abuse occur. Is that right? 

MS FORSYTH: Yes. 

MR SWAIN: Yes. 

MS FUREY: Yes. 

MS EASTMAN: Now, for Cara, you have developed something called an action plan, a valuation of measures to reduce violence, abuse, neglect and exploitation and discrimination against people with disability. And, Commissioners, it's tab 17 in your bundle. Ms Furey, do you have a copy of that with you? 

MS FUREY: Yes. Just let me go to it. Yes. 

MS EASTMAN: So can I ask you about the purpose of this policy. It's described as: 

An action plan that operationalises Cara's commitment to improving our prevention of violence, abuse, neglect and exploitation of Cara customers and evaluating our success in doing so. 

So the date of the policy is 12 November 2021. What was the reason to develop this policy in November 2021? 

MS FUREY: So it is an action plan, and it was developed before I joined Cara, which was very late August '22. So I cannot give you the background to the preparation of this document. 

MS EASTMAN: How is this document used within Cara? 

MS FUREY: My understanding is that an action plan is to operationalise change or to communicate, but to enact change within our service operations. And this is a plan that has been introduced to do that in respect - 

MS EASTMAN: What changes? 

MS FUREY: So the   yes, I'm not sure what has triggered the need for change. I'm not sure if that has come out of an earlier interaction with this Royal Commission. But an action plan is normally prepared to document appropriate change to address a particular matter within the organisation, and this is an action plan. 

MS EASTMAN: But you don't know if this was an action plan developed in response to a particular incident or matter. Is that right? 

MS FUREY: No, I'm unable to answer that. 

MS EASTMAN: And you're not able to say whether it's a plan developed to take a proactive approach to dealing with violence and abuse, rather than a reactive approach? 

MS FUREY: It was certainly my understanding that it is a proactive initiative. 

MS EASTMAN: All right. So, on this panel, we are going to talk about responses to complaints. And in terms of complaints, all of your organisations have received complaints in the period of the notice. So for Cara   and, Commissioners, this is tab 1, page 3. Ms Furey, if you've got that? 

MS FUREY: Sorry, what document are you referring to?

MS EASTMAN: So it is your response to the Royal Commission. So you described it as Notice to Give Information in Writing Notice, CTH-NTG 00313. Have you got that document? 

MS FUREY: I have that in front of me. 

MS EASTMAN: So page 3 has a pie chart, and it gives the Royal Commission an approximate proportion of complaints by reference to who has made the complaint: 35 per cent from people with disability; 48 per cent from a family member or friend of a person with disability; government bodies, two per cent; support workers, five per cent; and others, including guardians and advocates, 10 per cent. So that helps us know who is the source of complaints and the relative proportion for November '21 to November 2022. But how many complaints have there been in total? 

MS FUREY: I cannot tell you how many complaints were received and logged within Cara during the period November '21 to November '22. 

MS EASTMAN: Why not? We asked you for that information. Why can't you tell us? 

MS FUREY: Well, I have come with the number of complaints from 1 February to the 31st of the 12th '22 in preparation, but I   

MS EASTMAN: That pie chart would have had to have been developed based on some raw numbers, I assume? 

MS FUREY: Yes, I understand that is the case. 

MS EASTMAN: But you don't know? 

MS FUREY: I don't have the full details with me, but I can   

MS EASTMAN: Is that something you could provide that to us? 

MS FUREY: I certainly will provide that to you. 

MS EASTMAN: And if there is anyone in the room assisting you who can provide it during the course of your evidence, that would be appreciated. Mr Swain, can I turn to Endeavour. In terms of complaints   and if you've got your response, Commissioners, this is tab 26 at page 5. So Endeavour has told the Royal Commission that of the complaints received in the 12 month period prior to the notice, seven per cent were received from disability service users; 14 percent from family members and support networks; 31 percent from advocates and others acting on behalf of people Endeavour support, 33 percent from workers; and 15 per cent fell outside the specified categories. In terms of those proportions, what's the total number of complaints? 

MR SWAIN: Our total number of complaints is around   and can I just qualify that some of those categorisations might   that some of the employees, for example, may be people who are in receipt of an NDIS package. So they may be supported employees as well. 

MS EASTMAN: Okay. So they might be people working in the ADE businesses? 

MR SWAIN: That's correct. 

MS EASTMAN: All right. 

MR SWAIN: Yes. And, likewise, some family members may also be categorised as advocates. 

MS EASTMAN: Okay. So it's a sort of rough allocation. How do you work out that you allocate the complaint to a referable category? Is that under a policy, or is this something you've just done for the Royal Commission? 

MR SWAIN: That's something that's done within our system, and it's something that we need to improve: the categorisation. 

MS EASTMAN: Now, Ms Forsyth, can I turn to you. So, Commissioners, the relevant information appears behind tab 32, page 7. In terms of the information that you've provided to the Royal Commission, again, you've provided us both the proportion of complaints and the approximate number of complaints. So why do you say, "approximate number"? Is there any uncertainty as to the actual number of complaints? 

MS FORSYTH: I am unsure why the word "approximate" was used. It's probably just an error. My understanding is that there have been 203 complaints in the period of which we produced the notice for. 

MS EASTMAN: So 33 per cent of disability service users; 47 per cent of family and support networks; six per cent of independent complaints; and 14 per cent from NDIS provider employees. What do you mean by "NDIS provider employees" for this purpose? 

MS FORSYTH: For this purpose   and we do give a bit of a breakdown in an appendix   that includes employees of a service provider that provides NDIS services. 

MS EASTMAN: So the appendix, Commissioners, is Annexure C at page 22. So that sets out the number of complaints by reference. So when we look at the source of complaints, just looking at Annexure C, the highest level of sources of complaints are described as "customer's circle of support". What does that mean? 

MS FORSYTH: Customer circle of support are the people involved in the customer's life who support them around decision making in particular, or who support them to live their lives. And we give a breakdown of what "circle of support" means, which includes formal guardianships, parents, siblings, relatives, partners and children. 

MS EASTMAN: And then looking at that circle of support, in terms of the   by far the most significant source of complaints are parents. Now, does that reflect the nature of the services that you provide, that parents play some more active role than maybe some of the other services? 

MS FORSYTH: I think   

MS EASTMAN: Have you looked at that as a reason? 

MS FORSYTH: I think it reflects the nature of the supports that we provide, insomuch that lots of parents are formally engaged as decision makers on behalf of people we support. 

MS EASTMAN: Now, Mr Swain, I don't mean to be unfair to you in any way, but if we just take the numbers across just the group for Endeavour, there's a significantly lower percentage of complaints coming from family members and other support workers compared to what we hear from Northcott or Cara. Has your organisation done any analysis into who is making complaints and if, for example, in Northcott, a significant number of complaints from parents, that in Endeavour   is there a particular sort of area where the complaints are more likely to come, either because of the person's role or the nature of the activity? Have you done that analysis? 

MR SWAIN: Yes. And I think it's around the classification of whether it's family lodging in our system   whether it's the family lodging the complaint or if they are classified as an advocate. We would be of the view that over 50 per cent of our complaints are lodged by family. 

MS EASTMAN: Okay. So the numbers when   and I think you said earlier that some of those descriptions might overlap with advocates and families. So would that account for it? 

MR SWAIN: That's right. Yes. 

MS EASTMAN: All right. So we understand from the information that you have provided that each of your organisations have developed some new policies that have been developed and commenced operation in the period of the last two years. So that's why we have chosen you for this panel, because you have all undertaken an exercise of refreshing existing complaints. Can I ask, in the process of developing your new key policies, have any of your organisations undertaken a process of auditing and mapping the data available to you to work out what you need by way of a new complaints process by reference to looking at what has happened in the past? Ms Furey? 

MS FUREY: I am unable to   I do not know whether an audit has been undertaken in relation to the preparation of these policies. 

MS EASTMAN: Any mapping? 

MS FUREY: I can't answer that either, I'm sorry. 

MS EASTMAN: For Northcott? 

MS FORSYTH: I probably wouldn't use the term "audit", and the work that we've done has been refinement of existing policies and procedures rather than the creation of new ones. And we do have information that has fed into that process. Partly, that information has come from looking at trends around incidents and complaints through our internal quality and risk committee, which is a cross section across the organisation that looks at trends around the data and the information coming from our systems and makes recommendations for changes in response. In addition to that, we have a post incident review process whereby, for critical incidents, we undertake a process to identify broader systemic changes that could be implemented to either prevent or mitigate further risk in a similar situation, which has resulted in changes to our policies. 

MS EASTMAN: So can you explain how that work has informed the modification or any changes to the existing policies and the one that you now work with? 

MS FORSYTH: Yes. Probably an example of that within the policies has been to provide greater clarity to our staff around the nature of supports to provide a person who is the subject of an incident or a complaint. And so while our policy had referenced the requirement for staff to provide that support, we provided additional and extra information to be quite clear around the breadth and nature of that support, not just being immediately post - but broader than that, and to encompass a broader way of thinking about supporting someone across their physical, mental and emotional health, and thinking about the   providing sufficient resources for staff to identify other sources, external agencies, advocates, support services that they can refer to. 

MS EASTMAN: So that all has affected the way in which you've developed a complaint handling procedure, has it? 

MS FORSYTH: In terms of the nature of our policies in response, yes. So we   we have been working on ensuring that our policies and procedures - and   provide sufficient support for staff to undertake supporting our customers, as we call them, through those processes. 

MS EASTMAN: Thank you. Mr Swain, has Endeavour undertaken any auditing or mapping of what's occurred before in developing the complaint handling approaches? 

MR SWAIN: I would say that the complaint handling   we call it a feedback policy, was actually initiated in 2007. And it's been a process of continuous improvement since then, including improvement with feedback from people that have gone through the complaints process, as well as other general improvement   focus on - general improvement. 

MS EASTMAN: In the process of either developing or revising these new complaint handling procedures, what have your organisations learnt about the nature of violence, abuse, neglect or exploitation in your organisations? Mr Swain? 

MR SWAIN: I think what we've learnt in going through the complaints processes around the nature of the violence is, at its core   and I think we've seen this in the recent own motion inquiry   is a matter of culture. I think we've heard this week also the nature of   

MS EASTMAN: I just want to focus on your organisation  

MR SWAIN: Sure.

MS EASTMAN:   about before, not what you've heard this week. But in the process of doing the work that you've done, what did your organisation learn about the nature and/or extent of violence and abuse? 

MR SWAIN: Certainly. What we've learnt from that is that often it occurs, and we don't hear about it. So it's the lack of those forums and opportunities to connect with our clients and their families. And it's those connection points that are vitally important, providing that information on how to complain or how to provide feedback. So the need for much more active support for people to be aware of, how to complain or provide feedback and the need for provision of that advocacy. That's what we have identified. I think   

MS EASTMAN: Sorry. Forgive me for interrupting. 

MR SWAIN: Yes.

MS EASTMAN: That is the response to - my question is directed to the nature or the cause, not how to respond to it. But what have you learnt about the nature or the cause of violence and abuse? 

MR SWAIN: I think what we have learnt is the nature of the violence is   or abuse is - often around the disempowerment of individuals. 

MS EASTMAN: That might be a cause, but what's the nature? 

MR SWAIN: Can you just elaborate on   

MS EASTMAN: The nature. What's the nature of the violence? Is it   

MR SWAIN: What   sorry, what sort of   okay.

MS EASTMAN: Is it hitting? Is it kicking? 

MR SWAIN: Sure. Sorry. Yes.

MS EASTMAN: Is it something done by support workers? Is it between people with disability? 

MR SWAIN: Yes, the nature  

MS EASTMAN: What's the nature of the violence that you've learnt from the review to do the new complaint handling process? 

MR SWAIN: Certainly. The nature of violence that we've identified is   in our organisation, there is a number of falls that occur, and that may be related to neglect. Also, there is client on client abuse that may be related to the environment and the management of triggers. We are certainly looking at that and the need for the much more focus on more therapeutic environments. And also, one strong theme for us in the nature of abuse is the disempowerment of individuals. So around the neglect, not hearing the voice of individuals and allowing them to exercise choice and control. And that's not just in relation to our own staff, but that may also be in relation to families as well. 

MS EASTMAN: Okay. So that process sounds to me   can I summarise it this way: that you have got an overall sense of a problem without addressing that problem by specifying nature, extent and cause separately. 

MR SWAIN: Yes. And sorry   

MS EASTMAN: So you sort of roll that together. 

MR SWAIN: Yes.

MS EASTMAN: Is that the approach you have taken? 

MR SWAIN: We do analyse that regularly. We identify the nature of incidents. We roll those up. We report those to our board committee. We identify the nature of incidents, the contributing factors for those and also the actions that we are taking to respond to those. 

MS EASTMAN: In Cara, have you done an exercise of identifying nature, extent or cause? 

MS FUREY: So, in our organisation, we have a safeguarding team that triages all of our reported incidents - 

MS EASTMAN: Okay. Let me interrupt there. Sorry. Sorry to jump in. And forgive me if I've been in   not clear in my question. I'm not asking you about the response. I'm asking you about what the nature of the violence, abuse, neglect and exploitation is in the organisation, the extent and, if you wish, the cause, and whether an examination of nature, extent and cause informed the approach that you take in developing the new policy. So we are not up to how you deal with it now. Is that clear? 

MS FUREY: Yes. So my time with the organisation has been limited. But, for example, in the month of October, we had 28 incidents. The majority of those related to medication errors, to sunburn   neglect in the sun   and not following care plans properly. So they are the nature of incidents that I have seen during my period. In terms of our identification of the cause, we do go through a thorough investigative process, which includes meeting with our staff, with our customers, you know, their families and, depending on the severity of the matter, to clarify - mainly to - further training. But we do   depending on the severity, the most severe, we will do a root cause analysis to really understand how this has arisen. 

MS EASTMAN: So one thing is to do an analysis of a particular incident that's occurred, and you might do a root cause analysis. Do you step back from the review of one incident and look at, globally, a pattern of complaints or   sorry, a pattern of incidents to understand the nature, extent and cause, not just an immediate response to one incident? I'm trying to get to understanding whether that mapping or auditing has been done to understand the trends, patterns and to really identify if there's hotspots, for example, in the organisation. That's what I'm getting at. 

MS FUREY: Yes. So  

MS EASTMAN: Have you done that work? 

MS FUREY: The form in which it is done is to meet monthly as a management team and to review all incidents that have arisen during that period, to identify the trends and where they are   the particular severity is - to identify the cause. But there is much discussion, there is much consultation, to really understand the nature of the incidents that are occurring in our organisation and to take responsive action. 

MS EASTMAN: Right. So I want to move to a different topic now, and that is that when the policies were prepared, were they prepared internally by the staff of your respective organisations? 

MR SWAIN: I can't tell you when the   or how the policy that was prepared in 2007 was developed. But certainly with other policies   and our policies have a two yearly review cycle. The review cycle is the responsibility of the relevant operational manager in that particular area. 

MS EASTMAN: For Northcott? 

MS FORSYTH: To my understanding, yes. 

MS EASTMAN: Internally? 

MS FORSYTH: Yes. 

MS EASTMAN: And Cara? 

MS FUREY: Yes, internally. 

MS EASTMAN: Have any of the policies had legal advice or assistance from lawyers, either in drafting or reviewing policies, do you know? 

MS FUREY: Generally, yes, where appropriate, we have sought external advice   legal advice on our policy. I cannot say with respect to these ones we are looking at today. 

MS EASTMAN: For Endeavour? 

MR SWAIN: Yes, same, that where indicated, we seek legal advice. And we are seeking legal advice on a policy at the moment. But for these particular policies, I couldn't give you an answer on that. 

MS EASTMAN: And for Northcott? 

MS FORSYTH: And that would be the same situation for us. 

MS EASTMAN: All right. In terms of any legal advisors that you use, are the lawyers who you use to give advice people who, or firms that have specific expertise in understanding the human rights of people with disability? Do you know that? 

MS FORSYTH: I don't know the answer to that question. 

MR SWAIN: We have a panel approach to provision of legal advice, and we would be selecting the appropriate lawyers to provide advice in that particular matter. 

MS EASTMAN: But my question is whether you know whether the lawyers who give you advice have particular expertise and/or experience in the human rights of people with disability. 

MR SWAIN: I don't know. I would have to check. 

MS EASTMAN: Cara? 

MS FUREY: I'm also unable to answer that one. 

MS EASTMAN: In terms of any legal advice, do the legal advisors that you use have any experience or expertise in trauma informed approaches for survivor victims of violence? Do you know that? 

MR SWAIN: I don't know the answer to that. 

MS FORSYTH: I do not know the answer. 

MS EASTMAN: Do any of the legal advisors that you use have experience or particular expertise in culturally responsive approaches to dealing with violence and abuse? Do you know that? 

MR SWAIN: I don't know the answer to that. 

MS FORSYTH: I don't know. 

MS EASTMAN: Do the lawyers that you use have experience in insurance and liability and claims? Do you know that? 

MR SWAIN: Yes. 

MS EASTMAN: They do? 

MR SWAIN: Yes. 

MS FORSYTH: The nature of the policies we would seek advice on, yes. 

MS EASTMAN: And Cara? 

MS FUREY: And I would say yes. 

MS EASTMAN: Would we be right in understanding that if the expertise in terms of legal advice that you receive are focused on claims and insurance, that what sits behind these policies are policies to minimise the liability of your respective organisations? 

MR SWAIN: No, I don't agree with that. And our   certainly our focus is currently on model litigant approaches, which is not about limiting our liability or exposure. 

MS FORSYTH: I don't agree with that. And the policies that you have referred to for us in this session, to my knowledge, haven't had any legal advice. We broadly would in some policies, but for the complaints incidents policies haven't had any legal advice. 

MS EASTMAN: And Cara? 

MS FUREY: And I   so, no is my answer. We have developed our policies in relation to complaints and incidents internally. We have aligned them closely to the NDIS National Standards. We have engaged other experts or   within the team to assist us internally develop those policies. 

MS EASTMAN: So given that I think you have all had some legal advice, be it internal or external, in the preparation of or review of these policies, have you also received external advice from specialist disability advocacy groups? 

MR SWAIN: Can you please repeat the question?

MS EASTMAN: So you've had the legal advice. Have you also sought external advice from disability representative groups or disability specialist advocacy groups? 

MR SWAIN: In relation to policies and procedures?

MS EASTMAN: On complaints. I'm not dealing with all your policies, but just on complaints. 

MR SWAIN: I'm not aware that we've done that. 

MS EASTMAN: Northcott? 

MS FORSYTH: I'm not aware that we've done that. But the policies that we develop, we do use resources from those types of organisations to assist. 

MS FUREY: I'm unable to answer that one. 

MS EASTMAN: In terms of either the review or the development of policies, how many of the disability users within your organisation were consulted, either on any drafts of the policy or invited to participate in the drafting of policies? Do you know? 

MR SWAIN: Certainly with our organisation, we can certainly do better as far as   

MS EASTMAN: I'm just asking how many of the   

MR SWAIN: We can't give you a number, but I can tell you that the framework of   just generally, a framework around complaints, we do consult with family of those people with disabilities, and that's through our National Council and that's with our broader frameworks. So we do seek feedback from those groups. I can't tell you the number. 

MS EASTMAN: I'm very narrow today. 

MR SWAIN: Sure.

MS EASTMAN: I'm only on these complaint policies. So I want to know for each of the organisations in either preparing or reviewing the policies, to what extent did any of your service users participate in either the drafting or reviewing before they were finalised? Can you tell me whether you know that? 

MS FUREY: I'm not aware of any of our current customers having been involved in that process directly. 

MS EASTMAN: Northcott? 

MS FORSYTH: Yes. In terms it of the drafting, that was a while ago. I can't talk to that. But definitely in terms of the review, I'm not aware of any that were involved. But we do make amendments on the basis of feedback and incidents that may have occurred that require   

MS EASTMAN: Would you agree with this: it seems to be very odd, does it not, that the people who are the beneficiaries of these policies have not been consulted or involved in the preparation of or review of these policies and that you as the CEOs are able to say, "I don't know, but probably not." 

MR SWAIN: I agree with the assertion, and that's something that we have identified that we do need to improve. 

MS EASTMAN: So how would you improve it? 

MR SWAIN: How would we improve it? We do need to identify direct engagement with people with disabilities and their families in those client facing documents and particularly the ones that are under discussion today. 

MS EASTMAN: Northcott? 

MS FORSYTH: Yes. Look, I am aware that we had a previous mechanism, if you like, to enable participation. That was in the form of a policy review committee that, to my understanding, didn't necessarily enable people who were part of that to contribute in a valuable way. So I think we need to really understand how that contribution to the development of policy can be really valuable and not done in a tokenistic way, for the sake of it. 

MS EASTMAN: For Cara? 

MS FUREY: So we have   this is before my time. My understanding is we had a customer reference group specifically involved in our organisation for these sorts of things and that it was difficult to extract valuable input into those governance processes from this customer reference group. It was viewed as a social opportunity, and the desire and willingness and ability to contribute meaningfully was limited. 

MS EASTMAN: All right. So looking at the policies, there is various descriptions. Sometimes you see the expression "complaint", sometimes you see "formal complaint", sometimes you see "informal complaint", sometimes you see "concern", sometimes you see "feedback", sometimes you see "incidents", sometimes you see "notifications". So there's different expressions used. In   and I'm trying to sort of deal with this globally, so bear with me. In the approach taken to dealing with complaints, it seems that all of these policies start with the first step of characterising the complaint, generally by its seriousness, as to whether it's at a lower-level feedback, an intermediary level concern, or grievance, and then something that may take on the characterisation of informal but formal and then maybe a very serious formal complaint. So all your policies seem to have this sort of approach to gradation of the complaints. Who made the decision about characterising the complaints in that way? 

MS FUREY: I'm unable to say who made that decision. 

MR SWAIN: I can't tell you who made that decision. 

MS FORSYTH: Similarly, when the complaints policy was first drafted, I'm unaware. 

MS EASTMAN: From a person centred approach, would you not agree that if something is of concern to a person, that their concerns should not be determined by a category of somebody else who will be responding to the complaint deciding whether their issue is feedback, a concern, formal, informal, serious or not serious? Do you accept that? 

MR SWAIN: I think from our perspective, it's important for us to understand what sort of skill sets we need to help in the resolution of a complaint. And from our perspective, all complaints are critically important and valuable. But we need a way of interpreting or identifying who is best skilled to manage and support the resolution of that complaint. 

MS EASTMAN: Could part of that be done by asking the person who has the grievance as to what they wish to happen in relation to their complaint or concern, rather than that be determined by a piece of paper? 

MR SWAIN: And that's part of our standard protocol, is to engage with the person making the complaint or ask what a good outcome is from their perspective.

MS EASTMAN: Because these policies seem to categorise the seriousness of the complaint by reference to an organisational perspective of how you are going to deal with it, rather than a more qualitative perspective of the seriousness for the person concerned. Would you agree with that? 

MS FUREY: At Cara, we have a team that evaluate each complaint. So it is not a single individual following an objective set of criteria. There are social workers in that team, police investigator previously and   so individuals who have worked in services and who are now part of that team. So we do try to give it a depth and a breadth of consideration in making that evaluation. 

MS EASTMAN: In all of the policies, they appear to be triggered by the fact that somebody has to come forward to do something. So it's what I might call a reactive or responsive approach to complaints. It requires the person with disability, family member or the category of people who you've described earlier. So do you accept that it's a very responsive approach to dealing with complaints in the sense that it requires somebody to get to a point where they feel they need to raise something with the organisation that then might be characterised by the organisation as feedback, concern, informal, formal, serious complaint? Do you agree with that? 

MR SWAIN: Not fully, because I think that that's one mechanism of many mechanisms, that we do need to have a framework that allows people to initiate complaints. But our whole approach to safeguarding is to proactively engage in service reviews, management training, the rhythm of conducting house or site meetings so that we hear the voice of people proactively and hear their concerns and seek to resolve those. So that's just   that's another rhythm that's occurring in parallel with a complaints mechanism. 

MS FORSYTH: The purpose of the complaints policy is to outline how we will undertake a fair process around response. It does not include information in relation to all the ways that we engage directly with customers, hear from them and change in response, nor does it talk to preventative work that certainly we do around understanding where there might be issues before they arise. 

MS EASTMAN: And looking at the policies, for the most part, they are policies that assume a particular incident or incidents occur. Would you agree with me, reading your policies, it's difficult to see how a person who might get to what I might call "the last straw" on a pattern of behaviour that they have tolerated for a long period of time, what Sam Petersen calls the slow violence, or others might call systemic neglect, how that last straw reflects the whole of that person's experience? These complaint frameworks that focus on incidents are not capturing those types of complaints. Would you agree with that? 

MR SWAIN: I agree. It's often said, when I as a CEO, the first time that I hear about a matter is when someone is picking up the phone to talk to me, and that's those last straw things that you are referring to, which is why we need to work more proactively to hear voices much earlier on and to, you know, resolve issues at their source as early as possible. 

MS FORSYTH: Again, the policy itself is   the purpose of which is to have a clear process for response. So it doesn't talk to all the other ways that we work to prevent, and we have done some work that we are happy to share with the Commission in relation to understanding what might be issues and trends, particularly in supported living environments that actually indicate us to act early rather than waiting for a responsive   I guess a response from the organisation in relation to a complaint or incident. 

MS EASTMAN: And would we be right in understanding the complaints process are essentially premised that the incident will be something done by a person who is the direct care support or support worker? 

MS FORSYTH: Can you repeat the question, sorry?

MS EASTMAN: Sorry. When you look at the policies as a whole, and to understand what you can make a complaint about and who you can make a complaint about, to the extent that it's focused on an incident, it seems to have a focus on identifying the particular person, maybe a support worker or a team leader, who engaged in that conduct so that it's referable to incident and a particular person. 

MS FORSYTH: The intention of our complaints policy is not just incident specific, and it is intended to be clear with everyone that any expression of dissatisfaction about anything that occurs in the organisation can   should be considered, you know, appropriate response like it is a complaint. So we don't think of complaints as responses to incidents; we think of them as expressions of dissatisfaction in a whole lot of different ways across the organisation. 

MS EASTMAN: Is that same for the other organisations? 

MS FUREY: Yes. 

MR SWAIN: Yes. 

MS EASTMAN: Do the policies that you've provided to us   and we asked you to provide your policies in relation to quality and safety of services. Are these policies that would apply if a complaint was made against another service user, so an interpersonal complaint between service users? Does the policy apply to that cohort? 

MS FORSYTH: We   and it may be a question of which policy it references but which kind it doesn't really matter to us, because we've got a variety that we can use to help guide how we respond. But we do specifically deal with our abuse and neglect policy in relation to incidents or complaints that relate to two individual people who are receiving services in a setting that   and it outlines responsibility for responding appropriately to both parties. 

MS EASTMAN: Yes. For Endeavour? 

MR SWAIN: And certainly that's the case with our organisation as well. 

MS EASTMAN: And for Cara? 

MS FUREY: So there are opportunities for other organisations to feed back into our organisation and to capture those. 

MS EASTMAN: All right. So I want to turn to who is responsible for these policies in the organisation. So, at Northcott, you've got a dedicated team or a department for investigating complaints or incidents. Is that right? 

MS FORSYTH: That's correct. 

MS EASTMAN: And at Endeavour, do you have a dedicated department to deal with complaints or incidents? 

MR SWAIN: Yes, we do. 

MS EASTMAN: And Cara? 

MS FUREY: Yes. 

MS EASTMAN: And in terms of the composition of the people in that department, what's their skill set? We will start with Endeavour. 

MR SWAIN: So we have a broad skill set. So it's not only just in that department who is responsible for investigations, but it may also include those in HR investigations or in complex support. So it's actually a broad team of dedicated people in that safeguarding space. 

MS EASTMAN: Are there any people with disability employed to work in that department? 

MR SWAIN: I'm not aware of anyone with disability in that department.

MS EASTMAN: Has there been any consideration to ensuring that there is an employee with disability, perhaps somebody who has lived in or worked in the ADEs or attended your services? 

MR SWAIN: Not that I'm aware of. Yes. But our skill   skill sets are quite broad, from investigations, operations, social work, those people that have worked in supporting other vulnerable groups like Child Protection and Child Protection investigations. So we have quite a large group of dedicated people in that space. 

MS EASTMAN: Northcott? 

MS FORSYTH: Yes. To clarify the function of the team at Northcott, the team is there to support the operational parts of the business to undertake appropriate and safe responses, particularly in relation to complaints and incidents. So they don't necessarily do all the work themselves, but they are there to support the operational teams to do that, who are closest to the people they support in the situation. In terms of the broad skill set of that team, that certainly for us includes people who have experience and qualifications in investigations, who have backgrounds in working with vulnerable people, sometimes in the context of policing, who have trauma informed training across all our safeguarding team. And we do have people with   who have identified with   as having a disability as part of that team. 

MS EASTMAN: Is it standard for all matters that might be characterised as formal complaints or serious complaints to be investigated? 

MS FORSYTH: Yes. 

MS EASTMAN: And what complaints will not be the subject of investigation? 

MS FORSYTH: So, for Northcott, every complaint is the subject of some form of investigation and consideration in accordance with the policy. So it   the policy is set in a way to help guide how the organisation provides a proportionate response. But each complaint that we receive we don't just put in a category and accept that. We work with that person in terms of what response they actually want, and we will adjust and adapt our response accordingly. 

MS EASTMAN: So I think, Northcott, you've got an investigations practice guide which you have provided to us. Commissioners, at tab 36. Mr Swain, in Endeavour's response to the notice, you have identified the need to strengthen the team's capability in conducting investigations and using trauma informed practice. Is that right? 

MR SWAIN: Yes. And particularly for those that are undertaking investigations into lower classification complaints. 

MS EASTMAN: It's not uncommon in complaint handling systems to undertake investigations. That seems to be common practice now. Stepping back from that common practice, why does your organisation undertake investigations? Why is that necessary? 

MS FORSYTH: For us, it's about understanding what's happened and looking at how we can not only fix that situation but prevent it from happening again. 

MS EASTMAN: So it's got a two fold purpose: one, to understand what happened; and, two, to assist the organisation respond? 

MS FORSYTH: Yes. 

MS EASTMAN: On the understanding of what happened, if the complainant tells you their version of the story, do you not start with believing their version of the story? 

MS FORSYTH: Yes, we absolutely start with believing their story. 

MS EASTMAN: So in terms of   from thereon, is the process of investigation essentially more for the second purpose, which is to help the organisation understand where its liability might be or what it needs to do in response? Is that right? 

MS FORSYTH: Yes, perhaps I articulated it in a way that was a bit misleading. By understanding what went on, it's not to establish the veracity of a person's experience; it is to determine what the organisation or the staff, you know, did or didn't do that has led to that situation and fixing it immediately, but also then learning from that. 

MS EASTMAN: All right. And I ask you that because for people who have experienced violence and abuse, maybe survivor-victims of trauma, an investigation can actually compound the process. So what is the purpose of the investigation? And if it is for assisting the organisation, then do you not need to make that absolutely clear to any complainant, that the investigation is for the purpose of the organisation, not for them? 

MR SWAIN: Can I please clarify, that our investigation is really more about incidents. That's where I expect investigations. For complaints, it's about resolution. So if there are   if there is need for any investigation, it's about the best way to resolve that complaint or issue or matter. So I thoroughly agree that we should be doing this in a trauma informed way, yes. 

MS EASTMAN: And from the description that you've got of the qualifications in your investigations team, if you've got former police officers and people with experience in investigation, for a person with disability being brought into an investigation by a former police officer, how do you manage that very significant power imbalance and also perhaps the perception that a former policeman investigating you means you will be in trouble? And I raise that because the Royal Commission has heard a lot in Public hearings and in its submissions about people with disability having great fear of the police. So how do you manage that? 

MS FORSYTH: Look, we don't   to be clear, it's not that we have necessarily recruited people with that background. It just happens to be that's the make up of the background of people in that team in terms of the skill set. All of those people are trained in trauma informed approaches, and we do very   if it's an incident that is   or any incident, potentially, is likely to cause retraumatisation in terms of bringing up the issue. So we do have an extensive planning meeting beforehand to understand the nature of how that person communicates, who their circle of supports are, where they might need additional support, to make sure that we don't enter into that environment in that way. 

And that process is not necessarily conducted in terms of the investigation by someone who may have the qualification of being a police officer and interviewing. We garner information in a variety of ways. Lots of the people we support might not necessarily communicate verbally, so we use alternative communication. They may not wish to participate in the process, which is completely something that we establish upfront. So we take a range of steps to ensure that we have considered the issue, and we by no means go in like a police officer. No offence to police officers, but that's not the nature of the work that we are doing. 

MS EASTMAN: It's a perception shift. I could probably ask you questions about this all day, but my final question is to each of you: at the end of a person taking their complaint to the complaints process and thinking about the people who you've identified in the number of complaints and proportion of complaints, how do the complaint processes lead to particular outcomes for people with disability? What outcomes follow from a complaint process? Mr Swain? 

MR SWAIN: Yes. So our complaints process requires the complaints handling officer to focus on what are the outcomes sought in the first place. And at the end of that, this is well documented within our complaints management system, as to whether there's a satisfaction with the outcome of that process. 

MS EASTMAN: Can that be reviewed if somebody is not happy with it? 

MR SWAIN: Absolutely. 

MS EASTMAN: And I'm going to ask you some details of your policy in a moment, but   yes.

MR SWAIN: Sure. Absolutely it can be reviewed, and we provide for review mechanisms in what we call a closure communication. 

MS EASTMAN: And for Northcott? 

MS FORSYTH: Yes. The outcome can be varied because, again, it depends on what is sought through the process. And often it will be changes to the nature of the services they are receiving as a common outcome. We absolutely have an opportunity for people who are not satisfied with that to escalate it, to have it reviewed; not just internally, but we encourage people to go to the NDIS Commission if they are unsatisfied with our response. 

MS EASTMAN: And in terms of outcomes, when you say it's what the person wants, but surely the organisation should say somewhere very clearly in its policy and process what outcomes are available, so what you would be prepared to do. Do you do that, or do you just put the onus on the person making the complaint to look at it? 

MS FORSYTH: We currently don't document it in the policy. It's certainly part of the practice to have that conversation and to talk through the options that might be considered in resolving that, but it's not currently documented in our policy. 

MS EASTMAN: Why not document it in the policy? 

MS FORSYTH: Look, I think it is something that we should do   be clearer about in terms of the options available, because I think it's probably an area that we haven't been clear enough - with the people we support in terms of those options. 

MS EASTMAN: But that's like having a process that says to somebody, "Jump into my pool. It's fantastic, but I'm not going to tell you how deep it is or where you might end up." Surely if you are going to have a complaint handling process, you need to make it absolutely transparent and clear as to what the outcomes are going to be from that process for the person who is prepared to take the risk, to come forward, to make a complaint. So you will put them through a process, but you are not going to tell them in advance what the outcome might be. Do you think that is a weakness in the approach? 

MS FORSYTH: The policy is drafted in such a way to ensure that we treat each situation individually. And it's really difficult to be that specific in response to a person's complaint, because they are all responded to differently and each resolution of that looks different. So when I say we should be enhancing that policy further for - its use for people, is to be - giving examples of the natures of things that can happen. But there's no way that our policy could include every single possible outcome for a person. 

MS EASTMAN: But may I put this to you: it could, if you have done the nature, extent and cause and mapping work before having a policy focused on process. If you have done that work then you should know your organisation well enough to know what are the issues that are likely to be raised and the mapping work will have also told you what types of outcomes have worked successfully. So can I put to you that the absence of having clarity in a policy as to what the outcomes are likely to be is a weakness in that policy, and it could even be a deterrent to anybody using the policy. As I said, why jump in the pool where you do not know how deep it is and where you might end? 

MS FORSYTH: I agree it's a weakness in the policy. 

MS EASTMAN: For Cara? 

MS FUREY: So the comments that have already been expressed are similar for Cara. So, yes, we do record our outcomes in detail. There's a permanent record there. We have the action plans in place to implement improved practices. I was just reflecting on your discussion there. One of the complaints we often have is staff familiarity, you know, there's a different person coming to our service. And that is a difficult one because, you know, there are resourcing constraints too. So, I do think   I appreciate your comments, and I do appreciate that I can only answer on a case by case basis. 

MS EASTMAN: I can only ask you the answer. 

MS FUREY: Yes.

MS EASTMAN: The Commissioners make the decisions, not me. I'm just asking you the question. Commissioner, I'm just conscious of the time and so I will conclude my questions for this panel now. The Commissioners may have some questions for you. 

CHAIR: Thank you very much. I will commence by asking Commissioner Bennett if she has any questions. 

COMMISSIONER BENNETT: No, thank you. 

CHAIR: And Commissioner McEwin? 

COMMISSIONER McEWIN: Thank you, Chair. Ms Eastman asked you about the involvement of disabled people in the development of your policies and investigative processes. I would like to ask, from a senior management point of view, how many of your direct reports have a disability? 

MS FUREY: I cannot give you the exact number, but some. There are a number. 

COMMISSIONER McEWIN: Just to be a bit more clear, some, as in, you believe some of your direct reports are disabled? 

MS FUREY: Yes. Sorry. My direct reports   no, I do not believe any of my direct reports of which   are disabled. 

COMMISSIONER McEWIN: Okay. Thank you. Northcott? 

MS FORSYTH: None of my direct reports have disclosed that they have a disability, but one has disclosed that they are a parent of a child with a disability. 

COMMISSIONER McEWIN: To be clear, have a disability that you are not aware of? 

MS FORSYTH: That's   to be clear, yes. 

COMMISSIONER McEWIN: Thank you. 

MR SWAIN: And none of my direct reports have disclosed that they have a disability, Commissioner. 

COMMISSIONER McEWIN: I see. Thank you. 

CHAIR: Ms Furey, how many reports of this Royal Commission have you read? 

MS FUREY: How many reports have I read? So I have not read any reports in full. 

CHAIR: Don't you think it would have been a good idea   

MS FUREY: Yes. 

CHAIR:   to have read reports or follow the proceedings of this Royal Commission dealing with service providers in order to inform you of the sorts of issues that should be considered by your organisation? 

MS FUREY: Yes, I absolutely agree. 

CHAIR: Why didn't you? 

MS FUREY: Sorry? 

CHAIR: Why didn't you? 

MS FUREY: So I have   I'm not from the disability sector. I have been with the organisation now for five months. I have certainly read material around our documents, our policy, our procedures. I have sought to understand in a, you know, fairly short timeframe how our organisation delivers well for our customers. But I have not reviewed documents in full. 

CHAIR: Can I put the same question, first to Mr Swain? 

MR SWAIN: Chair, I have not read in full any reports of the Royal Commission. I have read materials summarising and relaying considerations of the Royal Commission, or the work of the Royal Commission, from peak organisations and from our own internal staff. 

CHAIR: And Ms Forsyth? 

MS FORSYTH: I can't tell you the number, but I certainly have read reports from the Royal Commission, including reports in relation to earlier hearings, particularly specifically related to service providers. 

CHAIR: Thank you. Thank you very much for your evidence in the panel. We are grateful to you for your assistance today. So thank you very much.

<THE WITNESSES WITHDREW

CHAIR: Ms Eastman, do we take a break, or do we proceed? 

MS EASTMAN: Well, I'm in your hands, Commissioner. So we could have a short break now, if that was convenient to you. 

CHAIR: Yes, we can have a short break. Let us take a   perhaps a five minute break and then we will have the morning tea adjournment a little later, then. 

MS EASTMAN: Thank you.

CHAIR: Yes. Thank you.

<ADJOURNED 11:12 AM 

<RESUMED 11:21 AM 

CHAIR: Ms Eastman. 

MS EASTMAN: Thank you. Our next witness is Terry Symonds, the CEO of Yooralla. So, welcome, Mr Symonds. I think you've got to give your oath or affirmation. 

MR SYMONDS: That's right. I haven't been affirmed yet. 

CHAIR: You have or have not? 

MR SYMONDS: Have not. 

CHAIR: All right. Well, thank you, Mr Symonds, for coming to the Royal Commission today to give evidence. This is a revisiting of Yooralla, as I'm sure you know. Yooralla was the subject of some evidence at Public hearing 3, of which there is a report available. If you would be good enough to follow the instructions of my Associate in front of you, she will administer the affirmation to you. 

<TERRY SYMONDS, AFFIRMED

CHAIR: Mr Symonds, thank you very much. I shall now ask Ms Eastman to ask you some questions. 

<EXAMINATION BY MS EASTMAN SC

MS EASTMAN: Thank you, Mr Symonds. Can I confirm that you are Terry Symonds? 

MR SYMONDS: Yes. 

MS EASTMAN: And you are now the CEO of Yooralla, and you commenced in that role on 1 March 2021? 

MR SYMONDS: I did. 

MS EASTMAN: And in terms of your professional background, you commenced your professional career in the not for profit sector here in Brisbane? 

MR SYMONDS: I did. 

MS EASTMAN: And before joining Yooralla, you were the Deputy Secretary of health and wellbeing   of the Health and Wellbeing Division of the Department of Health and Human Services in Victoria? 

MR SYMONDS: I was. 

MS EASTMAN: You have previously been the Deputy Secretary for strategy, closely working with the community sector on reform of out of home care? 

MR SYMONDS: Yes. 

MS EASTMAN: And you have also held senior roles with the Royal Melbourne Hospital and in Queensland Health. 

MR SYMONDS: Yes. 

MS EASTMAN: And you are a state committee member for NDS, who we heard from yesterday, in Victoria. Is that right? 

MR SYMONDS: Yes. 

MS EASTMAN: Now, in terms of Yooralla, as at its latest annual report, Yooralla supports 2,414 clients. 

MR SYMONDS: Yes. 

MS EASTMAN: Right. And you have over 2,000 employees, including about 1,900 employees and 140 supported employees. Is that right? 

MR SYMONDS: Yes. 

MS EASTMAN: And you're aware that the purpose of your appearance this morning is to address the matters that we asked you to address in two notices. So, Commissioners, we issued notices to Yooralla to give information to the Royal Commission, and you will have two responses from Yooralla dated 6 January this year and an earlier response of 31 August 2022. Have you got copies of those with you? 

MR SYMONDS: I do. 

MS EASTMAN: All right. You're aware that those notices concerned responding to actions Yooralla has taken following Yooralla's appearance at a very early Public hearing of the Royal Commission: Public hearing 3 held in Melbourne in December 2019. 

MR SYMONDS: Yes. 

MS EASTMAN: And obviously you did not give evidence at that hearing and the former CEO, Dr Devanesen, gave evidence. Is that right? 

MR SYMONDS: Yes. 

MS EASTMAN: Chair and Commissioners, I'm very conscious that for people who will recall Public hearing 3, and particularly the circumstances in relation to people who received services from Yooralla, that these are very traumatic and distressing events. While they might now be nine years - we understand that the impact of that trauma may continue for individuals. So the content warning that was put up on the Royal Commission's website in the opening had relevant telephone numbers, and I would encourage anyone who is concerned about those experiences to make calls and use those services. For the purpose of my questions to Mr Symonds today, I will not go into any of the circumstances or details in relation to the violence and abuse that we considered at Public hearing 3, and the focus of my questions will be directed to the actions taken by Yooralla following the Public hearing. 

So, Mr Symonds, I have got a few questions then arising. I assume that you have read Public hearing 3 and the Commissioners' Report. Is that right? 

MR SYMONDS: I have. 

MS EASTMAN: Have you also had an opportunity either to watch all or part of the evidence or to read the transcript of that Public hearing? 

MR SYMONDS: I have. 

MS EASTMAN: So when Ms Devanesen gave evidence at the Royal Commission, I think she told the Royal Commission that - she said Yooralla has realised that there were failures and significant shortcomings, and the evidence that she gave at that time sought to explain how Yooralla had embarked upon a path of reform and change. And the Commissioners noted that in the hearing report at paragraph 234. But Ms Devanesen also acknowledged that there was still more work to be done in particular areas, so I want to ask you about that. 

The first issue was the extent to which people with disability were represented in the decision making roles and in senior positions in Yooralla. We heard evidence of a committee called Yooralla's Committee Partnership and Advisory Committee, but we understood from its terms of reference that the members were required to sign non disclosure agreements, although as a matter of practice that did not occur. We asked about the role of this advisory committee and whether or not it was the only place that people with disability were seen in  - having the opportunity to be heard in decision making or policy within the organisation. 

At the time, none of the board directors were people with disability, but four board directors had children with lived experience of disability. And the board members had had some training in relation to the Convention on the Rights of Persons With Disabilities. So can you tell us   and you have set this out in the response of the   the January response at page 1   what Yooralla   what Yooralla now does in relation to people with disability being part of the board, senior management or the way in which the voices of people with disability are heard in Yooralla? 

MR SYMONDS: Yes, Counsel. There are now two directors of nine who live with a disability. The board has also initiated an observership program to contribute to a pipeline of future candidates for people with a disability to join our board and other boards across industry. We have our first observer joining our next board meeting. I will just comment on that point, the chair has shared with me her ambition to get to 50 per cent of our board eventually having a disability, and she considered that's appropriate for an organisation, and I agree with her about that. It may take some time to get there. I have currently one direct report with a disability. 

The board has approved a program for an internship for the CEO role, which will help develop succession planning for the most senior executive position inside the organisation, and I'm pleased to say we have our first CEO intern with a disability, who will commence working with me shortly. The organisation   the YPAC committee that you mentioned before now has its   at the time of the hearing these things were not in place - but the committee is now chaired by a person with a disability who is on our board. The executive sponsor for that committee is a person with a disability. There is several members with a disability on that committee, including now one member who is a tenant in a group home. That committee has now endorsed the establishment of a lived experience advisory panel, who have explicitly been asked by YCPAC to be involved in policy and service development across the organisation. We currently have 16 people who have elected or nominated to join that committee. Nine of those live in group homes. 

We have a range of committees across the organisation in which people with disability are participants, and clients are participants. Currently, 20 per cent of the committees that we have at a management level have a representative of a person with a disability. Our senior management team has agreed that where those committees relate to service delivery for our clients, the appropriate target is 100 per cent. We have also introduced external voices of people with disability. So YCPAC has changed its terms of reference to now include people with disability who are not clients of Yooralla so that we are challenged by external perspectives. And we have a commitment to employ more people with disability inside the organisation. 

MS EASTMAN: I want to ask you about something called the chief experience officer. So, in October 2021, Yooralla established the first chief experience officer role. And you've said in the response, it's reserved for a leader with lived experience of disability. What's the nature of that role and where does the chief experience officer fit in in terms of the senior management structure? 

MR SYMONDS: The chief experience officer reports to me. The role was created in October, I think, of 2021 or around that time. We advertised for somebody with a disability, and I'm pleased to say that the person we have in the role has continued during that time and led and supported and guided a lot of the work that I've described. They report to the board's safety and quality committee also, separately from other reports from management. They have established the lived experience advisory panel. They have also overseen work, such as development of a co design framework, which has been to both YCPAC and the service delivery and quality board.

MS EASTMAN: I want to move to another topic, and that was during the course of the hearing we asked Yooralla about what policy or practices did it have in transitioning people from group homes into alternative and different accommodation. This was in the context of having a discussion about the ongoing use of group homes as a form of accommodation for people with intellectual disability. Dr Devanesen said at the time that Yooralla had assisted people to move to independent accommodation in the community through what she described as transition facilities, but there were not enough alternate options available for Yooralla to assist everyone who might want to move out of a group home. And the Commissioners record that in the hearing report at paragraph 334. 

And Dr Devanesen said that Yooralla did not have a stand alone policy to review and develop alternatives to the group home model, but she agreed that this was something Yooralla should look into. And that's recorded in the report at paragraph 228. So we understand from your responses that Yooralla now has something called the new entry exit and relocation policy, dated 25 May 2020. And there's a version 2 that you have provided to us, dated 27 July 2022. And, Commissioners, that's in Bundle N behind tab 10. What's different about the new policy, if any, in terms of Yooralla's approach to the maintenance of the group home model and/or assisting people who want to leave a group home to transition to new or different accommodation? 

MR SYMONDS: I think the policy has a stronger requirement than the previous policy on eliciting the tenants' goals and aspirations in terms of housing and then trying to deliver on those. That is the primary difference that we intended to give effect. 

MS EASTMAN: Over the time since Yooralla appeared at the Royal Commission, has there been any trends or changes that you can comment on of people who have resided in Yooralla group homes looking for or moving to alternative accommodation and, if so, what have you seen in that regard? 

MR SYMONDS: Roughly 45 people, I think, have transitioned out of group homes over the last three years. The trend that, I would say, is that we have   we have learned that it's more   the support for people to leave a group home, if that is their goal, requires more than just the availability of an alternative physical location. It requires support and advocacy sometimes for their decision making. It requires the adequacy of funds in their NDIS plan. And there are significant delays for some individuals that we know would like to leave group homes because of some of those factors. We have tried to understand the current aspirations are of our tenants. 

We had a third party survey conducted last year in which tenants were asked where you would like to live, how many people you would like to live with. 15 per cent of the people who responded to that survey said they wanted to live with only one other person. No one responding to the survey said they wanted to live alone. About a third of the people said they don't know. And that   those responses tell me that there's quite a range of current views and goals and expectations amongst our tenants. But it also tell us there's a significant cohort   15 per cent would be 40 or 50 tenants   that we can work with who already have expressed through responses to that survey that they would like to live with less people than they currently live with. So we have something to work with. 

MS EASTMAN: I don't know if you have followed the proceedings of this hearing over the last few days. 

MR SYMONDS: Most them I have. 

MS EASTMAN: One of the issues, which I think I attributed to Afford but I meant probably Minda, was about the issue of the suitability of the housing stock and the legacy stock. Is that an issue for Yooralla in terms of the nature of the dwellings and the number of bedrooms and the organisation of the way in which the services are provided in group homes? 

MR SYMONDS: The physical state of the fabric, yes, it is. So we have homes which, perhaps less because of the number and   number of bedrooms and more because of their design, don't afford all of the tenants the privacy that they might wish, and they have to share amenities, for example, or share common areas. And, you know, it's our expectation, based on responses to the survey and conversations with people, that people may still want to live with a number of other people in a share house but in a different physical   a different design of their house   or their home. 

MS EASTMAN: What are you going to do, looking into the future, about those issues? What does that mean for Yooralla in terms of future planning? 

MR SYMONDS: The board has approved, in principle, a proposal to transition our legacy group homes out through partnerships with housing developers. There are now many developers, you know, who are designing and building suitable properties. We think some of those developers may be interested in working with us   we know some of them are interested in working with us   where they might provide the physical location and we might provide the support. That doesn't address all of the criteria needed for people to move, but we think that would be a good start. 

I might, if I could, draw your attention   or the attention of the Commissioners to a report published only today, I think, from the housing   the Summer Foundation, which is   I don't know its exact title. It's something called Towards a Better Model of Shared living. We think that it's a comprehensive paper that addresses the range of supports that people require for informed choice and a transition out of group homes, and we contributed to the development of that paper and agree with its findings. 

MS EASTMAN: I think they are coming to tell us about that tomorrow morning. 

MR SYMONDS: They can do a much better job than me, Counsel. 

MS EASTMAN: So the next topic I want to ask about is the investigations. And Dr Devanesen gave evidence about a range of cases of sexual crimes and incidents of sexual and physical abuse that have been investigated by Yooralla's internal investigator, and evidence about how the internal investigator operated. And, Commissioners, you record this at paragraph 232 of the report. And during the course of the hearing, the Chair asked some questions about the independence and qualifications of the internal investigator. 

Are we right in understanding that following that Public hearing that Yooralla had an opportunity to review the way in which it conducts investigations and both the qualifications of internal investigators and the extent to which external assistance is sought in conducting investigations? Do you want to tell the Royal Commission what's occurred in terms of the way investigations are done and anything about the qualifications of the investigators? 

MR SYMONDS: Yes. In early 2021, shortly after I arrived, there was an investigation underway following a whistleblower allegation of abuse at one group home. The whistleblower had resigned from the organisation by the time we were partway through the investigation and, at that time, was not responding to invitations from the internal investigator to come forward and give evidence. Our people and culture team converted the internal investigation into an external investigation   had an external investigator take over. The whistleblower came forward, gave evidence. The investigation was resolved, I'm pleased to say, without   without, you know, findings that abuse had actually occurred in that case. But it was a learning for us. And shortly after that investigation, we put in place a new guideline to indicate that external investigations should occur where there are allegations made about the management, as was the case in that whistleblower allegation, and also where there are likely   allegations are likely to lead to, you know, criminal charges, for example. 

MS EASTMAN: The next topic was Yooralla's approach to redress and its guiding principles. And in the Commissioners' Report at paragraph 343, the Commissioner said: 

Evidence heard by the Royal Commission at Public hearing 3 suggests that there were considerable disparities as to any support, compensation or other forms of redress that were provided by Yooralla to a person with disability. 

And that was in the context of an examination in relation to the response and the different responses in relation to the victim survivors. And at paragraph 6   sorry, I withdraw that. Paragraph 364 of the Royal Commissioners' Report, they identified the following issues, among others: 

First, the forms of redress available to people with disability who are subject to violence, abuse, neglect and exploitation while residing in group homes or supported accommodation, and whether it's feasible to establish a scheme to provide a compensation to people with disability who have sustained serious harm as a consequence of violence, abuse, neglect or exploitation in circumstances where no other redress is available. 

So we understand from your response that, in September 2022, there's now something called the Yooralla redress working party, and that's developed a guideline for some principles for responding to victim survivors of abuse. And that's produced in both a standard form but also in easy English, and you have provided copies to us. Can you briefly tell us what, following the hearing and now the establishment of the Yooralla redress working party, is doing to address the issues identified by the Royal Commission in Public hearing 3? 

MR SYMONDS: Thanks, Counsel. The board has established a working group that includes senior management and two members of the board, including a person with a disability, to guide us as we think through how Yooralla might develop a more consistent and appropriate response to cases of abuse and complaints related to abuse that might come forward that is an improvement on the previous response, as discussed in hearing 3. The   we have developed guiding principles at this stage. Those guiding principles are informed partly by our participation in the existing National Redress Scheme. We have taken that as a starting point because we agree with the principles that are in that scheme   or reflected in that scheme. We have conducted initial consultation on the guiding principles before we go any further with formalising responses. Those consultations include conversations with families of victim survivors, victim survivors and people with disability inside our organisation, where those people are willing to be part of that conversation. And I acknowledge how difficult a topic this is for some of the people that we would   that we might invite to participate, and I thank those who have contributed. 

We have also engaged a third party, and that is VALID, Victoria's, you know, prominent advocacy organisation, particularly for people with intellectual disability, to conduct consultations on our behalf, because we understand how difficult it might be for Yooralla, given our history, to get a honest response, perhaps, or a kind of direct response from people. We have asked VALID to both develop an easy read version of our principles, which they have done, and conduct initial consultation around those principles, both with people with intellectual disabilities, including two people from group homes, and families, including family members of people who reside group homes. Only two days ago, we received the initial report of that consultation. And I hope you have a copy of that, Counsel. We provided a short report on that. 

MS EASTMAN: You did. Thank you. 

MR SYMONDS: Great. It's hot off the press, as you can tell, but my initial impression of that   and I spoke to the person who led those consultations   is there was overwhelming support from people with intellectual disability and from families for the principles, with some very insightful feedback and suggestions as well. And that, I guess, is   affirms, I think, the direction that we are going and also strengthens our view that a National Redress Scheme would be appropriate, and we agree with the comments that were included in the November discussion paper or report from the Royal Commission where it briefly discussed this question. 

MS EASTMAN: So a related topic to that, redress is one thing, but there is also how victims are supported in being able to make a complaint and also on criminal matters, referrals to the police and support during that process. And you may recall the extent to which referrals are made to other forms of compensation, such as victims' compensation. And one other issue that was raised and also dealt with by the Commissioners in their report at paragraph 364 was the measures to support people receiving independent advice to enable them to pursue remedies, if that's what they wish to do. I wasn't entirely clear whether that is part of the redress working party group, or has that been addressed separately? So I think your response at paragraphs 12 to 16 cover that, but I wasn't quite sure whether all of those issues had been addressed. 

MR SYMONDS: And I'm sorry, Counsel. Is your question whether we   whether it's only through the redress work that we are considering that question? 

MS EASTMAN: Yes. Or are you looking more generally at the supports for victim survivors, the pathways of assisting them if the reporting is to the police or to other areas and then providing them the opportunity for access to any form of advocacy, I suppose, but I think, in Public hearing 2, very much looking at it through the lens of legal supports through community legal centres and the like? 

MR SYMONDS: Yes. So it is   we are   the way I might put this, Counsel, is our work on redress, I think, is our latest and best thinking that will inform our work across the whole of what the Commission has referred to as the complaints landscape, and that includes our policies for handing complaints and incidents and investigation. But I think we are hearing things in feedback on redress that are relevant to other policies. 

MS EASTMAN: So would they   just to interrupt there, would they be relevant to policies you provided us, referred to as accessing independent disability advocacy procedures manual and advocacy information for customers? Is that where we would find that work? 

MR SYMONDS: Well, that is an example. Those procedures are an example of advice that we give to managers inside our organisation now where they are given direct resources to which they can direct clients of the organisation around advocacy, and we have existing policies which promote the use of advocacy. I guess our work on redress is informing us about how strongly and how early, perhaps, we might engage or offer to engage people with that. If I give you an example, I had a conversation recently with the family and the   with a parent and a victim of an assault that was committed by one of our staff. I'm pleased to say he was properly terminated and has since been charged. The family was unaware of the outcome of the sentencing, and I met with them to disclose the sentencing. 

They were pleased to hear about the sentencing, I guess, but I   were unaware of or had not considered what their other options might be. And with the feedback on redress and our work on redress in mind, I was able to encourage the family to consider their options and follow up with a referral to independent legal advice. I don't know that our policies and procedures, as they stand now, would exactly have indicated that step. But our work on redress, I guess, has made us more mindful of that. And my thinking is that as the redress work comes to a close, or as we get further along with it, we have to fold back upon the other policies and check that the principles in there around independence of advice and early support are reflected across all of our policies and procedures. 

CHAIR: The document entitled Yooralla's Guiding Principles for Responding to Claims Involving Allegations of Abuse contains principle 8: 

Yooralla's initial response will include an offer of support and assistance to access independent legal advice if legal assistance has not been obtained by a victim survivor or their family and friends. 

Is that a principle that's actually enforced now, or is this something that's in draft that is part of the process you're describing? 

MR SYMONDS: It is a draft that has received unanimous support from every client and family who has seen it. And I guess the point I was making to Counsel, Commissioner, was I don't know that our existing suite of policies strongly enough reflects that principle that is in our redress principles. And given the level of support we are getting for that principle and the, you know, directions and guidance, including in the November paper from the Royal Commission, I think we need time to reflect on those and build that principle back strongly into all of our existing policies. 

CHAIR: Thank you. 

MS EASTMAN: Those were my questions. 

CHAIR: Thank you very much. Commissioner Bennett? 

COMMISSIONER BENNETT: No questions, thank you. 

CHAIR: Commissioner McEwin? 

COMMISSIONER McEWIN: Yes, one question. Thank you, Mr Symonds. When Ms Eastman asked you about transitions away from the model of group homes, and you said that you are working   well, you and Yooralla are working with designers and builders to develop suitable properties. Can you tell me, of those suitable properties, are they multi bedroom homes? Can you give me an idea of how many are one bedroom, three bedrooms, et cetera? 

MR SYMONDS: So we have about 13 apartments currently on offer. I don't think we have any examples yet of the sort of combined two and three bedroom homes that I know are kind of increasingly available in the market as well. So we   our view, Commissioner, is that we need the widest possible range of options for people. And that's not yet in place. 

COMMISSIONER McEWIN: Thank you. 

CHAIR: Just following up on Commissioner McEwin's question, the 13 that you referred to, they are single occupancy apartments, are they? 

MR SYMONDS: That's right. 

CHAIR: You referred to a survey, and you indicated that in that survey none of the respondents expressed a preference to live by themselves. How does that relate to the 13 separate apartments? 

MR SYMONDS: So not all of the people who are going to move into our individual apartments are people who are currently residing in our group homes, Commissioner. 

CHAIR: I see.

MR SYMONDS: So our survey was a survey of existing clients of Yooralla, and their responses to that survey tell me something about people with a history of living together in group homes and what they might be looking for next. But there are people entering the NDIS and entering the market for accommodation now who don't have that history and experience in group homes and may well be and, in fact, are interested in living independently on their own, individually, and we are very happy to support them in that if we can. 

CHAIR: So in your experience, there is a disparity between the preferences of those who have not experienced group home living and those who have? 

MR SYMONDS: Yes, I do think that, Commissioner. I think it's a very interesting question, and it's one which we explored with Summer and other partners in the publication I mentioned, that I think the NDIS has probably responded to an initial surge in demand for individual living but has not yet fully grappled with the needs of a cohort of participants who have perhaps spent much of their adult lives living together and have goals and expectations for some form of shared living but for whom we can do better than the existing group homes. 

CHAIR: I see. And the survey that was conducted, how many people were asked to respond? What proportion did? Did they receive assistance in order to respond to the survey? 

MR SYMONDS: I can supply you with the actual numbers. I don't have the numbers off the top of my head, Commissioner, but I'm pleased to say that we, for the first time, had a third party survey firm conduct the survey, instead of us conducting it ourselves, and that survey firm attended on site in some of the group homes to provide independent assistance to people in completing surveys. And I think that methodology is one that should be of interest across the sector in terms of getting responses to surveys like this in future. 

CHAIR: All right. Well, I think it would be helpful for us to have a copy of the report of that survey, and I'm sure that can be arranged with the Office of Solicitor Assisting. 

MR SYMONDS: I think we have provided it already, but I will check. And if we haven't, I certainly will. 

CHAIR: I think Commissioner Bennett has a question.

COMMISSIONER BENNETT: I do have a follow up question. Thank you, Chair. For those people that are existing residents in your group homes   your quite large group homes, do you think it's because they have never had that alternative experience, that they would   so it's not really a choice because that's all they know, isn't it? 

MR SYMONDS: Commissioner, I think there's a couple of different elements involved here. One is an element of informed choice, and I think this applies to accommodation and it applies to employment. I think there are many people who feel safe in existing congregate settings, or what the Commission might refer to as segregated settings, who haven't had the experience of other alternative settings to make an informed choice. And one of the jobs for us in the sector is to provide those opportunities for people. It's not to say to them that that is a better alternative; it's to provide them with the experiences to inform their choice. 

But there are other elements here as well. I have spoken with the family, for example, of a victim survivor of abuse, and I asked the family the direct question as to why they considered that their loved one should still stay in a Yooralla group home given the experience they had had. And their response to me was that I didn't understand the history and the previous experience of their family member living in an institution and how difficult that had been, and they considered that the group home was now their home and that was the place that they had come to after an institution, and they were determined to make it as good as they can be. And their view was, therefore, Yooralla has to work as hard as it can to make that home as good as it can be, rather than have them leave the home. And so people's attachment to existing homes and locations is not something that I underestimate. And, you know, people have a whole range of emotional and psychological attachments to these places, and it's our job to understand those, I think, and respond. 

COMMISSIONER BENNETT: So you could also conclude that those people that are seeking to live alone or maybe with one other person are people who have not been institutionalised and, therefore, are in a better position to make a genuine choice? 

MR SYMONDS: I don't necessarily make that assumption. I'm mindful of the advice of others, that people can be institutionalised living alone. And we don't understand   and I don't presume to sort of judge the costs and benefits for individuals. I think there are risks involved in every form of accommodation. Professor Bigby gave evidence at hearing 3 that the evidence is not yet in on any form of accommodation being better or worse; it is how supports are provided in any setting which is the key. And we strongly support Professor Bigby's advice around that. 

CHAIR: Thank you very much for returning to the Commission. It seems that there have been some significant developments since Public hearing 3 took place. And speaking for myself, I'm very pleased to hear about them. Thank you. 

MR SYMONDS: Thank you, Commissioner. 

<THE WITNESS WITHDREW

CHAIR: Ms Eastman, do we take a short break? 

MS EASTMAN: Can we take an adjournment for, say, 10, 15 minutes? 

CHAIR: Yes. All right. It's just before 12, so if we resume at 12.15. 

<ADJOURNED 11:58 AM 

<RESUMED 12:17 PM 

CHAIR: Yes, Ms Eastman. 

MS EASTMAN: Thank you, Chair and Commissioners. So we turn to our second panel of the day. Mr Swain has returned, and you will see that we are also joined by Annie Doyle, who is the chief executive officer of Civic Disability Services Limited. I think, Ms Doyle, you have done your oaths or affirmations. Is that right? 

CHAIR: Yes. Well, thank you, Mr Swain, for returning. Thank you, Ms Doyle, for coming to the Royal Commission to give evidence today as part of a panel of two. We look forward to your evidence. And I shall now ask Ms Eastman to ask you some questions. 

<ANNIE DOYLE, CALLED

<DAVID SWAIN, RECALLED

<EXAMINATION BY MS EASTMAN SC

MS EASTMAN: So, Ms Doyle, I will start with you with some introductions. So you joined Civic as the CEO in May 2015. 

MS DOYLE: Correct. 

MS EASTMAN: You might just have to keep your voice up a little bit. 

MS DOYLE: Correct. 

MS EASTMAN: And you have more than 20 years' experience as a management professional, including eight years in not for profit disability organisations. That includes three years with Sunnyfield as the chief finance officer and the chief operating officer. Is that right? 

MS DOYLE: That's correct. 

MS EASTMAN: And you have a Bachelor of Business and an Executive MBA. Is that right? Now, about Civic, so Civic Disability Services Limited, known as Civic, was a not for profit organisation founded in the 1950s by a group of parents caring for children with disability in the Sutherland Shire. 

MS DOYLE: That's correct. 

MS EASTMAN: And over time, Civic has increased significantly. And it now operates exclusively in New South Wales. 

MS DOYLE: That's right. 

MS EASTMAN: Your head office is in Caringbah. And according to your report to the ACNC, you employ 936 staff on a casual, part time and full time basis. Is that right   sound right? 

MS DOYLE: We have   that's correct. And I would say that most of those, I think 25 per cent, are in the casual realm. 75 per cent are permanent full time or permanent, yes. 

MS EASTMAN: So 25 per cent casual. 

MS DOYLE: Correct. 

MS EASTMAN: And balance being permanent part time or permanent full time. Is that right? 

MS DOYLE: Correct. And we barely use agency at all. 

MS EASTMAN: All right. And I think what we don't know from the information provided to us is how many   and I will use the expression we have used in the notices   service users. So how many people with disability does Civic support? 

MS DOYLE: So we have approximately 500 service users at any one time, and some of them use multiple services. 

MS EASTMAN: And what are the nature of the services that Civic provides? 

MS DOYLE: So we are in SIL accommodation services. We are in community services, one to one and drop in supports. And we are also in supported employment. 

MS EASTMAN: Now, on the information that you have provided to the Royal Commission, are we right in understanding that for the relevant period there were 107 complaints, and 63 of the complaints related to safety issues? That's tab 18, page 7. 

MS DOYLE: That's correct. 

MS EASTMAN: Right. So that figure is accurate? 

MS DOYLE: That's correct. 

MS EASTMAN: All right. Now, I do want to ask both of you about your particular policies around complaint   dealing with complaints, and I want to work through those policies in terms of how they apply at a practical level. But, Ms Doyle, before I do that, the Royal Commission is aware, and many people would be aware, of a story on The 7.30 Report earlier this week. You are aware of that? 

MS DOYLE: Yes, I am. 

MS EASTMAN: And, Commissioners, I just give a warning now that the material that I need to deal with with Ms Doyle may be traumatic and distressing. And, again, if the Royal Commission's content warning could go up, that would be appreciated. So, Ms Doyle, you are obviously aware of a coronial inquest that was conducted by the New South Wales Coroner into the death of Alex Jeremy Raichman? 

MS DOYLE: Yes. 

MS EASTMAN: And he was 11 years old when he died on 22 April 2018. 

MS DOYLE: Yes. 

MS EASTMAN: And the coronial inquiry was held last year between 19 and 29 April. 

MS DOYLE: Correct. 

MS EASTMAN: And you received a copy of the coroner's findings on 21 October 2022. 

MS DOYLE: Yes, I did. 

MS EASTMAN: Commissioners, and those following the proceedings, the copy of the coronial findings and reasons are publicly available on the coroner's website. Now, having received the coronial findings in October last year, can we assume that Civic, and you in particular, paid very careful attention to the matters identified by the coroner where the coroner identified failings on behalf of Civic in relation to Alex's death? Is that right? 

MS DOYLE: Yes. Yes. 

MS EASTMAN: And when The 7.30 Report dealt with its story on Tuesday, I think, this week, a statement was provided by Civic Disability Services Limited, which is available publicly on the ABC website. And I've given you a copy of that. 

MS DOYLE: Yes. 

MS EASTMAN: All right. Commissioners, I don't know if this would assist   it is publicly available, but we have a copy that can bring up   we will bring up on the screen. So you're familiar with this statement? 

MS DOYLE: Yes, I am. 

MS EASTMAN: Did you prepare the statement? 

MS DOYLE: Yes, I did. 

MS EASTMAN: So you wrote it yourself? 

MS DOYLE: Yes, I did. 

MS EASTMAN: And you gave careful thought as to what you wanted to include in the statement? 

MS DOYLE: Yes. 

MS EASTMAN: Did you get any advice on this statement? 

MS DOYLE: I did. 

MS EASTMAN: Who did you get advice from? 

MS DOYLE: I had my impact and design GM assist with the writing of it, just to ensure that we used appropriate wording, and it was reviewed by our lawyers. 

MS EASTMAN: By your lawyers as well. 

MS DOYLE: Yes. 

MS EASTMAN: And you knew that this would be a public statement? 

MS DOYLE: Yes. 

MS EASTMAN: And you knew that this might be a statement not only read by the family but also by the general public. Is that right? 

MS DOYLE: That's correct. 

MS EASTMAN: So I just want to take you to some parts of the statement and understand what these things mean and what Civic has done. The second paragraph says: 

Since 2018 Civic has been committed to the full involvement in internal and external reviews to ensure we learnt from this tragic accident. 

The first thing is, why have you described Alex's death as a tragic accident in light of the coroner's findings? 

MS DOYLE: I believe that, for us, it was a tragedy that flowed from the   you know, the lack of important processes and procedures that weren't followed and, to me, this tragedy was not something that was planned or   for us, it was   it wasn't meant to happen. We didn't set out for this to happen. It was   in our eyes, it was a tragedy. And we have since 2018   not since the coronial finding, but since 2018 we have taken extensive measures to ensure that we learnt from what happened to Alex. And there is not   I understand the family's grief, and we   particularly being a mother myself. 

MS EASTMAN: Can I just   my question was fairly   I hope, fairly clear. 

MS DOYLE: Yes. Yes.

MS EASTMAN: Why do you describe it as an accident in light of the coroner's findings? 

MS DOYLE: I believe   maybe I haven't described it as well as I could. But I   for us, that is   it was tragic, and it was an accident. 

MS EASTMAN: Well, I accept it when you say that no one intended this to happen. But it was fairly clear from the findings, was it not, that it was preventable? You agree with that? 

MS DOYLE: The coroner did say that. 

MS EASTMAN: Now, in terms of internal and external reviews, who or what has been the external review process? 

MS DOYLE: Who? 

MS EASTMAN: Who or what? 

MS DOYLE: We had several parties review our external processes   our processes, sorry, and we hired them. And all of those reports   

MS EASTMAN: Who were they? 

MS DOYLE: They were   we did the Belton report, and we did another one with another company after that. The name escapes me. But those   those reports were tabled, full disclosure, and we have put action plans in place from day one. 

MS EASTMAN: So were these external reviews directed to any support for the family and any redress for the family? 

MS DOYLE: So I tried to reach out to the family. I - 

MS EASTMAN: No, no. 

MS DOYLE: Sorry. 

MS EASTMAN: Step it back. 

MS DOYLE: Yes.

MS EASTMAN: I'm asking you about the external reviews. Did any part of an external review directed at what support or redress should be provided to the family? 

MS DOYLE: I would like to say that there were recommendations. However, the family was not open to receiving   

MS EASTMAN: From an external review? 

MS DOYLE: Correct. 

MS EASTMAN: Right. Now, just dropping down a bit, the paragraph starts: 

In 2022 Civic committed fully to the coronial process and submitted significant evidence to the coroner for consideration. 

And then you say: 

Civic has also complied with all of its obligations, including notifying and cooperating with SafeWork New South Wales. 

Do you see that? 

MS DOYLE: That's correct. 

MS EASTMAN: When you say Civic is fully committed to the coronial process, that process has now been complete. 

MS DOYLE: Yes. 

MS EASTMAN: But you don't say anywhere in this statement that you accept in full the coroner's findings that were adverse to you personally and to Civic. Do you agree? 

MS DOYLE: That is an oversight. Yes. 

MS EASTMAN: It's an oversight. 

MS DOYLE: I should have said that in this statement. 

MS EASTMAN: But you haven't said that, have you? 

MS DOYLE: No. 

MS EASTMAN: And it was an opportunity, in making a public statement, to indicate whether you personally and Civic accepted the findings of the coroner and accepted the responsibilities that flow from that. Do you agree? 

MS DOYLE: I have offered a sincere apology to the family and accepted our guilt at that   at the front end of the coronial. I was clear. So whilst I may not have said it in this statement, I have said it out loud in the Coroners Court. And I   I think that I could have said it better in the statement, yes, but I also wasn't aware that the 7.30 was going to run a report. 

MS EASTMAN: When you say in the next paragraph: 

Recommendations provided by the coroner in 2022 have already been adopted by Civic. 

Can I be clear in understanding what you mean by that. Do you mean that the recommendations adopted by the coroner you had already addressed before the coronial inquiry and findings, or do you mean the recommendations provided by the coroner in 2022 have been acted on since you received the coronial findings in October? 

MS DOYLE: From the minute the accident occurred, we have turned over everything. Everything. And so, in 2018, we did a full gap analysis. That gap analysis formed the basis for our review of everything to do with risk, policy, procedure, property, ways of working. And that   so when the findings came down from the coroner, we had done many of the recommendations that the coroner put forward. The last one outstanding was the understanding about our voluntary out of home care status, and that has also been dealt with now. 

MS EASTMAN: Have you published anywhere on your website or in any other public forum what you have done in relation to responding to the coroner's recommendations and how, in detail, you have responded to each of those recommendations? Have you done that? 

MS DOYLE: I'm not sure. I probably have not. 

MS EASTMAN: Has any particular employee or officer of Civic been disciplined in relation to the circumstances of Alex' death or following the findings of the coroner's   the criticisms made by the coroner? Has any disciplinary action been taken? 

MS DOYLE: We had   some staff have since left Civic's service. 

MS EASTMAN: Have any board members resigned as a result of the coroner's finding and taking responsibility for what occurred? 

MS DOYLE: No. 

MS EASTMAN: And you remain as CEO. Is that right? 

MS DOYLE: That's correct. 

MS EASTMAN: Can I ask you now about the second last paragraph in the statement. And you say here: 

The death of Alex is a reminder of the high risks involved in providing disability support work. 

What do you mean by that? 

MS DOYLE: Well, every disability service provider has a   has multiple sites where they deliver services in a community care environment. That requires, then, a distributed workforce. When you have a distributed workforce, what happens is that you rely on policies, procedures, process, culture, risk treatment plans, intervention plans, things that are all human   human service related. And so you have   if I was working in a manufacturing environment, I would have   I would be able to automate and rule out all risk. But by its very nature, the NDIS is about providing additional support to those people who have disability. That additional support is human in nature. 

MS EASTMAN: Do you not think that there is something fundamentally misconceived in understanding the nature of risk to describe the child as the risk, rather than understanding that the risk arises because of the way in which the service provider conducts its business? 

MS DOYLE: I'm not describing Alex as the risk. 

MS EASTMAN: But you are saying publicly that the death of Alex is a reminder of the high risks involved. What else could that possibly mean? 

MS DOYLE: It means that we have to take very seriously our service delivery in a human services environment, and that is something that I do not take lightly. 

MS EASTMAN: Can I ask you whether the following two sentences is an attempt by you to try to excuse or evade Civic's liability. Firstly, are you seeking to evade responsibility by suggesting that more funding is required? And, secondly, are you trying to evade responsibility by suggesting that this is the only incident of its type that has occurred in Civic's history? What are the purposes of saying these things publicly? 

MS DOYLE: I think   I think   I think we are not evading our responsibility. We have taken this very seriously. Every staff member at Civic have grieved over the loss of Alex. It is not something that we take lightly, and we do not want to abrogate our responsibility at all. And I think the fact that we have spent so much time and effort in reviewing everything   everything   at Civic has meant that we have developed, I think, really a fundamental way of working that, for me, will rule out incidents of this type ever occurring again. 

MS EASTMAN: Is there any reason why you have not acknowledged any regret, any apology or expressed any sorrow for the loss of Alex to his family? There's no apology in here, is there? 

MS DOYLE: I rang Alex's mother and left - 

MS EASTMAN: There is no apology in the public statement, is there? 

MS DOYLE: Apologies, I   I   

MS EASTMAN: You have not apologised to the family. 

MS DOYLE: I had already apologised to Alex's family at the coronial   I am happy to apologise again. I will go on record as being apologetic about this incident. I have no issue in saying that I got it wrong. 

MS EASTMAN: Have you apologised to the community for letting a young man with disability down? 

MS DOYLE: Yes. I think I have. 

MS EASTMAN: You have apologised to the community? 

MS DOYLE: Yes. 

MS EASTMAN: Thank you. All right. Commissioners, I will turn to the topic that I want to deal with - 

CHAIR: Sorry, just one question from me following on from what Ms Eastman has asked you. For someone who has just read this document recently, the sentence that says: 

As a sector we need to ensure adequate funding and supports are in place for individuals, families and the organisations delivering care. 

When I read that, I understood that to mean that, somehow, inadequate funding had some relationship to the death of Alex. Is that what you were intending to indicate? 

MS DOYLE: So I think what I would like to say is that when the NDIS was created, it was created based on an outcomes model. So it was about goals and achieving outcomes. But I think it's now more about the funding received and ensuring services delivered equal those funding agreements. So I feel that the areas that we are going to talk about today that require a lot of training, a lot of forethought around how you can get relationships and achieve those really important relationships to hear the client voice, that is not part of our funding and supports. It's something that we choose to do as an organisation, but that   it's not recognised as a funding line in the NDIS. 

CHAIR: But the juxtaposition of that sentence with the preceding sentence would suggest to a reader that, somehow, inadequate funding had something to do with Alex's death. Do you not agree with that? 

MS DOYLE: I think that risk treatment and the whole spectrum of delivering services as safely as possible is of paramount importance. And so part of that, then, is   what I'm trying to say there is that, you know, we have to ensure as a sector   I think, you know, Civic are lucky that we have, you know, the skill set in house to deliver this. There are smaller providers who are delivering great services who may not have these opportunities. 

CHAIR: Yes. Alright. Well, I was actually asking you about these two sentences, but thank you. Yes, Ms Eastman. 

MS EASTMAN: So, Ms Doyle, I want to ask you about your complaints processes. The Commissioners have got behind tab 21 in Hearing Bundle H a copy of the Civic feedback disputes and complaints guide. Have you got that? 

MS DOYLE: Yes. 

MS EASTMAN: And were you here earlier this morning when the other panel gave evidence? 

MS DOYLE: No. No. 

MS EASTMAN: Alright. So your policy uses different language, "feedback" and "complaints". And "complaint" and "feedback", "serious complaint" and "dispute" are defined in the document. Do you see that? 

MS DOYLE: Yes. 

MS EASTMAN: Why is a distinction made between a complaint, feedback, serious complaint and dispute? 

MS DOYLE: I think it goes to how we manage those. So - 

MS EASTMAN: So   so that's really for convenience of Civic as to how you are going to manage the subject matter? 

MS DOYLE: Well, I think it's also for training staff so they understand what   what they are hearing and how they can understand and how they can act appropriately. 

MS EASTMAN: And over the page, this is a policy about feedback, disputes and a complaint guide, but it then tells you the types of matters that will not be registered as a complaint. Now, looking at that list, some of these matters would squarely be the sorts of things that might give rise to not only feedback or a complaint but also a serious complaint. Why is it that these important matters in the dot points on page 2 are excluded? 

MS DOYLE: Because there are other avenues for those. They may well be notifiable incidents, or they may be   they may be outside the remit of a complaint. 

MS EASTMAN: Why? 

MS DOYLE: Because they have different ways of being handled. So   

MS EASTMAN: But isn't the purpose of a complaints policy to assist the person who wants to raise feedback, a grievance, a concern or a complaint to know   

MS DOYLE: Every   

MS EASTMAN: Can I just finish, please? To know what they need to do and what they can do. So I'm asking you, why will these not be registered as a complaint? 

MS DOYLE: In particular? 

MS EASTMAN: 

A request for services unless it is the second request and there has been no response to the first. 

MS DOYLE: So a request   

MS EASTMAN: That might be a very significant reason why somebody would want to raise   

MS DOYLE: So a request for services is a complaint, I'm sorry, is that what you are saying? 

MS EASTMAN: Yes. Why would it not be registered as a complaint? 

MS DOYLE: A request for services would go through our customer experience team to go through to onboarding. So it becomes part of the customer journey. 

MS EASTMAN: Why wouldn't a request for information or an explanation of policy guides and instructions   if someone was feeling aggrieved that they didn't know what that was or what it   why wouldn't that be treated as a complaint? 

MS DOYLE: If they were feeling aggrieved, it would go to complaint. If they are not feeling aggrieved, if they are just requesting information, it stays as a request for information. 

MS EASTMAN: Right. And who determined in the drafting of this policy that the matters on page 2, the dot points, would not be registered as a complaint? 

MS DOYLE: That would have been discussed with the   with the team, and they would have decided that these have other avenues. 

MS EASTMAN: Right. One other mechanism that you have a specific policy for that seems to exclude people or things from the complaint procedure is the document behind tab 22, and that's titled Managing Unreasonable Complaint Conduct Procedure. Are you aware of that? 

MS DOYLE: Yes.

MS EASTMAN: Now, this was last reviewed on 10 August 2022. 

MS DOYLE: Correct. 

MS EASTMAN: Was this part of the review that was done internally and externally in response to the incidents concerning Alex? 

MS DOYLE: Not specifically concerning Alex. 

MS EASTMAN: In what circumstances would an organisation such as Civic wanting to   wanting to use something called an Unreasonable Complainant Complaint Procedure? 

MS DOYLE: So the only time we use this procedure is when   so I   not only do we have an obligation to the clients, we also have an obligation to staff. And where complaints go to an abusive type of complaint, then we endorse this   the use of this protocol. 

MS EASTMAN: I'm just looking at the date here, 10 August 2022. Were you involved in the review of the Managing Unreasonable Complainant Conduct Procedure? Did you review it? 

MS DOYLE: I would have reviewed it. 

MS EASTMAN: And by that stage, had you followed or were you aware of the Royal Commission's Public hearing 13 in relation to Sunnyfield? 

MS DOYLE: I was. We followed it closely. 

MS EASTMAN: And were you   do you recall the evidence where Sunnyfield described a complainant as "querulent"? Do you remember that? 

MS DOYLE: We do not use that language. 

MS EASTMAN: You don't remember hearing that?

MS DOYLE: I do remember hearing that. We do not use that language. 

MS EASTMAN: So is this Managing Unreasonable Complainant Conduct Procedure for querulent complainants? 

MS DOYLE: Definitely not. Definitely   I'm talking about work health and safety here, where it's abusive and where it's   undermines the service delivery. Because Civic endorse human centred design principles, and that means not only for clients but also for staff. Happy staff, happy clients. So what we are about is ensuring that this type of conduct is not okay for staff. 

MS EASTMAN: But this is a policy not about an unreasonable complaint; this is about an unreasonable complainant. So this is a policy   can I just say, I have never seen a policy like this. This is why I'm asking you. 

MS DOYLE: So   

MS EASTMAN: But there is a policy that describes who is an unreasonable complainant. Is this   

MS DOYLE: Well   so the proof is that we have obviously had someone within our organisation, a family member, who was abusive and who was undermining service delivery. And we had to look at an opportunity to ensure that we followed a protocol so that we addressed that situation, and this is the fruit of that. And we have hardly used it at all, bar in that circumstance. 

MS EASTMAN: So this was a policy designed in response to one person who was difficult to deal with? 

MS DOYLE: No, not designed in response to one. We have had several over time. But this   this   this is part of making sure that staff are safe and well cared for so that they can do what we need them to do, and that is have great relationships with clients. 

MS EASTMAN: So   

CHAIR: What's abusive about reframing a complaint in an effort to get it taken up again? 

MS DOYLE: Because it's not   it's not the once; it's the number of times that it gets reframed. 

CHAIR: This is not what this says. 

MS DOYLE: It may not have been stated as clearly as it should   

CHAIR: All it says is reframing a complaint in an effort to get it taken up again qualifies as unreasonable. 

MS DOYLE: I think   these things can be subjective. And I think that, for us, use of this is when all else has failed   when the relationship has effectively failed, and we think that they would be better served with another provider.

MS EASTMAN: Well, the policy   

CHAIR: It is the sort of thing that lawyers do all the time, reframe a complaint. 

MS EASTMAN: But the policy doesn't say that it's sort of last resort. It says: 

This procedure applies to all complainants whose conduct is determined as unreasonable under this procedure. 

And in my understanding of the way in which this occurs, that might be a matter that makes its way to you to determine whether the complainant is unreasonable. Is that right? 

MS DOYLE: I think, walking in our shoes, we would see the number of issues that are raised   this is not an overnight thing. This happens after many months of trying to build the relationship. So this is   this is the end of that relationship. 

MS EASTMAN: Could I put this to you; is this part of a culture in Civic where you see the risk as people rather than the risk in the way Civic does its business? 

MS DOYLE: No, we are very clear about how we see risk. 

MS EASTMAN: Mr Swain, sorry, you have been sitting there very patiently. Endeavour also has a policy that speaks to the concept of frivolous or vexatious complaints. I don't know if you have got your copy of the feedback, compliments and complaints policy. So this is a policy which is encouraging some nice things to be said. Is that right? As well as complaints? 

MR SWAIN: Sorry. Yes, absolutely. 

MS EASTMAN: Alright.

MR SWAIN: All feedback is welcome. 

CHAIR: Sorry, do we have this?

MS EASTMAN: Yes, you do. It's behind tab 27. 

CHAIR: Thank you. 

MS EASTMAN: Or 28. So in terms of the way in which complaints are characterised   we discussed this a little earlier this morning. But do you in this policy make or form a view that a person is an unreasonable complainant? And you do have on the procedural fairness, second paragraph, recognising there may be instances of frivolous or vexatious complaints made to organisations. You say: 

These complaints will not be dismissed without due consideration to ensure genuine issues are not overlooked. 

But what is the process? I couldn't find that you had an unreasonable complainants policy. 

MR SWAIN: No, not at all. And, typically, any determination on whether something is frivolous or vexatious is after a due procedure and permitting natural justice, as it's referred to in the procedure. 

MS EASTMAN: So isn't it often the case that the very nature of a complaint might be, as I asked you earlier this morning, the last straw? 

MR SWAIN: Yes. 

MS EASTMAN: And is it not uncommon that people who have reached the last straw may present as perhaps reacting maybe disproportionately to the one issue that's arisen? But unless there is the care and time taken to understand why that distress exists, to understand the nature of trauma that might manifest in how a person presents or behaves, that it would be premature to make a decision that somebody was an unreasonable or querulent complainant? Would you agree with that? 

MR SWAIN: I couldn't agree more. 

MS EASTMAN: Would you agree with that, Ms Doyle? 

MS DOYLE: Yes, I agree. 

MS EASTMAN: Can I ask you whether or not an understanding of trauma and the impact of trauma over a long period of time was taken into account by anybody in August last year when the unreasonable complainant procedure was reviewed? 

MS DOYLE: We do trauma informed care. We  

MS EASTMAN: That's not the question I asked you. 

MS DOYLE: We understand the basis of that, and we understand the history of people within our services who have had significant trauma in their lives. And we do bring that into play in these situations. And as I've stated, we have rarely ever had to invoke this policy. 

MS EASTMAN: Well, you have reviewed it in August last year. And my question was, in reviewing it, did you give consideration to an understanding of how trauma can be a life long condition? 

MS DOYLE: Yes. 

MS EASTMAN: You did? 

MS DOYLE: We understand that, yes. 

MS EASTMAN: Alright. Now, assuming that somebody picks up the policies   so, Mr Swain, they pick up your policy   and that they want to make a complaint, does this feedback policy tell the person exactly what's going to happen if they make a complaint? 

MR SWAIN: This policy doesn't say   well, it says that once a complaint is lodged, a complaints handling officer will be allocated and that person will be in contact directly with the complainant. 

MS EASTMAN: So in terms of a person saying to Endeavour, "I want to make a complaint. I'm not sure whether I describe it as a feedback or a serious complaint or an informal complaint, but I want to raise something." 

MR SWAIN: Yes. 

MS EASTMAN: And the person say, "But I would also like to know in advance what that means for me in terms of what I'm going to have to do, the information I have to provide"   and you heard my questions earlier about what the outcome would be. This policy doesn't set that out. So where is that person going to find the information that they might need before they decide to make a complaint? 

MR SWAIN: That's a good question, and I would expect that either the staff member, the person taking the complaint, could make that referral to our safeguarding team to talk through the process, to give an option as to whether they wish to continue with that complaint. 

MS EASTMAN: So what do you mean by "whether they continue with the complaint"? So does that bring them to a dead end early? 

MR SWAIN: Sorry. As I understand from your question, that if the complainant is looking to understand what the likely process will be for management of the complaint, those in our safeguarding team are best describe   best placed to describe that. 

MS EASTMAN: Alright. The other document that you've got behind tab 28, Commissioners, is the Feedback, Complaints and Compliments Management Procedure. Is that publicly available? So would that be something that somebody who wanted to know, "What's going to happen if I make a complaint," that they would have access to this, or is it internal - 

MR SWAIN: I don't think it is   sorry. 

MS EASTMAN: Is it just internal for the complaints unit or something? 

MR SWAIN: I believe what's publicly available on our website is our policy, not our procedure. 

MS EASTMAN: Okay. Is there any reason why this procedure couldn't be available publicly? 

MR SWAIN: I'm not aware. I would have to take it on notice. 

MS EASTMAN: Alright. The procedure seeks to categorise the complaints based on the seriousness of the complaint. Is that right? 

MR SWAIN: Yes. 

MS EASTMAN: And in terms of the procedure of submitting a complaint, the Management Procedure says that: 

Regardless of whether it is a big or small issue, all feedback is treated seriously, welcomed and valued. 

At what point in the assessment process does feedback turn into a complaint? Is it the nature of the feedback, or is it something about the person about whom the feedback has been made? What is it that moves it from feedback into something that might give rise to an investigation? 

MR SWAIN: I would believe that it would be something in its nature that's requiring some form of resolution, maybe critical in nature. Yes. 

MS EASTMAN: And then if it's serious enough to proceed to an investigation, what happens to the complaint from there on? Is it, for example, a process where the investigation will be conducted and at the end of the process the complainant might find out what happened, or is the complainant involved in the process the whole way along? 

MR SWAIN: Yes, the complainant is involved in the process the whole way along. As soon as a complaint is lodged, it's put on to our internal risk management system. And within the day, it's reviewed by our safeguarding team, who allocate a complaints handling officer, who makes timely contact with the complainant. And we do have the guidelines you will see there around regular communication, but clearly involvement in the complaint, including identifying expected resolutions or outcomes. 

MS EASTMAN: Ms Doyle, can I turn to your Feedback, Disputes and Complaints Guide. So assuming that the   I'm not an unreasonable complainant, and my complaint might be received, I can make a complaint in any way, can't I, in person, on the phone, on the website, but also via social media? 

MS DOYLE: You can. 

MS EASTMAN: And an advocate or representative can make a complaint? 

MS DOYLE: Correct. 

MS EASTMAN: Alright. And your policy says that you can make a complaint or give feedback in a survey. What does that mean? And what surveys are you referring to? 

MS DOYLE: So we often put out surveys, and we assist clients to fill in those surveys. They can do it with their family member, they can do it with an advocate. And it's for them so that we are sure that they are understanding. Yes. 

MS EASTMAN: Then there is a process internally of registering the complaint and having it in the database. 

MS DOYLE: Yes. 

MS EASTMAN: Generally, the policy requires complaints to be resolved within a month. But if additional time is required, that's available. In terms of the way in which most complaints are addressed, are they just sort of dealt with by a discussion with the person concerned or is it your policy that any complaint has to be subject to an investigation? 

MS DOYLE: So all complaints come in through our Hive management system. So however we receive the complaint, they are logged. And they are then triaged   as Mr Swain described, they are triaged, and the appropriate person can be sought to effect a remedy with the person involved. The allocation of the feedback complaint is based on the   how serious the matter is. So  

MS EASTMAN: Sorry, who determines the seriousness of the matter? 

MS DOYLE: So we have   it goes through our Quality and Risk Team, and the   we also not only look at this complaint, but we also look at the trend to see if there any further things that could be impacting at this site or with this particular client so that we understand the bigger picture rather than just, you know, this one off. 

MS EASTMAN: And are we right in understanding that under the Civic policy that how a complaint might be treated might also depend on to whom the complaint concerns? So there might be different processes of addressing the complaint if it's a staff member, if it's a complaint involving a Board member or the CEO, or a complaint that might concern another person with disability receiving the same services? So why are there different processes in relation to the way complaints are dealt with depending on the respondent to the complaint? 

MS DOYLE: So that we can give total autonomy to the decision making. We do not want to restrict the opportunity for the voice to be heard, and we don't want total overview by myself. You know, we want people in the organisation   if it's a staff related matter, it will sit through HR. But if it's a Board related matter, then often, you know, there is the whistleblower and there is the company Secretary who would deal with that so that it's outside the remit of the Board. 

MS EASTMAN: And in terms of investigations, are we right in understanding that there's not a dedicated investigations team at Civic? 

MS DOYLE: There is a dedicated team. 

MS EASTMAN: There is?

MS DOYLE: That is Quality and Assurance. 

MS EASTMAN: But there is something about the levels of delegation so that investigations could be done by lower-level staff members? 

MS DOYLE: So often a complaint comes in and it's at the site and it's something   you know, the mirror is not straight   I'm making this up, but that can be dealt with immediately. It doesn't   it still gets registered. Everything gets registered. But it can be dealt with immediately, and that   then it's closed at the same time. But if it's a significant complaint, it can be quite complex, and it does need to be escalated so that I understand what the   what is going on. And it forms part of our analysis around, you know, what is actually going on at that site? Is there more? Should we look further than just what we are hearing? So we take every complaint very seriously. 

MS EASTMAN: Is   is the way in which you approach complaints putting the interests of the complainant at the heart of everything you do, or is   because the way you just described that might suggest that the approach to dealing with complaints is also looking at where there may be issues for the organisation. So it may be your liability, it may be   

MS DOYLE: No, I hear what you are saying. No, absolutely. So when a complaint occurs   and sometimes   you know, a lot of our clients are non verbal. So for them to broach these issues with us is   it does require supports. And so when we get a complaint, we actively listen to the person making the complaint. We spend a lot of time and effort to hear what is   what it is that they are saying and what they would like to see as the outcome. So we never walk away from a complaint, just sending it off to HR. We actively listen and support the person making the complaint. 

MS EASTMAN: Mr Swain, just picking up on that point, that some of the people who may wish to make a complaint may not be able to communicate in written English or verbally, and your Customer Safeguarding Incident Management Procedure   that's behind tab 31 in the bundle at page 2   says that: 

Where a customer has difficulty expressing their views or recollecting events, or where preventative measures may impact on a person's choice and control, the person must be allocated an advocate to assist them through the process to ensure a person centred approach. 

And there's the   employees can contact the complex case hub. What was the thinking in terms of saying for particular complainants, including complainants who may have difficulty recollecting events, that they must have an advocate to assist them in the process? 

MR SWAIN: The thinking behind this is to ensure that complainants are supported through any process of complaint. Fundamentally important   and I think we were discussing it earlier   around the power relationship and power dynamic is that someone   has someone on their side ensuring that their voice is heard. That's the thinking around that one. 

MS EASTMAN: And in terms of the advocates, what do you mean by advocacy? External advocates, internal advocacy, family members? 

MR SWAIN: Yes, it's  

MS EASTMAN: What do you mean by "advocate"? 

MR SWAIN: Sorry. It's multiple. And that includes family   appropriate family. It's certainly external advocacy if that's what the client requests, and we will facilitate access to external advocacy. We have done that on 20 separate occasions in the past year. But it's not always easy to access external advocates. So with our complex support team, we provide social work support so we can provide some internal advocacy in the interim until an external advocate can be appointed. 

MS EASTMAN: Right. And, Ms Doyle, your Feedback, Disputes and Complaints Guide refers to a principle of feedback and complaint handling being to ensure support and/or advocacy is available to any client who makes a complaint. That's a little different to Endeavour because it is either support and/or advocacy, but it's not a guaranteed right to advocacy. Is that right? 

MS DOYLE: If they have   if they have close family supports, then we deem that sufficient. But if they   if they don't have close family supports, we will absolutely provide an advocate. 

MS EASTMAN: In terms of investigating any complaint that might arise between disability service users where both parties to the complaint may need support and advocacy support, how do you approach those circumstances and how do they fit into the complaint handling procedures? Ms Doyle? 

MS DOYLE: So can you just rephrase that? 

MS EASTMAN: So if it's a complaint and the complaint concerns two service users   so two people with disability, both who may require some support or advocates in the process, how does your policy work in those circumstances? 

MS DOYLE: So both people have the right to advocacy in those situations. The other thing I would say is, in those circumstances, we have a clinical team, and we have psychologists and behavioural support practitioners on site, should they be required. So immediate steps would be to call in the clinical team. Longer term, it would be to find those appropriate supports to allow both sides to be heard. 

MS EASTMAN: Right. So how is that done in practice? 

MS DOYLE: In practice   

MS EASTMAN: What would it look like in the course of an investigation? 

MS DOYLE: So am I taking an example of two supported employees who are fighting, let's say, and they complain about each other. I will give that as an example. So they are separated and then they are both heard separately, asked what the complaint is, why, what would they like to see happen. Sometimes it's as simple as they don't want to stand next to the next person whilst doing their work. It's an easy one to resolve. Other things are much more complex, and it may involve their home environment, it may involve bullying or all those things. So we look at the whole   we look at each person's individual complaint, and we take them from scratch as if   you know, it wouldn't matter that it's another client. So we look at each individually, and we accord them both the respect of listening to them and then trying to come to a resolution together. 

MS EASTMAN: Alright. And do you know, on average, looking at the numbers of complaints that you've told us about, are they complaints that meet your timeframe of being resolved within a month, which I think is the policy for Civic? 

MS DOYLE: So we flag when they go past those timeframes, and it's   all of that gets reported to our subcommittee   our Risk Subcommittee and also to our Board. And those flags are really important because we want to understand why there's a delay. And sometimes there can be a delay because we are waiting on a neurosurgeon to get back to us or a   you know, there is some intervening allied health professional that hasn't filled in a form and so we can't close the issue. But   so under normal circumstances, we do like to see a complaint resolved and that the client has accepted the outcome or has been part of the outcome of that complaint. 

MS EASTMAN: Mr Swain, have you got timeframes that you measure outcomes in terms of complaint handling? 

MR SWAIN: We do have timeframes, but I can't tell you what our average resolution timeframe is. And I am aware that there are more complex complaints that I'm aware of in the past year that would have exceeded the timeframes that we stipulate. I think it's around 25 days is the maximum timeframe for resolution. 

MS EASTMAN: Right. Now, with the outcomes of complaints   and, Mr Swain, I partly raise this with you a little earlier, so I will ask Ms Doyle. What are the outcomes of a complaint? What can happen if somebody makes a complaint, and their complaint is substantiated? 

MS DOYLE: So it depends what the complaint is about, obviously. But should   should the outcome be substantiated, and it is in any way, shape or form to do with their living environment or to do with their work environment or community setting, then we look to how we can address that or provide appropriate outcomes for that client. Now, sometimes it may be big. It may be like they want to leave the property that they are living at and want to live somewhere else. So we would have to put them through our onboarding again to see where an appropriate matching would apply for them and if that is what they would be happy with. So it's all done in conjunction with that person, and at all times we ask if that is the outcome that they want to receive. 

MS EASTMAN: What if the complaint that they make and the complaint that's substantiated results in Civic as an organisation failing to meet its duty of care or failing to protect a human rights, a breach of privacy? What are the outcomes that the complaint can seek from Civic? 

MS DOYLE: So if it's that dire, obviously they can   they can go through all the formal channels, and we will support them to do that. Any notifiable incidents would be   

MS EASTMAN: I'm just asking you what the outcomes would be. 

MS DOYLE: If Civic is in breach, then we deserve to have the penalties that are provided at law to   to   to make the   

MS EASTMAN: Well, this is your own internal complaint handling. 

MS DOYLE: Internal complaints, then  

MS EASTMAN: So, no doubt, when you are investigating a complaint, you are also investigating what Civic might have done poorly. 

MS DOYLE: Correct. Yes.

MS EASTMAN: What Civic might have done to prevent something occurring. 

MS DOYLE: So we would take   

MS EASTMAN: So assuming the outcome of an investigation is that the finding is that Civic has failed in some respect to the person, say if it's failed to protect their privacy or caused an injury or harm. What outcomes, under your policy, are available for the person who has made the complaint against Civic? 

MS DOYLE: First and foremost, an apology, a hearing of our failure. 

MS EASTMAN: Why are you making an apology? 

MS DOYLE: To the client, if they feel that we haven't done   that they have complained and it's proven, that we have failed in our - 

MS EASTMAN: Do you ask the client first whether they want an apology? 

MS DOYLE: We would ask them exactly what outcome they would like to receive. 

MS EASTMAN: And if they don't want an apology, you wouldn't make one, would you? 

MS DOYLE: Then we   well, no. But if that's what they want, then I would apologise. If they want some type of redress, then we would work towards achieving that. But it would be based on what they want. 

MS EASTMAN: Alright. So say if they said that they would like some financial compensation or they would like disciplinary action to be taken against somebody senior in the organisation. Would that be a redress open to them under your Complaints Procedure? 

MS DOYLE: I think everything is open. It's whether or not it's endorsed by, you know, everybody around that. So we would have to explain to them that some things we can do automatically, other things we would have to seek advice on and look at those opportunities. 

MS EASTMAN: Alright. And, Mr Swain, for your organisation   so using that scenario that it's not at a lower level, but this is   Endeavour has failed to meet its duty of care. What would be the options in those circumstances for redress? 

MR SWAIN: So our Feedback Procedure does build in locally outcomes or redress, which include apology or financial compensation. Throughout the process also, we build in access to counselling and psychological support. If we consider also the environment of our supported employment, redress or outcome might take on different features there. And that might relate to the role, the roster, remuneration. So there's many different aspects in that environment, and that's where there is crossover into our   more of an industrial relations environment. 

MS EASTMAN: Commissioner, I'm just conscious of the time. So I will cease my questions now in case the Commissioners have got any questions they wish to ask you. 

CHAIR: Thank you, Ms Eastman. Commissioner McEwin, do you have any questions? 

COMMISSIONER McEWIN: One. Ms Doyle, I wanted to understand better one of your responses to Ms Eastman's question about the statement. Could we please have the statement put back up on the screen? 

CHAIR: You mean the media release? Yes. 

COMMISSIONER McEWIN: Yes. The Civic statement of   thank you. The second to last paragraph. Ms Eastman asked you, what did you mean by the sentence: 

The death of Alex is a reminder of the high risks involved in providing disability support work. 

And I'm just   I want to understand, on what basis do you describe   or why do you describe disability support work as high risks? 

MS DOYLE: Because it's a human service. And it means that, in a distributed environment where people are not in one building   they are   we have 61 sites. And so when you are working with people at separate sites, you are   by its very   you have to have a great process, great procedure and great culture to ensure   and that people are well trained in your policies and your procedures to make sure that we safeguard all clients and that we also safeguard our staff. So you are operating in a distributed manner. 

COMMISSIONER McEWIN: Safeguarding your staff   please bear with me. I'm really trying to understand. When you say safeguarding your staff  

MS DOYLE: Just that they follow   

COMMISSIONER McEWIN:   as opposed to a human working with a human   I really am struggling. I need to understand better the basis of what you mean by "high risks". 

MS DOYLE: A human working with a human is exactly what it is. It's exactly what it is. And a human has the power to make decisions about certain aspects of the delivery of support work, which is why the NDIS funds additional supports, because that's the human factor. You are looking   you are looking at the human factor. And so what I'm saying is that when you are dealing with a human factor, there are additional risks that you need to factor in. 

COMMISSIONER McEWIN: Alright. I will close it off by saying, are you suggesting that in that environment you describe that it's inherent that it will be high risks of providing support to disabled people? 

MS DOYLE: No. No, no. Because if you do appropriate risk treatment plans, if you understand the risk, if you understand what   you know, when you go out   otherwise you would leave people sitting in front of a television all day. That's not appropriate. So you need to understand, implicitly, the risk of what you are doing and then manage that appropriately, and that's   that's the human element that I'm talking about here. 

COMMISSIONER McEWIN: Thank you. Thank you both. 

CHAIR: Commissioner Bennett? 

COMMISSIONER BENNETT: No questions. 

CHAIR: Ms Eastman took you through in some detail the Managing Unreasonable Complainant Conduct Procedure. Can I suggest to you a fundamental problem that is consistent with, I think, the questions Ms Eastman was asking you. One of the examples of unreasonable lack of cooperation, which appears on page 3, is: 

Refusing to follow or accept Civic instructions, suggestions or advice without a clear or justifiable reason for doing so. 

Now, when you look at page 2, which talks about the responsibilities of staff in the second paragraph, staff are responsible for explaining the contents of this procedure to all complainants, particularly to those who engage in unreasonable complainant conduct. It's the staff under this policy who are going to determine whether someone is providing a clear or justifiable reason for not acceding to a suggestion or advice. And the person who may not be acceding to a suggestion or advice, as you said, was someone who may be non verbal. How on earth can this be an appropriate policy for an organisation providing services to people with high support needs, including those who are non verbal? 

MS DOYLE: Because we have never used this for clients. 

CHAIR: I don't think that's an answer. 

MS DOYLE: I understand your question. 

CHAIR: How do you know what your staff are doing? 

MS DOYLE: Because we have trained them appropriately. 

CHAIR: Okay. Alright. Thank you. Yes. Thank you very much to both of you for participating in the panel. Ms Eastman, when should we resume?

<THE WITNESSES WITHDREW

MS EASTMAN: If we could come back maybe at 2 pm? 

CHAIR: Yes. 

MS EASTMAN: Thank you. 

CHAIR: The tentative suggestion is 2 o'clock, so we will resume then. 

<ADJOURNED 1:16 PM

<RESUMED 2:02 PM

CHAIR: Yes, Ms Dowsett. I think there may be another appearance, is there, to be announced?

MS DOWSETT: Yes. Online. 

CHAIR: Online. 

MS CALLAN: If it please the Commission   if it please the Commission, Mrs Callan   my name is Callan. I appear on behalf of Ms Robbs of Life Without Barriers with your leave. My junior is Ms Ellicott. 

CHAIR: Yes. Thank you very much, Ms Callan. 

MS CALLAN: Yes, Commissioner. 

CHAIR: Yes, Ms Dowsett. 

MS DOWSETT: Thank you, Chair. The next witness this afternoon will be Ms Robbs, who is returning to the Royal Commission to speak   to answer some questions about Life Without Barriers, arising from Public hearing 20. Before I introduce Ms Robbs and proceed to the questions, I will give an overview of Public hearing 20. But I think before that, we need to have Ms Robbs take her oath or affirmation. 

CHAIR: Yes. Thank you, Ms Robbs, for coming back to the Royal Commission to give evidence. If you would be good enough to follow the instructions of my associate, who is seated opposite you, she will administer the affirmation. 

<CLAIRE ROBBS, AFFIRMED 

CHAIR: Yes. Thank you, Ms Robbs. I will now ask Ms Dowsett to ask you some questions. 

<EXAMINATION BY MS DOWSETT 

MS DOWSETT: Thank you, Chair. Public hearing 20 was held in Sydney from 7 to 14 December 2021. It examined the experiences of two groups of people living in   people with disability living in supported accommodation. One group lived in two houses in northern New South Wales. These were referred to as the Goonellabah house and the Lismore house, and collectively the Lismore houses in the hearing. The second group lived in one house in Melbourne, referred to as the Melbourne house in the hearing. The accommodation and support services in each house was provided by a non government disability services provider, Life Without Barriers, and I will refer to them as LWB. 

The hearing focused on the experiences of Sophie and Natalie in the Lismore houses, and Robert and Rebecca in the Melbourne house. The residents and their families were referred to by pseudonyms by direction of this Royal Commission. The case studies raised common issues, including allegations and proven incidents of violence, abuse, neglect and exploitation experienced by the residents at the hands of staff, other residents and people outside the houses; the adequacy of the measures LWB took to prevent such violence, abuse, neglect and exploitation; and the adequacy of LWB's responses to the allegations of violence, abuse, neglect and exploitation. 

Following the hearing, written submissions were provided. Relevantly, Counsel Assisting's submissions were provided on 25 March 2022, and LWB's submissions were provided on 13 April 2022. On 24 January 2023, a draft hearing report was provided to LWB. That hearing report has not yet been published, but LWB has had an opportunity to examine it. In this afternoon's evidence, I will focus on addressing recommendations from that draft report. I will do so by reference to the numbers in the report but noting, where relevant, their numbers from the submissions. 

So turning to you now, Ms Robbs. You were the   you have been the CEO of LWB since 2011? 

MS ROBBS: Yes. 

MS DOWSETT: And you gave evidence at Public hearing 20. 

MS ROBBS: Yes. 

MS DOWSETT: Now, I want to ask you if there have been any changes to the board or the senior leadership team in the period since Public hearing 20. We know from records on your website and an ASIC search, four directors have ceased, and two new directors have been appointed. Ceased to be directors, yes, Chair. 

CHAIR: Thank you for clarifying that. 

MS DOWSETT: So four have ceased to be directors and two new directors have been appointed. Have there been any changes in the senior leadership team? 

MS ROBBS: Since the hearing 20, there have been changes in the executive team that report directly to me. We have recently recruited a new executive responsible for our disability services nationally, and we have also made some changes in our back office, so our finance and our HR and ICT, and we have a new executive starting there in April. We have also recruited a new position to lead our access/inclusion employment plan, and that person reports directly to me, and another senior role that leads our reconciliation action plan, and they report directly to me as well. I think they are the main changes at the executive level. 

MS DOWSETT: So those are all new people stepping into existing roles, or are some of them also new roles? 

MS ROBBS: No, some of them are new roles. The accessibility employment inclusion plan is a new leadership role. We launched a new Reconciliation Action Plan middle of last year, and that's a new leadership role. And the corporate role is   we had   previously had an executive responsible for the different corporate functions, so ICT, finance, and we have really amalgamated that all into one executive role. The disability executive role, we have a person acting in that role, has been acting in that role around   just over a year, maybe 18 months, sorry. So it is the same role, but it's a new permanent appointee. 

MS DOWSETT: And are any of the current members of LWB's board people living with a disability? 

MS ROBBS: Yes. One of the new members that we recruited of the two that you mentioned. One of the new members has a lived experience of disability, and we are also recruiting two further board members at the moment and are specifically looking for another person with lived experience of disability in that recruitment as well. 

CHAIR: What was the reason for the four directors ceasing to be directors? Was it the expiration of their terms or did they resign? 

MS ROBBS: So two different reasons. Two of the directors was - the terms, as a result of us introducing that in 2015. So their terms ran out. And two of the directors both left to other opportunities in the disability sector. 

CHAIR: Thank you.

MS DOWSETT: And at the senior leadership level, are any of those people in the senior leadership team people with disability? 

MS ROBBS: Yes, I have one person with disability that reports directly to me. 

MS DOWSETT: Turning, then, to the draft report and the recommendations. I want to begin with recommendation 1, which was that: 

LWB should review its policies and procedures and its training to better equip staff in supporting LWB's clients to enjoy intimate relationships and do so with amendments being co designed by clients. The policies and procedures include but are not limited to LWB's disability services, principles, care and support environments procedure, disability policy and procedure manual, New South Wales health and wellbeing procedures and their more recent iterations. 

Now, in its submission following Public hearing 20, LWB undertook to amend its policies and procedures to ensure they contain concrete advice that a person with disability should be permitted to have their intimate partner stay overnight and to ensure that the rights of LWB's clients to have intimate relationships are prioritised. And there was going to be some training to staff, with some supplementary individual training. In its response to a Notice to Give information to the Royal Commission   and that response was dated 2 September 2022   two things were described. Firstly, a scoping of work and a proposal to undertake a review of policies; and the development of a client rights statement. Firstly, to the policies, is it the case that there is still no policy which contains that concrete statement that LWB undertook to amend in its written submissions? 

MS ROBBS: It is the case that the policy is still in development, and we   at this stage, we don't think that will be finalised until the middle of this year. And I appreciate that that is slower than we had hoped and intended - and informed the Commission of such - and I apologise for that. We are   we have ensured that we do have clients involved in the development and the finalisation of the policy, and staff as well. And it has taken us a little longer than hoped to get the external expertise that we really required to make sure that we are able to get some of those particular directions or advice that you referenced to as correct as we can for our staff. 

MS DOWSETT: What practical steps is LWB taking in the meantime? While it's going through this work, what are you doing right now, or what have you done, to address this issue? 

MS ROBBS: Yes. Look, they are really serious issues, particularly with regards, obviously, to the case study that was in hearing 20. Extremely serious. And so whilst we are doing the policy work, we have in the meantime engaged external expertise that I have spoken to and - made sure that - we have delivered training through to our disability support workers on the ground, and also specific and more targeted training to our frontline leaders that we would call our disability service leaders, so that the frontline leaders have got more targeted support. 

We did   because of the particular learnings from the case study from this Commission - we did use that as an unidentified case study in the training with the frontline disability support workers, the direct support workers, and our frontline leaders as well. And then from that, we developed some FAQs and some other guidance. And we have some particular resources that are practice quality teams, our Centre For Practice Excellence, which is one of the improvements since the hearing 20. They provide particular support then if situations arise   even though people are trained, if situations arise with any particular practice support around intimate relationships and the other topics identified in that recommendation. 

MS DOWSETT: And what is LWB doing to communicate to its clients that LWB understands the client's rights to have these intimate relationships and that they will be prioritised? 

MS ROBBS: So my understanding is that   again, communication with clients and families was one of our key learnings from hearing 20. It was very obvious from the case studies that we as an organisation - but - our staff didn't really feel equipped or supported, or skilled perhaps, to have some of those conversations and understand the expectations around communicating with clients or families. So we absolutely recognise that that was an improvement. So we have been working on that. 

MS DOWSETT: Yes. So you have spoken   excuse me for interrupting. But you have spoken about the training to staff. My question now is, what are you doing with clients, for clients, communicating to clients? 

MS ROBBS: Yes. So the client rights statement   and that's why I think in our response in September we referred to the client rights statement. So we have used the implementation of the client rights statement as the opportunity to be able to have conversations with our clients across the organisation about their rights generally, as you will see in the client rights statement, and included in that is the intimate relationships piece as well. 

MS DOWSETT: And, Commissioners, you have a copy of that client rights statement in Bundle I at tab 2. Just to confirm, Ms Robbs, you said that this document is general. It doesn't deal with the specific issue of intimate relationships. 

MS ROBBS: Yes, I accept that. Absolutely. Sorry, I should have been clearer, that what we have used in the absence of the material that the group are developing at that policy level   we don't want to wait for that until we start having conversations. And so we chose to use the client rights statement discussions as an opportunity to at least start those conversations with our clients and our direct staff as well. 

CHAIR: What's happened to the relationships rules that were the subject of evidence at the Public hearing? 

MS ROBBS: So the relationship rules that were in the case study would not be a practice that we would be encouraging or wanting to be repeated at all. 

CHAIR: That's not what I asked. What's happened to the rules themselves? 

MS ROBBS: The   the document that's specific to that particular case study? 

CHAIR: Yes. Yes, the rules   the relationship rules that are the subject of a finding in the document you have. But that finding was accepted in advance by LWB's submissions in April 2022. They were the rules that did not sufficiently respect Sophie's dignity and risk and privacy, didn't sufficiently support her right to intimacy, had the real potential of creating unsafe situations for Sophie and undermined her sense of having a real home. That was a finding that was accepted in advance, as it were. 

MS ROBBS: Yes. Yes.

CHAIR: What's happened to the rules? Are they still somewhere? Have they been withdrawn? What's happened? 

MS ROBBS: So my understanding is that the rules were specific to Sophie. Sophie is no longer with Life Without Barriers. And it's not   the rules weren't a document that was a general document that   as a guidance for staff. They were specifically drawn up for Sophie's   in Sophie's case. 

CHAIR: So what has replaced it, if anything, for other residents? 

MS ROBBS: So whilst we are doing the policy work, the guidance that staff have is through the heart and healing training that we conducted with staff, the FAQs that we have developed as a result of that and the other practice advice and tools that we give to frontline leaders, as I mentioned before to Counsel. 

CHAIR: Yes. 

MS DOWSETT: Thank you, Chair. Moving on to recommendation 2, it says: 

LWB should review its personal care policies to provide clear guidance to staff in respect of how rostering decisions should be made to accommodate personal preferences and how staff should respond if rostering decisions cannot accommodate personal care preferences. 

In its submissions, LWB accepted that it should review its personal care policies to provide that clear guidance. And then in its response to the NTG, LWB said that it was working with its Centre For Practice Excellence to ensure clear guidance is provided about the steps to be taken when shift cancellation occur on short notice. There was an estimated time for completion for that of 31 October last year. And "where possible", staff should document the reasons why a client's personal preference could not be adhered to. So, firstly, I just want to check, what guidance was given about the steps to be taken for late shift cancellation? So what guidance was provided? What are the steps? 

MS ROBBS: So the update with regards to that, since we last provided, is that the policies and procedures have been completely reviewed and encompassed all of the points that we reflected on from the hearing 20 from the Commission. We have really clear guidance now around what a disability support worker and then the disability service leader needs to do in the instance – both - firstly, to proactively make sure that we understand people's needs and wants in regard to staff members supporting them, obviously with the specific strong reminder for all of us of the seriousness of the impact of that in the case study that was in hearing 20. So make it really clear that we have a good process to ask people to document that and then a good process in the instance that that is not able to be met, be that in a reactive matter because someone doesn't come on shift as a cancellation, or other   something else that might happen in the roster. And a very clear protocol around the expectation both of where the disability service leader goes for advice in those instances, but   

CHAIR: Is all of this in a document? 

MS ROBBS: Sorry. Yes, it is. Sorry. 

CHAIR: Do we have that document?

MS DOWSETT: No. 

MS ROBBS: Sorry. Yes. We will absolutely provide that document. My apologies. 

CHAIR: Sorry?

MS ROBBS: We can provide that document.

CHAIR: But you haven't. 

MS DOWSETT: No, we don't have that document. 

CHAIR: So what's the document called? 

MS ROBBS: Sorry, I   it will have a specific title, but it will be around the personal choice   around personal care. I don't think we have been asked for that, but absolutely happy to provide all of that material. If I could just add, perhaps, one more to your question  

MS DOWSETT: Well, my question was what are the steps. 

MS ROBBS: Yes. Okay.

MS DOWSETT: And I understand if you don't know what they are, but do you know? What happens when there's a shift cancellation that means a personal preference cannot be accommodated? 

MS ROBBS: So in that instance, the instruction is then that the disability service leader needs to be contacted if they are not in the house or if they are away. Then they need to contact the family member or the guardian or the appropriate person for that client, explain the situation, explain why and then see if there is able to be an outcome negotiated. For example, some people   and there's examples provided to guide people on how to have that discussion. Sorry. So, for example, someone might decide that actually, we will wait until the morning for a particular personal care, perhaps, or sometimes a family member may choose, well, actually they will come home for a shower or   you know, a number of negotiated outcomes so that, most importantly, particularly referencing back to the learnings from the case study, we are not in a situation where we are not able to provide, for example, a female worker if that has been requested. 

MS DOWSETT: Now, as I emphasised when reading what the NTG response said, it says "where possible" the reasons will be documented. Why would it not be possible to document the reasons? 

MS ROBBS: Sorry. Yes. I take your point on that completely, actually. And I'm happy to provide a response on that when we provide the documents. I don't know why it says, "where possible documents". Sorry. 

MS DOWSETT: And what are the reasons for documentation   documenting that reason why the personal preference can't be met? What happens to the document? 

MS ROBBS: Yes. So the reason is also so that we can make sure that that's then in the discussion around the rostering for the house generally. So that we want to know that if someone has expressed a particular, you know, worker or particular   something around personal care, if there's an instance where that's not been able to be met, then that needs to a discussion with the staff, with the service leader and then escalated through to their manager as well, because of the importance of that, which was crystal clear from the case study in the hearing. 

MS DOWSETT: And you said it gets escalated to the manager. Does it go further than that? Does it come to you or to the board, any trends on not being able to meet personal preferences? 

MS ROBBS: At the moment that doesn't happen, and the main reason for that is because the next step   and we have not done this yet, we are working on it   is to have that automated in our system so that we   so that then we actually can get the trend data and also that flag is then provided up through the organisation. We have not been able to do that in the timeframe. We have done what we have, but that is the intention with the next step. 

MS DOWSETT: Moving on to recommendation 4. Recommendation 4 is: 

LWB should amend the vacancy management policy... 

And I will skip over the name of the policy: 

...to make clear that consultation of existing clients and their families must occur before any decision is made to accept a new resident into a group home. 

Now, in its submissions, LWB accepted that it should amend its vacancy management policy to make that clear. In its NTG response, you described some steps that were being taken, including the trial of a new approach to vacancy management in order to receive feedback from existing and prospective residents, their families or authorised decision makers, client services and landlords to further   to identify further opportunities for improvement in that policy. 

CHAIR: Which page are you referring to, Ms Dowsett? Which page?

MS DOWSETT: Of the NTG response? 

CHAIR: Yes. 

MS DOWSETT: Just a moment, Chair. I'm talking from my notes, so I will turn that up for you. 

CHAIR: All right. Just leave it for the moment and you can let us know. That's all right. Go ahead. 

MS DOWSETT: So my question is: did the trial, in fact, occur and what, if any, refinement happened to the vacancy management policy? 

MS ROBBS: Yes. So the vacancy management policy has been completely reviewed, and that is finalised and does include all of the recommended points from hearing 20 in that. Again, I don't think we have been asked to provide that, but happy to do so if that's helpful to the Commission. With regards to the pilot, the pilot was completed, and we did get good feedback in regards to process - particularly, for example, around how the family members would like to be communicated with and the fact that they wanted some of the decisions to be able to be made at a house meeting and also who needed to be attending those meetings as well. So we factored those   that feedback from the pilot into the finalised policy and procedure, which is in place today. And we have implemented that policy across the organisation, and we monitor at a national level the process around vacancies and the   to make sure the policy is implemented. 

CHAIR: Is there some reason you didn't provide these revised documents with your response? 

MS ROBBS: Well, the   sorry, the documents that we are talking about have been completed since our last   in September. Sorry. Yes. 

MS DOWSETT: Chair, thanks to my instructors, the recommendation that I was speaking to is on the first page of the NTG response. So it's recommendation 4 in the hearing report, but recommendation 3 in the NTG response. 

CHAIR: Thank you. 

MS DOWSETT: The vacancy management procedure that is outlined in the NTG response refers to a process for consideration to be given   significant consideration to be given to issues raised by residents and their families, and then the placement of somebody into that group home doesn't proceed until the issues have been   issues raised have been addressed. Who decides when the issue has been addressed? 

MS ROBBS: Yes. So in the policy that we have, we have clearly said that we really want it to be a unanimous decision. So we work really hard, and our local leaders that I have referred to before, responsible for the houses, try to do that with the team effectively, be that the clients, family members, decision makers. We do want to try to achieve a unanimous outcome of the fact that it's a good   it's a good step for everyone. We do have in the policy that if that's not possible, then we will go with a majority, if there is perhaps one issue that's not resolved. And I   again, I will share the information, so my wording is correct. But then there is a conversation that needs to be had between that person and their line manager and the practice team as well. If a unanimous decision is not able to be reached   because we really want to try to do that as much as possible. And for a unanimous decision to be reached, I assume, therefore, that the various issues would have been addressed. 

MS DOWSETT: And if you're not able to reach a unanimous decision, if you go with majority, does LWB then have a policy to work with the minority, the person who didn't agree, to help them explore other living arrangements, or are they then just in the house in the minority? 

MS ROBBS: Yes. So if it was a client or family that expressed the view, everyone that lives with Life Without Barriers is always absolutely free and encouraged to consider whether they want to keep staying where they are. I think what we would want to be happening is if there was a serious issue, you would be   you wouldn't be going with the majority view. If it was more something that could be accommodated in the house, then we would want steps to be put in place to try to make that as manageable as possible for everyone. And absolutely everyone has that choice. If people then decide that that's not the home they want to be living in, of course   and we would do everything we can to support them. We would not want that outcome, but we would do everything that we can to support them. 

MS DOWSETT: My next question isn't   doesn't flow directly from a recommendation in the final report but rather from LWB's submissions, and it's on the topic of the board reporting practice and governance framework. Chair, for your information, this is pages 26 and 27 of LWB's submissions. In its submissions, LWB said that on reflection   I'm paraphrasing, not quoting   including consideration of the evidence given and the issues raised in Public hearing 20, LWB intend to commission expert advice with respect to reporting significant incidents to the board to assist the board to discharge its responsibilities. And then you have provided some information about who has been commissioned to help with that work. And then in the NTG response, you spoke about the independent consultants who had undertaken a review of the framework and provided some recommendations. And a new practice governance framework was approved by the board in August 2022, and it was to commence in September 2022, with full organisational commencement set to commence in 2023. So against all that background, have the recommendations been received and implemented? 

MS ROBBS: Yes, they have. And in regards to the practice governance framework, that has been implemented. And in the development of that, the findings   the draft findings probably at that time from this Commission were specifically taken into consideration in regards to the board reporting specifically around the types of incidents that were raised in hearing 20 as well. 

MS DOWSETT: Now, LWB has provided to the Royal Commission   and, Commissioners, this is in Bundle I behind tab 3   its reportable incidents responding to allegations and incidents of sexual violence procedure. 

MS ROBBS: Mmm. 

MS DOWSETT: This new procedure doesn't include any information about those kinds of incidents and allegations being reported to the board. Is there something specific in that new board reporting framework that you've just discussed that deals specifically with allegations and incidents of sexual violence? 

MS ROBBS: No, you're right, that document doesn't encompass the organisational reporting. I'm thinking about the framework   and I don't know if it specifically calls that out. However, we do have other   whether it's in the framework document or other related documents that guide the reporting specifically for the board, that have been updated as part of the practice governance framework review that you commented on, and I'm happy to provide those to the Commission too. And they do articulate the   the reporting to the board and the internal reporting around the matters in the policy. 

MS DOWSETT: And does that   

MS ROBBS: Procedure, sorry. The procedure, sorry. 

MS DOWSETT: Does that additional documentation that you have just referred to   does it specifically address the incidents of the kind that were dealt with in the case study in Public hearing 20? So sexual violence   your evidence at the time   so in Public hearing 20, your evidence was to the effect that you didn't think those allegations needed to be reported to the board. I suppose, firstly, do you maintain that view? 

MS ROBBS: So, no. 

MS DOWSETT: And so is there now guidance that would ensure that anyone coming into your role, anyone below you, would understand the obligation to report those kinds of things? 

MS ROBBS: So, to be very clear, we have   I have reflected a lot and reviewed the material, and we watched that part of   well, the entire hearing last time, and particularly that piece. And in the review of the practice governance framework, I absolutely do agree that the board absolutely need to understand the matters occurring in the organisation, particularly matters of serious impact, like the ones in the case study. As I said here, I'm obviously struggling to give you the specific name of the document. So my apologies for that. But I can certainly assure the Commission that that finding and the questioning from the Commission in hearing 20 was taken into consideration and now reflected in the board reporting. 

MS DOWSETT: Moving on to recommendation 5, and so this was: 

LWB should promptly take action to date all current policies and date all future policies and make all policies readily available to residents, their families and any staff who may be affected by the policy. 

Now, in the submissions, LWB undertook to do that. And then in its NTG response, there was estimated date of completion for the dating of policies, 30 September 2022. I take it that's been done? 

MS ROBBS: That has been done, yes. 

MS DOWSETT: And then making all policies available to residents, families and staff, estimated date of completion, 31 October 2022. That's been done? 

MS ROBBS: All policies are not yet available. We are   the policies are going on to the website, and we are uploading them in tranches, for want of better language. We   and prioritising the ones that need to be up there. We are also working to try to make sure that those policies are simpler. One of the reflections from hearing 20 was that some of our documentation was too complex for people to be able to follow. So at the same time as uploading, we are trying to make sure that we simplify those documents. We have also   in the meantime, whilst all of the documents are not up on the website, we understand the importance of people having   absolutely having access to them   families and clients, sorry. We have the capacity for people to then request specific policies, which I think was another point made by the Commission as well. And we will keep   

CHAIR: Sorry. Can I just interrupt what you are saying just for the moment. What's been the problem about uploading them? 

MS ROBBS: It's not really so much a problem as such. It's more that we have thousands of policies, and we want to do it in a way that's really helpful. 

CHAIR: Thousands of policies? 

MS ROBBS: Sorry? 

CHAIR: Thousands of policies? 

MS ROBBS: Well, a lot. 

CHAIR: A lot.

MS ROBBS: I would say a lot of policies. 

CHAIR: Yes.

MS ROBBS: Some of those are much more relevant to clients and families than some others might be. And so we are doing it in a priority order. And we also want to do if it in a way where   

CHAIR: Let me put the question another way. 

MS ROBBS: Yes.

CHAIR: Have all policies relevant to clients, residents and their families and any staff who may be affected by the policies   have those policies been uploaded, all of them? 

MS ROBBS: So all staff have access to all policies. 

CHAIR: No, my question   I think it was tolerably clear. Have all the policies that are relevant to residents, their families and any staff who may be affected   have they all been uploaded? 

MS ROBBS: No. 

CHAIR: Why not? 

MS ROBBS: I guess the process that I was trying to explain about making sure that the priority policies are uploaded that are most relevant to clients and families. Staff access the policies via the intranet and not the   they might access some on the website too, but they do have full access to all the policies on the website. And so it's the clients and families ones that we are still uploading. And I appreciate that   

CHAIR: Does this suggest that Life Without Barriers hasn't given this process of providing information to residents and their families the priority that is envisaged in the acceptance by LWB of the proposed recommendation that became recommendation 5? 

MS ROBBS: I would most certainly hope that that was not the impression that we were giving at all. It's certainly not the intent at all. I do appreciate that it is a   it is taking us longer than we had previously intended, and I do apologise for that. But it's certainly not a sign that we are not absolutely committed and appreciate the importance of the recommendation as well. 

CHAIR: Yes, Ms Dowsett. 

MS DOWSETT: Thank you. Still on that policy question, is the process being delayed because LWB is reviewing and revising policies along the way and then uploading the new ones, rather than taking the existing policies that are relevant to clients and their families and uploading what you've got now and then doing your review? 

MS ROBBS: I understand. I think that that is contributing to some of the policies, and the others will just be around that technical capability for us. There's not   it's not as though we are trying to, you know, review them all before we upload. Sorry. Yes. 

MS DOWSETT: Turning then to the final recommendation, which is recommendation 6: 

LWB should consider making an ex gratia payment to Natalie as compensation for the conduct of LWB worker 3. 

Now, in its submission, LWB said   sorry, I've lost my place in my notes. So LWB spoke firstly of apologies, and it said that the board did not make an apology to Natalie when LWB became aware of what had happened to her and it should have. You referred to LWB's active apology policy and noted that you didn't take that action and   but you had given an apology then. You also acknowledged the circumstances where the investigations by LWB resulted in findings that two staff members had played a part in allowing the assault to occur and, by that, LWB had committed a serious breach of duty. 

So that's the submissions. And then in the NTG response, you provided some detail about what had happened in the meantime about the ex gratia payment. So, in June 2022, LWB approached the Royal Commission to request contact details for Natalie and her mother to broach the subject of an ex gratia payment. And then in late July, the Royal Commission advised that it didn't have those contact details. In September 2022, LWB sent a letter using the contact details that it had. Can you provide the Commissioners with an update? What happened after September? 

MS ROBBS: So, September, we did send a letter to action the recommendation from the Commission and the hearing. And then in the past few weeks, proceedings have been commenced on behalf of Natalie. Sorry. 

MS DOWSETT: I don't want to get into the proceedings, but you have said that's the last few weeks. So between September when you sent off the letter and the last few weeks, there was no action. Is that accurate to understand? 

MS ROBBS: Yes, that is. Yes. 

CHAIR: Did Life Without Barriers make an offer of an ex-gratia payment at any stage? 

MS ROBBS: In the letter, we made apology and we   

CHAIR: No, no, my   I didn't ask about an apology. I said: did Life Without Barriers at any stage offer to make an ex-gratia payment? I'm not worried about whether it was accepted or not. Was an offer made? 

MS ROBBS: The offer was made but not a specific amount, if that's   sorry, if that's where you are   

CHAIR: And that's not an offer at least as lawyers would understand. Thank you. 

MS ROBBS: Sorry. 

MS DOWSETT: Thank you, Chair. Thank you, Ms Robbs. Those are my questions, but the Commissioners may have more for you. 

CHAIR: Ms Robbs, I take it that you read very carefully the submissions made on behalf of LWB in response to Counsel Assisting's submissions. 

MS ROBBS: Yes. 

CHAIR: You have also received the report that was referred to that's been prepared by Commissioners but not yet generally published. 

MS ROBBS: Yes. 

CHAIR: You appreciate, I take it, that the report for the Public hearing that you have received makes 32 factual findings adverse to LWB. 

MS ROBBS: Yes. 

CHAIR: You also appreciate, I take it, that 20 of those   19 of those findings were foreshadowed in Counsel Assisting's submissions and were accepted by LWB. 

MS ROBBS: Yes. 

CHAIR: And another one was not disputed, making 20 in all. A further six findings of the 32 were partially accepted by LWB to a great extent or lesser extent. 

MS ROBBS: Yes. 

CHAIR: If we limit ourselves to those findings that were accepted or partially accepted, do you now, having reflected on the matter, accept that these constituted very serious institutional failings by LWB? 

MS ROBBS: The first thing is that we   I appreciate that we may have made statements around the findings at that point. But now that we have the final   draft final report, we   I accept the findings of the Commission   all of the findings of the Commission. 

CHAIR: My question was: having reflected on the matter, do you accept that the matters accepted by LWB in its submissions amounted to very serious institutional failings by LWB over a period of time? 

MS ROBBS: I understand that those are findings specifically around that too, and I feel like I have tried really hard to express the   the accountability that we have accepted for the failings and, most importantly, the impact to the people involved in the case studies. I   

CHAIR: I will ask the question again, because I don't think you're answering it. 

MS ROBBS: Okay.

CHAIR: Given that LWB accepted 20 of the findings that have been contained in the report that you have received   they accepted those in advance, and they partially accepted another six others. Taking those, do they not indicate to you now, as you sit there, that there were very serious institutional failings by LWB over a period of time towards its clients? 

MS ROBBS: I understand that what you want me to say is yes, and   

CHAIR: I want you to give an honest answer, Ms Robbs. 

MS ROBBS: Yes. And I think   what I do   what   in reviewing the hearings and reading all of the reports and recommendations, and particularly hearing the experiences from the clients and families involved, I absolutely accept that the experience of those people was nothing like we want them to experience at Life Without Barriers, I accept. And the   

CHAIR: Would you be good enough to answer my question? 

MS ROBBS: Well, I'm trying very hard to answer your question. 

CHAIR: It's not all that difficult, Ms Robbs. 

MS ROBBS: Yes. I think   I'm trying very hard to answer the question. I think the view that we would take is that, in those instances, there is no doubt that some of the processes and the checks and balances and capabilities that we would want to have in place to keep people safe and to provide people with the care and support that we want them to have did not do the job that we designed them to do. There was absolutely no doubt of that, and we have been really clear on that the whole way along, and that's why we do accept all of the findings. The reason that we   I have resisted slightly the suggestion or finding that that then speaks to broad systemic failings   I'm trying to use the   I can't remember the exact language, sorry, you have used   is because I think that it's not representative of everything across the organisation in that way. 

But, that being said, in the reflections on this, I do understand and accept that the things that we've done to improve things and to make a difference have been done at a system level. And that   that's the piece that I feel I wasn't perhaps able to clearly articulate in hearing 20, that I accept that the processes and training capability and the reporting   I absolutely accept that that did not work in those instances, and we have worked really hard to improve that and to learn. But the piece that I am slightly resisting is then the suggestion that that is then attributable to all of Life Without Barriers across all of its time. That's the piece. Sorry. 

CHAIR: I'm not sure that was implicit in the question I asked you, but thank you. I understand your answer. I think you said, unless I have mistaken you, that having had the opportunity to read the draft report that's been submitted, that you now accept all the findings in that report. 

MS ROBBS: We   if I can comment on that. We   I do accept the findings   we do accept the findings, and the reason that we do that is because the Commission has had all the evidence and we have had the opportunity to express our views in a multiple avenues. And you have your final findings, and we respect and accept those findings - 

CHAIR: All right. 

MS ROBBS:   as a result of the Commission's process. 

CHAIR: One of those findings is finding 32: 

Ms Robbs, as Chief Executive Officer of LWB, and LWB more generally, did not take an active approach to monitoring, detecting and rectifying deficiencies in the operations of LWB, but rather responded to revelations about deficiencies as they occurred. 

I take it from your answer that you and LWB accept that finding. 

MS ROBBS: Again, on reviewing all the material, and particularly on watching the hearing and the experiences, there   absolutely accept that, in those instances, this   I and the organisation were not proactive enough. And if we had been and those same instances were to occur now, I'm really confident there would be a different   a different response. 

CHAIR: Just putting to one side for the moment the different response. Has anybody been held accountable for what you accept has been failings that you yourself have just confirmed? Has anybody been held accountable by LWB, the board or anybody else, for those failings? 

MS ROBBS: So I feel I'm being held highly accountable by the board in the way that I   the conversations that we've been having and the way that we have been regularly reporting the improvements and being held accountable to those improvements by the board, quite properly. I feel a high level of accountability to the Commission, to   as we just have gone through, to report back on the recommendations and the improvements that we have made. And I feel a particular accountability to the clients and families involved, which is why we have both endeavoured to make the apologies, but also, importantly, been motivated   more motivated than ever, on hearing their statements and their experiences, to make the improvements that we are working really hard to make. 

So I feel like I'm highly accountable, and I   and we discussed that at the board. And I appreciate   and I know   speak on behalf of the board. But in the discussions, we are very clear that we are accountable, most importantly, to the clients and families involved and the broader clients and families and staff across Life Without Barriers. So we are in no doubt of that at all. 

CHAIR: I take it from your answer that nobody below staff level but at senior levels of LWB has either been dismissed or suffered   experienced any disciplinary action as a result of the matters investigated and reported on at PH20? 

MS ROBBS: We have not dismissed anyone as a result of that at senior level, no. 

CHAIR: And as far as you're aware, the board has not issued any public statement acknowledging responsibility of LWB for these failings, or has it? 

MS ROBBS: We do have a public statement, and we are intending   were intending to publish that with the final report. And we have   publicly, but also particular communication with our clients, families and staff and stakeholders. We are waiting for the final report for that statement. 

CHAIR: But there's nothing up to date? 

MS ROBBS: Publicly? I   not from the board, I don't think so. Sorry, I would just need take that   I think we have made statements, but I don't think the board have made a public statement, certainly not of the form that we intend to make when we have the final report, at all. 

CHAIR: Thank you. I will ask Commissioner Bennett whether she has anything further. 

COMMISSIONER BENNETT: Mine are of the more mundane nature. I would like to   when you said there is thousands of policies  

MS ROBBS: Yes.

COMMISSIONER BENNETT: But the question still goes   the process that you're going through to review the policies, you have a working group. Is that right? That's what I read in   

MS ROBBS: The   possibly. Certainly, the review of the intimate relationships piece has an extensive working group, but perhaps   

COMMISSIONER BENNETT: No. Page 29, I think - 

MS ROBBS: Yes. Sorry. Yes. 

COMMISSIONER BENNETT:   in your response. Is it 29? It says that there   this is particularly about the recommendation about reviewing the policies that families and clients would be able   

MS ROBBS: Sorry. Yes. 

COMMISSIONER BENNETT: And there were 50 policies that are listed in here. 

MS ROBBS: Yes.

COMMISSIONER BENNETT: So is the process   it says you had a working group looking at the policies. Is that an internal working group, staff or experts or people with disability? 

MS ROBBS: I   I think that will be staff. However, I would take a note that often   and particularly with the client rights statement, for example   we do consult with our disability   National Disability Advisory Group. But I can't assure you that that happened in that working group. 

COMMISSIONER BENNETT: Is your National Disability Advisory Group, residents? 

MS ROBBS: Sorry. Yes, it is. Sorry. 

COMMISSIONER BENNETT: It is?

MS ROBBS: Yes, it is. My apologies. 

COMMISSIONER BENNETT: So you   these policies that affect people living or receiving services, you have a mechanism for consulting with those clients? Policies that affect them? 

MS ROBBS: I   very honestly, I am not sure that   I don't think that mechanism is as strong as it needs to be, and a lot of that reflection has come from listening to this hearing, actually, over the week. We do have a National Disability Advisory Council. It is made up of clients of Life Without Barriers. It's chaired by clients. Absolutely we consult them on key policies and key practices and changes. But one of the reflections that came from listening to this hearing is that we will definitely be able to strengthen the involvement of our clients in the policy process. 

COMMISSIONER BENNETT: About the ways that they might live - 

MS ROBBS: Yes. Absolutely. Yes. Absolutely. 

COMMISSIONER BENNETT:   and how they get information. 

MS ROBBS: Yes. Absolutely. 

COMMISSIONER BENNETT: Okay. But it's been more than a year since this hearing, and the policies   those 50 core ones that have been identified in your response have still not been all completed and not uploaded so that they are available for family and residents to access. Is that right? 

MS ROBBS: I'm not sure if the full 50 are definitely up there, but there are definitely   there will be policies up there, but I cannot say that it will be the full 50. Sorry. 

COMMISSIONER BENNETT: Has the board showed an interest in monitoring the progress of the recommendations and the findings of the Royal Commission and asked you regularly at every board meeting how they are progressing, why there are delays, what they look like, those changed policies? 

MS ROBBS: Absolutely. So we report to the risk committee practice governance committee and then into the board every quarter on all of the recommendations and other improvements that we have identified from our experience through the hearing, as I reflected. We report on all of that to the board quarterly, including the status of things and any material reflections or changes that we have in that. 

COMMISSIONER BENNETT: Have they expressed concern about how long this is taking? 

MS ROBBS: The board   we are all concerned. I'm not   certainly not sitting here now saying that I wouldn't have wanted to meet the original deadline that we gave the Commission, by any means. And I apologise if I have given you that impression at all. So we absolutely wanted to meet the deadline. We haven't been able to do it, and I'm just being really honest, and we are working really hard. And I absolutely understand the importance. And, yes, the board are aware of the delay and, yes, they have asked me to make sure that that's prioritised. 

COMMISSIONER BENNETT: And the last question goes to the thousands of policies. 

MS ROBBS: Sorry. 

COMMISSIONER BENNETT: Well, the many, obviously. There are many. 

MS ROBBS: Many. Sorry. My apologies. I shouldn't have used that language. 

COMMISSIONER BENNETT: How   we have heard about staff throughout this hearing, how much pressure is on them, how much admin is on them, how they   and we have heard in other hearings where   how are you ensuring that they have easy access to understanding the policies, to finding them and to ensuring that they understand them and they are practical and sensible   commonsense way of applying those many policies that you have and are reviewing and changing? How are you doing that? 

MS ROBBS: Yes. Look, I've listened a lot to the evidence   well, I have listened to the whole hearing and the evidence given on that from   and my, you know, fellow chief executives. So the way that we are trying very hard to manage it   it is a challenge for everyone   is that we have a specific place on the intranet where the staff are able to access, and the staff do all have access. Rather than just have all of the policies there, we have sort of   we have sectioned it up so that we can make it easier, simpler, for staff to be able to access the policies that are most relevant to their day to day. 

Some of the other policies around perhaps how we   just run the security and the ICT system   I just picked something   that's probably not as relevant, obviously, to a disability support worker, as some of the other really important policies. So we have tried to simplify the language and the format and the policies to make them shorter. That is an ongoing process, but we are trying very hard to do that. We are making sure that it's easier for them to find it on the intranet. And we will, you know, continue to try other technical innovations, I guess, to make it easier for the staff members to get access to the information they need, nice and quickly, and in a really user friendly format. 

COMMISSIONER BENNETT: Thank you. 

CHAIR: Commissioner McEwin? 

COMMISSIONER McEWIN: Thank you. Thank you, Ms Robbs, for your evidence. My question relates to leadership opportunities for disabled people. We heard this morning from Terry Symonds, the CEO of Yooralla, who told us that recently Yooralla has set up a CEO internship program which gives disabled people an opportunity to potentially become CEOs. Do you have any comments or observations on that? 

MS ROBBS: I mean, I've spoken to Terry Symonds   Mr Symonds at depth about that. I think that's a fantastic thing that they are doing, and I would absolutely love to be involved, and I'm hoping that he can help make that happen. I did note that yesterday   I think yesterday in the panels, there was also questions around some of the really good AICD opportunities for directors and people with a disability to become directors, and also the Disability Leadership Institute work too, and we are certainly actively engaged in both of those initiatives. And I think that the work that Yooralla have been doing on that front that they spoke about in the hearing earlier today, you know, I'm very keen to be involved in that. And I know that our board members existing and the board members that have left us were really central to working with the AICD, particularly on their initiative, and the institute as well. 

COMMISSIONER McEWIN: So can we expect Life Without Barriers to, in the next six to 12 months, set up similar things - 

MS ROBBS: That would be fantastic. 

COMMISSIONER McEWIN:   to Yooralla? 

MS ROBBS: Yes. Absolutely. 

COMMISSIONER McEWIN: We can expect that?

MS ROBBS: I will say yes to that, for sure. Thank you. 

COMMISSIONER McEWIN: Thank you. Thank you, Chair. 

CHAIR: Thank you very much. Thank you, Ms Robbs, for coming to the Royal Commission to give evidence today. We appreciate your assistance. 

<THE WITNESS WITHDREW 

CHAIR: Ms Dowsett, what should we now do?

MS DOWSETT: Chair, if we could take a five minute adjournment for the customary reconstituting of the panel and then we will proceed with the last panel of the afternoon. 

CHAIR: Yes. We have taken just a little longer than anticipated, but we shall take the five minutes and resume then. 

<ADJOURNED 3:05 PM 

<RESUMED 3:12 PM 

CHAIR: Yes, Ms Eastman. 

<LIZ FORSYTH, RECALLED

<ANNIE DOYLE, RECALLED

<SONYA FUREY, RECALLED

<EXAMINATION BY MS EASTMAN SC

MS EASTMAN: Thank you, Commissioners. I appreciate on a Thursday of a five day hearing starting a session after 3 pm is probably a big ask for everybody, but I'm very grateful that Ms Doyle, Ms Forsyth and Ms Furey have returned and remained during the day. We want to turn our attention now to one aspect of responding to complaints, and that is not the internal process but when the organisation turns externally. So that's the focus of the panel this afternoon. 

So the first topic I want to ask you about is   and I will call it transparency and data in relation to complaints and incidents. So the broader issue is the extent to which, as an organisation, you report   probably a better word is to say that you share the information that you learn from the complaints received over the course of the year with relevant stakeholders. So, in the first instance, is there any steps taken by your organisations to inform people with disability to whom you provide services, and their families, about the numbers of complaints, the nature of the issues raised in the complaints and what the outcomes might be? Do you do that, Ms Forsyth, for Northcott? 

MS FORSYTH: We currently don't do that on a broad level. We clearly communicate to individual people in relation to their individual issues, but we don't currently do that. And one of the things we are mindful of in considering how we should appropriately share that type of information is that, at times, numbers of complaints or incidents reporting can sometimes serve as a disincentive around a culture of open reporting. So it's something that we are very mindful of trying to work through. 

MS EASTMAN: Looking at the responses for Civic and for Cara, are we right in understanding that you don't make information of that kind available to the people who receive services or the family networks? 

MS FUREY: At Cara, we have just issued our 2022 annual review and, in that, we identify the number of incidents and complaints that were actively managed during that year. 

MS EASTMAN: Okay. 

MS FUREY: We have   that may   we would like to improve on how we disclose and see great benefit in doing so, but at this stage we have just disclosed the number. 

MS EASTMAN: Right. And Ms Doyle? 

MS DOYLE: So, like Ms Forsyth, we disclose the complaint and all the surrounding evidence around it back to the family, the client, et cetera. But not holistically, no, we don't. 

MS EASTMAN: One reason organisations generally don't like to tell people about their complaints and the nature of those complaints, and the outcomes is that it creates a perception that this might be an organisation with trouble or difficulty. But equally, if it's done in an appropriate way, it might also show the opposite, that this is an organisation that has a culture that is one committed to accountability and to encourage people to feel that they can make complaints and that those complaints will be acted on. In the decisions that your organisations have made, in Cara's case to share information the way you have described, or for the other organisations not to publish that, has that tension between reputation, and potential damage to reputation by publishing the fact of the complaints, been a factor weighed against the transparency and accountability of doing so? 

MS FORSYTH: Certainly, for Northcott, it's not something that we have considered. Our main consideration in thinking about the information we share in response to complaints and incidents has really been about encouraging a culture of complaining and reporting, particularly with staff. And we absolutely acknowledge and see the tension around whether or not doing that publicly encourages the people you support to do it, but it's never been an issue of reputation when we have thought through the issues. 

MS EASTMAN: All right. What about to the worker, so your own employees? Cara, I think the workers   Cara, the workers can view a dashboard? 

MS FUREY: Correct. 

MS EASTMAN: And so workers can see through the internal processes what the situation is at Cara in terms of the numbers of complaints, where the complaints might be coming from and the nature of those complaints. Is that right? 

MS FUREY: Correct. 

MS EASTMAN: And in terms of the staff who can access that, is that from support worker up to interim CEO? 

MS FUREY: Yes. And, yes, it is a comprehensive dashboard updated four times a day for incidents that are logged. 

MS EASTMAN: And Civic, the approach you take is a general response that managers and leaders are responsible for ensuring that staff are provided with regular feedback about incident, hazard and complaints events. 

MS DOYLE: We have dashboards that talk to those incidents, yes. 

MS EASTMAN: So   well, just looking at the response, I don't think you raised that you have a dashboard that employees can look at. 

MS DOYLE: We also provide dashboards. Yes.

MS EASTMAN: So, like Cara, you have got that?

MS DOYLE: We have dashboards that are shared with the leadership team. 

MS EASTMAN: But not to all employees. 

MS DOYLE: And they are shared down in their talks   in their toolbox talks.

MS EASTMAN: So it depends on the leaders telling   

MS DOYLE: Correct. 

MS EASTMAN:   the staff who they supervise. 

MS DOYLE: Correct. 

MS EASTMAN: And it will be up to the leaders as to whether they share that and the nature of what they might share. Is that right? 

MS DOYLE: Yes.

MS EASTMAN: And at Northcott, you don't generally make available data and trends about all complaints and incidents to workers. Is that right? 

MS FORSYTH: We certainly don't make a dashboard available at a frontline worker level, but we do similarly have dashboard reporting through the system through managers who are able to see information in relation to complaints and incidents. 

MS EASTMAN: We have heard during the course of this week some evidence about the situation of workers and the cultures in organisations that encourage workers to be the eyes, in effect, building a culture that the standard you walk past is the standard that you accept. To the extent that you want to build a culture where the workers feel confident to make complaints or raise incidents without any adverse consequences to them, do you think sharing the information about the complaints, the nature of the complaints and the way in which from a management perspective you are responding to it would be a helpful tool in building confidence in the disability workforce? Who wants to take that one? From Cara?

MS FUREY: Well, from my view, yes. So we proactively encourage reporting across the organisation. We run campaigns like "see something, say something" with a catchy heading and some good examples underneath of where this is good for outcomes for our customers and the organisation. So I think it is a positive thing to do, to share more broadly. I am going to add to that, is that if an incident is reported by one colleague in relation to their fellow colleague, they are marked as confidential, and it is not transparent at all the details of that incident. 

MS EASTMAN: So there is some protections against victimisation. 

MS FUREY: Correct. 

MS EASTMAN: And at Northcott, you don't share that information across the staff generally. How does that   how is that consistent with your philosophy of having a culture that's one that does report and that there's not a fear of   

MS FORSYTH: Yes. Look, as I said, it is a   an issue that's complex around competing, I guess, components of how much to give that encourages reporting versus creates an environment whereby people are fearful because it turns up as a KPI, for example. So what we have been trying to do is be mindful of how some of our KPI for managers can give effect to the outcome that we are seeking without unintendedly serving as creating a culture of silence. So a good example might be around manager KPI around complaints may not be around a number of complaints, and a reduction of, but actually about a responsiveness within the compliance timeframe within our policy. And we also, similarly to Cara, run other campaigns to support our staff to speak up about abuse. We also offer a safeguarding hotline, which is when people can call a member of our safeguarding team and talk through a concern or query in a really informal way to get a sense of, you know, whether   if and how they should report. 

MS EASTMAN: And do each of your organisations have whistleblower policies that reflect the Corporations Act requirements?

MS DOYLE: Yes. 

MS FORSYTH: Yes. 

MS FUREY: Yes. 

MS EASTMAN: And in terms of encouraging anyone to use those whistleblower protections, and given the confidential nature of that, have you seen any particular impact of that whistleblower policy? 

MS FORSYTH: When we communicate and remind staff in relation to whistleblower policy, we often see people   I guess an uptake in whistleblower issues coming through, which is a good thing because it reminds people that it's an avenue with which they can raise concerns. 

MS EASTMAN: Ms Doyle? 

MS DOYLE: So our whistleblower doesn't get utilised often. We do   we have easy reads. We have a lot of work   we have done a lot of work around getting that information out there. What we do have   as we say, if in doubt, shout it out. And that can be about absolutely anything. So   

MS EASTMAN: I'm just asking you about that the Corporations   

MS DOYLE: No, no. 

MS EASTMAN:   requirements?

MS DOYLE: No. That one does not seem to get utilised much at all. 

MS EASTMAN: Okay. And Cara? 

MS FUREY: Sorry, what was the question again?

MS EASTMAN: So I'm just asking about the whistleblower requirements due to the Corporations Act. 

MS FUREY: Yes. So my experience with the organisation, of course, is limited. We have a stop   we are registered with Stopline to ensure anonymity. And my experience with that policy has been quite positive within the organisation. 

MS EASTMAN: All right. So the   all your organisations also have external reporting obligations as well as the internal complaint handling. Before I ask you about the processes with the NDIS Commission, can I ask you about engagement with local police, for example. Do each of your agencies have a particular arrangement with the local police in where you provide services as to the nature of reporting and any support required by police? 

MS FUREY: My understanding is that   and we certainly have a policy in relation to how our support workers and when and how to report matters to the police and express the nature of those matters that must be reported immediately before reporting internally. But we also, in practice, do make contact with our local service to identify is this one that we should be   you know, we need more details to clarify. Is this one that should be reported immediately or is it   

MS EASTMAN: So, if in doubt, contact the police first? 

MS FUREY: Correct.

MS EASTMAN: And is that because, if there is a risk that if there is an internal investigation commenced or action taken, that that might impair any steps taken by the police - 

MS FUREY: Correct. 

MS EASTMAN:   to investigate? 

MS FUREY: Yes. 

MS EASTMAN: Have you got any arrangement with the police such that   assuming that sometimes police may not be familiar or have experience in working with victim survivors with disability, what arrangements are in place so that when the police do need to investigate and engage with someone for whom you provide services? What arrangements have you addressed? 

MS FUREY: So in terms of general support, if   I guess you are contemplating an incident that warrants calling the police because it's so severe. So I   you know, in my review of the policies, I haven't identified something specific in relation to how to support that investigation. But general support of the   our customer. 

MS EASTMAN: Let me give you a hypothetical, and it reflects an issue I raised yesterday. If, for example, the nature of the service is a group home, a number of people living together, and if you assume that that is an environment that might be described as a family or domestic setting, and an incident occurs in the house that might be characterised as family or domestic violence, and the police are involved, that's obviously going to be the police coming into a situation where there may be questions of violence for people with disability as both perhaps the perpetrator and also the victim survivor. What arrangements do you have with police, that if police need to come and intervene in a situation such as that, that police will know and understand the particular nature of the environment that they are coming into? That's what I was getting at. 

MS FUREY: Yes. And I haven't identified   it doesn't mean that they don't exist. Just in my short time, I have not identified particular arrangements with our local police force. I would need to   I would like to take that on notice, in fact, and come back to you, because we may well. 

MS EASTMAN: For Northcott? 

MS FORSYTH: Yes. Look, I can provide some insight into our approach. We ensure that our Safeguarding Team is involved in any contact with the police first and foremost, because they have worked previously and continue to work closely with those police to they understand the nature of the support needs of the people involved and ensure that they understand how they need to communicate, given the various ways that people we support communicate. In addition to that, in local areas, certainly our supported independent living homes do have local relationships with local police whereby, in addition to our centralised Safeguarding Team to facilitate that to be appropriate and safe for the person with a disability, that they have an ongoing relationship to understand the needs of those people and kind of work collaboratively. 

MS EASTMAN: Ms Doyle, is there any arrangement in Civic? 

MS DOYLE: Yes. So we have close relationships with police force in our areas and, in particular, we have had police come and do work experience at Civic, and we have sat on discussion panels with the police force to enable them to understand some of the complexities that may arise in domestic situations. And it's been a really good relationship. 

MS EASTMAN: So the other   just stick with the scenario that I've used and think about the group home as the workplace for your support workers. And if, for example, there is an incident that occurs in their workplace, that might give rise to a risk of health and safety, and there may be a reporting obligation to the relevant WorkSafe or SafeWork authority in the local jurisdiction. Have you got any arrangements in place in terms of inspectors from such agencies coming into the home? Has that come up at all for Northcott? 

MS FORSYTH: I don't   I'm not aware of particular arrangements in relation to that. Again, we have a system whereby that's coordinated on our side to ensure it's as seamless and as easy as possible for everyone. But I'm not aware of a specific arrangement locally. 

MS EASTMAN: Anybody else? 

MS FUREY: Our procedure, I've just noted, requires in the event that there is a work health and safety matter that has arisen in one of our services, to contact SafeWork SA through our work health and safety manager. 

MS EASTMAN: Right. Now, some of the same incidents that I've just described, a domestic situation and a report to the police or a WorkSafe type arrangement, might also give rise to a reportable incident to the NDIS Commission. Is that right? 

MS FUREY: That's correct. 

MS EASTMAN: So have you found that there are circumstances where there might be a number of regulators or a number of particular entities that reports need to be made to? And how do you take   what do you do when you might have a number of different entities or agencies to whom you have to report? 

MS FORSYTH: Yes.

MS EASTMAN: At Northcott, what's your approach? 

MS FORSYTH: Yes, that does happen. And our approach   we certainly have an incident notification procedure to help provide some clarity of the expectations and requirements under the regulatory environments in each setting. And we use our central teams to coordinate and ensure that that happens. So an incident will occur and management will be notified. In addition to that, we have an online incident management system that sends automatic notifications of those nature of incidents to those internal teams. Now, that's not necessarily the only means by which they are notified, but it provides an additional layer of ensuring those central teams, be that safeguarding team for police, be that the work health safety team, are coordinated in engaging and making sure we fulfil our requirements. 

MS EASTMAN: Alright. So I want to come to the NDIS commission. And in Cara's response, you have said there is two internal teams responsible for investigations, and Cara does consider whether matters are more appropriate to have an external investigator engaged and, in the previous three years, has approached the NDIS Commission on two occasions to inquire about whether the Commission could conduct an external investigation. The Commission has declined, and that has led to Cara appointing an external investigator in the form of former detectives of the South Australian Police. I wanted just to ask you about what was your expectation with respect to the NDIS Commission coming in itself and conducting an investigation? Why did you take that step? 

MS FUREY: I'm unable to answer that question. This is before my time. I'm aware of the circumstances  

MS EASTMAN: Have you got the NTG there? 

MS FUREY: Yes. 

MS EASTMAN: So it's Bundle H, tab 1, page 4 to 5. 

MS FUREY: Yes. Sorry, what page?

MS EASTMAN: Page 4. And it's paragraph 9. So it starts at the bottom of page 4 over to page 5, paragraph 9.

MS FUREY: Bear with me. My copy does not have a paragraph 9 on page 4. Yes. Sorry. Are we back to the two internal teams responsible for investigation? 

MS EASTMAN: Yes, that's it. 

MS FUREY: Yes. Okay. Yes. Sorry, I've got it.

MS EASTMAN: Yes. So that's the bit that I've just read. I just asked about the circumstances of approaching the Commission. Why did you do that? 

MS FUREY: So I can only   I had asked internally that question, just to prepare myself, and I am unclear. I don't know what triggered that. I can only guess that it's required expert knowledge and   

MS EASTMAN: You're not sure.

MS FUREY:   the Commission might have been better prepared, but I can't answer that one. 

MS EASTMAN: Okay. So in terms of the NDIS Commission, have you all read, or had an opportunity to read, the inquiry   the report, Own Motion Inquiry Into Aspects of Supported Accommodation? 

MS FUREY: Yes. 

MS FORSYTH: Yes. 

MS EASTMAN: And you will see that the Commission in its report, page 66, makes a number of observations arising from its examination of the reportable incidents. And it records here that: 

The providers with higher rates of reporting told the inquiry that the NDIS Commission's policy of "when in doubt report", and sometimes inconsistent advice from NDIS Commission officers regarding whether an incident should be notified or not, is in part a reason for their rates of notification. 

So the numbers don't necessarily reflect a clear understanding of what should be reported. That's what I take from that. Have any of you through your organisations   have been in the situation of being unsure what needs to be reported and taking the "when in doubt, just report anyway"? 

MS DOYLE: When we are unclear about the guidelines, we go to the Commission's guidance materials. But when we are not sure, we pick up the phone and we ask the question, and they very quickly tell us if it's reportable or not. So it's actually quite easy. What we do find is that we possibly overreport, and that is because if there's any doubt, slight, you know   whether we are unsure and we then report anyway   and they do get closed out very quickly. So we do have higher numbers than we would normally. 

MS EASTMAN: Why would there be any uncertainty at Civic to know what was a matter that should be reported to the Commission? 

MS DOYLE: It's the nuances of the incident. So sometimes there is something that's a little bit grey, you are not sure, so you report it anyway. And then it comes back quickly as a closed, and that's   the matter has been dealt with. But it makes us feel more comfortable being transparent and saying that this has occurred, rather than not reporting it and then, yes, underreporting. 

MS EASTMAN: Coming back to your Unreasonable Complainants Policy. If, for example, Civic applied that approach   and I take it that you've said that there's only one, and the policy is not generally used. But if someone in Civic formed the view that the matter that might need to be reported to the NDIS was brought about by an unreasonable complainant, what would happen in those circumstances? 

MS DOYLE: If the   if the complaint   if the incident meets the reportable guidelines, it will be reported. 

MS EASTMAN: Regardless of whether the person might be, in somebody's view, an unreasonable complainant? 

MS DOYLE: It's reportable. If it's reportable, it's reportable. 

MS EASTMAN: Okay. In terms of Northcott, have you had any of the circumstances described by the NDIS Commission, having uncertainty about whether to report or not? 

MS FORSYTH: I think in the early days of the application of the scheme, the regulatory   the regulator essentially coming into operation, there was work that we had to do to understand the application in a practical sense, and we have a very close relationship operationally with our NDIS team and would seek guidance on those reportable incidents and then adapt our appropriate policy or practice in response to that. 

MS EASTMAN: And in Cara's response   so if you've still got that document, it's page 6, paragraph 14   you have suggested the NDIS Commission could strengthen its guidance to have a greater focus on best practice examples and innovative solutions that have produced quality outcomes for NDIS participants. And then you talk about best practice examples. Is the aim on having some better guidance on best practice examples to help Cara understand what it should or shouldn't report? 

MS FUREY: It is, I guess, the role of the NDIS Commission to enable providers to provide a high quality service. So from their   you know, the reports that they have reviewed, their experience, their knowledge and skill, what can we learn from their processes more generally? So not just if something should be reported, but to assist us to be a better provider. 

MS EASTMAN: Alright. So coming back, then, to any guidance on the types of matters that constitute reportable incidents or when to raise any complaints or issues with the NDIS Commission. Do you think at this stage the Commission needs to provide further or clearer advice to service providers? 

MS FUREY: I am not hearing from our Safeguarding team that that is the case. We have a fairly comprehensive matrix to evaluate all incidents. We rate them from level 2 to 5 and, from that, determine what is reportable. We also   because the criteria is a negative impact, and impact can be difficult to determine. So we have a daily triaging team of social workers, you know, people with experience in services and appropriate skills around the table to actually determine, you know, is this impact such a threshold that it should be reported. So I do believe that we have quite an informed process for determining whether something should be reported. 

MS EASTMAN: For Northcott? 

MS FORSYTH: Can you just repeat the question? 

MS EASTMAN: Just a question whether you think there needs to be any further guidance or assistance from the NDIS Commission to help service providers understand what they should or shouldn't notify. 

MS FORSYTH: Look, I think there should be constant reinforcement and support for all of us to make sure that we are understanding the interpretation. And I can only speak on behalf of my organisation, and we have spent a lot of time and effort to ensure we do, and a close relationship to ensure that we can talk to the Commission directly. But   not speaking on behalf of others, but considering the importance of reportable incidents, I think it's useful for the Commission to continue to support and educate the sector around the issue. 

MS EASTMAN: Is something like the Own Motion Report a helpful tool, that if the Commission is undertaking inquiries of this kind and publishing its results? Is that something that, as an organisation, you would look to for improving and having a better understanding of what should be reported and the approach to reportable incidents? 

MS FORSYTH: From my perspective, I think any additional understanding of the issues and the nature of reportable incidents is and can be useful. And we certainly make sure that we are across those inquiries and understand what they might mean for us and where the learnings are. 

MS EASTMAN: So coming back to Cara and that observation that you make about the Commission could strengthen its guidance to have a greater focus on best practice examples and innovative solutions. You will have seen in the Own Motion Report that the Commission has drawn on the literature review done by Professor Bigby and then Professor Bigby's account of what would constitute a good or best practice framework. Have you had an opportunity to review that? And does that provide you with some examples or focus on best practice that you had identified in your response? 

MS FUREY: Yes. No, it is   it is on my list to do that gap analysis, and we have not completed that gap analysis. 

MS EASTMAN: All right. Now, with respect to a matter that makes its way either through to the police, perhaps to a safe work agency or the NDIS Commission, obviously there will be a person with disability about whom those notifications are made. To what extent does the person with disability and/or their family and/or their advocate remain informed about the process of external reporting? What are your policies in that? Northcott? 

MS FORSYTH: Yes. So we make sure that we are very clear with the people   the person with a disability involved in that situation, that they understand our obligations to report, and we also explain to them that some of those reporting requirements from a regulatory perspective don't require their consent to do so. We are obliged to do so under the regulation and the Act in which we deliver services. However, we ensure that that person is kept up to date of that process and what it means and explain it to them in a way that they would understand. In terms of informing other people in their circle of support, if that person is their own decision maker, that would be completely up to them to determine as to whether or not that information was shared. However, if they have a legal decision maker, we would engage that person. 

MS EASTMAN: Okay. And what's the situation for Civic? 

MS DOYLE: It's exactly the same. 

MS EASTMAN: Alright. If, for example, the NDIS Commission works through its own investigation and finds that there has been   and I have just used some layperson's language here, but a failing on the part of the service provider with respect to the matters reported, the Commission has got a range of powers that it can take in terms of the service provider. I have asked the Commissioner at a previous hearing whether she considers those powers extend to her making a recommendation or requiring a service provider to make redress to the victim survivor of the conduct that gave rise to the report and the investigation. And I will ask her about that tomorrow to see if she's reflected more on that. Just noting that. But have there been any discussions with you as service providers about the outcome of any reportable incidents that may require some remedial action to support the victim survivor? Have you had those discussions with the NDIS Commission? Cara? 

MS FUREY: No, I'm not aware of any discussions with the NDIS Commission. 

MS EASTMAN: And that hasn't arisen as to an outcome from the Commission requiring action to be taken to provide some remedial   or some redress   remedial actions or redress for the victim? 

MS FUREY: No, I cannot point to an example. I'm not aware. There was a matter   a dealing with the Commission earlier on in relation to some recommendations that they had made. That's a completely separate matter. 

MS EASTMAN: Yes. And you have set that out   the steps out in your response. So nothing on that one. Northcott, has that come up for you? 

MS FORSYTH: We certainly receive direction from the Commission in relation to   or have received direction in the Commission in relation to specific requests for particular actions on our part. And an example might be undertaking of mediation with a person involved in order to seek a resolution to a situation, as an example. 

MS EASTMAN: Okay. So that's a   at the prompt of the Commissioner or at your suggestion to the Commissioner? 

MS FORSYTH: It could be either or both. It really does depend on the situation. But we certainly   the Commission on an individual complaints and incidents level can and has talked to us about what they would like to seek   to see from us in response to a particular experience for a person who we are providing supports to. 

MS EASTMAN: And for Civic? 

MS DOYLE: So we have only ever been asked for extra information to provide and not for anything to be addressed. 

MS EASTMAN: Alright. Now, I just want to ask you a series of questions to understand from the perspective of albeit three service providers whether any of the following would assist service providers in meeting their external reporting obligations. Do you think service providers would be assisted with training on best practice in complaint handling? 

MS FUREY: Yes. 

MS FORSYTH: Yes. 

MS DOYLE: Yes. 

MS EASTMAN: And who do you think should provide that? Would that be a function you would expect from the NDIS Commission or from other agencies? 

MS FORSYTH: Previously there's been similar types of support from the Ombudsman when they had functions similarly responsible. It may not have been called training; it may have been information sessions or education sessions. So I think that   given the Commission has taken over some of the functions of the Ombudsman in that space, that would be a welcome assistance. 

MS EASTMAN: I think we heard yesterday that NDS   and I don't know if your organisations are members of NDS   provide quite a lot of material for their members. Do any of you have access to that material or use that material? 

MS DOYLE: Yes. 

MS FORSYTH: Yes. 

MS FUREY: Yes. 

MS EASTMAN: But you still think there would be some benefit in the Commission doing some work on training on best practice in complaint handling? 

MS FORSYTH: One of the reasons why I think it would be useful for the Commission to have a role in that   and it may not be that they have to conduct that themselves, but that they have the opportunity to gain insights around broader issues and trends for all of us. And I think that that information could be valuably put back into an education or information approach for the industry. 

MS EASTMAN: And what about training on incident management and reporting?  Would that equally assist service providers? 

MS DOYLE: I think you can always use training on incident management, but I think it goes to the culture of the organisation and how well the calling out of the incidents is, you know, embraced in the organisation. 

MS EASTMAN: All right. We have asked you and many others over the course of the last few days about their policies on a whole range of different issues, but today we are focused on policies in relation to complaint handling. If we assume that support workers may have several jobs and work for different providers who may have different policies, particularly in relation to what constitutes a complaint, a feedback, a grievance, a serious complaint, whatever it might be, and that service providers have very different approaches to the way in which complaints will be addressed, both in terms of the involvement of participants' timeframes, outcomes and the like, do you think it would assist NDIS providers and support workers to have model policies and procedures set out in a template form on complaint handling and complaint processes? Or would your preference to be able to continue to do things your own way? 

MS FUREY: I can see a standard approach across the sector would be helpful. We have invested considerably in our policies, and they   I think they work well for our organisation. But I can see that level of consistency. I just add in our case, yes, of course, we have customer support workers that work for a variety of organisations, and that may well be the case, they have different views. We have full time permanent leaders in each service, so the first   when an incident arises, it's always to be communicated to the leader too, so at least we get that consistency and understanding of how our policies   

MS EASTMAN: At Northcott? 

MS FORSYTH: Look, all of us providers have clearly developed our policies and procedures in response to our particular regulatory obligations in relation to the Commission and the Practice Standards. So I think the ability to streamline or get a consistent nature of some of the structures we talk about, be that terminology, definitions, frameworks for assessing risk, would be useful, because I think that might provide frontline workers the ability to understand it across settings. One of the issues, though, to consider is that each organisation will have different systems in terms of online incident management systems, in our case. So we need to be able to still provide the opportunity for that to fit in with that framework. But certainly being part of the conversations in relation to the Commission's work in that space, it is really evident there is a lot of confusing ways that we all talk about what is essentially the same thing. 

MS EASTMAN: But I'm also sort of thinking it from the perspective of a worker. Say, for example, that she has casual shifts and in the course maybe of a month works at a few different locations, and each of her employers has very different complaint handling systems and also different definitions about what might be the subject of a complaint or a grievance. So in one organisation, if something happens and it's zero tolerance, she might be stood down immediately. But in another organisation, she might be required to provide a written reason or attend an interview before she's stood down. And in another organisation, she might not have to do anything and just mainly continue to work. From the worker's perspective, having to work providing the same type of service, albeit in different locations, subject to different disciplinary rules and procedures, there's an unfairness on support workers, would you agree, to navigate a range of different systems? 

MS FORSYTH: In terms of an organisation's response to a worker and applying their disciplinary policy, I think that is an organisational issue related to the industrial means by which they are employed, and I find   I think it would be difficult to try and separate that. I think there's benefit around the   as I said, the terminology, the definition, the frameworks. But I don't think that you can get a consistent response in those settings, because I think that points to the culture of an organisation. It points to the nature of their industrial agreements as well. 

MS EASTMAN: In terms of what may assist service providers, do you think guidance about conducting fair and thorough internal investigations and when and how to engage external investigators and what you require of external investigators would be of assistance? 

MS FORSYTH: I think, again, that that kind of resource would be of assistance. We have undertaken some work to determine a panel of external investigators that we deem suitably qualified and experienced and appropriate. But not all organisations would necessarily have the capacity to do that. 

MS EASTMAN: Well, we have had an opportunity in the Royal Commission to see quite a large number of different types of investigations that have been undertaken. Some have been very lengthy. Some have been conducted through legal advisors so that the investigation outcome reports will be privileged and confidential. Some have been done by people with no skills in investigation, and others have been done by retired detectives. So there's quite a broad range of people involved in investigations. What we haven't seen is investigators who have particular skills and expertise in understanding how to conduct an investigation from a rights based perspective with a deep understanding of a human rights approach, meets trauma informed, meets culturally responsive. Are you aware in the   your work in commissioning investigations as to whether or not there are investigators who are not just the lawyers, the police or people who might be experienced in doing investigations because that's what they have done a lot of in their workplaces? 

MS FORSYTH: We talked a little bit before about just the panel of investigation, I guess, agencies we use. We don't attempt to use lawyers and police. That's certainly not been our intention in my understanding at all of the organisation's approach. We have sought appropriately skilled people who understand the vulnerabilities of the people who they are undertaking investigations who do appreciate the impact of trauma. So I   I think assisting organisations to make appropriate decisions will be good. And I'm happy to take that on notice back to my team to provide further information if we have some useful recommendations about particular agents that may well reflect those requirements. 

MS EASTMAN: I have not seen this myself in the material, but I haven't seen any program to support people with disability, and particularly people with disability who use these services, to have the opportunity to develop the skills for themselves to be able to participate as investigators or conciliators, or to assist organisations in any type of dispute resolution. Most of the policies and the way in which the practices apply seem to be about people with disability, but very little involvement of people with disability, in the process. Do any of your organisations include people with disability in the process and, if not, would it assist to have some guidance about best practice in how that might be able to be achieved? 

MS FUREY: Can I just clarify. When you say "include people with disability in the process", is that the development of the process of conducting an investigation? 

MS EASTMAN: So you may have, for example, at the early stage, which we talked about, people with disability as part of co design in a policy. That's getting it   the rules on paper. Then there's co designing a process, and then there's the execution of the process. So, for example, how somebody might give their story and how they will tell you about the events that occurred to them. To what extent are people with disability involved either as a facilitator, as an intermediary or to be able to provide that advocacy support? So it's building into each stage of the process not just people with disability as the subject of it, but actually active participants in all stages, to build up that skill of investigation dispute resolution and also to have a voice in deciding the outcome. I haven't seen that in the material that's been produced on anything under the vast notices that we have. So I was keen to ask you whether or not that's something you have seen in practice at all, and it might just not have been recorded anywhere. 

MS FORSYTH: I have not seen it in practice, but I think it's a really good idea and a way that we could collectively as an industry think about, you know, I guess, a mechanism to undertake that. I would be really excited to be involved in that. 

MS EASTMAN: But something like that sits very well with models of supported decision making. So the same processes in the skill in supported decision making could equally apply to processes in terms of resolving disputes and being engaged not only in the outcome but obviously how that dispute is resolved. But you're not aware of anything   

MS FORSYTH: I'm not aware. Again, I'm happy to take that on notice and see if any of my team are. 

MS FUREY: I'm not aware of it either.

MS EASTMAN: At Civic? 

MS DOYLE: We use clinicians, not   but not external. 

MS EASTMAN: So when you use clinicians, are you not sort of framing things in a health model? 

MS DOYLE: No, because  

MS EASTMAN: And I'm trying to think about a model that brings you to a more social disability model  

MS DOYLE: I agree with you. Yes.

MS EASTMAN:   than just clinicians or a legal model or a police type model. 

MS DOYLE: So I think we do go quickly to clinicians, and we may need to think outside the square on that. I agree. 

MS EASTMAN: And Cara? 

MS FUREY: Yes, I think  

MS EASTMAN: I know it's early days for you.

MS FUREY: Yes. So all of our policies, referred to advocacy in the general context, don't encourage and promote the idea of people with disability being advocates for others. It's a very welcome concept. 

MS EASTMAN: So this is really thinking of different ways of dispute resolution rather than the traditional ways. I suppose that's what I'm asking you. Is there an openness, do you think, in the sector to think more broadly about different techniques of dispute resolution? 

MS FORSYTH: Yes.

MS FUREY: We would welcome that. 

MS DOYLE: Yes. 

MS EASTMAN: Commissioners, I have made it to one minute to 4. So those are my questions. Thank you. 

CHAIR: Thank you very much. Commissioner McEwin, do you have any questions? 

COMMISSIONER McEWIN: Thank you. I do. Thank you, again, all of you again for your contribution. My question relates to   and the question is for any or all of you. It relates to what both Cara and Northcott were talking about internally, your campaigns to   for example, Cara used "See something, Speak up". Can you point us to any specific examples or evidence that they actually work? Are these campaigns effective? Do staff feel really empowered to really speak up? Perhaps, Cara, from your point of view, you have only been with the organisation for a short time. But any observation? Have you seen - 

MS FUREY: I can, yes. So through our safeguarding team, we monitor services where reporting may be low or generally the number of reporting seems to have declined over a month. And that's when we do actively go back and promote our "See something, Say something" campaign or something similar. We use Workplace, social media, internally to actively promote. And whilst I haven't seen the numbers, that's in response to any decline, generally, of course, but in addition   in response to a decline in reporting numbers. 

COMMISSIONER McEWIN: But just quickly, before I hear from any   it sounds like you constantly then have to remind people to do that. So there's been no change, really, in behaviour. 

MS FUREY: Well, I think the change in behaviour is evident in an uptick of the number of reported incidents into our system. But I think it is a constant program of just encouraging, reminding   you know, it's a healthy thing to do. 

COMMISSIONER McEWIN: And   

MS FORSYTH: I would just add to that that the way that we survey our staff can also help provide information in relation to those campaigns. So when we are asking staff whether they feel equipped to do their job or whether they understand when they need to report, and those types of questions, can also be a good way to gauge the responsiveness of the campaigns. And the reason that we   and we do keep those campaigns going. They are not a one off; they are an ongoing piece of work, because we want to ensure that it's a consistent cultural change across the organisation and not just a one off education piece. 

MS DOYLE: Civic also has an ongoing campaign of "If in doubt, Shout it out". And that, we know, works because we receive several personal emails to myself, to members of the leadership team, apart from our inquiry lines or our feedback lines. So we know that people do actually follow the messaging. And we do reinforce it as well with safety weeks, safety months. We constantly ask staff to know   or we tell staff that they can, you know, use that slogan and   yes. 

COMMISSIONER McEWIN: So, again, it sounds like you need things like safety week and, again, something specific to really remind   

MS DOYLE: We remind them so that   yes. Because we have   obviously staff change, or things happen. We send it out often to ensure that everybody is across it. 

COMMISSIONER McEWIN: I have one more topic, and it relates to Ms Eastman's question at the end about supporting disabled people in the process. I might have misunderstood some of the questioning. But in my mind, I was thinking about what we have heard and what I've heard, for example, in private sessions of people who have really very significantly   you know, they have significant barriers. They are in group homes where they are just left isolated. They have no way of making a complaint. So that's the hypothetical I have in my mind. So I wasn't quite sure if you had answered Ms Eastman's question. So I put it to you: how do you support those people in particular? You said you were open to ideas, but do we know it's happening? Any response from any of you? 

MS FORSYTH: Yes, I had a different interpretation of Ms Eastman's question, being more about a way to involve people with disability, build the capability of people with disability to develop skills to undertake investigation processes, if you like. That's what I understood Ms Eastman's question   

COMMISSIONER McEWIN: Well, I may have misunderstood. Perhaps Counsel can help me   yes. 

MS EASTMAN: And I'm sorry if my questions were not clear. It was not so much supporting people with disability to participate in the process but, in effect, to empower people with disability to actually run the process, to be the investigators, to be the conciliators and to think of different forms of dispute resolution, ideally designed by and for people with disability rather than, in a sense, be just the subject matter. So active participants. 

COMMISSIONER McEWIN: Yes. Right. Thank you. And I heard your responses earlier, so thank you for that. Thank you. No more from me. 

CHAIR: Commissioner Bennett. 

COMMISSIONER BENNETT: Can I ask, has the NDIS Commission visited any of your sites? 

MS FORSYTH: Yes. 

MS DOYLE: No. 

MS FUREY: Yes. 

COMMISSIONER BENNETT: No. If a worker is dismissed for an action that they have   or something that they have done that you believe is serious enough to warrant dismissal, what do you do with that information? We have heard that workers can often work in multiple places, including in aged care facilities or something. Do you report that worker that could then trigger a broader investigation of their right to work with vulnerable people? Or if it's reported through the NDIS, do they take that action? What happens to try and stop those workers moving or never being caught out or whatever that might be? What is your involvement in that broader sector protection? 

MS FORSYTH: We are certainly obliged to report to the NDIS Commission, and they make   take that information and use it in their worker screening program. I don't know what else they do across sector as a result of that, but we would certainly   and we are obliged under the standards to report that to the Commission. 

COMMISSIONER BENNETT: Same for all of you? 

MS FUREY: Yes. And we have had this discussion internally as we look to recruit as well, how do we make sure that we are   you know, the screening is effective. 

COMMISSIONER BENNETT: You all seem to know each other in a state or in an area. Do you share that information, that   that someone   

MS DOYLE: If another provider asked me about a particular   

COMMISSIONER BENNETT: A reference or   yes. 

MS DOYLE:   person, I would say that I   

COMMISSIONER BENNETT: You are explicit that - 

MS DOYLE: Yes. I would say we   

COMMISSIONER BENNETT: That they were dismissed for that reason. 

MS DOYLE: Correct. Yes. 

MS FORSYTH: Yes, if there is information sought from us in relation to verifying employment details, but we have to be mindful that we are not able to breach privacy around just talking to colleagues about situations. 

MS FUREY: Well, I'm a bit too short in my term to be able to contribute well to that one. We certainly have had discussions around the appropriateness of doing that internally that I'm aware of, but I cannot point to examples where we have had that discussion with another provider. 

COMMISSIONER BENNETT: And when you recruit someone, do you look carefully to get references and see what their past experience has been? 

MS FORSYTH: Yes, our recruitment policy requires at least two positive referees, one of which must have been the previous supervisor, and we ensure that we undertake sufficient research in relation to that. So if someone puts a mobile number, for example, we make sure that we have gone through and we have contacted that business entity through its official number and sought the name of that person to try and make sure that we address those concerns. 

COMMISSIONER BENNETT: And you think these arrangements between the NDIS and the way you do it are strong enough to prevent these people who could do harm to continue working? 

MS FORSYTH: I don't   probably don't know enough about what the Commission does in response to the information to answer whether it's adequate. What I would say is that anything that enables across the care industry the ability to understand where there are people who should not be employed to support vulnerable people, we would support such an arrangement. 

COMMISSIONER BENNETT: Thank you. 

CHAIR: Ms Furey, Ms Forsyth and Ms Doyle, thank you very much for your repeated contributions to the Royal Commission. We appreciate your assistance. Thank you so much. 

MS FORSYTH: Thank you. 

MS DOYLE: Thank you. 

<THE WITNESSES WITHDREW

MS EASTMAN: Thank you, Chair. 

CHAIR: Ms Eastman.

MS EASTMAN: That concludes for today, and we resume at 10 tomorrow. 

CHAIR: Can we reserve the actual starting time so we can perhaps have a talk about that tomorrow   later on and let people know?

MS EASTMAN: Sorry, what   the time to start tomorrow? 

CHAIR: Yes. We can let people know. We will have a discussion about it. 

MS EASTMAN: At 10 am? Sorry, I'm not understanding what you're saying. 

CHAIR: Perhaps we could start at 9.30, is what I'm going to suggest. 

MS EASTMAN: Well, if the Commissioners wish to start at 9.30, I'm sure we can start at 9.30. But probably those following the proceedings and in the room would need to know that now. 

CHAIR: Yes. Well, is that an inconvenience to anyone? I think that would be a sensible thing to do. So let's start at 9.30. 

MS EASTMAN: We were scheduled tomorrow, on our best endeavours, to be finished by 3 tomorrow afternoon. So we will finish by 2.30. 

CHAIR: I understand. But anyway, let's start at 9.30. Thank you. 

<ADJOURNED 4:11 PM TO FRIDAY, 16 FEBRUARY 2023 AT 9:30 AM