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Public hearing 23 - Preventing and responding to violence, abuse, neglect and exploitation in disability services (a case study), Sydney - Day 2

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CHAIR:  Good morning everybody. We commence with the acknowledgement of Country. We wish to acknowledge the Gadigal People of the Eora Nation, the traditional custodians of the land upon which my colleagues and I are participating in this hearing today.  We wish to pay our respects to their elders, past present and emerging, and we also pay our respects to all First Nations people who may be in the hearing room or who may be following these proceedings on the live screen. Yes. 

MS GLEESON:  Commissioners, the first witness today is Dianne.

CHAIR:  Thank you very much for coming to the Royal Commission to give evidence. We appreciate your attendance. If you would be good enough to follow the instructions of my Associate, he will administer the affirmation to you. 



MS GLEESON:  Your name is known to the Commission but today we're going to refer to you as Dianne; that's right? 

DIANNE:  Yes. 

MS GLEESON:  And your address is also known to the Royal Commission. You prepared a statement. 


MS GLEESON:  For the Commissioners' benefit that is in hearing bundle A, tab 59. Do you have a copy of that statement with you? 

DIANNE:  Yes, I do. 

MS GLEESON:  Have you read that statement recently? 

DIANNE:  Yes, I have. 

MS GLEESON:  And are you content that everything in that statement is true? 

DIANNE:  Yes. 

MS GLEESON:  Now, you were employed at Afford from 2010 to 2019; is that correct? 

DIANNE:  That's correct. 

MS GLEESON:  Can you give a brief overview to the Commission about your qualifications and experience prior to commencing with Afford? 

DIANNE:  So prior to commencing with Afford? So I was in school when I started   before I started with Afford, and as I left school I began employment with Afford as a casual. And then through my employment with Afford, I gained my Certificate IV, and then later on completed a Diploma in Disability and a Diploma in Case Management. 

MS GLEESON:  And so Afford was your first job in disability support; is that right? 

DIANNE:  Correct. 

MS GLEESON:  What was your position description when you first started your employment? 

DIANNE:  I was a Disability Support Worker as it was known back then, or is now known as a Lifestyle Assistant.

MS GLEESON:  In that job as Lifestyle Assistant, did you commence your employment at the Mount Druitt day centre. 

DIANNE:  I commenced my employment at Windsor. 

MS GLEESON:  What year did you move to Mount Druitt? 

DIANNE:  It was 2018. 

MS GLEESON:  2018. 

DIANNE:  Beginning of 2018. 

MS GLEESON:  And the Windsor centre, was that also a day centre? 

DIANNE:  Yes, it was.

MS GLEESON:  And all of your experience during your time at Afford has always been in day programs. 

DIANNE:  Yes. 

MS GLEESON:  Could you tell us a little bit about day programs, what's involved in that service provision, and where they take place? 

DIANNE:  Yes, so they   are you willing   do you want me to be more specific about Mount Druitt or Windsor or just overall what a day centre is?

MS GLEESON:  Generally what it does.

DIANNE:  Day program, day centre is where participants living with disabilities will come and gather throughout the day. What was typically   prior to the NDIS, we would generally operate from nine till three, where we had a selection of different programs for participants to choose from. Some of them were in the community. Some of them were in centre based such as   centre based programs might be cooking or sensory or art or music or some different kinds like that. 

And then some in the community would be bowling, parks, barbecues, different community based activities. As time's gone on, with the introduction of the NDIS, we've then been able to sort of extend our range of options for participants and time   times that we operate to be able to go through week and evenings and such. 

MS GLEESON:  Afford offers a service called Club Afford; can you tell us a little bit how that operates. 

DIANNE:  Yes, that ran on a Saturday from eight till four typically, depending on the events, we would find different markets or just general events happening throughout different areas of Sydney where we would take participants. They would book in as sort of needed. There would be a calendar sent out, they would select what days they wanted to attend and we would arrange from there. 

MS GLEESON:  Did that fall within clients' NDIS coverage? 

DIANNE:   Where they had the option, it was available to those who had the funding, yes. 

MS GLEESON:  Was it possible to engage with Club Afford if you didn't have the funding on a user pays basis? 

DIANNE:  If   there could be arrangements made where you fee for service, although it was very uncommon. 

MS GLEESON:  I'm going to ask you about the staffing arrangements at each of the centres. I'll ask you to speak generally, but if there any differences between your time at Windsor and your time at Mount Druitt, please let me know.


MS GLEESON:  I want to ask you first about Lifestyle Assistants. What were their duties? 

DIANNE:  So day to day duties? 


DIANNE:  Again, the role sort of changed as time went on. The Lifestyle Assistants were generally allocated clients where we had different   they would perform under different ratios depending on the client needs. So sometimes they would be one on one, one to two, one to three, and back in the formation of the NDIS, prior to the NDIS and we were under ADHC funding, the ratios were a lot greater. So where we might have heard yesterday about the high, very high moderate funding, the ratios attached to those, it wasn't really a thing and if clients   if staff called in sick, we were stretched much thinner under the ADHC system, whereas now we do need to make sure we fall within a ratio as much as   like, fall within the ratio service.

MS GLEESON:  Just a couple of things arising out of that, you just said, "Heard yesterday". Is it right that you were watching the live broadcast. 

DIANNE:  Yes. 

MS GLEESON:  The second thing is could you give a rundown of Lifestyle Assistants work and what their duties are throughout the course of the day? 

DIANNE:  Yes, so typically speaking now, where lifestyle centres are operating now, they would generally start   if they were to start at eight, there would generally be a transport run they had to go on first where they would go and pick up participants from their house, then bring them to the centre. Clients would rearrange into programs, ratios, the correct buses and vehicles for the day or stay on centre, and then we would sort of disperse again and commence the day. They would then come back to the centre some time in the afternoon to be rearranged back into transport runs or to be picked up. You know, there were things like personal care medications things like that being done during the day in the early afternoons as well before they were then handed over to go home for the afternoon. 

MS GLEESON:  At some point there was introduced a position of Senior Lifestyle Assistants, is that right? 

DIANNE:  Yes, 2016, I believe that was, I held that position out at Windsor. 

MS GLEESON:  Can you give an overview of what the daily duties are for a Senior Lifestyle Assistant? 

DIANNE:  In 2016, that was sort of around the time when the Team Leader's role was changing and adapting. That was again around the introduction of the NDIS.  So the idea behind it was that, given the Team Leaders had a higher administrative workload, there was someone   there was another sort of tier between the floor staff and the office staff, and that was to be the Senior Lifestyle Assistant. 

MS GLEESON:  So the idea was there would be a more senior person who could concentrate more on general supervision   

DIANNE:  Floor.  Yeah, that's right.

MS GLEESON:    of the Lifestyle Assistants and clients. And that let the Team Leader at a higher level than that.

DIANNE:  They could feed back to and from us as needed. Correct. 

MS GLEESON:  That takes us to the Team Leader. Could you give us a brief description of what the Team Leader's duties were? 

DIANNE:  Day to day? 


DIANNE:  And we're talking post 2016?


DIANNE:  Yeah.  So our jobs   we had a very heavy financial load to carry, in that we would do service agreements, service bookings and we would have to complete daily audits of progress notes, ensure correct services were provided to aligned with the   like the progress notes, aligned with what the services were provided, and then we had to do a daily invoice and then upload that through to PRODA and report on that daily. 

We had other   that was to be done every day. Every week we had to complete a sales analysis of how   of what was projected to have been claimed per client, what was actually claimed, and an explanation for variations. That was done client by client. We also had Clear Management invoices, we had things such as wage analysis, things as completing pays, doing purchase orders, teleconferences, meetings, things like that. 

MS GLEESON:  And I'll flesh some of these matters out in more detail  

DIANNE:  Absolutely.

MS GLEESON:    in the course of my questioning. I just want to turn to the more supervisory roles, so the Board.  Next above the Team Leader was the District Manager;  that's correct.

DIANNE:  Correct. 

MS GLEESON:  How many individual sites did the district manager have management of? 

DIANNE:  That varied time to time. So when it was just filed west, the District Manager had five, I believe it was, but as time went on I believe that was dissolved into eight   about eight sites. 

MS GLEESON:  And in your experience, how often did a District Manager visit or otherwise interact with the sites that you were working at in Windsor and Mount Druitt? 

DIANNE:  That was dependent   that was dependent on who my District Manager was. 

MS GLEESON:  If I can say, optimally, for the best District Managers you worked with, how many times would they visit the site? 

DIANNE:  Weekly. And as needed too, given when I was in Mount Druitt I might have had a heavier load, therefore if I was falling behind, it took a phone call. 

MS GLEESON:  Then above a District Manager is a State Manager. Do you remember having a lot of interaction with State Managers in the course of your time at Windsor or Mount Druitt? 

DIANNE:  Not a whole lot. Here and there we had   prior to    when it was the Operations Manager, this is prior to when it was separated out into accommodation and day program State Manager, it used to be one, there would be times where we would see her around critical incidents and site inspections, things like that, and then that was   once that person left, it was dissolved to day programs and accommodation. I think I may have seen her about three or four times.

MS GLEESON:  And can I just ask you about other people who worked in different positions at Afford, probably in the head office. Were there any occasions to your memory in which people from the head office visited the sites that you were working at at Windsor and Mount Druitt. 

DIANNE:  Not unless there was a reason for it, really. So I thought   so my site was overflow   we called it overflow to initially start   into part of the Cherrywood site. The Cherrywood site had a lot of grants and things like that, so we would occasionally see the CEO and occasionally a Board member here and there where grants were being given, but generally speaking, unless there was a reason for it, not very often, no. 

MS GLEESON:  Did you understand why it would be relevant for either the CEO or Board members to visit if there were grants involved in the provision of services. 

DIANNE:  I think it depended on who was giving the grants as to whether it was warranted. 

MS GLEESON:  Just at paragraph 4 and 5 of your statement you give a description of the way that your job operated during the period that you were a lifestyle assistants at Windsor. 

DIANNE:  Yeah. 

MS GLEESON:  Can you tell us just briefly about the way in which the service operated at that time? 

DIANNE:  This is about the time   we're talking about ADHC funding here. We would have provisions in the funding, I guess, where we were able to   we were able to work from eight   from 8 am to 9 am and 3 pm to 4 pm without being responsible for another participant. That allowed us time to make sure our paperwork was up to date, to make sure that our   our plans were up to date, and we were actually having a bit of a general understanding, what was sort of what's known as a key worker role, sort of got a bit lost as time's gone on.

We were able to be   have a real in depth understanding about participants back then. Nowadays   once the NDIS came in, it became evident to us that we weren't allowed to pay for staff where money wasn't coming in, so that was the sort of difference where things changed under   when the funding structure changed where if we're not billing clients, we can't be paying staff. 

MS GLEESON:  So the provision for paid time to complete administrative tasks went away after the NDIS? 

DIANNE:  That's correct. That went the same that, you know    client free weeks went for a little while after the introduction of the NDIS but that was more for formal training where   where instead of actually being able to have staff on site and learning client paperwork and key worker responsibility, it's having an actual genuine knowledge of their participants rather than a tick boxing sort of system. 

MS GLEESON:  And the benefit of a client free week is you'd have a paid week where you can get on top of all the information that pertained to the clients at the centre. 


MS GLEESON:  And get a real familiarity with their care needs. 

DIANNE:  And that was on a ground level too, not just as a Team   and that was for me on a ground level finding that beneficial. 

MS GLEESON:  When you say on a ground level, as a Lifestyle Assistant? 

DIANNE:  Yes, that's right. As a Lifestyle Assistant, we actually had a pretty genuine understanding of our participants back then. We were able to make sure that the paperwork was up to date, and even every few months we may even switch key workers around so that we were able to have an understanding   an in depth understanding of a greater number of participants as the year went on. 

MS GLEESON:  Now, at paragraph 6 of your statement you talk about your relationships with the clients when you were at Windsor. 

DIANNE:  Yeah. 

MS GLEESON:  Could you just let us know how and when you communicated with the clients and their support persons while you were at Windsor?  What were some of the mechanisms you used to give them information and receive information about the clients and their needs? 

DIANNE:  Yeah, so to   we're talking about things like the communications diary? 


DIANNE:  Handing over. At the start transport was another thing, it wasn't offered for a really long time, so we were able to have face to face in   face to face meetings at handover and things like that. Yep, communication diaries were there as well. 

MS GLEESON:  Would you tell the Commission a little bit about communication diaries? 

DIANNE:  Yes. 

MS GLEESON:  Were they also called communication books? 

DIANNE:  Yes, so each participant had a diary that was to be filled out each day. They   we just gave a recap of their day, basically.  It wasn't anything serious that generally got put into it. I remember once an Executive   an Executive Manager was referring it to as the fluffy stuff that went in there. Because things that were serious or   things that were serious that could have occurred in that person's day was to be done through another channel of communication. 

MS GLEESON:  Yes. And to the extent that there was something serious, how would that be communicated with the support people of clients? 

DIANNE: That was to be done by email or phone call. Ideally, phone call before the participant got home. If it was a less serious. If it was very serious it was to be done as soon as the client was safe. 

MS GLEESON:  And how were staff at the centre able to make themselves available to support people so that they could communicate issues with the clients that you needed to know in order to give them appropriate care? 

DIANNE:  Sorry, can you repeat that? 

MS GLEESON:  How   in what ways are you available to support people so that they could tell you things about the clients that you needed to know? 

DIANNE:  Well, we were to work on site generally as much as we could, and as much as we could by phone.  That was another channel in which the Seniors could also get to   they were also available to get to us as well. But yeah, as often as we could we'd be there. But sometimes I had two different premises that I had to operate out of, so I would bounce from one to the other. 

MS GLEESON:  Now, in your statement I think you've already told us that you were promoted to Senior Lifestyle Assistant in about 2016? 

DIANNE:  Yeah, it was around the formation of that position. 

MS GLEESON:  That position was created around the time? 

DIANNE:  Around that time, yes.

MS GLEESON:  In 2017 you were promoted to Team Leader. 

DIANNE:  Correct. 

MS GLEESON:  At the end of 2017 is when you moved to the Mount Druitt centre. 

DIANNE:  I was told at the end of 2017 I would be moving and I started in January 2018?

MS GLEESON:  And that was a bigger centre than the centre in Windsor; is that correct?

DIANNE:  Yeah.

MS GLEESON:  How many Team Leaders were supposed to be assigned to that centre? 

DIANNE:  So when I went there, there was two when I was transferred. The second Team Leader was only there for a matter of couple of days before she was moved to another site and I was on my own. 

MS GLEESON:  Alright. And was another Team Leader appointed in his or her place at any time? 

DIANNE:  Several months later. 

MS GLEESON:  Alright. Did that person remain in the position of Team Leader? 

DIANNE: No, she didn't. 

MS GLEESON:  Okay. In the two years that you were at the Mount Druitt centre, can you estimate how many months there was a second Team Leader assigned to that centre? 

DIANNE:  It would be sitting around the four to five month mark, to the best of my recollection.

MS GLEESON:  Then you had how many Senior Lifestyle Assistants under you. 

DIANNE:  I had two. Yeah, two the whole time. 


DIANNE:  They were to work solely on the floor, though, at that time.

MS GLEESON:  Right. 

DIANNE:  It was only after I left that they were allowed administration time throughout the day. 

MS GLEESON:  At that time they were providing on the floor support so you could complete administrative tasks, you weren't receiving any administrative support. 

DIANNE:  Yeah, they were to work on the floor, five days. 

MS GLEESON:  And just moving to the position above Team Leader, what was the staff turnover like for the District Manager position while you were at the Mount Druitt centre? 

DIANNE:  So how many District Managers did I have? 


DIANNE:  I had three. 

MS GLEESON:  We heard yesterday from some of the parents of the clients at Mount Druitt that the high turnover of staff made communication in relation to their sons very difficult. 

DIANNE:  Absolutely. 

MS GLEESON:  You think that's a fair criticism? 

DIANNE:  That's a very fair criticism. 

MS GLEESON:  And at paragraph 10 of your statement, you describe some of the challenges that you faced in the course of your role as Team Leader at Mount Druitt? 

DIANNE:  Yeah. 

MS GLEESON:  Now, you say there were between 60 to 90 clients at the centre at Mount Druitt? 

DIANNE:  Yeah, it varied from time to time. It was the same   it was a fluctuating number. 

MS GLEESON:  And at one time there was up to 100 clients? 

DIANNE:  Yeah, I do recall in my weekly sales analysis typing a name into the hundredth tab. 

MS GLEESON:  That's in   you were filling out a spreadsheet of clients, and it went over 100? 

DIANNE:  It was an Excel spreadsheet. I do remember sitting there going, "I can't believe I'm typing a triple digit   name next to a triple digit." 

MS GLEESON:  Of the clients that were in the centre, on average how many would you say would be at the centre on a particular day of the week? 

DIANNE:  That could vary greatly. We had a large operation of people that ran from a community base. We had home care that we were offering, and then we had the two centres as well. So if we're going to say   are you asking specifically about Paull Street? 

MS GLEESON:  Yes, and Paull Street is the site that the Mount Druitt centre was at when you first commenced as Team Leader? 

DIANNE:  Yeah, that's correct. Paull Street could have up to 50 on the busiest day, I'd say, 40 to 50 at a busy day, yeah. 

MS GLEESON:  Alright. And assuming 40 to 50, not all of those clients would be in the centre for the whole of the day. 

DIANNE:  Yeah, that's correct. Because we had all these buses that would leave from head office, so they'd sprout out to the community, come back, we would all re congregate and then split back off again. 

MS GLEESON:  But there would be periods of the day where the whole of the 40 to 50 clients would be in the centre? 

DIANNE:  For small periods, that's correct, yes. 

MS GLEESON:  And what number of staff would be required to cover client numbers of 40 to 50? 

DIANNE:  40 to 50, 25 to 30   25   25ish, I'd say. It very much depended on the kinds of participants we had coming in that day. Some days you could have 10 participants that were one on one, and then other days you'd have a lot of group based clients where it's separated out a lot more. 

MS GLEESON:  Yes. Did you have any concerns about the safety of the clients and staff in the centre due to the volume of people that were in the house at various points in time? 

DIANNE:  Yeah. We had identified that that site needed to be upgraded for quite some time even before   while I was at Windsor, that was discussed for quite sometime. 

MS GLEESON:  What were some of the safety concerns that you had? 

DIANNE:  Well, that it was quite a small   it was quite a small house. There was a lot of participants that used wheelchairs. There was vision impairment. There was such a wide range of disabilities there that if there were something to occur   also there was a really steep incline going in through the driveway and we had a lot of complaints from neighbours as well, in relation to the noise and stuff like that, so   

MS GLEESON:  Did you have any concerns about the quality of services that could be provided to clients when the centres were particularly overcrowded? 

DIANNE:  Yeah, it was definitely a tricky task to manage, to try and keep your   to keep your quality as high as you possibly could while managing as many people as we did, yeah. You know, there was also an ever growing number of participants walking in that door. 

MS GLEESON:  And were you happy that there was always sufficient staff to maintain the staff to client ratio provided in the clients' NDIS plans? 

DIANNE: That became difficult on days. The way we would generally work it   so we would have a handful of participants that would, for example, have one on one booked for an outing to do something that was important to them, where at times we had to   in order to fulfil it correctly and make sure their plan was fulfilled correctly, we would have to ask the participants and the families to delay the service so that we weren't fraudulently claiming. 

MS GLEESON:  But that service would then be provided to them on a different day? 

DIANNE:  A different day, correct. 

MS GLEESON:  When the correct ratio could be maintained. 

DIANNE:  Correct. 

MS GLEESON:  And before that decision was made, was there any discussion with the clients about the fact that that was what was going to occur? 

DIANNE:  Yes, we would let them know because they would know they're obviously not getting their staff members for that day. 

MS GLEESON:  Do you remember there being any difficulties with maintaining ratios during transport? 

DIANNE:  So that was an area that was highlighted to us later on in the piece, really, where we realised we were claiming a group base   we had times where we had to readjust things where we had participants with Epilepsy to adjust to make sure there were safe ratios provided while they're on transport. So there were some staff had to be charged a one on one ratio whilst in that bus   purely just for the time they were in the bus, just to make sure   the instruction given to us was to charge the person with Epilepsy one on one so that they had their support staff in the event that they were to have a seizure while transporting. 

MS GLEESON:  And we heard evidence yesterday from some of the parents of Afford's clients that there were issues with the ratios provided in their services agreement being adhered to during transport. Do you remember hearing that evidence? 

DIANNE:  Yes, I do. 

MS GLEESON:  Do you also remember that the time of arrival of the transport buses could be variable and that caused both inconvenience and distress to the clients and to their families? 

DIANNE:  Yeah, absolutely that could, yeah. 

MS GLEESON:  You accept that that would be a fair criticism? 

DIANNE:  That would be a fair criticism.

MS GLEESON:  Now, shortly before you left the Mount Druitt centre   

DIANNE:  Year. 

MS GLEESON:  There was a proposed move to a new location; is that right? 

DIANNE:  Yeah, in Mount Street, yeah. 

MS GLEESON:  About when did that occur. 

DIANNE:  A matter of weeks. At a guess, I would say at the end of April, slash, early May of 2019. 

MS GLEESON:  And how did the change of location come about? Was it due to any agitation station on your part, for example? 

DIANNE:  It had always been   it had always been an issue that we need   it was always identified we needed a new premises. I think the catalyst driving behind   like, the motivation from people above us may have been the fact that our vans were taking up a significant amount of parking space, and that they were eager to have their parking spaces back as well. As well as   as well as us also needing a bigger site. 

MS GLEESON:  And that   the move occurred in May of 2020; is that right? 

DIANNE:  I couldn't tell you exactly. 

MS GLEESON:  But you believe it was at that stage? 

DIANNE:  I was no longer there. 

MS GLEESON:  Yes. And there had been discussions about the location of the new centre before you'd left? 

DIANNE:  Yes. 

MS GLEESON:  Did you have any issues   

DIANNE:  Yes. 

MS GLEESON:    whether it was going to be a suitable location? 

DIANNE:  So I had gone and done one of the first inspections of it, and in terms of space, the open space of the room was great. However, I think it was a builder, an engineer   I can't exactly recall who it was   that was the   the main concern I had about it was the accessibility of the new place. They had mentioned that only one   there was two doors out the front and only one of them was able to be made wheelchair accessible and that was via a kitchen which   

MS GLEESON:  And did that cause you any concerns about, for example, fire risks and evacuation. 

DIANNE:  That's exactly what I'd said, yeah, there was a risk if there was a fire. 

MS GLEESON:  Did you tell anyone about these concerns. 

DIANNE:  Yeah, I told them on the spot then. 

MS GLEESON:  When you say, "Them", who did you tell. 

DIANNE:  The builder, and from memory I believe it was my District Manager who was there at the time. 

MS GLEESON:  Do you remember what the response of that District Manager was? 

DIANNE:  I think it was   because it was in the initial stages, I think it was all sort of handed to them at that stage, but I don't recall. From that stage on, it was only a matter of weeks and I was gone. There was not much discussions from that point on about it.

MS GLEESON:  You're not aware whether or not the concerns you raised were addressed. 

DIANNE:  I've got no idea. 

MS GLEESON:  But you know they moved into that centre. 

DIANNE:  Yeah, and the general area   the geographics of that area were dangerous.

MS GLEESON:  Could you explain the way in which they were dangerous. 

DIANNE:  So the buildings were hidden from a lot of the general public area. I remember having   I recall having a brief conversation with the CEO at the time about how eager they were to have the buses offsite and I recall saying that some of my staff finished shift at 11 pm at night and might be five foot tall women.  I'm not letting them walk around that particular area at 11 o'clock at night, because it's dangerous there. Where it was, there was a park there, there was a methadone clinic nearby and there was a Centrelink nearby. It was not   there was a lot of loitering in that area. 

MS GLEESON:  Right. I just want to come back to in a little bit more detail now about your daily responsibilities as Team Leader. 

DIANNE:  Yep, okay. 

MS GLEESON:  In paragraph 11 of your statement, and you've given evidence about this before, as more clients started coming to the centre, your job got bigger and the tasks you had kept piling on. 

DIANNE:  Yeah. 

MS GLEESON:  And then was the increase in the task that you had solely attributable to there being new clients, or were there new   were there additional duties that were imposed on you during your time as Team Leader? 

DIANNE:  With every new client there was less vehicle space, less seats on vans, more staff that was required, more claims to be made, more resources that were required. So it didn't just stop at the fact that we had additional paperwork to do with each person. It was the fact that everything got stretched that little bit thinner. We had more resources that were required for every participant.

MS GLEESON:  And I take it that staffing increased as client numbers increased. 

DIANNE:  Yes, correct.

MS GLEESON:  But those increases in staff numbers were generally Lifestyle Assistants;  is that right.

DIANNE:  Yes. 

MS GLEESON:  In paragraph 13 of your statement you say:

"There was a person who was employed by Afford to seek out new clients, and they got a commission for doing that work."

DIANNE:  Yeah, that was a Customer Care Manager, I believe was the name of the job at the time. 

MS GLEESON:  Do you know what their commission was calculated on? 

DIANNE:  I   I can't perfectly say. From memory it was a percentage of service bookings claimed. So the service booking that was made was for $48,000, and we claimed $1,000 a week. I think it was like a percentage of what was claimed, but I can't perfectly testify to that. I'm not exactly sure. 

MS GLEESON:  And did you have a lot of interaction with the Customer Care Managers, for example, in dealing with service agreements for new clients or   

DIANNE:  So they were   so the Customer Care Manager met with the   they found the new participant, they went and met with them. Sometimes we would come if we felt   if they'd asked us. They would do   they would complete the service agreements themselves   the initial ones. Sometimes   sometimes they would just do six week or eight week ones and then hand them   hand the participants over to us with their onboarding paperwork. 

MS GLEESON:  Alright. And did you have any interactions with the clients prior to them entering into a service agreement about the contents of the service agreement or what their provisions were, what the client needs were,  and whether they were in the service agreements? 

DIANNE:  At times, yeah, often   at times we would. Often we would be asked to attend some of the initial intake meetings. Sometimes if they were, so just smaller   smaller services, let's just   as an example, a work experience participant who is quite high functioning, lives quite independently, might just want a bit of a Saturday interaction. They were pretty straightforward sort of things, I might not always be involved with that, but I would go through and read the paperwork and the service agreements prior to commencement. 

MS GLEESON:  You may have seen some evidence yesterday of some of the parents of the clients having issues with the way in which the service agreements were presented to them. 

DIANNE:  Yep. 

MS GLEESON:  And being pressured to sign those service agreements. 

DIANNE:  Yeah. 

MS GLEESON:  Do you remember having any interaction with clients about problems they were having with the service agreements? 

DIANNE:  So the service agreements could be quite complex to some of the   some participants and families that don't see them everyday like we do. I think sometimes that got lost because we were looking at them so often, we were looking at those codes and those line items and those things so often that they were like second nature to us. I can still   I can still rattle off the line item for a one on one ratio off the top of my head now. But they all   they   the time that it   sorry, let me re   let me start that sentence again. We weren't able to   I don't think that the families had a clear understanding of how they broke down   breakdowns perfectly worked and yeah, they were   trying to think, sorry. I've lost my train of thought, sorry, guys. 

MS GLEESON:  Alright. Is it a fair conclusion between what you're saying about having a fairly mechanical knowledge  

DIANNE:  Yeah.

MS GLEESON:    of what needs to be in a service agreement and how it relates to various items of NDIS funding   

DIANNE:  Yeah. 
MS GLEESON:    is there might have been a disconnect between Afford, who wanted to set up the agreements in that way, and the clients who were looking for that agreement to represent what their family member needed  

DIANNE:  Exactly what they were getting.  Yeah.

MS GLEESON:    and what that family member was going to do. 

DIANNE:  Yeah, that's a fair statement. 

MS GLEESON:  Now, I want to turn to some of the administrative tasks. 

DIANNE:  Yep. 

MS GLEESON:  That you needed to deal with while you were Team Leader. The first thing I want to ask about was the invoicing work that you were to undertake. 

DIANNE:  So we're talking referencing NDIS specific invoicing. 

MS GLEESON:  I was going to break it down  

DIANNE:  Okay. 

MS GLEESON:    into different kinds of invoicing. Can you tell the Commission first about how it is that invoicing worked with NDIS managed clients? 

DIANNE:  Yep, so with NDIS managed clients, at the beginning of the NDIS, a lot of the participants were NDIS managed. So through the   once the service agreement was signed, we would go on and make a booking for X amount of money. They were often broken down into 48 weeks because we allowed for closures under my   under   while I was a Team Leader. I think those closures may not have been always happening after I left. 

So let's just say a participant has a $48,000 service agreement that they've signed off for us to fulfil over 48   over the next 48 weeks. I would then go on to their   the PRODA, search that participant by their NDIS number, we would lock $48,000 out, and at the end of it   at the beginning of every day, we would invoice via a bulk invoice for the day prior. A bulk invoice was done where staff were   would do their progress notes at the end of each day and they would attach a line item to the progress notes. 

I would then go back in the next morning. I would complete an audit of all of those progress notes, make sure the quantities and the line items were correct according to the roster from the previous day. We would then export out of CIMS and into our invoicing system which was NAV, generate an Excel invoice, upload it to the PRODA and then we would check the rejections at the end of that. 

MS GLEESON:  Can I ask you about a few of the acronyms you've used there. 

DIANNE:  Okay. Yep. 

MS GLEESON:  Starting with PRODA, can you explain what that is? 

DIANNE:  PRODA is the government portal that's used for participants' funding. 

MS GLEESON:  It's the NDIS funding portal, essentially. 

DIANNE:  Correct, yes. 

MS GLEESON:  Then you talked about Lifestyle Assistants filling in progress notes in CIMS. 

DIANNE:  CIMS is the CRM that we used. 

MS GLEESON:  I'm terrible with acronyms, customer relations database?  Anyway, it's a client database. 

DIANNE:  Yeah. 

MS GLEESON:  It was the responsibility of Lifestyle Assistant to fill in these progress notes. 

DIANNE:  Yeah. 

MS GLEESON:  What was contained in each individual progress note for a client. 

DIANNE:  It was supposed to attribute to the client   to the participant's NDIS goals. So a lot of the participants have got pretty standard goals such as access to social and recreational activities, so simply by being in attendance they were fulfilling those goals. So they would have   so that's generally how it was supposed to tie in, then we would write that they attended, you know, "Bob attended this program today", like, just wrote a bit of a story about their day and what they had done. If any issues had arisen you would generally make a comment to say, "Refer to incident report for today". Personal care and medication was attended to. 

MS GLEESON:  Yes, and that would be matched up with an NDIS line item? 

DIANNE:  Yep. 

MS GLEESON:  Am I right that that would involve there being a line item that had a particular activity and a particular quantity that would be the time spent? 

DIANNE:  There would be a time   so generally speaking, it would be typically six hours for a standard day and yep, unless told otherwise   unless it was done out of hours or something like that, yep, it was six, the generally billed amount. 

MS GLEESON:  And I think at the end you said that there was then an export into another system. 

DIANNE:  Yep. 

MS GLEESON:  What was that. 

DIANNE:  So NAV was the invoicing or financial system that they had. 

MS GLEESON:  And that was maintained by Afford. 

DIANNE:  Yep. 

MS GLEESON:  Can I ask you about what happened with plan managed clients? 

DIANNE:  Okay. At the start of the NDIS, we didn't   we used to use a Word document initially and then as time went on, that became integrated in with our NAV financial system as well when we raise   raise an invoice similar to raising a PO through our finance system purchase order where we would again go through a participant, have their NDIS number, and then go through a code, like, fill out the code quantities, and then export it out into an invoice, email the plan manager. 

MS GLEESON:  Alright. So that didn't go to the client; it went to the client's plan manager. 

DIANNE:  Plan manager, yep. 

MS GLEESON:  And then were there any self managed clients at Afford? 

DIANNE:  Not that I can recall. 

MS GLEESON:  Right. Then can I also ask about invoices for programming and what that involved? 

DIANNE:  So client activity fees. 


DIANNE:  So this was a bit of an ever changing thing as time   like, with us, so the way some participants work such as   Lilly was a centre pay participant where they had an automatic deduction, that was automatically transferred to Afford. That was to cover for things that weren't covered by the NDIS such as the facilitators for music programs or if we had massage therapists or things like that coming. We would try and break that down into a fee that would   where the   where the participant had chosen that program, there would be a fee allocated to that. 


DIANNE:   Where possible, we had grants applied for and obtained to lower the cost of facilitator programs.  As an example Nordoff Robbins would attend every Monday and we had a grant that would cover their bill for about   as long as I was there, their bill was covered. It was just coming up to its expiry date as I was leaving, and then that was being reapplied for. 

MS GLEESON:  And to the extent that plans were either prepaid or postpaid, how was that accounted for by Afford? 

DIANNE:  So for the centre pay participants, that was an automatic   they were automatically deduct that out of their plans, and out of their DSPs and that would come into our account. Some participants would choose to BPAY. Some participants would choose to pay cash on the day. 

MS GLEESON:  If that happened, did they get any form of receipt to account for what they pay? 

DIANNE:  There was a receipt book on the day, but not many participants chose to pay by cash. And then there were some participants   we had a letterbox   because I wasn't always there because I had the multiple sites, we had a letterbox on the wall, a locked letterbox, where participants could drop money into as well. 

MS GLEESON:  And otherwise invoices could be given if there hadn't been   

DIANNE:  They were just handwritten receipt books.

MS GLEESON:  Right. 

DIANNE:  It wasn't, like, from our finance department as an acknowledgement of   of it being received, and so for an example of   if a   if a participant were to BPAY I don't know how they would receive a receipt because I can't   

MS GLEESON:  Do you know how that was ultimately accounted for in Afford's system? 

DIANNE:  You could see it coming off their bills, but there was never a receipt sort of given when it went from participants direct to the finance department.  There was never any acknowledgement of it being received. 

MS GLEESON:  Alright. Just turning back to NDIS plan clients, how were they able to access the amounts that were charged to the NDIS for their services? 

DIANNE:  Yep, so that   that could have been done through their own myGov portals where they're able to go in. It looked something like a pie chart type of thing where you can see all of their NDIS funding and then you can see Afford has blocked, this much, LWB has blocked this much, and so on and so forth. And you can see what's been blocked and what's available, and as it's claimed you can see it changing colour as it goes.

MS GLEESON:  And plan managed clients could get that information from their plan manager? 

DIANNE:  From their plan manager. 

MS GLEESON:  And once progress note entries have been completed by the Lifestyle Assistants  


MS GLEESON:  Was it possible to amend those entries once they had been posted? 

DIANNE:  Yes, it was. 

MS GLEESON:  And was there ever any occasions where you would do that? 

DIANNE:  There would be times where I'd have to make sure the correct line item, correct hours of service, things like that, were amended, yes. 

MS GLEESON:  That was a part of your job was to run through, check all of the entries that had been made. 

DIANNE:  Yeah, otherwise they could and very well would have been charged incorrectly, yes. 

MS GLEESON:  And just on the amount of time it took to run through those entries, roughly how many entries would there be for a day if there was a client allocation of   

DIANNE:  Because I was working in both centres at one time, it could be 50, 60 of them. And then the other thing was   sorry, I'm sort of skipping   something's just come to my brain here that if they were charged transport through their NDIS packages as well through a line item code, we would have a progress note just for transport, then we'd have a progress note for their day program.  As an example it should say they got home and we performed personal care to get them ready for the evening, there would be another progress note for that. Sometimes participants could have four progress notes just for one person each day. So there were times when we were importing, say, 100 lines from CIMS into NAV. 

MS GLEESON:  Did you ever receive any complaints from support people for clients that the entries you needed, the invoices or their NDIS plan charges, were inconsistent or confusing, or were different to the services that they were expecting   they were expecting   

DIANNE:  It was definitely confusing; that's a very warranted   it took me many, many months to get my own head around it. That was my job, I remember complaints about that. 

MS GLEESON:  Do you remember hearing complaints about it from any of the support people of any of the clients at the centre? 

DIANNE:  Yeah, you're talking in codes, literally. To try and determine, to try and explain these things you're literally talking in codes and trying to break down to them exactly what cost is attached to which service, it   

MS GLEESON:  Did you ever receive any complaints from support persons that they were being charged for services that exceeded their plan allocation? 

DIANNE:  Yeah, that could happen at times whilst we were trying to apply for applications for reviews and things like that, that was the case, yes. 

MS GLEESON:  Just so I'm clear on that, an application would be made to the NDIS for a review of the plan, but the services would be provided in accordance with whatever the application was so that they were receiving the current plan; is that right? 

DIANNE:  Sometimes we were advised that was to happen.  As a result of an incident that would occur, we would sometimes be told that that person would be one on one if they wanted to continue support, yeah. 

MS GLEESON:  So there would be a lag time between when the NDIS would sign off on their being one on one support   

DIANNE:  Yeah it was a   

MS GLEESON:    and the need to actually provide that service. 

DIANNE:  Yeah. 

MS GLEESON:  To your knowledge, when that occurred, do you remember whether or not the NDIS would meet that shortfall, or would it end up being funded by the individual client and their support people? 

DIANNE:  No, we would try as best as we could to try and beat that lag, you know, and apply for the additional funding. Sometimes we were advised by our Executive Manager of, like, the NDIS department that sometimes that was used as   as proof or evidence of what was required for the rest of their plan. So it was not encouraged, but it was told that this is what's required, so this is what you should do. We would at times have to get our own if we were starting to sort of shortfall and get panicked from it, we would try and get our own Allied Health teams involved as much as possible, but yes, that's   

MS GLEESON:  Can I turn now to some of the other finance related tasks that you were required to undertake. 

DIANNE:  Yes. 

MS GLEESON:  That you were required to undertake. 

DIANNE:  Yes. 

MS GLEESON:  Can you describe what other accounting type tasks that you were expected to undertake while you were Team Leader at Mount Druitt? 

DIANNE:  Yep. 

MS GLEESON:  At paragraph 21 you give a rundown of them. The first one is   sorry, at paragraph 24.  The first one is wage analysis. 

DIANNE:  Yeah. 

MS GLEESON:  You would describe what that involves. 

DIANNE:  Yeah, that took most of the day. That was a spreadsheet where we had to go through each participant that had attended the previous week before. We would complete the claims for the week, for the Friday, Saturday, Sunday.  On the Monday morning, we would submit those figures to Finance. They would come back at us with a sheet of what had been   what had been raised through our finance system on NAV and then we had to record that in a spreadsheet. That spreadsheet had a projected amount of what was expected to have been claimed for the previous week and then what was actually claimed was emailed to us by our finance department.

So we would input those numbers, and then we had to explain if or why there was a variance, what it was, and why it might have occurred. Then   and let's just say as an example, we worked on an accrual basis of finance as well.  So if there was a participant who had a lapsed NDIS plan that was currently in review, the payments would no longer go through. So we had to keep tally of how much that participant owed us. Or if we were waiting for a signed service agreement would be another one, we had to say how much that participant owed us and what we were doing about that to try and actively seek out getting that signature on the paper or what we were doing about trying to get the review, about where we're up to with the review. 

MS GLEESON:  And how often did you have to prepare the wage analysis documents? 

DIANNE:  Sorry, wage analysis, sorry, I'm saying weekly sales here.

MS GLEESON:  No, that's fine.  The sales analysis, how often did you have to produce that document? 

DIANNE:  Weekly.

MS GLEESON:  Weekly. And was that presented at a meeting? 

DIANNE:  Yes, every Tuesday, 12 pm, there was a weekly sales conference call. 

MS GLEESON:  And the wage analysis being a different document, what was involved in that? 

DIANNE:  That was just a   our staff, the wage analysis was based on our budget, we were   had a projected amount of where they were expecting us to sort of grow over the next 12 months based on our previous 12 months.  So there was always a projected amount that they were expecting us to spend on staff each fortnight. At   once the pays had been   once we processed our staff timesheets, we would get sent a spreadsheet. We would be told how much we had spent on staff for the previous fortnight and what we were projected to have spent, and if there was a variance, why that variance was there. 

MS GLEESON:  And how frequently did you have to prepare the wage analysis? 

DIANNE:  Fortnightly. 

MS GLEESON:  And with whom did you meet about the   

DIANNE:  That was the same; our district had a fortnightly telecon. 

MS GLEESON:  Fortnightly.  And then did you have to prepare profit and loss statements? 

DIANNE:  Yes, we did. 

MS GLEESON:  And with what frequency did you have to prepare those? 

DIANNE:  They were sent to us every month and we had to report on any variance that had occurred. So we would have a   P&L would be sent monthly, and then we had to report on each variant in our monthly report which would then go through   which would sometimes take us to breaking down and going through and investigating our general ledgers.

MS GLEESON:  When you commenced as Team Leader, did you feel like you had sufficient training or qualifications to complete financial documents of the nature that you've described? 

DIANNE:  Not of this calibre, no. Not of this calibre. 

MS GLEESON:  What assistance did you get from Afford in being able to complete those documents correctly? 

DIANNE:  Initially we had the assistance of what was known as an opt accountant, was one of the positions that we had who could help us break down these sorts of things and help us dig through our ledgers and things like that, but that   that position was made redundant. But generally speaking, we had our District Managers teaching us   teaching us the ins and outs of this at the start, yes. 

MS GLEESON:  Taking together the financial documents that you've just told us about  

DIANNE:  Yes. 

MS GLEESON:    as well as the invoicing, can you give us a rough estimate of how much of the standard day was taken up with financing and administrative tasks when you were Team Leader at Mount Druitt? 

DIANNE:  Finance and administrative tasks? 


DIANNE:  100% of it, pretty much.  There was very little time to walk away from the computer, very little.  And that's not including the time that was volunteered at home. 

MS GLEESON:  When you say, "Volunteered at home", why would you need to volunteer any of that work at home? 

DIANNE:  Because we were able to get it done eight till 4 Monday to Friday. 

MS GLEESON:  Do you feel that the finance and administrative aspects of your job affected your oversight of the clients and the staff and the work that they were doing. 

DIANNE:  Absolutely. 

MS GLEESON:  Do you feel like that then created any risks to the clients?

DIANNE:  Yes. 

MS GLEESON:  Can you elaborate on  

DIANNE:  For starters   

MS GLEESON:    the issues that that created? 

DIANNE:  For starters, there was a rapid increase in this particular program. We were growing constantly. We were asking   there were times were I asked for intake to be capped or, restricted that I canned, or a monetary   or a number value each month. There was   I remember a time when I believe it was a Northcott in the area had closed down and there was just client after client after client who was just trying to   trying to get through the doors. It was a risk. 

MS GLEESON:  In a perfect world  

DIANNE:  We weren't able to catch it. 

MS GLEESON:  Sorry. 

DIANNE:  We weren't able to catch every issue coming through that door because it was just growing too quick. It was dangerous.

MS GLEESON:  In a perfect world, how much time would a Team Leader have available to them to make sure that what was happening on the floor of Afford and out that the activities that Afford clients were undertaking was properly supervised and   

DIANNE:  By myself? 


DIANNE:  There wouldn't have been a whole heap of time where I was able to do it. I was there, so I could hear things happening if I needed to go out if something had happened. While I was at one site, there was another site completely unwatched. So you could automatically say that 50% of the time I wasn't watching one of my sites.  And then while I was there, there was such that   like our claims were due by 12 pm every day so we had to go through and do that kind of task before 12 pm every day, so you basically walk in the door and you'd beelined it straight into that office to start auditing your progress notes. There was a whole heap of other administrative tasks. We needed   we weren't able to catch those to be able to see those floors as often as what we needed to. 

MS GLEESON:  Just turning back to the work that you were undertaking outside of hours at home, were you paid overtime for those hours? 


MS GLEESON:  Just turning briefly to the Senior Lifestyle Assistants and the Lifestyle Assistants, you've told us that the Lifestyle Assistants completed at least the first part of the progress notes. And did they have time allocated to them in their day to complete that work? 

DIANNE:  There was always about trying to improve   there was   we were always trying to improve the, you know, the system that would allow us to have CIMS running on phones, on site phones and things like that where they were able to do it. We had staff where   transport runs, there might be a lapse of time between where we were able to temporarily hand clients over for periods of time but there wasn't a complete, like, slot to say   there wasn't a slot of time where we say here's half an hour every day where you have no participants and no   and your only responsibility is to do progress notes. That wasn't something that was given to everyone. 

MS GLEESON:  So what would the Lifestyle Assistant do in that circumstance? 

DIANNE:  As an example, sometimes transport runs might get back to the site at quarter to 4. They would use that 15 minutes to try and do it, or if there was a participant that was picked up at 2 o'clock, as an example, where you had an hour to   where we could try and rotate staff around to try and get into the offices. 

MS GLEESON:  Is what you're saying that what ended up happening was that there was a juggling of staff to try and continue to maintain  


MS GLEESON:    staff to client ratios whilst giving the staff an opportunity to complete those administrative tasks? 

DIANNE:  Yeah, that's right.

MS GLEESON:  You've already spoken about the impact of your administrative burden on oversight of what was happening at the centres. 

DIANNE:  Yep. 

MS GLEESON:  What about communication support persons during the time that you were Team Leader?  Do you feel like that impacted on our ability to communicate with them about what was happening  

DIANNE:  Yeah, hugely. 

MS GLEESON:    with the clients? 

DIANNE:  I would have loved to do more of that. 

MS GLEESON:  What did you do to try and maintain communications with clients over that period? 

DIANNE:  We would try as much as possible to do group texts   not group but text message chains or things like that, or emails as much as possible, but it was quite difficult to try and upkeep with that many   that many participants. 

If I had allotted every family an hour of my month, it would have been more than 50 per cent of my working, you know   my working hours would have been just   and that's just given if they were able to walk in one after the other and no lapse in between. 

MS GLEESON:  The Learning Assistants had   sorry, the Lifestyle Assistants had other responsibilities from a paperwork perspective as well, didn't they?

DIANNE:  Correct. They would help us with clients, they were   client files, sort of stuff. They would help trying   we would try to keep up with the Epilepsy plans and things like that, they would help us try and keep up with those yearly documents as well as making   helping   they would help us get ahead on rosters. 

MS GLEESON:  Just taking a step back. When you said there were documents such as Epilepsy plans. 

DIANNE:  Yes. 

MS GLEESON:  Were they part of a client plan that was maintained somewhere in Afford's files? 

DIANNE:  There was a folder. Each participant had a folder.

MS GLEESON:  A physical folder? 

DIANNE:  Yeah,  it was electronic and physical.

MS GLEESON:  And the electronic file was stored where? 

DIANNE:  On the computer, on the database. 

MS GLEESON:  Was the database CIMS? 

DIANNE:  Yeah.

MS GLEESON:  Were there ever any issues for accessing CIMS for yourself or for Lifestyle Assistants? 

DIANNE:  If it ever went down? 


DIANNE:  Yes, it did. I remember it would fluctuate for   sometimes it went down for days at a time. 

MS GLEESON:  And what would happen when it went down for days at a time?  How would the work that needed to be done be completed? 

DIANNE:  For me in terms of a bulk processing process, we would do a bulk manual process which is where we filled out Excel spreadsheets and manually filled out what was done. 

MS GLEESON:  Did that take longer than having it completed in CIMS? 

DIANNE:  It could have done if you didn't have the templates there. 

MS GLEESON:  Just back on the Lifestyle Assistants, were you aware of whether the Lifestyle Assistants ever had to take work home with them? 

CHAIR:  The actual Lifestyle Assistants, they   some of them   well, they did have access to it on their phones. The CIMS   that was a   

MS GLEESON:  Did any of them let you know that they were having to complete that work out of hours? 

DIANNE:  Sometimes they did, yes, because sometimes they would do things such as   they would finish from a participant's house and they would do the progress notes when they got home. 

MS GLEESON:  Were you aware whether they were paid for that work? 

DIANNE:  I can't recall. 

MS GLEESON:  And at paragraph 18 of your statement, you describe raising concerns with Human Resources about the number of clients at the Mount Druitt site? 

DIANNE:  Yep. 

MS GLEESON:  You say that you proposed a cap on the number of clients. 

DIANNE:  Yeah. 

MS GLEESON:  Every month. 

DIANNE:  Yeah. 

MS GLEESON:  Who did you speak to at Human Resources about this issue. 

DIANNE:  There was a meeting with   can I say their name? 


DIANNE:  The Executive Manager was [Redacted]. 

MS GLEESON:  And what was the response that you received from your proposal? 

DIANNE:  It was that it was not really in line with their vision. 

MS GLEESON:  Did they explain what they meant by their "vision"? 

DIANNE:  There was always this need to be the biggest and the best in the service, in the sector. 

MS GLEESON:  Can I move now on to training, and in particular training in relation to   to Health and Safety compliance and incidents. 

DIANNE:  Yep. 

MS GLEESON:  When a Lifestyle Assistant commenced employment at Afford during your time there, what was the induction that they received? 

DIANNE:  We had a buddy shift check list that was completed. 

MS GLEESON:  And what was involved in that? 

DIANNE:  Where we would have   generally with the Seniors would be working with them, while still allocated to clients though, where they would do a shift   they'd do a shift together on the floor, type of thing where they were known, you know, bits and pieces of where things were and how to find things. We had a folder of policies and procedures, things like that, where we'd show them around the sites, where medication was stored, stuff like that and how to work with the participants. 

MS GLEESON:  And there was a check list and the experienced team member would check off that they'd been shown   

DIANNE:  That's right, yeah. 

MS GLEESON:    everything they needed to do. And was a new Lifestyle Assistant given any introduction to the client plans for the particular clients they would be cared for and any general discussion about clients' needs? 

DIANNE:  We had the clients' plans kept in a folder also where we had meal time, Epilepsy,  behaviour support plans.  But let's be realistic, some of these plans were 20 or 30 pages long.  How much of this were you going to take in?  If we took   if I handed you a folder with 26 Epilepsy plans and said, "Read these", how long do you think it would take before you actually understood that? That's about 100 plus, 200 pages of documents. 

MS GLEESON:  And were there policies and procedures in place to deal with identifying abuse and neglect, and behavioural incidents, medical   medical incidents that affected clients? 

DIANNE:  Yep, there were many policies and procedures in place. The knowledge around them, and again, how much of this can we actually absorb? 

MS GLEESON:  Were they given to clients at any point, those policies? 

DIANNE:  Abuse and neglect ones? 

MS GLEESON:  Yes, and incident reporting? 

DIANNE:  The policy and procedure, I can't recall a time where we would have given the   handed policy and procedure over to families. 

MS GLEESON:  I'm talking about Lifestyle Assistants.

DIANNE:  The Lifestyle Assistants, yeah, they would have been   they were available in the general area. There was a folder that we had sitting that had policies and procedures with acknowledgements attached to them.

MS GLEESON:  When you say, "acknowledgements", does that mean the Lifestyle Assistant would read the policy and then sign to say that they had read it? 

DIANNE:  Correct.

MS GLEESON:  Would that happen when they commenced with Afford? 

DIANNE:  It wouldn't always immediately happen, but it would happen of a due time, yes. 

MS GLEESON:  Does that mean it didn't happen on their first day, but you ensured it happened at some point at the beginning of their employment? 

DIANNE:  There was a lot to take in on their first day, yep. 

MS GLEESON:  Were they given any updates or refreshers on those policies over the course of their employment? 

DIANNE:  I can't recall really, to tell you the truth. I mean, there would have been times   so we had team meetings where we brought them up, so we had   in a team meeting, we would bring up a standard and we would bring up a policy sort of that would work   that would correlate to that standard that we were discussing. That was part of our Paces   part of our bonus structure that we had to mention those things in team meetings. 

MS GLEESON:  Team meetings occurred how frequently? 

DIANNE:  Monthly. 

MS GLEESON:  When they were presented with a policy at a team meeting, would you or someone else take the Lifestyle Assistants through any changes? 

DIANNE:  Normally I found it best practice that one person read it out then everybody else would   then it would be passed round and acknowledged. 

MS GLEESON:  Then each of them would sign a form that they had read the policy? 

DIANNE:  Yep. 

MS GLEESON:  And you said that that was something that was then taken into account in something which I'll come to, which is the Paces scheme. 

DIANNE:  Yep, but in saying that, we would be sent emails daily of updated policies and procedures.  They would change so often that, yeah, we would be   they might have been   they might have signed to acknowledge something that might have changed the very next day. 

MS GLEESON:  And were the policies and procedures about identifying abuse and neglect or other issues affecting the safety of clients and how to respond to and report those incidents, were they displayed anywhere where they were readily accessible to Lifestyle Assistants? 

DIANNE:  They wouldn't have been displayed on a wall, if that's what the sort of discussion is   if that's the question. There was   there was a folder, and I can't even   we   we would go through   sorry. The folder that had the acknowledged policies and procedures would change and adapt here but I can't even recall exactly, it's been so   it's been too long; I can't even recall exactly which policies I had in that folder. 

MS GLEESON:  And what would happen if an incident arose outside of the day centre at Mount Druitt?so, for example, when clients were out on an activity. What access did they have to what it was that they were meant to do in relation to particular clients when they were out? 

DIANNE:  In terms of incident reporting,, there was generally speaking   depending on what category the incident was classed as, but most often would be a red alert procedure was generally a safe bet, when they would call   again, that changed as time went on. So it would be the Operations Manager, and then I think as time went on there was a number that they could call that would pass through a chain of different people's numbers. 

MS GLEESON:  And it was your responsibility as Team Leader to manage red alerts and incident reports? 

DIANNE:  No, not red alerts. It was the Operations or the State Manager, where they had to call them, so it came   it was supposed to be a united front type of thing in terms of response to incidents which was above my head. 

MS GLEESON:  And just to break down on what was to occur on a red alert, was that effectively some emergency that was immediately affecting a client? 

DIANNE:  Yes. So from memory, it was any client on client assault, staff on client, client on staff, medication, absconding, missing clients. I can't think of any others but off the top of my head they're the main reasons why you would call a red alert   injury. 

MS GLEESON:  Who was   was there then a set number that Lifestyle Assistants were to call? 

DIANNE:  Yeah, so, in the   in its   in the introduction of the red alert, it was originally to go to the Operations Manager at that time. It was just her mobile number that we called. And then as time went on, it became a central number that was tasked. I think the calls would transfer between a select few different people's numbers until someone answered. 

MS GLEESON:  And what would then happen after the red alert was raised by the Lifestyle Assistant?immediately, what would happen? 

DIANNE:  Can you give me an example of what, an incident that you would like me to   

MS GLEESON:  Let's assume for the purpose of this example that a client absconded   

DIANNE:  Yep. 

MS GLEESON:    whilst out on an activity, what would be done by the person who raised? 

DIANNE:  The first thing would be   the first and foremost thing is just make sure the participant was safe, so we are going to   I'm going to try and support. So the staff would call the number and generally speaking from there, they   we would follow the directive of whoever had answered that call. They would give us a list of instructions to do. And it would generally be   and then from then on, it would be my job to support the staff member as best as possible. If I were nearby I would get in my car and drive up there and help, but   

MS GLEESON:  But the evidence you gave was that you weren't the person who was contacted in the first instance where the red alert was raised. 


MS GLEESON:  How would you find out about it?  Would the Operations Manager then contact you so that you   

DIANNE:  They should do. That's right, that's right.

MS GLEESON:  And How about in the longer term   

DIANNE:  Or they would tell the staff to call me as well. 

MS GLEESON:  How about the longer term? Assume that the incident had been resolved and the client has been located.  What was done to investigate the incident and what caused the incident and to communicate with the families about what had occurred? 

DIANNE:  Yeah, so I think it depends on exactly where it was, they had   and exactly what point of time this had have occurred at and who the upper   who the management team in place was. There have been times where   I can recall a time where a client has absconded and the Executive Manager at the time went to the shops and retrieved the CCTV footage of that as part of the investigation against   to the staff. 

MS GLEESON:  When you say the investigation to the staff, what does that mean? 

DIANNE:  Well, we were trying to investigate   like to try and investigate   yeah, well, the staff would go under investigation where that sort of things would occur, and sometimes so would I.

MS GLEESON:  And just turning to the first thing you said, which was the staff were investigating the incident. 

DIANNE:  Yes. 

MS GLEESON:  Who had management of that investigation? 


MS GLEESON:  And do you know whether there was any separate investigation or was HR responsible for an investigation that was not into the staff member, but into what happened with the client and what the outcomes for the client were? 

DIANNE:  Yeah, so they would generally send you a list of   on this date you were allocated to this client, can you comment. And then, on this date, this client absconded from you, can you comment. And then they would ask, sort of, list of different questions that would go through   that would go through and give the staff member a chance to explain, and then as a result HR would give the staff   the staff member would respond. And then they would come back with a conclusion at the end of that. 

MS GLEESON:  And the conclusion, what were the outcomes of the conclusion? Were they outcomes for the employment of the staff member? 

DIANNE:  They could be   

MS GLEESON:  Or were they outcomes for the client and how the client should be managed in the   

DIANNE:  They were outcomes for the staff member, and I would often   and I had a list of things that I had to perform, and if I had a performance plan to implement with that   with that particular staff member.

MS GLEESON:  And it's the case, isn't it, that some incidents also needed to be reported to the NDIS? 

DIANNE:  Yeah, that's right. 

MS GLEESON:  Whose responsibility was it to determine whether or not a red alert that was raised was a reportable incident? 

DIANNE:  That was District Manager. 


DIANNE:  So we could identify if they were reportable, but we didn't go through and complete reportables.

MS GLEESON:  Once a red alert had been raised, what records were created of that red alert? 

DIANNE:  So we had the incident report. 


DIANNE:  That was done through CIMS. 

MS GLEESON:  Was that governed by a policy governing the incident reports. 

DIANNE:  There is an incident report policy, yes. 

MS GLEESON:  Can the witness be shown a document at hearing bundle E, tab 10. It will just go up on the screen next to you. 

DIANNE:  Yeah. 

MS GLEESON:  And this is the incident report procedure that you were referring to? 

DIANNE:  Yes. 

MS GLEESON:  And at 3.1, it's got responsibilities on staff members to witness a report or who are involved in an incident to submit an incident before the end of their shift? 


MS GLEESON:  And then Team Leaders, and that would include you, are responsible for reviewing those incidents and recommending strategies to address the incident and prevent reoccurrence. 

DIANNE:  Correct.

MS GLEESON:  And then going down to 3.4:

"District Managers are responsible for reviewing and submitting serious incidents for completing and submitting immediate and five day reportable incidents to the NDIS."

DIANNE:  Yes. 

MS GLEESON:  And in your experience were each of those steps adhered to with every incident that occurred at Afford? 

DIANNE:  So even down to the fact of trying to get   the policy is not exactly a realistic approach.  Like, to say to a staff member that you must complete an incident report before the end of your shift is not really a realistic approach. Sometimes the incidents were that there was a significant injury that had occurred to them.

MS GLEESON:  Or it may have occurred in the transport on the way to the centre. 

DIANNE:  Yeah, that's right. 

MS GLEESON:  Just before the end of the day. 

DIANNE:  That's not a realistic approach   not a practical approach to how things actually played out.

MS GLEESON:  And in paragraph 4.5 which is   commences at the bottom of page 1 but then   

DIANNE:  Yep. 

MS GLEESON:    goes over on to page 2. 

DIANNE:  Yep. 

MS GLEESON:  There's a list of duties and in particular, about the fourth point down on page 2, there's responsibilities of Team Leaders in completing a review of the incident report. 

DIANNE:  Yep. 

MS GLEESON:  And you can see there that it's got reviewing the completed of the incident report, conducting investigation,  debriefing staff, identifying corrective strategies and developing a performance management plan. 

DIANNE:  Yeah. 

MS GLEESON:  How did you undertake each of the responsibilities in this part of the report in practice when an incident occurred? 

DIANNE:  Again in practice   in theory it's great. We can have a look, we can do all these things, where there's actually   sometimes there was simply a record keeping   incidents done for basic record keeping just to make sure that, you know, when it comes time for, you know, review of funding or things like that that we've got a record of incidents that are occurring. But then for much more serious incidents, we would do them as much as possible. We would do all this, but again it was often for   when we're talking about reportable, serious and critical incidents, often the actual investigation was done by Human Resources. We would do   we would do our own investigations as much as possible and we would liaise in and out with Human Resources, but   

MS GLEESON:  Did an investigation that was undertaken by Human Resources achieve the outcomes that are identified in the paragraph I've just taken you to such as, did it involve providing feedback to staff, identifying corrective strategies and preventative actions for the client and developing a performance management plan?do you remember HR achieving those outcomes in their investigations? 

DIANNE:  Yeah, in particular with like performance management plans and things like that that would get put in place by   they would often be put in place as a result of an investigation outcome from Human Resources to me, but conducting an investigation as required comes down to how   like, transparency of what's actually occurred on the day or the time. How we ever conduct an investigation, I'm not an investigator. 

MS GLEESON:  You've given   you've told the Commission about the administrative tasks that you had to undertake  


MS GLEESON:    on a daily basis. How much of your time were you able to devote to undertaking investigations and then engaging with staff and support people about what occurred in relation to incidents? 

DIANNE:  Yep. When it came to incident response we   especially if we're talking in response to a critical incident, we didn't have any option. We had to make sure that   we had to make sure that we were responding to these sorts of things as much as possible. It just meant that we had less time at home that night, you know, or we were catching up more at home that night. 

MS GLEESON:  So again it was work that bled into your private time and you weren't receiving any pay for that? 

DIANNE:  Correct. 

MS GLEESON:  Can we now look at a different document. It's hearing bundle E, tab 14.

CHAIR:  Ms Gleeson, I note the time. How much longer are you likely to be with Dianne? 

MS GLEESON:  I think with this witness I am going to be probably another 10 or 15 minutes.

CHAIR:  Sorry? 

MS GLEESON:  Another 10 or 15. 

CHAIR:  Well, that's going to put us behind schedule. 


CHAIR:  Let's do it in 10, shall we? 

MS GLEESON:  Yes. Can I ask you, have you got the document behind hearing bundle E, tab 14 on our screen? 

DIANNE:  Abuse and neglect? 

MS GLEESON:  Abuse and neglect policy, yes. Can I just ask you to turn very quickly to   at the bottom of the page, you've got 5.0 procedure. 

DIANNE:  Yes. 

MS GLEESON:  And then there are some definitions there, including a client abuse, assault etcetera. 

DIANNE:  Yes. 

MS GLEESON:  And then it goes over the page with a number of other concepts. And then if you turn over to page 4, there's then a detailed account of recognising signs that may be indicators of abuse. 

DIANNE:  Yep. 

MS GLEESON:  Were you and were Lifestyle Assistants provided with any training on abuse and neglect concepts   these abuse and neglect concepts? 

DIANNE:  We had   so we had the standards hanging up in the centre which outlined what it was. We had access to these policies and procedures. This particular one, it's not exactly flagging anything in my memory bank. We did have the folder there with policies and procedures in it. But in terms of actual, like   I can't recall but it's been a long time. 

MS GLEESON:  And can I ask generally in relation to the documentation that   that related to both these procedures   

DIANNE:  Yep. 

MS GLEESON:    and also in relation to clients and that's the client file that's available on CIMS and in hard copy. 

DIANNE:  Yep. 

MS GLEESON:  You've told the Commission that that involved a large volume of information  

DIANNE:  Yep. 

MS GLEESON:    that was written. And it's right, isn't it, when it comes to things like medication management plans and Epilepsy management plans, that involves a lot of medical terminology? 


MS GLEESON:  Of the Lifestyle Assistants that were employed at Mount Druitt, about what proportion would you say had English as a second language? 

DIANNE:  It would be about   it would be at least 50 per cent of my   of my mainstay team when I was there, it would be probably around the 50 per cent mark. 

MS GLEESON:  Did you observe that that presented any challenges for those Lifestyle Assistants to absorb and understand the documents that they needed to understand to care for the clients that they were assigned to? 

DIANNE:  Yes, it wasn't always immediately identified but at times you would see their written   their written skills yourself, when you were, you know, auditing progress notes and such, things like that, where you could actually   that was where it was identified that  

CHAIR:  I'm not sure it would be the fact of English as a second language. It may be that  

DIANNE:   I mean you can be born in Australia and  

CHAIR:    a deficiency in English might be a problem. There are actually bilingual and trilingual people in this country. 

MS GLEESON:  To the extent that you observed that any Lifestyle Assistants were having difficulty with understanding the written documents that they were presented to, were you aware of any steps that were taken to ensure that they were taken through the plans and could understand and absorb them? 

DIANNE:  I can think of an example of a   of a staff member that I managed out at Windsor who was diagnosed with Dyslexia, as an example, and she would   where possible we would read them out. If not, she would ask to take the policy home where her daughter was able to sit with her and read out the policy with they are before she signed and acknowledged it. 

MS GLEESON:  And was she paid for that additional work to be on top of the policy? 

DIANNE:  Not that I can recall. 

MS GLEESON:  During your time as Team Leader at Mount Druitt did you have any concerns that incidents were being underreported by Lifestyle Assistants? 

DIANNE:  I wouldn't know, because I was not on the floor to be able to see underreporting or over reporting. 


DIANNE:  But it's safe to say   it's a safe assumption to say that yes, because sometimes human error landed staff with formal warnings, so you   it wouldn't be a far jump to make to think that maybe I won't report it if it meant that I'm not going to get in trouble. 

MS GLEESON:  Did you observe at all that the fact that HR was managing the investigation of incidents might have been a deterrent to any staff members to speak up about incidents that occurred because they thought there might be consequences for them? 

DIANNE:  That would be a fair assumption. I myself was threatened with   if I was late calling into a teleconference which commenced at 8 am in the morning, that I would receive a formal warning. 

MS GLEESON:  And on how many occasions did that occur? 

DIANNE:  We were told that that would occur weekly and if we   if we called in late, by the time   sometimes lucky that by the time roll call made it through, that we were there.

MS GLEESON:  Alright. I'm just going to wrap up with some very quick final questions. 

DIANNE:  Yeah. 

MS GLEESON:  You've   since completing your employment at Mount Druitt, you've now worked for a number of other disability organisations. 

DIANNE:  Yes. 

MS GLEESON:  And at paragraph 38 of your statement, you   and following of your statement, you identify a number of issues with the way that Afford operated, and we have them in your statement.  But I was wondering whether you could tell the Commission, based on your experiences at Afford and your experiences at the centres where you've worked at since   

DIANNE:  Yes. 

MS GLEESON:    some of the ways in which you think that the services operated at day programs could be improved so as to maximise the benefits to the clients? 

DIANNE:  Yeah. Well, one of the main things that I've sort of   that I've highlighted throughout this is that, with the introduction of the NDIS, there's been a bit of a billable hours sort of model go on here where participants   where, you know, services are sort of forced to make sure that, you know, if money's not coming in, money's not going out. It's given the idea in their head that bigger   you know, of trying to obtain more and more clients, more money, and they've turned people into dollar figures.

It's created risk, and this model that we need to get bigger to make more money to service our overheads as time's gone on. You know, there's   it's a risk to these clients when they're being put   when they're being put in a position where they are a dollar figure and with a rapid growth model it means that we're not always able to catch some people that are sliding in through our doors here. 

Traditionally as a Team Leader our jobs are meant to lead a team. That's what the job is. But we're stuck behind computer screens. We weren't able to catch our staff. We weren't able to look at them, you know. They weren't able to see, you know, a pattern of behaviour with our participants when matched with certain staff, and they were left vulnerable and open because of that. 

MS GLEESON:  And in paragraph 46 of your statement you say that:

"It's a positive thing to have competitive service offerings, but that should never stop disability service providers from keeping eyes on their clients and offering a genuine service."

Is that right? 

DIANNE:  That's correct. 

MS GLEESON:  Alright. 

DIANNE:  I'm sorry, where was   which paragraph was that? 

MS GLEESON:  I believe it's paragraph 46. 

DIANNE:  Yep. 

MS GLEESON:  And just one last question: you've given a number of examples in the evidence you've given to the Commission today about the amount of time that is dedicated by Lifestyle Assistants and yourself to complete administrative tasks.

DIANNE:  Yep. 

MS GLEESON:  And the impact that has on providing appropriate services to clients in accordance with the NDIS plans. What are your suggestions to how that can best be managed by disability service providers going forward? 

DIANNE:  Not only is it the disability service provider. It has to come some onus on the structure of the funding also, where we need to possibly look at ways where we can empower our staff to have a genuine understanding of participants. But there needs to be an allowance for training funding buckets in play as well, where staff   you know, the NDIS might turned around as an example and say that people need to be Dysphagia trained but   we can tick a box and put staff through a formal Dysphagia training but that doesn't actually necessarily teach the staff member on how to read the meal time management plan to support the person, to give the actual genuine understanding of the staff member to the participant.

You can train someone on what Dysphagia is and identifying it, but does that actually teach you how to work with it, with a particular person and identifying it with the individual, the genuine actual understanding of people, of the individual person, not just a definition of what we need to identify as a hazard, but what it looks like when you're actually working with it day to day.

MS GLEESON:  And would one of the solutions be to either allocate a dedicated staff member who was able to provide cover so that people could undertake necessary administrative tasks like updating client files   

DIANNE:  Yeah, that could be. 

MS GLEESON:    while still maintaining customer ratios. 

DIANNE:  That could be one way around it. There could also are client free weeks or things like that being introduced. 

MS GLEESON:  So paid time in order to allow staff members to do all the administrative tasks they need to do that are relevant to client care, and then they can spend their time when the clients are actually at the centre with the clients; is that right. 

DIANNE:  Yeah, and even to come from a Team Leader as well. I recall back when I first started, my Team Leader took a week off out of the office to help me. You know, I was trained for a week straight from my Team Leader when I left school.

MS GLEESON:  And in a perfect world, that person would be paid for their time. 

DIANNE:  Yeah, both of us. Yeah, absolutely. 

MS GLEESON:  Thank you. There may be some questions from the Commissioners.

CHAIR:  Thank you. Dianne, if it's okay with you, I'll ask my colleagues whether they have any questions, and that I hope won't take too long. Commissioner Bennett. 

COMMISSIONER BENNETT:  On notice. I just want to turn to just a few things in your statement. 

DIANNE:  Yeah. 

COMMISSIONER BENNETT:  And thank you for talking to us today and sharing your experience. On paragraph 13, you talked about Afford's relationship with the schools in the area. 

DIANNE:  Yes. 

COMMISSIONER BENNETT:  So have I got this right, that their Customer Officer that would go out   the recruiter   

DIANNE:  Yeah. 

COMMISSIONER BENNETT:    for want of another word, would go out to the school. 

DIANNE:  Yeah. 

COMMISSIONER BENNETT:  Were they skilled to be able to assess if a day program was the right thing for that person, or were they really there just to increase the numbers? 

DIANNE:  From my experience, the Customer Care Manager was actually one of my subordinate support workers at one stage, and then she was promoted into the Customer Care Manager position, so there was no formal qualification. 

COMMISSIONER BENNETT:  So they wouldn't have been in a position to advise   

DIANNE:  No and nor   

COMMISSIONER BENNETT:    the family to say the day program is not the best place for that individual? 

DIANNE:  No, that's correct, yeah, so that was   their job was to sell that. 

COMMISSIONER BENNETT:  And do you think the school or the family knew that they were paid a commission? 

DIANNE:  No, I don't believe so, no. 

COMMISSIONER BENNETT:  Okay. And when that person was trying to recruit or increase the number of clients, would they actually have any understanding of that goal to build capacity and independence and then match what the individual person with disability needed and what was offered at the day program? 

DIANNE:  Sorry, can you repeat that? 

COMMISSIONER BENNETT:  Did they know enough to see how the goal of capacity building and independence, which is in the service agreement   

DIANNE:  Yep. 

COMMISSIONER BENNETT:    that would be fulfilled at the day program? 

DIANNE:  No, they wouldn't know. Once they   once the participant was   like, once the participant was with us, then they stepped back. There was no follow up from that point on. 

COMMISSIONER BENNETT:  And did you as the Team Leader with   or should Team Leaders have looked at that component about building capacity and independence in looking at what activities that individual would do? 

DIANNE:  In what way? Sorry. Would you mean that   

COMMISSIONER BENNETT:  Well, we heard from some witnesses that there were times were there was just watching TV, people lost communication skills, that they lost or weren't helped with other life skills that were needed. 

DIANNE:  Mm hmm. 

COMMISSIONER BENNETT:  So I was trying to see where this sat at the forefront, this building capacity and independence. 

DIANNE:  So we offered some   we offered capacity building programs as much as possible such as, you know, the work experience and the cooking programs and things like that, in conjunction with our Allied Health team as much as possible. The problems start to lie when you've got a centre with so many people and resources going further   being stretched further and further. 


DIANNE: Became harder to   


DIANNE:  Yes, minding is a   not really something I would agree with personally, but the resources stretched thinner. 

COMMISSIONER BENNETT:  And do you have any sense how many of the clients came directly from Afford Residential. 


COMMISSIONER BENNETT:  In the day program so how many resided in an Afford, let's say, group home? 

DIANNE:  Under my   under Mount Druitt, I'm just trying to think of   I can't actually think of any   we didn't have any group homes in the area towards Mount Druitt for them to attend because there's now   there's now a   there's now a group home in Mount Druitt that was my day program. That's now converted to a group home. But because I didn't have a whole lot of them around there, we didn't have   see any residential participants attending our day program.

And when I   when I was in Windsor, they didn't own the group homes out there at that particular point, so I can't really comment a whole lot.

CHAIR:  I think it's probably better if we ask Afford about that. 

DIANNE:  Thank you. Yep.

CHAIR:  Okay. Commissioner McEwin. 

COMMISSIONER McEWIN:  Thank you, Dianne, for your evidence. A couple of matters that I want to understand better. 

DIANNE:  Yep. 

COMMISSIONER McEWIN:  We heard from parents yesterday that when they first met with Afford, or at the beginning of the commencement of the day program, they wanted their child to ensure that they had the communication devices or the iPads or the AAC, and that that should be part of the day. 

DIANNE:  Yep. 

COMMISSIONER McEWIN:  And we heard that that wasn't the case. Do you have any observations on that? 

DIANNE:  So in my time, we had our own iPads that were available   that were available to the day program, but it wasn't actually something that we restricted in our   in my management. That was something that   around the 2014 mark where this was maybe a more prone issue, iPads maybe weren't as common back then, but it certainly wasn't an issue under my   if there were participants with iPads later on. But by that stage I actually can't recall whether Simon brought his iPad to the best of my knowledge. 

COMMISSIONER McEWIN:  Is it fair to say that, from what we heard from the parents yesterday   

DIANNE:  Yeah. 

COMMISSIONER McEWIN:    they felt some of their children's communication capacity declined because there wasn't an effort to be person centred for that adult, or that adult child's particular communication needs. Is that a fair observation? 

DIANNE:  That's a fair observation. 

COMMISSIONER McEWIN:  Okay. Thank you. One final question: when Ms Gleeson asked you about your attempts to meet or address with Human Resources you're concerned about the rapid growth   

DIANNE:  Yes. 

COMMISSIONER McEWIN:    and too many clients, how did you feel about the response and what would you have liked to have seen happen? 

DIANNE:  By that stage, I was kind of at my wit's ends, really, at that stage. I knew that   I knew that I was no longer a part of their bigger picture. I could already see that they were ready   they were ready to part ways with me, and by that stage, I wasn't overly surprised by the response. So I was burnt by then. 

COMMISSIONER McEWIN:  Okay. Thank you very much. Thank you, Chair.

CHAIR:  Thank you Dianne. There are a lot of questions I could ask, but I think we had better move on. There are other issues we are going to have to deal with today. But thank you very much indeed for coming and giving your evidence. We appreciate what you have brought to the Royal Commission. 

DIANNE:  Thank you.

CHAIR:  And we understand it's not an easy thing to do to tell us of your experiences in the way that you have, and it has been extremely helpful to the Royal Commission. So thank you very much indeed. We do appreciate it. 

DIANNE:  I'm glad I could help.


CHAIR:  Ms Gleeson, 15 minutes shall we say. 

MS GLEESON:  If I can interrupt briefly I'm unsure whether any other parties wish to ask any questions in the way that you ordinarily offers.

CHAIR:  Very good. It's now 1.45 more or less. We'll resume at 2 pm. 



CHAIR:  Yes. I think there's one more appearance to be announced on behalf of Erynn, I think. Is that right? 

MS MAKRIS:  Yes. May it please, for the witness Erynn. 

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

MS GLEESON:  Now, your name is known to the Commission, but today we're going to refer to you as Erynn; that's right? 

ERYNN:  Yes. 

MS GLEESON:  And your address is also known to the Royal Commission? 

ERYNN:  Yes. 

MS GLEESON:  You've prepared a statement for this hearing? 

ERYNN:  Correct. 

MS GLEESON:  And for the benefit of the Commissioners, that statement is appearing in bundle A, tab 56.

CHAIR:  Yes. Thank you very much. 

MS GLEESON:  You've got a copy there with you? 

CHAIR:  Just before you go on, thank you very much for coming to the Royal Commission today to give evidence. We appreciate the assistance you're giving and also the statement you have made. What I will ask you to do ask, if you would be good enough to follow the instruction of my Associate who's just sitting there, he will administer the oath to you. 



CHAIR:  Yes.  Now, Ms Gleeson will ask you some questions. 

MS GLEESON:  Thank you, unfortunately I do traverse into matters that probably required the oath. Now, you have your statement there in front of you? 

ERYNN:  I do. 

MS GLEESON:  Excellent. You've indicated that you want to make a correction to that statement. 

ERYNN:  I do. 

MS GLEESON:  And that's over on page 6. 

ERYNN:  Yes. 

MS GLEESON:  And the first line of paragraph 25, there's the date, 2018. 

ERYNN:  Yes. 

MS GLEESON:  And that date should be 2019. 

ERYNN:  Correct. 

MS GLEESON:  With that correction, are you content that your statement is true? 

ERYNN:  Correct. 

MS GLEESON:  Now, you were employed at Afford from 2016 to 2020? 

ERYNN:  Correct. 

MS GLEESON:  You were employed as a Lifestyle Assistant when you first commenced at Afford? 

ERYNN:  Correct. 

MS GLEESON:  And at some point you were then promoted to Senior Lifestyle Assistant? 

ERYNN:  Correct. 

MS GLEESON:  And when was that? 

ERYNN:  That was at the end of 2016. 

MS GLEESON:  And you were employed at the Mount Druitt day program? 

ERYNN:  Correct. 

MS GLEESON:  When you started at the centre, approximately how many clients were there on a daily basis? 

ERYNN:  34. 

MS GLEESON:  And could you describe to the Commission generally what the support needs were for the clients who were attending the centre? 

ERYNN:  Personal care needs, feeding, that the goals were met, taking them out to programs, and transport. 

MS GLEESON:  I'll just walk you through your statement. I'll keep referring to paragraph numbers and just ask you a few questions about what you describe there. At paragraphs 5 and 6 of your statement, you discuss your duties on transport runs involving picking up clients and taking them to the centre and returning them home. 

ERYNN:  Correct. 

MS GLEESON:  You mentioned there after about eight months you suggested a change to the way in which transport runs should be organised. Can you tell the Commissioners about that? 

ERYNN:  Correct. So transport runs were a little bit all over the place when I started. I was a Lifestyle Assistant at the time. I approached the Team Leader at the time and the Seniors at the time if I could put in place transport runs so staff weren't going around all different areas. So we put together transport runs for a bus to go to the Colyton, Erskine Park, St Clair, and then the Mount Druitt area, so buses would go out, to, like, Oakhurst, Hebersham, Dharruk, like, and then into Bidwill, Whalan, Lethbridge Park. Once this was done, there was a routine happening, clients were picked up on time, family members knew what staff members were coming, and they knew what time the buses were coming each morning. 

MS GLEESON:  Just jumping to a different part of your statement, at paragraph 30 which is on page 8, you also mention that from 2018, Afford changed its practices so that more than one staff member would do the transport runs. Can you tell the Commissioners about how that change came about? 

ERYNN:  We were getting more and more Epilepsy clients on our transport runs, and for the safety of the clients I went to my Team Leader at the time and asked if she could get approval for more staff to be on the transport runs. 

MS GLEESON:  I take it you were watching the broadcast of the evidence that was given by the parents of some of Afford's clients yesterday? 

ERYNN:  Correct. 

MS GLEESON:  Do you remember some evidence being given from some of the parents of the clients that the ratios provided for in their services agreement might not have been achieved during transport? 

ERYNN:  Correct. 

MS GLEESON:  And do you remember that they also said that on occasion the time of arrival of buses was variable and that that caused them distress and inconvenience? 

ERYNN:  Correct. Because changes did happen around 2019. 

MS GLEESON:  And what were the changes that was   

ERYNN:  New Team Leader was put into place. 

MS GLEESON:  And you've given some evidence about the way in which you suggested that transport runs should be organised. Did that change when this new Team Leader came to the centre? 

ERYNN:  Correct. 

MS GLEESON:  And what happened then? 

ERYNN:  Staff   the regular staff that did transport runs which was the permanent part timer staff were taken off the runs and casuals were put onto the runs. So transport was showing up late. Different staff members then were showing up, which affected the family members and the clients also. 

MS GLEESON:  And if I can take you back now to paragraph 9 and 10 of your statement, and in those paragraphs you talk about the information that you received when you first started at Afford and then in relation to clients for the period of your employment. Can you tell the Commission what information about clients that you think it's important to know so that you can support them effectively throughout the day? 

ERYNN:  I think you should know all their diagnosis, you know, to behaviours, if they're on medication, to Epilepsy, if they have Autism, if they're verbal, nonverbal. It was very important to have as much information on each client to provide service. 

MS GLEESON:  Were you confident during your time at Afford that that information was stored in a way that you could readily access it when you needed it so you could attend to a client's needs? 

ERYNN:  It was easily accessible but client documentation wasn't up to date. 

MS GLEESON:  When you say it was easily accessible, where could you access it? 

ERYNN:  In the Team Leader's offices. 

MS GLEESON:  Was it ever stored electronically? 

ERYNN:  Yes, on CIMS. 

MS GLEESON:  Was there any difficulty accessing the information on CIMS? 

ERYNN:  Yes, we had no internet at the time and CIMS would crash. 

MS GLEESON:  When CIMS would crash in that way, your only recourse was to go to the paper files? 

ERYNN:  Correct. 

MS GLEESON:  Did you ever take any steps at any time to ensure that there was access to the client's paper files in other places other than the Team Leader's office? 

ERYNN:  Correct. I introduced a folder for Epilepsy. I introduced a folder for their medication. And I introduced a folder for the meal time management plans, and that was located at the front door of Paull Street. Every access bag had information inside. Each van had the information inside so it was accessible for the clients at the beginning of the service. 

MS GLEESON:  And about when did that happen. 

ERYNN:  We promoted that in 2019. 

MS GLEESON:  Can you tell the Commission about access bags and what function they had? 

ERYNN:  So access bags was to go out with the staff, and in that access bag was sunscreen, cutlery, cups, the meal time management plan, Epilepsy plans, medication plans, gloves, wipes, and incontinence pads. 

MS GLEESON:  Can you talk to me about how easy you found it reading and absorbing the information that you needed about clients? Did you find that difficult while you were at Afford. 

ERYNN:  At times, yes. 

MS GLEESON:  Can you explain some of the things that interfered with your ability to keep up to date about client information? 

ERYNN:  Meal time management plans could be a little tricky.  Could be on the first page of a time management plans, and it would state the client's food had to be cut down into small bite size pieces and then you flip over and then you had a photo of how their food texture should be. And then you read further and it would be stating, okay, the client's food needs to be cut down small bite pieces but moist. So it was different information from the first page to the second page, so then you have to go and clarify with the Team Leader on the situation. 

MS GLEESON:  You told the Commission just before that you   that some of the client information was incomplete or out of date. 

ERYNN:  Correct. 

MS GLEESON:  What were some of the reasons you observed as to why that was happening? 

ERYNN:  Well, we were all just under the pump. The workload was horrendous, and some of the information by Customer Service wasn't given, or family members didn't provide the right information also. 

MS GLEESON:  To the extent that you were under the pump and you needed to find time to read up on the information about clients from their files, how would you make that time? 

ERYNN:  In the morning between eight and nine when there was less clients or any time after three and four. 

MS GLEESON:  And did you ever find that you needed to   to inform yourself about the client files outside of working hours? 

ERYNN:  No. 

MS GLEESON:  There was also a mechanism for recording client information in communication books; is that right? 

ERYNN:  Correct. 

MS GLEESON:  And was that one of your duties to complete the client books while you were a Lifestyle Assistant at Afford? 

ERYNN:  Correct. 

MS GLEESON:  And what sort of information was recorded in those books? 

ERYNN:  We recorded what they did for the day, how their day was, and, if they ate, if they ate well, and that was basically, yes. 

MS GLEESON:  Did that book need to be completed on a daily basis. 

ERYNN:  Correct. 

MS GLEESON:  We heard some evidence yesterday from some of the parents of the clients that communication books weren't always filled out, depending on which Lifestyle Assistant was assigned to their client. Do you remember receiving any complaints from support people? 

ERYNN:  I don't recall. 

MS GLEESON:  That you recall. 

ERYNN:  No. 

MS GLEESON:  Just turning to paragraph 13 of your statement, that's over on page 3, you referred there to there being issues with having dedicated paid administrative time to read and memorise yourself with what was in the client file. 

ERYNN:  Correct.

MS GLEESON:  And do you think that that would be an advantage to make sure that Lifestyle Assistants are properly informed about the information that   that they need to properly care for clients? 

ERYNN:  Yes. 

MS GLEESON:  And you also refer to issues with getting paperwork completed. 

ERYNN:  Mm hmm. 

MS GLEESON:  Can you describe some of the paperwork that you were required to complete while you were at Afford at Mount Druitt? 

ERYNN:  So around, we had PACES and, like, the internet always crashing on us and CIMS crashing. I would do a brief note on the PACES paperwork. I would take some of the paperwork home and complete it at home. And, like, yeah, we just   we didn't have the time, like we just ran out of time. 

MS GLEESON:  In relation to PACES, could you just tell the Commission what PACES means? 

ERYNN:  Yeah, so we had a monthly audit check and that was medication audit, inspection audit of the premises, first aid kits, medication, I think I just said, and fire   fire drills. 

MS GLEESON:  And was the purposes of that PACES documentation that needed to be completed tied to bonus benefits for staff? 

ERYNN:  Correct. 

MS GLEESON:  And who got the PACES bonus benefits. 

ERYNN:  Seniors, Team Leaders, I believe the District Managers and if any of the Lifestyle Assistants helped out. 

MS GLEESON:  So was the way it worked that there would be a lot of paperwork completed in relation to medication, to   to the way in which the centre was constructed, to whether or not training was being adhered to, and once that documentation was completed, there would be a bonus paid to a Team Leader, and some of that would be allocated to any Lifestyle Assistants that  

ERYNN:  Helped. 

MS GLEESON:    helped to complete the paperwork. 

ERYNN:  Yeah, correct. 

MS GLEESON:  Did you ever receive any benefits from the PACES scheme? 

ERYNN:  Twice. 

MS GLEESON:  Did you find that the Mount Druitt site regularly achieved its PACES goals? 

ERYNN:  No. 

MS GLEESON:  So there was only a couple of incidents in which a bonus was received? 

ERYNN:  Correct. 

MS GLEESON:  But nonetheless on every occasion the PACES review time came up, you had to complete the paperwork within that time and you just spent some of that time was completed after working hours. 

ERYNN:  Correct. 

MS GLEESON:  And were you paid for that time? 

ERYNN:  No. 

MS GLEESON:  Now, I want to talk to you about your promotion to Senior Lifestyle Assistant in 2017. You talk about that from paragraph 17, and at paragraph 22 of your statement, you refer to being provided with a document that listed your duties. 

ERYNN:  Correct. 

MS GLEESON:  And I'll just take you to that document. It's hearing bundle A, tab 57.

CHAIR:  Thank you. 

MS GLEESON:  Have you got that?it's just on the screen. 

ERYNN:  Yeah. 

MS GLEESON:  To your right there. And this sets out the duties that you had to perform on each day when you were a Senior Lifestyle Assistant. 

ERYNN:  Correct. 

MS GLEESON:  Is that right? 

ERYNN:  Correct. 

MS GLEESON:  And it's got first of all a list of activities that were to be completed between 8 and 9 am. 

ERYNN:  Yes. 

MS GLEESON:  And there's dealing with transport runs and then, where it's got, "Make appropriate changes", can you just describe where the bullet points are underneath that what you needed to do in relation to each of those matters? 

ERYNN:  So to make appropriate changes could be looking at the casuals. We had to know if they had the Afford training so we could put the right staff with the right client so the client's needs were met. Changes to transport runs. Also additional too, we also had to make sure that we had the right clients on the transport runs because some clients did clash with other clients so yes, there was always an additional adjustment. 

MS GLEESON:  And that was all to be done on a running board. 

ERYNN:  Correct. 

MS GLEESON:  Which then let the Lifestyle Assistants know what they were to do for the day. 

ERYNN:  Yes. 

MS GLEESON:  And then underneath the bold writing:

"Check respond and action any emails."

There's now a list of other things that needed to be done for the day, including complete any outstanding paperwork including any new client files. 

ERYNN:  Correct. 

MS GLEESON:  How often was there outstanding paperwork to be completed during that morning part of the day? 

ERYNN:  A lot. 

MS GLEESON:  Looking at all the other tasks that needed to be done to be ready for the day, did you find that there was enough time to get outstanding paperwork done? 

ERYNN:  No. 

MS GLEESON:  During that allotted period? 

ERYNN:  No. 

MS GLEESON:  And if I can then just take you down to the bottom of the document under the time period, 3 to 4 pm. 

ERYNN:  Mm hmm. 

MS GLEESON:  This is again at the end of the day. The first thing you need to do is to check parent carer group homes are signing off from transport run and also communicate with whoever is signing off about information they need to be informed of. 

ERYNN:  Mm hmm. 

MS GLEESON:  In your experience, was that something that occurred during transport drop offs? 

ERYNN:  Correct. 

MS GLEESON:  And then again underneath the bold entry, it's got "Send client allocations." Can you explain what that means? 

ERYNN:  So client allocations have to be sent through to the District Manager and also the Team Leader had a copy. 

MS GLEESON:  And then   and what do client allocations mean in this context. 

ERYNN:  So they're ratio. So we would do, for the day program  


ERYNN:    we worked off a board and client allocations would be you have your one on ones, your one to twos, your one two threes. 

MS GLEESON:  Were they client allocations that had been completed for the day or the following day? 

ERYNN:  They had just been completed. 

MS GLEESON:  And again, "Complete any outstanding paperwork including scanning, uploading progress notes". 

ERYNN:  Mm hmm. 

MS GLEESON:  Was it part of your duties as Senior Lifestyle Assistant to complete the progress notes for clients? 

ERYNN:  Not all clients, only allocated ones. 

MS GLEESON:  Only the ones for whose care you were allocated that day. 

ERYNN:  Correct. 

MS GLEESON:  And again, in the time that was available, being one hour before 4 pm, did you generally have enough time to complete the progress notes within that time period? 

ERYNN:  No. Some clients weren't picked up on time by group homes and unfortunately we had a curfew that we had to be off the premises at 4, so some clients still weren't even picked up around 4, and if the clients weren't picked up you had to take them out the centre and go around the corner of the street. So there was times where we had no time to complete progress notes. 

MS GLEESON:  Can I just ask you about having to go around the corner and wait with clients on the street. Was it the case you needed to vacate the premises because there was a neighbour who   

ERYNN:  Correct. 

MS GLEESON:    objected to people being on the site after 4 pm? 

ERYNN:  Correct. 

MS GLEESON:  Does that mean in order to comply with the curfew, clients were being taken outside and just waiting outdoors in the street? 

ERYNN:  Correct. 

MS GLEESON:  Regardless of whether   

ERYNN:  Rain, hail or shine. 

CHAIR:  I think you said this document we are looking at was the first time you were told what your duties were; is that right? 

ERYNN:  Yes, so the previous Team Leader when I first started to become Senior, I was basically told that I was to run the floor and to help with transport, and then as the Team Leader role got bigger, the Senior role got bigger.

CHAIR:  So when you were appointed the Senior Team Leader, was this document presented to you at that time or did it come   

ERYNN:  No, couple of months after.

CHAIR:  When you got the document which says, for example, towards the top:

"Doing inductions when needed."

Did you understand what you had to do? 

ERYNN:  Staff induction.

CHAIR:  When you get an induction? 

ERYNN:  When I first started, yes, then we had to do staff inductions as well.

CHAIR:  My point is, were you given guidance as to what an induction was supposed to cover? 


CHAIR:  How did you work it out? 

ERYNN:  We just fed off each other, so we did any information, induction, like, when I went in there, like, you know, my first day when I went in I got shown the fire point safety. I got shown photos of clients. Got shown where medications were kept, the chemicals, the client folders. And because we had no time to read clients' folders we would feed off each other about the clients. That's all, yeah, my induction was.

CHAIR:  So it was learning on the job for everybody. 

ERYNN:  Yes, correct.

CHAIR:  We heard a little while ago from Dianne in her statement   she didn't call it Peter's principle but she referred to Peter's principle in that she said that there were internal promotions, and what that meant was that people got promoted to the level of their incompetence. I'm not talking about you of course, but was that your experience of the process within this organisation? 

ERYNN:  Yes, I believe so. 

CHAIR:  Thank you. 

MS GLEESON:  Just turning over to the second page of that document, at the top there's some wording in italics and in particular it says that you need to complete any admin between 9 am and 3 pm, always seek approval so you're covered as to why you're doing admin during those hours. Is the reason why approval is needed for that is because if any paperwork was to be done during the hours of 9 and 3 someone else would need to cover the clients that you were supervising? 

ERYNN:  Correct. 

MS GLEESON:  And that was to make sure they were supervised and staff to client ratios were maintained? 

ERYNN:  Correct. 

MS GLEESON:  Was there ever any occasions, because paperwork needed to be attended to, staff to client ratios weren't achieved for a period of time? 

ERYNN:  No, we never dropped the client ratio for us to attend paperwork. The only time that client ratios were changed were for lack of staff. 

MS GLEESON:  And in circumstances in which client ratios were changed because there was a lack of staff, what was done then in order to make sure that the ratios were still achieved? 

ERYNN:  We'd contact the family in regards to letting them know we were short staffed and could we please provide one on one service the following day, and we also had to ring our District Manager. 

MS GLEESON:  And you make reference to this at paragraph 29 of your statement; is that right? That's over on page   

ERYNN:  Mm hmm. 


ERYNN:  Yes. 

MS GLEESON:  And you say when that happened you ensured that the invoices   the invoices then reflected the changed level of support that was provided because of the short staffing. Were you aware of any incidences where this didn't happen and clients complained? 

ERYNN:  No. 

MS GLEESON:  I'm just picking up on a point that the Commissioner just raised. At paragraph 31, you refer to there being a new Team Leader appointed in 2019. 

ERYNN:  Mm hmm. 

MS GLEESON:  And there being problems with the organisation from that time, and you've given evidence in relation to transport. In relation to rostering the clients, you give some evidence in paragraph 31 about rosters not being provided to staff with adequate notice so that clients might have been left alone and not collected? 

ERYNN:  Correct. 

COMMISSIONER McEWIN:  Ms Gleeson, before you go any further, can I just ask about the client allocation. I just want to understand better. As a Team Leader, did you work closely with the Team Leaders to provide advice on appropriate client allocation or were you just told what the ratios would be and then you would advise the family. 

ERYNN:  No, the Team Leader would communicate to us Seniors the ratios. 

COMMISSIONER McEWIN:  And did you have any active involvement? Did you make suggestions?did you say, "We're not sure this will work today", etcetera. Was there an active involvement? 

ERYNN:  Yes, there was, like if we were short staffed it would not have worked. 

COMMISSIONER McEWIN:  Okay. Thank you. 

MS GLEESON:  Now, you speak in your statement from paragraph 40 about challenges that arose in relation to turnover of Team Leaders that were appointed. 

ERYNN:  Mm hmm. 

MS GLEESON:  And you say at paragraph 40 that at least 17 Leaders were   were working at the centres that you worked out of over your four years at Afford. 

ERYNN:  Correct. 

MS GLEESON:  And can you tell the Commission about some of the problems that occurred because of the turnover in management at the centres? 

CHAIR:  Sorry, I think you said 17. It's recorded as seven. 

MS GLEESON:  Seven. 17 Leaders I'm sorry. 

CHAIR:  It's recorded as seven. Yes. Okay. 

MS GLEESON:  Can you tell the Commission about some of the issues that arose because of the change in management over time? 

ERYNN:  Yeah. Communication was a big affect. Things that were put in place being changed which affected the families, the staff, the clients. 

MS GLEESON:  And we heard yesterday from some of the parents of the clients that the high turnover of staff at Mount Druitt made communication from their perspective very difficult. I take it from what you've just said that you think that's a fair criticism? 

ERYNN:  Yes. 

MS GLEESON:  At paragraph 43 of your statement, you refer to an incident about a client aspirating and vomiting because he was given food contrary to his mealtime management plan. 

ERYNN:  Mm hmm. 

MS GLEESON:  Were you there when that incident occurred? 

ERYNN:  I wasn't. I was in the centre but I wasn't present when the incident occurred. 

MS GLEESON:  Did you have any involvement in what occurred immediately after the incident? 

ERYNN:  After the incident. 

MS GLEESON:  And can you tell us what happened from the time you became involved? 

ERYNN:  I assisted the client with getting changed because he had vomit all over him. Once the client was cleaned up, he was brought back to the table. I then went to the back room and I was folding up clothes, because we had to get clothes out for him to change into. So I was putting all the clothes that I had taken out of the wardrobe back into the wardrobe, and there was just all so much kerfuffle going around. 

And then I recall my Team Leader referring to the other Senior that the Team   that the group home was dealing with the matter, and normally once you heard the Team Leader say that the group home's dealing with the matter, in my understanding is that it was put through the red alert system, and then the Team Leader was following instructions from the red alert team and also the other Senior. 

MS GLEESON:  And   and following that incident, do you remember there being any investigation of what occurred? 

ERYNN:  There was an investigation. I was contacted by HR to know what I heard, and the only thing that I heard was the Team Leader saying that the group home would deal with it. 

MS GLEESON:  And when you say the group home will deal with it, does that mean the group home will deal with the immediate care of the client who suffered the choking incident? 

ERYNN:  I can't   I can't comment.

CHAIR:  Was that an incident involving, as you recall, a cut up chicken sandwich? 

ERYNN:  A client ate a cheese ball and choked.

CHAIR:  Alright. Thank you. 

MS GLEESON:  And do you know whether there were any changes made to the procedures in relation to mealtime management plans as a result of that incident? 

ERYNN:  No. 

MS GLEESON:  Do you know   you said that you were questioned by HR in relation to the incident. Do you know whether there were any outcomes for the staff members that were involved as a result of the incident? 

ERYNN:  Yes. One lost their job. 

MS GLEESON:  One lost their job. In your experience, were investigations of incidents concerning client safety, behaviour, violence, medication issues or mealtime management issues, were they generally investigated by HR? 

DIANNE:  Correct. 

MS GLEESON:  Was it a frequent occurrence that what would occur as a result of that investigation was that the staff member who was involved would be given either a warning or would have their employment terminated? 

ERYNN:  Correct. 

MS GLEESON:  Do you think that that contributed at all to whether or not staff members were willing to report incidents that occurred? 

ERYNN:  Staff members were afraid to report some incidents because they were scared that their shifts would get cut. It directly come from staff themselves. 

MS GLEESON:  When you say that directly comes from staff themselves, is there things that staff had told you over time? 

ERYNN:  Yes, so more affecting to around bullying and harassment, issues with the Team Leader. 

MS GLEESON:  Is the Team Leader that you're referring to now the Team Leader that you've spoken of on a couple of occasions earlier in your evidence? 

ERYNN:  No. 

MS GLEESON:  A different Team Leader on this occasion? 

ERYNN:  Mm hmm. 

MS GLEESON:  You say, and this is at paragraph 23 of your statement, that:

"By late 2017, 2018, the day program had grown 45 clients."

And your role had become more demanding. 

ERYNN:  Mm hmm. 

MS GLEESON:  And at paragraph 24, you give a description of the layout of the day centre and   and you make reference to the fact that there would be up to 55 clients in the space, and it was packed.

ERYNN:  Mm hmm. 

MS GLEESON:  In your observation, were there any impacts on the services that were provided to clients because of the number of clients that were in the centre? 

ERYNN:  Yeah, it all depends on what program was on for the day and how many clients were left in house to how many clients went out on community access. 

MS GLEESON:  And on days in which more of the clients were resident in the centre and undertaking activities there, did you observe the varying impacts on the quality of services that they received? 

ERYNN:  It could cause behaviours. 

MS GLEESON:  And were   did you find that there was enough space to physically carry out the activities that were allocated to the clients on that day? 

ERYNN:  No. 

MS GLEESON:  And on   did you have any concerns about the safety of clients while they were in the centre when numbers were at a peak? 

ERYNN:  Yes, because when it was very crowded, it did cause a lot of behaviours to occur. Different clients   due to the noise of other clients, and just the safety of the whole environment in general. 

MS GLEESON:  Was there an incident in relation to a particular client, and you mention this at paragraph 25 of your statement, with being difficulties in relation to the space at the Mount Druitt site and trying to accommodate a client's wheelchair that was too wide to fit into the doorway? 

ERYNN:  Yes. 

MS GLEESON:  And did you find that the client was getting frustrated by the difficulties in manoeuvring him or her around the site? 

ERYNN:  Correct. 

MS GLEESON:  And did you report back to the District Manager? 

ERYNN:  The District Manager was present at the time at Mount Druitt. 

MS GLEESON:  And did you discuss the problem with him or her? 

ERYNN:  Yes. 

MS GLEESON:  And what was the response from the District Manager? 

ERYNN:  "Toughen up". 

MS GLEESON:  Sorry, did you say that you were told to toughen up? 

ERYNN:  Yes.

MS GLEESON:  What was the name of the District Manager? 

ERYNN:  Wayne Anderson. 

MS GLEESON:  Was that Wayne Adamson? 

ERYNN:  Sorry, Adamson, yeah. 

MS GLEESON:  At the end of your   that paragraph of your statement you say that you felt disgusted by that response and that management didn't care about how their staff or clients were impacted by not having adequate facilities to provide the necessary care to clients; is that right? 

ERYNN:  Correct. 

MS GLEESON:  Just staying on overcrowding for a second, did you also think that there were challenges with the amount of staff members that were able to provide services to clients? 

ERYNN:  Can you repeat that, sorry? 

MS GLEESON:  Did you feel like the resourcing was sufficient so that clients were receiving all of the services that they needed to at the centre when a large number of clients were present? 

ERYNN:  Yes. 

MS GLEESON:  At paragraph 26, you speak of the day program and moving to a bigger site in Mount Druitt. 

ERYNN:  Mm hmm. 

MS GLEESON:  Did you find that this resolved the issues that concerned you with the former site? 

ERYNN:  No, there was still issues with the   the new site. 

MS GLEESON:  Can you describe what they were? 

ERYNN:  Fire exits, there was no windows for air flow to come through. Change room again was too small. 

MS GLEESON:  Just in relation to the fire exits, how many were they? 

ERYNN:  You had the front door, the main front door, and you had the kitchen door. 

MS GLEESON:  And did that present any problems with accessibility, for example, for clients with wheelchairs? 

ERYNN:  Correct. 

MS GLEESON:  And did you also have any concerns about the location of the centre where it was in Mount Druitt? 

ERYNN:  I did have concerns because we had the methadone clinic up the road. There was syringes outside in the car park and in the grass area. 

MS GLEESON:  And did you ever raise those concerns with either your Team Leader or   

ERYNN:  Team Leader. 

MS GLEESON:  And to your knowledge was anything done to meet your concerns? 

ERYNN:  No. 

MS GLEESON:  Can I ask you to go to paragraph 44 to 46 of your statement. That's over on page 11. And you talk there about invoicing and receipts, and in particular some issues in relation to invoicing for NDIS and non NDIS services. 

ERYNN:  Mm hmm. 

MS GLEESON:  Was one of the issues that arose that some families prepaid for non NDIS services but didn't get a receipt, so they got invoiced twice? 

ERYNN:  Correct. 

MS GLEESON:  At paragraph 46, you refer to clients being charged for one on one support but then being put in group activities exceeding those ratios? 

ERYNN:  Correct. 

MS GLEESON:  You mentioned that that might be then recorded in the progress notes as still being a one on one support. 

ERYNN:  Mm hmm. 

MS GLEESON:  How did that happen? 

ERYNN:  So, I would have a client on Monday, one on one support, wasn't able to give that client one on one support, so that client was put to one to two. The next day I would have the same client and when I went to do the progress notes   so the next day when I went to do the progress note, sorry, I had put in on Monday ratio for one to two but then I had notice that my ratio had been changed to a one on one. 

MS GLEESON:  And what did you do when you noticed that that had occurred? 

ERYNN:  I went directly to the Team Leader and, yeah, she denied or didn't know how it changed. 

MS GLEESON:  You changed that information back though, didn't you? 

ERYNN:  I did. 

MS GLEESON:  And you say in your statement that you were angry about what had been done because you thought that it could be fraud. 

ERYNN:  Correct. 

MS GLEESON:  And you didn't want to be responsible that you had entered the information incorrectly. 

ERYNN:  Correct. 

MS GLEESON:  You say at paragraph 48 that by late 2019 you had lost faith in reporting things like this to one more Senior because your concerns were either ignored or you were made to feel isolated at work. And is one of the examples of your concerns being ignored or dismissed, the example you gave in relation to your complaints about the door frames at the old Mount Druitt centre? 

ERYNN:  Correct. 

MS GLEESON:  And you also made reference to being isolated at work. Can you give some examples of how that happened to you? 

ERYNN:  I had   there was no communication between the Team Leader and previous Senior. I was taken off discussing transport runs, allocations, was told that the other Senior will now be appointed to deal with the transport runs and the allocations. 

MS GLEESON:  And can I show you an email. And just before I do, you mention at paragraph 49 to 50 of your statement that you were unhappy under a new Team Leader that had commenced at Mount Druitt, and so that you then, after taking a short holiday and moved to a separate nearby site at Cherrybrook; is that right? 

ERYNN:  Correct. 

MS GLEESON:  And can I show you hearing bundle E, tab 265C. And there's a series of emails there commencing at the top on 21 October 2019. Can I ask you to go to the second page and the email that's got at the top, the date 11 October 2019. 

ERYNN:  Yep. 

MS GLEESON:  And the names of the recipients of this email have been redacted, but you would recall receiving this email? 

ERYNN:  Correct. I was currently on annual leave when I received this email. 

MS GLEESON:  So you were on annual leave, you were at a point where you were on holiday and shortly after that you were going to move to the Cherrybrook site; is that right? 

ERYNN:  Correct. 

MS GLEESON:  And at the bottom of the page we can see that this is from the Team Leader at the Mount Druitt site. 

ERYNN:  Correct. 

MS GLEESON:  I'll just take you through the first couple of paragraphs here. First of all, this Team Leader complains that after making sure staff were onsite were doing their job rather than doing their role, that Team Leader spent Friday evening making up for the work that couldn't be done that day. To your memory, was it part of the role of Team Leader to be present on site to supervise the work of Lifestyle Assistants and the experiences of clients? 

ERYNN:  So the Team Leader's role was to ensure that, you know, all staff were doing their job, but they did have a very impacted job, they were under the pump. A lot of Team Leaders couldn't come out at most times. 

MS GLEESON:  And when you say they couldn't come out, could they not come out because they were attending to various administrative jobs in their office? 

ERYNN:  Correct. 

MS GLEESON:  And she mentions that on this occasion she spent her Friday evening making up for the work that she couldn't get done that day. To your knowledge, was that something that happened to Team Leaders on a regular basis? 

ERYNN:  Not that I can recall.

MS GLEESON:  And she then mention that she was checking progress notes for plan management clients and that there were 18 progress notes missing and that this didn't include the amount of missing transport entries. So there's two problems there; there's the problem of missing progress notes and then also missing transport entries. Can you think of any reason why those entries wouldn't have been completed at the end of the day? 

ERYNN:  Same again. No internet, CIMS crashing. Staff members may be dealing with behaviour clients. Staff members may be going to hospital with a client if there was an injury to that client. 

MS GLEESON:  And was that something that regularly occurred, that the work of completing progress notes for billing purposes would not get completed because of either the system wasn't available in order to allow that to be done during working hours. 

ERYNN:  Correct. 

MS GLEESON:  Or that there was various tasks that needed to be attended to that involved servicing clients? 

ERYNN:  Correct.

MS GLEESON:  In the next paragraph, she mentions that she doesn't want to spend every evening or weekend catching up on her work, and then she says:

"Following on the other email that I sent earlier today, failure to do your job or repeat offenders with not entering progress notes will be referred to HR for performance management."

ERYNN:  Mm hmm. 

MS GLEESON:  Now, when you received this email, what was your reaction to it? 

ERYNN:  I was just like, "Oh wow." 

MS GLEESON:  Was it a frequent occurrence that you were threatened with being referred to HR for any shortcomings in performing some of the tasks that you were assigned during the day? 

ERYNN:  This is the first time. 

MS GLEESON:  And was this the only email like this that you received during this end period of your employment? 

ERYNN:  No, there was two more emails that I can recall while I was on leave that went a similar scenario and then I was cut off emails. 

MS GLEESON:  Cut off because you were moving to the Cherrybrook site? 

ERYNN:  I   yeah, can't explain why.

CHAIR:  Sorry, you wanted to answer. Please do.

ERYNN:  Yeah, I can't yeah, give an explanation as to why I was cut off the emails. 

MS GLEESON:  And did you speak to other staff at Mount Druitt about this email or the other emails you referred to? 

ERYNN:  Correct. When I got back off holidays, staff did contact me and said she was showing her true colours. They felt like that they   the permanent part timers felt like they were being pushed out and casuals were being put in place. So casuals were actually getting more hours than the actual permanent part timers. 

MS GLEESON:  When they felt like they were being pushed out, was that because their   because of any manner in which they were being   they were treated during the working day, or was it because of matters such as shifts being cut? 

ERYNN:  Yeah, just, like, their shifts being cut. 

MS GLEESON:  Alright. And as a result of there being a downgrade in shifts from the permanent part timers, did you notice that there were any impacts on the services that clients received? 

ERYNN:  Yes. Transport was a major issue. 

MS GLEESON:  And that feeds back into what you've told us before.

ERYNN:  Yeah. 

MS GLEESON:  About transport generally being an issue once  

ERYNN:  Yes.

MS GLEESON:    this Team Leader commenced employment; is that right? 

ERYNN:  Yes. 

COMMISSIONER McEWIN:  Erynn, did you feel that this email was an appropriate way to try and deal or resolve the issues that were going on? 

ERYNN:  Correct. 

COMMISSIONER McEWIN:  Did you feel that was an appropriate way. 

ERYNN:  Yes, I thought it was very inappropriate. 

COMMISSIONER McEWIN:  Yes. Thank you. 

MS GLEESON:  And you then said that once you moved to Cherrybrook, your experience was much better. 

ERYNN:  Mm hmm. 

MS GLEESON:  What were some of the improvements that you observed at the Cherrybrook site? 

ERYNN:  The Team Leader that was present was, you know, very organised. We had three Seniors, so admin got done. So two seniors were able to do admin between 8 and 9 and 3 to 4. The other senior would be down on the floor in case any clients showed up early. Yeah, it was just better run, structured, clients' needs were met, yeah, it was bigger, bigger environment. 

MS GLEESON:  And I think I need to correct myself. I think I keep saying Cherrybrook; it is, in fact, Cherrywood. At paragraph 53 you talk about returning to Mount Druitt and that your experience, at least initially, was more positive.

ERYNN:  Mm hmm. 

MS GLEESON:  Can you tell the Commission what had improved? 

ERYNN:  Sorry. The Team Leader, she was fantastic. Great. 

MS GLEESON:  Please go on. 

ERYNN:  Great communication skills, made sure the clients' needs were met. 


CHAIR:  Would you like some water? I think there's some. 

ERYNN:  That's how it happened. 

MS GLEESON:  And was one of the other advantages that you felt that the documentation for clients was more up to date during this period? 

ERYNN:  Yeah, so we   I had another Senior working alongside of me and she would have one day at admin. I would have one day admin, and she would have one day admin, and we took turns. So paperwork was coming along very   like, along well. 

MS GLEESON:  And then at paragraphs 54 to 55 of your statement, you talk about things deteriorating again because a new Team Leader was appointed. 

ERYNN:  Mm hmm. 

MS GLEESON:  Can you tell us some of the issues that arose after that Team Leader started? 

ERYNN:  Clients' choices. Clients didn't get a choice. She made the choices. So she   

MS GLEESON:  And when   I'm sorry to cut across you. When you say that she took away clients' choices, was that in relation their preferences for doing particular activities or working with particular Lifestyle Assistants? 

ERYNN:  Activities. 

MS GLEESON:  And were there any issues in relation to updating client information that occurred after she   after this Team Leader commenced? 

ERYNN:  I was taken off all that side of it. My responsibilities was doing the vehicle checklist for the vans. 

MS GLEESON:  And so you weren't yourself updating client information. Did you observe that it was getting done by anyone else after that work was taken away from you? 

ERYNN:  Yes, I did. 

MS GLEESON:  And who was doing it? 

ERYNN:  The new Senior that come on board. 

MS GLEESON:  And did you feel like that new Senior was performing the task adequately? 

ERYNN:  Yes. 

MS GLEESON:  And you also make reference to staff being rostered for less support than clients were funded for, and you give an example in your statement. Can I take you to hearing bundle A, tab 58. And this is a roster for 4 November 2020? 

ERYNN:  Correct. 

MS GLEESON:  And it's got two sections for programs between 10 am and 2 pm, and then at the bottom there's allocations for offsite morning services; is that right? 

ERYNN:  Correct. 

MS GLEESON:  And in the middle bracket, the second program, 10 am to 2 pm, if you go across, three of the columns, there's an allocation for [Redacted]. 

ERYNN:  Mm hmm. 

MS GLEESON:  And then there are two names above [Redacted] and one of them – and both of them have got 1.2 next to them. Can you explain what that means? 

ERYNN:  So they're a one to two ratio. 

MS GLEESON:  So there's two clients and both of them   

ERYNN:  Yeah.

MS GLEESON:    need to be working on a one to two ratio with  

ERYNN:  Yeah, one client. 

MS GLEESON.    a Lifestyle Assistant, and then you're next to [Redacted] and, again, you've been allocated two clients on this one to two ratio. 

ERYNN:  Correct. 

MS GLEESON:  And [Redacted]'s got a note under her entry and if you go down to the bottom row, you can see there's a direction to [Redacted] in the second last column which says:

"Sign your clients over to Erynn during this time to support [Redacted]." 

ERYNN:  Correct. 

MS GLEESON:  And if you go back two you can see that [Redacted] is doing hydrotherapy at the pools. 

DIANNE:  Correct. 

MS GLEESON:  Is the consequence of that that during the period where [Redacted] was assisting [Redacted] at the   at the hydrotherapy, you were taking on clients at a one to four ratio? 

ERYNN:  Correct. 

MS GLEESON:  And that was contrary to the NDIS plan? 

ERYNN:  That's correct. 

MS GLEESON:  Do you know whether, for the hours that the client was supported at a one to four ratio, their plan charges reflected that that happened? 

ERYNN:  I'm not aware. 

MS GLEESON:  Okay. Is the Team Leader that we're discussing during this period still at Afford? 

ERYNN:  Yes, she's been promoted. 

MS GLEESON:  And what position is she in now? 

ERYNN:  District Manager. 

MS GLEESON:  Now, at paragraph 57, you then mention that you left Afford to provide home assistance to Simon. 

ERYNN:  Correct. 

MS GLEESON:  And can you tell the Commission about your observations about the difference in the care that you provide, the difference in the care that you provide to your client now versus the care that you were able to provide when you were at the Mount Druitt centre? 

ERYNN:  Yeah, so I provide personal care in the mornings   


ERYNN:    to Simon. Simon now attends community access. Simon can write his name, he can do different initials. He can now cut up food. He is more independent, can make choices. Can identify money. The timeframe, he will know, okay, it's 2.30, we've got to head home, he can identify time now. He's just grown leaps and bounds. 

MS GLEESON:  Is part of the reason why you can observe positive outcomes arising from Simon's care that he got constant one on one support? 

ERYNN:  Correct. 

MS GLEESON:  Is another that because your only duty is attending to Simon, a lot of the administrative tasks that were involved in working at a busy centre   

ERYNN:  Correct. 

MS GLEESON:    you no longer need to deal with; you can just concentrate on care. Do you have any suggestions about how day centres can find some middle ground between one on one support and   and the social benefits of attending a centre undertaking activities with other people, with disability and achieving those social aspects? 

ERYNN:  Yeah, I believe there should be more staff allocated, should be a floater floating about. Yeah, just   and the environment really needs to be looked at. 

MS GLEESON:  And when you say the environment needs to be looked at, can you give me examples of   

ERYNN:  The space of where they're meant to be doing their programs. 

MS GLEESON:  And what suggestions do you have about how that might be improved? 

ERYNN:  Find the appropriate place for the clients to be in. 

MS GLEESON:  Can I ask you briefly about the training that you received when you commenced employment at Afford? Is it right that you received, and this is at paragraph 9 of your statement, an induction about fire exit procedures? 

ERYNN:  Yes.

MS GLEESON:  Photos of clients? 

ERYNN:  Yes. 

MS GLEESON:  And an employee pack   

ERYNN:  Correct. 

MS GLEESON:    which included policies such as abuse and neglect, medication management, etcetera? 

ERYNN:  Mm hmm. 

MS GLEESON:  And do you remember whether you   anyone took you through the employee pack or were you just required to read it? 

ERYNN:  They were emailed to me and I had to read the policy and procedures myself. 

MS GLEESON:  And then did you have to acknowledge you read it? 

ERYNN:  And then acknowledge. Yes. 

MS GLEESON:  And do you remember whether that employee pack was provided to Lifestyle Assistants that started at Afford after you did? 

ERYNN:  I can't recall. 

MS GLEESON:  Okay. And at paragraphs 35 to 37, you refer to some of the difficulties with Lifestyle Assistants in understanding individual client needs?

CHAIR:  Ms Gleeson, if you're just going to take us through what's in the statement, we do have that, and I don't think we need to do that in any detail. We have that information very nicely set out for us. 

MS GLEESON:  Just staying on the policies that were made available to clients, do you remember being provided with updates of the policies from time to time? 

ERYNN:  Yes, so we would get an email to say there was an updated policy. Team Leaders would   well, not all Team Leaders, some Team Leaders would print the policy off and put it into a folder, which was next to the sign in desk at the front doors of Paull Street. And then we had to sign an acknowledgement form that we had read. 

MS GLEESON:  And at paragraph 19 you refer to staff meetings occurring month to month attended by Team Leaders, Lifestyle Assistants and Senior Lifestyle Assistants? 

ERYNN:  Correct. 

MS GLEESON:  And you   at those meetings, did you receive updates of some policies from time to time? 

ERYNN:  Yes. 

MS GLEESON:  Can the witness be shown hearing bundle E, tab 265E. I'm hoping that that will come up on the screen. And they're minutes from 4 November 2020. 

ERYNN:  Mm hmm. 

MS GLEESON:  And you can see at the bottom of the first page under the heading New Items to be Discuss as per Agenda, it's got various procedures that are listed? 

ERYNN:  Mm hmm. 

MS GLEESON:  And then if you turn over two more pages to page 5105 and then over to page 5106, I apologise, it's at the bottom of mine, there's then a staff acknowledgement sheet and it has at the top, Red Alert Mount Druitt, and then people who   a series of dates, staff names and signatures. 

ERYNN:  Mm hmm. 

MS GLEESON:  And over the page it then has the particular policy which in this case is red alert policy. 

ERYNN:  Mm hmm. 

MS GLEESON:  And is it the case that you were provided with those policies at that meeting and then had to sign off? 

ERYNN:  Correct. 

MS GLEESON:  To say that you'd read the policy? 

ERYNN:  Correct. 

MS GLEESON:  Was there in the meeting any discussion about the content of the policy and what might have changed? 

ERYNN:  No. 

MS GLEESON:  And if I can then ask you to go over to 5111, there's then a procedure for medication management and administration. And in the final page of this document which is 5123   I'm so sorry, it's actually 5112. 

ERYNN:  Mm hmm. 

MS GLEESON:  It's actually back on page   I apologise, I don't have the numbers at the top of the document directly. 

CHAIR:  Ms Gleeson, as Mr Watson will testify, I'm well known for the subtlety of my hints. 


CHAIR:  I'm in danger of damaging that reputation. So can we move towards a conclusion. 

MS GLEESON:  Yes. Yes, I'll move away from that document. I   I just want to take you to paragraph 61 of your statement. You refer there to some of the   if I can describe them without reading it out as cultural issues that caused problems at Afford, and you gave   given some reference to that in your evidence. Can I ask you for your observations on what can be done to improve the culture at   at   amongst Lifestyle Assistants at day centres and   and in particular some of the factors that you think led to the cultural problems you identify there? 

ERYNN:  Okay. Yes, it was very just, like, stressful, disheartening, relations seemed to be like reflected on each other, incidents. Not being supported. 

MS GLEESON:  Do you have any suggestions about   I'll move on to a different topic very quickly. In your statement, you make some suggestions about things that you think Afford needs to change to bring the focus back to client care. Do you have any suggestions about how it is that staffing and resourcing can be approved   improved so that the focus is brought back to client care? 

ERYNN:  I believe there needs to be continuity of staff, not such a big changeover, and a breakdown on client's paperwork. So yeah, sort of mini care plan put out on each client, brief rundown on how to support the client's needs.

MS GLEESON:  And are some of the advantages that you can contain from have been a mini care plan is that it's up to date but also that it's digestible so that   

ERYNN:  That's right, like broken down. 

MS GLEESON:     Lifestyle Assistants can see the issues very quickly and be able to apply them to client care? 

ERYNN:  Yes. 

MS GLEESON:  And do you have any suggestions about how it is that a day centre such as Afford can increase the choices that are available to   to clients, the activities they participate in, and   and make sure that they have sufficient input in making those choices? 

ERYNN:  Yes. 

MS GLEESON:  And what suggestions do you have? 

ERYNN:  Well, they've got a activity sheet that the clients get a choice to choose what program they would like to do, but I do believe there should be more choices. 

MS GLEESON:  And would one of the improvements be for there to be greater consultation with both clients and their support people about what activities they wish to be involved in so that they can be built in   

ERYNN:  Correct. 

MS GLEESON:    to the services that are offered by the centres? 

ERYNN:  Correct. 

MS GLEESON:  And   yes, I think I can leave it there, Commissioners.

CHAIR:  If it's okay with you I'll ask my colleagues if they have any questions, starting with Commissioner McEwin. 

COMMISSIONER McEWIN:  No. Thank you for your evidence.

CHAIR:  Commissioner Bennett. 

COMMISSIONER BENNETT:  Thank you.  Very   two short questions. In your view, has Simon's outcomes and his own personal choice and control been better now he's not in a day program? 

ERYNN:  Correct. 

COMMISSIONER BENNETT:  And do you believe that many other people with disability, that they would have better outcomes, more aligned with the objectives of the NDIS individual plans and goals if they were not in day programs? 

ERYNN:  Correct. 


CHAIR:  From the time you were promoted, what was your experience with missed medications at the day program? Was that something that happened often and, if it did happen, what was the reporting process? 

ERYNN:  No, it didn't happen often. I can only ever recall once, and it was to be red alerted. So you would call the red alert team. You would say your name, what site you were from and then explain the incident.

CHAIR:  So that was the only occasion you were aware of that a participant had medication omitted   not administered properly. 

ERYNN:  Yes. As a Senior, sometimes you can get told about every incident as well.

CHAIR:  Yes. Alright. Thank you. You've made a number of suggestions, and they're very helpful, thank you. An impression I get from listening to the evidence from you and others is, well, really, it's a question, and it's a question that's prompted by a question of one of our colleagues who is not here today frequently asks, is this fit for purpose.

And that question arises because I'm having some difficulty understanding how the NDIS system, with its individual funding, individual plans, assumptions of continuity of support and care, can actually be accomplished within this environment that you were, and perhaps   well, you're not now, but were working in where 60 or 90 people are gathered together, where there are economies of scale that have to be used in order for there to be an appropriate, as the management would see it, appropriate use of resources. 

And I just wonder at a broader level   I understand the particular point you're making, at a broader level, is that something that you've thought about, and if so, am I on the right track or am I missing something? 

ERYNN:  No, you're on the right track, yeah, I think you're understanding my version.

CHAIR:  That's a very good answer. I like that answer. Right. Okay. Alright. Thank you very much. Now, I'll just check as to whether there is anyone who wants to ask you some questions. In that case, thank you very much indeed for the evidence and for the detailed statement that you've given. I think we've learned a lot from your experience. It's very helpful to us and as I said previously too, it's not easy to give evidence in an environment such as this, and we appreciate that you have been prepared to do so. So thank you very much indeed. 

ERYNN:  Thank you.


CHAIR:  Alright. We're now going to take, I take it, Ms Gleeson, a 15 minute adjournment and we shall therefore resume at 3.30. 



CHAIR:  Yes, Mr Fogarty. 

MR FOGARTY:  Thank you, Chair.  The next witness is Samantha Taylor, the NDIS Quality and Safeguards Commission. Ms Taylor's statement dated 22 April 2022 is in hearing bundle C, tab 1. The one page corrigendum to that statement that is 16 May 2022 is same hearing bundle C, tab 1A. And the Royal Commission would note Ms Taylor has also given evidence both oral and written in last year's Public hearing 20, preventing, responding to violence, abuse, neglect and exploitation disability services to case studies, and also in 2020 Public hearing 5, experiences of people with disability in an ongoing COVID 19 pandemic.

CHAIR:  Yes. Thank you, Mr Fogarty.  And Ms Taylor again thank you for coming back to the Royal Commission for your third visit. I'm sure they get more enjoyable on each occasion. 

MS TAYLOR:  Thank you, Chair. 

CHAIR:  If you would be good enough to follow the instructions of my Associate, he will administer the affirmation too. 



MR FOGARTY:  Thank you, Chair. 

Ms Taylor, I understand you have a copy of your statement with you. 

MS TAYLOR:  Yes, I do. 

MR FOGARTY:  My questions will hopefully follow through the paragraphs and sections of that, so if you need to refer to a part or you'd like me to refer to a part just let me know as we go. Firstly in terms of the registration of Afford as an NDIS service provider. Afford was a transition provider, am I right, from 1 July 2018 to 17 September 2020? 

MS TAYLOR:  Yes, that's right. 

MR FOGARTY:  First registration, then Afford submitted an application for its current registration on 11 February 2020 and that application was approved and   sorry, current registration now commenced on 17 September 2020, so that followed on from transitioned registration. 

MS TAYLOR:  Yes, they're the dates I believe are in my statement. 

MR FOGARTY:  That current registration expires on 17 September 2023. 


CHAIR:  What does registration   if you can tell us what registration means and what Afford had to do in order to get registered. 

MS TAYLOR:  Thank you, Chair. It's obligatory to be registered to be a provider in the NDIS when providing supports to participants whose plans are managed by the National Disability Insurance Agency and also where a provider may be delivering particular classes of support and those are set out in rules. They include things such as behaviour support or implementing restrictive practices and other higher risk services.

To be registered, a provider needs to satisfy the Commission that they meet the practice standards that are relevant to the classes of support that they're seeking to register to deliver, and those classes of support and the   and the standards that apply to them are also set out in the provider registration and practice standard rules. There are different forms of assessment that the Commission requires a provider to undergo but in whatever form, there is a requirement for an independent auditor that's approved by the Commission to undertake that assessment against those practice standards. 

In addition to that, the provider is required to provide the Commission with certain information about   about them and their key personnel, and that enables the Commission to also undertake what's referred to in the rules as a suitability assessment. That suitability assessment is undertaken both of the provider itself and also its key personnel. And those things together, the application of the provider, the assessment by the independent group quality auditor and the suitability assessment, plus any other information that the Commission might have on hand, either available through its own functions or through intelligence from other parties, is taken in full to consider whether or not under the provisions in the Act the provider is able to be approved.

Of course, one of the requirements in the Act is for the Commission to only provide approval for registration if a provider is deemed to have met the practice standards as assessed, and that assessment, as I say, is undertaken by an independent auditor approved by the Commission, but takes account of the standards that are specific to the classes of support and the indicators that   that are set out in a prescribed instrument that  

CHAIR:  And in that case is the auditor selected by the NDIS Commission or by the applicant? 

MS TAYLOR:  The Commission has currently 19, I recall, approved Quality Auditors. We have an audit scheme which is administered for us by the Joint Accreditation Scheme of Australia and New Zealand. So it's overseen by the body that audits audits   auditors. JAS ANZ enters into arrangements with   accredits the body to participate in our scheme and makes recommendation to the Commission about whether an auditor is recommended to be considered by the Commission as an approved quality auditor.

CHAIR:  I understand that there are approved auditors. But the particular auditor who reported on Afford, was that auditor chosen by Afford from the panel, or does the Commission choose the person? 

MS TAYLOR:  Yes, Chair, the auditor would have been chosen by the provider.  We give providers choice over the auditors that they can   that they can use off that list of approved Quality Auditors. Of course, that selection is, you know, still requires the auditor, of course, to   to be guided and to implement their audit, undertake their audit in accordance with the guideline that is we have available.

CHAIR:  I follow that. And the auditor in this case presumably provided a report to the Commission which was taken into account in determining that Afford was an appropriate body to register. 

MS TAYLOR:  That's   that's correct, and because of the   in the example of Afford, because that organisation is delivering a range of supports and services in the NDIS, some low risk, for example equipments and therapies, and some higher risk like accommodation and day activities, for example, they were subject to a certification audit. And that means that there would have been, in addition to their initial self assessment against the practice standards, the auditor would have undertaken a two stage audit which includes, in the first stage, a review of their self assessment, their own exploration of the policies and procedures and guidance that the organisation might have that are applicable to the standards, and the indicators that support them.

The stage two audit then takes a randomised selection of sites as well as participants or family members to explore their experience with   with the services provided by the organisation.

CHAIR:  Alright. Mr Fogarty, I'm sure, will take you through your statement. But the question I wanted to ask is, and perhaps we can come back to it after Mr Fogarty has done that   perhaps Mr Fogarty will be doing this. I'll be interested to know whether there's been any retrospective assessment of the auditor's report that led to the registration of Afford but we'll come back to that later on. Yes, Mr Fogarty. 

MR FOGARTY:  Yes. Thank you, Chair. 

Before moving on, just so to be clear you talked about a stage one audit, stage two audit. A recommendation then comes from the stage two audit; is that correct? 

MS TAYLOR:  Well, it comes in full so the auditor looking at the stage one audit, any issues that might have been identified in that stage, the organisation's activities in response to those matters, then the stage two would form in full a certification recommendation or not   


MS TAYLOR:    by a Quality Auditor. 

MR FOGARTY:  The process is recommendation to certify or not to certify. That goes back to the NDIS Commission   


MR FOGARTY:    to do a suitability assessment? 

MS TAYLOR:  Well, that's a separate process to the audit. So the audit recommendation stands alone. 

MR FOGARTY:  Does it feed into the suitability assessment? 

MS TAYLOR:  No, because that process is a separate process. 

MR FOGARTY:  And done internally with the Commission? 

MS TAYLOR:  It's done internally, yes. The audit doesn't support the Commission with undertaking that suitability assessment. 

MR FOGARTY:  No, but what does the Commission do with the recommendation once it comes in as part of the final steps towards registration or not approval. 

MS TAYLOR:  So I think I've set out in my statement some of the stages that the Commission undertakes to form a briefing, if you like, for a delegate to give consideration to whether to register a provider or not. The audit recommendation is one input into that process. As I was just referring to, the suitability assessment is another. But so is information that's available to the Commission from its own activities, for example, incidents that are reported to it, complaints that it receives. 

MR FOGARTY:  Right. 

MS TAYLOR:  And compliance or enforcement action that it might be undertaking. 

MR FOGARTY:  The Commission, the Commissioner at the end who approves or not approve; correct? 

MS TAYLOR:  The Commissioner or the delegate. I'm obviously one of those delegates, as are others. 

MR FOGARTY:  Thank you. That assists in understanding that process broadly. I'll take to you paragraph 12 which I think is on the second page. I just want to understand, you refer to the classes of support for which a provider can be registered. Paragraph 12, you list those for which Afford has been registered to provide since 17 September 2020. There's a couple I wanted to refer to. The (c) high intensity daily personal activity, (e) assistance with daily personal activity. And you're probably seeing this relates to would seem to the day program and supports around it. Assistance for travel, transport arrangements, assess the positive behaviour support, assistance with daily life tasks in a group or share living arrangement, innovative community participation. And working my way down the list, development of family living and life skills, participation in community, social and civic activities, group and centre based activities. Those are the sorts   in this case those are some of the classes for which they   Afford remains registered as far as you understand? 


MR FOGARTY:  And I think you referred a moment ago to some of those classes being low risk and some being high risk? 

MS TAYLOR:  Yeah, we differentiate the classes of support for the purposes of determining the assessment methodology that applies to them. 


MS TAYLOR:  To inform the registration. However, if an organisation is delivering a significant number of what   higher risk supports, many of which you just listed, a certification audit of the stages that are described at stage one, any non conformity action in stage two would be relevant to the organisation. 

MR FOGARTY:  I see. Were you able to follow the evidence yesterday of Sally, Lilly, Suzie or Rob? 

MS TAYLOR:  I must admit, I had other commitments. I heard it in part. I was in and out most of the day. 

MR FOGARTY:  Have you had a chance to read their statements? 

MS TAYLOR:  I haven't, no, I was hoping to read the transcript but unfortunately it's not available yet. I will when it is. 

MR FOGARTY:  You refer in your statement, just to be clear, Afford also had its registration varied in 17 September 2020. Is that an application that Afford or the service provider would make? 

MS TAYLOR:  Yes. So it's   it's very regular for the Commission to receive applications for variation to registration that may involve the provider seeking an adjustment to any manner of things, the period that the registration is in force, the classes of support they're registered for, they might seek to add some. 


MS TAYLOR:  They might seek to remove some. It's a very large part of our decision making, and it's not irregular for an organisation to, in making an application, to particularly if   if they're adding classes of support that attract additional standards that they hadn't originally been assessed against when the Commission made a decision for registration that that application is accompanied by a   an additional audit report around   to furnish us with what we require to make that decision to vary or not. 

MR FOGARTY:  One of the variations you refer to from 14 April 2021, paragraph 13, is specialised support coordination. 

MS TAYLOR:  Mm hmm. 

MR FOGARTY:  Is that separate to   is that a particular kind of support coordination, different to a more broad type of support coordination? Are they two different things? A specialised   a particular type of support coordination? 

MS TAYLOR:  It is. I can't speak to the nuances of what is   these classes of support are really connected to the NDIA and their catalogue of supports, but the specialist support coordination relates to support coordination for people with more complex needs. 

MR FOGARTY:  Needs. Prior to that   well, it was a variation, is it your understanding that prior to that they were not registered for specialist support coordination? 

MS TAYLOR:  I wouldn't   wouldn't appear to have been unless they were originally transitioned with that class and didn't then reapply when they renewed their registration. 

MR FOGARTY:  And just so I'm clear, paragraph 12 has a list. I referred to some of them. 

MS TAYLOR:  Mm hmm. 

MR FOGARTY:  But is that list you put in 12, all of the classes for support Afford was registered for from September 2020? 

MS TAYLOR:  Yes, I believe it is. 

MR FOGARTY:  Alright. I'd like now to ask you some questions to gain an overview of the NDIS Commission's investigations and compliance actions taken in respect of Afford since 2020. I know a number of them are open investigations so I don't propose to traverse those in a way that might prejudice those. I've umbrellaed them in a fourfold fashion. Firstly, there's been an investigation into the 2019 death of Merna Aprem who was an NDIS participant and resident in Afford's care at Woodbine supported accommodation.

Just to get the chronology correct, the involvement of the NDIS Commission was shortly after the death, when a notifiable reportable incident was provided to the NDIS Commission; is that correct. 


MR FOGARTY:  And then last year, 21 December 2021, the Commission   the NDIS Commission commenced civil penalty proceedings in the Federal Court of Australia. 


MR FOGARTY:  I'm jumping ahead. They're still on foot. 


CHAIR:  Why did it take so long to institute proceedings? 

MS TAYLOR:  Chair, in a matter such as that, the investigation has to be incredibly thorough. There's the need to get evidence from a number of sources and a number of parties. I can   I prefer not to really refer to the process, but it took us to the filing, if you wouldn't mind, but certainly the steps of this involved then a revision of what evidence is available, and what else might need to be obtained.

CHAIR:  You can take it I'm familiar with the process. 


CHAIR:  I'm just wondering why it took two and a half years. Alright. Yes. Thank you. 

MR FOGARTY:  Thank you, Chair. 

In your statement, you indicate that they're the first civil penalty proceedings taken by NDIS Commission in the Federal Court of Australia   


MR FOGARTY:    which was commenced in New South Wales, and you indicate that the work necessary to commence those, along the lines of what you were   you've been asked about, was a matter of the highest compliance importance of priority for the Commission in that period of time, or has been. 

MS TAYLOR:  It was an extremely high priority matter, yes. 

MR FOGARTY:  And from it, and I'll move on to the other parts of my fourfold breaking down of the compliance of investigation matters, other documents and other investigations arose from some of the information that was received as part of that investigation; correct? 

MS TAYLOR:  It was a multifaceted investigation, yes. 

MR FOGARTY:  The second compliance matter or the second matter was one that is termed in the Commission's operating system COS as apparent systemic noncompliance. You recall that? You refer to that in your statement? 


MR FOGARTY:  According to your statement it was commenced on 5 March 2021 and this arose, didn't it, from documents discovered during the NDIS Commission's investigation into the Aprem matter, do you recall? 

MS TAYLOR:  Yes. Yep. That's a   that was the creation of a record in our system which collected a number of issues which had fallen out, if you like, from the investigation that   that warranted compliance consideration as opposed to potential enforcement pathways. 

MR FOGARTY:  And it   if you want to go, look at paragraph 24, there's I think nine incidents referred to there as   there was an initial assessment of this compliance matter and the following nine incidents listed at paragraph 24 of your statement arose. I'll take you through those:

"A complaint by a participant who alleges he was hosed down like a dog after soiling himself while receiving respite services."

And I should indicate this remains an open investigation; correct? 

MS TAYLOR:  These matters   

MR FOGARTY:  Compliance matter, I should say. 

CHAIR:  Perhaps just to be clear, the status of this is an allegation by a participant of this conduct. That allegation has not yet been determined. 

MS TAYLOR:  This is a   this is a complaint. I couldn't speak to the status of the particular complaint. But these are matters which together were at the time considered to be of concern in aggregate about systemic issues that warranted our investigation in a   in terms of our compliance.

CHAIR:  Right. Thank you. 

MS TAYLOR:  Oversight. 

MR FOGARTY:  Is it your understanding that these nine incidents or alleged incidents were not matters that were   that had been notified to the NDIS Commission?

CHAIR:  I think what   do you mean that they were   

MR FOGARTY:  Discussed.

CHAIR:    revealed as far as the investigator was concerned as a result of the investigation into the other matter and had not previously come to the attention of the Commission by way of a notifiable incident? Does that   

MR FOGARTY:  Thank you, sir.

CHAIR:     capture what you're putting? 

MS TAYLOR:  And I would say   and thank you for that clarification, Chair   no, that would not necessarily be the case. These are matters that come into the Commission as complaints or reportable incidents and our investigators are connected with those other functions of the Commission, and in the course of their investigation look to other pieces of information or intelligence that are collected by the Commission about a particular matter.

 For example, if they were investigating, as they were at the time, a particular incident, they might look to see whether or not there are other similar examples of   of issues with   coming up for a particular provider to see whether or not there are any relationship between those issues and the matter that they're   they're investigating and that would help them determine whether or not there was a   the issue that they were   that were at the heart of their investigation was an isolated issue or whether or not it spoke to broader issues on the part of the provider. 

MR FOGARTY:  I suppose my question is, is it the case that these incidents could have been notified as reportable incidents? 

MS TAYLOR:  They could have been, and I think I've referred to a couple of complaint and incidents through the reportable incidents mechanism. 

MR FOGARTY:  Yes. When you list them there are references. For example, there's a reference to   well, the first   the first reference is a complaint by a participant. It's unclear   I don't mean to be critical of you   whether that's a complaint made to the NDIS Commission or a complaint made to Afford that was picked up in documents, that I understand refer to, were uncovered or were circulated within the NDIS Commission from the statement arising from the investigation into Ms Aprem's death. 

MS TAYLOR:  I'm happy to provide clarification on this. I don't have these matters on hand obviously.

CHAIR:  Mr Fogarty, this may be something about which we seek some further information, bearing in mind that I assume you're going to be coming to issues relating to the failure to notify a notifiable incident. 

MR FOGARTY:  Yes. Thank you, Chair. 

The third of the fourfold investigation compliance matters was, do you agree and refer to in your statement, that on 28 July 2021 the NDIS Commission commenced the investigation regarding alleged misuse of NDIS funds by Afford, is also an open investigation as I understand it by the NDIS Commission? 

MS TAYLOR:  Yes, that's right, yes. 

MR FOGARTY:  Prompted by a story published on the ABC's website and by report that was on the 7.30 Report on or about that time; is that correct? 

MS TAYLOR:  Yes, that's correct. 

MR FOGARTY:  To your knowledge, it involved serious allegations, I emphasise they're allegations, of possible failure by Afford to meet obligations in respect of its condition of registration. Do you agree? If it assists paragraph 33   

MS TAYLOR:  Yes, I've included   

MR FOGARTY:  An excerpt. 

MS TAYLOR:    an excerpt from my own reflections on that   that media, do I?  And that's consistent with what I've said, yeah. 

MR FOGARTY:  Yes, the serious allegations of the possible failure in respect of conditions of registration, I think you say particularly practice standards between governance and operational management? 


MR FOGARTY:  And secondly, in respect of code of conduct, acting with integrity, honesty and transparency. In July 2021, again from your statement, the Assistant Director of investigations completed an initial assessment, noting it's still open. And again at paragraph 46 for your reference, in that assessment there's an excerpt:

"It was reported to the Commission that Executives with Afford created a culture of excessive spending for staff and employees on matters unrelated to the care of participants. Money would be spent on extravagant functions which was termed Buzz Nights."

That's part of this investigation? 

MS TAYLOR:  Well, that's   

MR FOGARTY:  The allegation. 

MS TAYLOR:  I'm describing what had been relayed in the course of looking into those things, yeah. 

MR FOGARTY:  This investigation also uncovered information about a Mr Thomas Stumpo; is that right? 

MS TAYLOR:  Yes, that was part of the ABC report. 

MR FOGARTY:  Right. And a reportable incident   arguably a reportable incident or allegedly reportable incident involving him in the care of Afford in June 2019. 


MR FOGARTY:  That hadn't been reported to the NDIS Commission at the time, had it, in 2019?


MR FOGARTY:  It was reported, wasn't it, approximately two years later just after the ABC report.


MR FOGARTY:   Was notified, I should say   

MS TAYLOR:  Notified, yes. 

MR FOGARTY:     by Afford. I'll come back to a couple of those matters or those investigations. The last, and this is a closed one, relates to the New South Wales and ACT investigation   team investigation opened on 4 May 2020 into eight, what became eight reportable incident investigations made by Afford regarding allegations of abuse by NDIS participants who were clients at the Mount Druitt day program by Mr Daniel Nuumaalii who was an Afford Lifestyle Assistant. 


MR FOGARTY:  That is now closed, and closed I think in 2020. 

MS TAYLOR:  Yes, that's right. 

MR FOGARTY:  Alright. In respect of the   taking you back to the alleged misuse of NDIA funding, noting it remains open, is it the case that as part of that, the NDIS requested reportable incidents   well, I withdraw that. That the NDIS Commission reviewed a reportable incident and other data from Afford such as its growth and size which reported that Afford was notifying the reportable incidents at about half the rate of other providers between July 2018 and July 2021? 

MS TAYLOR:  Yes, that was the assessment about one of our officers. 

MR FOGARTY:  And is that your data that you   

MS TAYLOR:  I think that was actually based on that particular Senior Leader's experience of the sector and her ability, because of her experience, to compare providers of a similar size. 

MR FOGARTY:  Over that period of time. 

MS TAYLOR:  Yeah. 

MR FOGARTY:  Does that remain a cause of concern for you? 

MS TAYLOR:  Sorry, what does   

MR FOGARTY:  Does it remain a cause of concern for you in respect of Afford that opinion, I put it as opinion. I note it's still open and if you can't comment you can tell me. 

MS TAYLOR:  No, I'm happy to comment on that. Yes, Afford's compliance with its obligations around reportable incidents is a matter of concern for me and although we've seen   we've spent   there's been a considerable amount of work between the Commission and with Afford on these kinds of matters, and although we've seen an improvement, I'm still not satisfied and I've set that out in my statement and I've   I've commissioned some further work and I've written to the CEO about my intention and offered to talk through with her what my concerns continue to be. 

MR FOGARTY:  And I will hopefully come to that document. Thank you for flagging that now. One matter you refer to still within this alleged misuse of NDIS funding is a referral made to the NDIA. You recall that in terms of it issuing a final debt outcome notice? 

MS TAYLOR:  Yeah, the matter's ongoing but, of course, the Commission doesn't manage   


MS TAYLOR:    funding matters and so we have a relationship with the NDIA to explore issues. They have an interest and we have an interest also, although they are separate interests.

CHAIR:  This is paragraph 65? 

MR FOGARTY:  Yes, thank you. I should have  

CHAIR:  I wonder if you could just explain what a final debt outcome notice is, and what is said to be owing by Afford to either the NDIS Commission or the NDIA. I'd like to understand that. 

MS TAYLOR:  Well, there's nothing owing to the Commission because the Commission doesn't manage any  

CHAIR:  Alright. What's owing to the NDIA, in that case? 

MS TAYLOR:  What I'm doing here is conveying what I understand from the information I've seen about a debt outcome that the NDIA issues where they find that they've paid for things they shouldn't have. It's probably a question put better to them to explain how they go through that process and what's in a debt outcome notice, than I can perhaps give you to the level of detail you might need.

CHAIR:  But this is an outcome of the NDIS Commission's investigation, isn't it? 

MS TAYLOR:  No, there is no outcome of our   of our investigation as yet. The matter is under consideration.  The NDI   we referred   both the NDIA and the Commission had concerns about the   the issues that were reported by the ABC. We've been engaging with the NDIA to   for them to advise us about whether or not there are any issues in the billing patterns of Afford and whether things that have been claimed by Afford or paid by the agency to Afford against people's plans were appropriate to be paid. The NDIA makes that assessment.  The Commission does not. 

However, what the Commission is interested in is if there are irregularities in billing patterns that the NDIA assesses and confirms, that they will then advise us of what, from their engagement with the provider, led to those irregularities and the Commission  

CHAIR:  Just pausing there; paragraphs 31 through, really, until paragraph 65   paragraph 60, I'm sorry   all relate to NDIS Commission's investigations. It's the NDIS Commission that's undertaking the investigations. And then the NDIA is contacted, paragraphs actually 59 and following, and then the NDIA, in effect, takes over and says, "We want some money please."  So the NDIA appears, from your own chronology, to be acting on the investigations and the outcome of the investigations by the NDIS Commission. 

MS TAYLOR:  I don't think that's an accurate representation.

CHAIR:  Well, that's what your document says. 

MS TAYLOR:  Chair, with respect, you asked me about what a debt outcome notice was and what was owing to both the Agency and the Commission.

CHAIR:  That was a previous question. I've asked a different one now. 

MS TAYLOR:  Okay. Sorry about that, if you wouldn't mind repeating the question.

CHAIR:  I'm trying to understand the proposition that really this is the NDIA that's pursuing the money, and no doubt in a technical sense that's true. But the NDIA appears from your own account to have come into it by reason of the NDIS Commission's investigation. 

MS TAYLOR:  Yes, that is   as I was saying, the NDIA and the NDIS Commission work on these matters together. We both have concerns. We do point out things to the NDIA as they do to us which enables us both to act on our respective areas of interest. Our consideration  

CHAIR:  So the NDIS Commission has pointed out to the NDIA that there seems to be a problem and that it may be that Afford owes the NDIA money because of the matters that have been uncovered in the course of NDIS's Commission. Is that an accurate way of putting it? 

MS TAYLOR:  Chair, no, I don't believe that is an accurate way of putting it. We would not approach the Agency with the interest about whether or not a provider owed the NDIA money or not.  We would seek the NDIA's assistance to understand whether or not there were any irregularities in the way in which a provider was billing, and the reason we would ask the NDIA to consider those matters is so we could determine whether or not things such as integrity, transparency, as articulated under the code of conduct   

CHAIR:  Alright. Just   alright. What then was the NDIS Commission Investigator doing? 

MS TAYLOR:  Well  

CHAIR:  If it wasn't that? 

MS TAYLOR:  He's been engaging with the NDIA as they've gone through their assessment as well as looking at a raft of other information about this particular matter that we obtained from Afford that's set out in my statement, as well as a number of other connecting issues to do with the other investigations that Mr Fogarty just took me through.

CHAIR:  Yes. Alright. Mr Fogarty. 

MR FOGARTY:  Ms Taylor, still on this point, if the referral   I'll call it a referral   was made to the NDIA or the NDIA compliance team came to your Commission and said, "We're investigating potential wrong  " I'll use wrong "  payments made." If it came back to you later and said, "Look, we were wrong, it's all fine, there's some things that we thought were irregular but it's all fine," as opposed to in this case, as I understand it from your statement, that they   they, NDIA, have identified to the Commission an amount of $110,593.62 as this debt outcome notice to Afford to be paid to the NDIA, and they also identify   and this is still I think in paragraph   this is in paragraph 61 of your statement   the NDIA identifies what it   what it was investigating in the irregularities were threefold, it seems:  additional hours were claimed above the hours supported in documentation; secondly, supporting information did not adequately support payments, for example, a higher group or support ratio was claimed than what was agreed to in the service agreement that was funded in the participant's plan; and thirdly, from the NDIA, no supporting information was provided at the services were provided as claimed. That notification from the NDIA to the NDIS Commission, would it not have an effect on, when it comes to review or suitability or re registration in terms of code of conduct, acting with integrity, honesty or transparency, or you couldn't make that call? Would it not have an effect   so the consequence, okay, the money doesn't go back to the NDIS Commission because it never came from them. 

Would there possibly be a consequence, and perhaps the reason why the two entities talk to one another in this situation, that the NDIS Commission might review this outcome and what the NDIS informed it as to the irregularities when it comes to registration or re registration? Is that of significance for the NDIS Commission? 

MS TAYLOR:  I think they're separate considerations because within the context of a   of a registration period, a provider can be subject to compliance and enforcement action by the Commission. And that can be any manner of things. We've got a compliance enforcement policy which I think has been provided to the Royal Commission in evidence previously. But that sets out a number of different approaches that the Commission can take when noncompliance is identified. And each of those potential remedies, because remedy is our preference, I would have to say, is   affords the organisation, for want of a pun, the procedural fairness to respond to the issues that we've identified. But the issues that enable   well, the conditions of registration that a provider is subject to provide us with the levers to take that compliance action. 

And that might be a matter of a condition of registration to comply with the code, but it also may be matters of the conditions of registration around compliance with the practice standards and these things might surface during a registration period where we think the provider has moved away from conformity or more information has come available to us to inform our decision. And, of course, the third in this kind of example, because the provider is also bound by the NDIA's conditions around claiming whether or not they've met their obligation in complying with the laws of the Commonwealth, or in this case the Commonwealth alone, but there might be other matters around State or Territory laws. 

So all those things work together as part of an ongoing monitoring throughout a registration cycle. And that can lead to us taking compliance action, adding additional conditions on registration, for example, or if the provider is unable in that cycle of registration to remedy the matter, and we think that, you know, the outcome of that is that it does not meet particular standards or suitability is not able to be demonstrated, then the Commission can, depending on where in the cycle these matters arrive, decide to revoke a registration or to refuse an application for registration, if that is what is on hand. 

MR FOGARTY:  Alright. Thank you. Quite comprehensive. But at this stage, this is an open investigation by the NDIS Commission into alleged misuse of NDIS funding. 

MS TAYLOR:  That's right. And an input into that investigation   


MS TAYLOR:    is the information that is   that has been provided to us by the NDIA about the finding of irregularities in billing, and our consideration, once the information is made available from the NDIA about the reasons for that   


MS TAYLOR:    after their engagement with the provider were then done. 

MR FOGARTY:  That would integer in your   how you   how you would deal with that? 

MS TAYLOR:  How we would then treat and deal with those providers. 

MR FOGARTY:  Returning to the Thomas Stumpo incident which I note too is open, and in respect of that as you   as you understand it, set out in short, Mr Stumpo was a client of Afford, part of a short term accommodation respite. I'm looking at paragraph 68, I think it begins, and goes through to 118. On this occasion, he'd been sent home from the respite accommodation. He'd been picked up I think by his mother and it turned out that there was food stuck in his airway, because he'd been fed solid food by Afford staff prior to being picked up that day   later that day by his mother, and that was contrary to his mealtime management plan which stipulated he couldn't eat solid food. Part of also the incident, do you agree, as you understand it, was that he appeared unwell I think when his mother came. She asked the staff about that and they suggested that it could perhaps be a virus. So   

MS TAYLOR:  That's as I understand. 

MR FOGARTY:  That is as you understand it. Alright. And then on arrival at home his mother called an ambulance and they discovered that there was food lodged. I think I asked you earlier there had been no notification of that as a reportable incident in 2019   June 2019 by Afford; correct? 


MR FOGARTY:  But it did notify in July 2021 just after the ABC story broke; is that right? 


MR FOGARTY:  In your statement at paragraph 76, you say that:

"Afford informed the NDIS Commission that they were unaware the incident was reportable."


MR FOGARTY:  And then they set out in their response or the notification to the NDIS Commission that HR had investigated the matter on 19 June 2019, had issued formal warning letters to the Lifestyle Assistant and the Team Leader involved in Mr Stumpo's care that day. And then they also indicate that the letters included the following information: firstly, that there was no nutritional swallowing plan on Afford's client information management system, otherwise known as CIMS; that secondly, the Team Leader had not communicated the nutritional swallowing plan to staff; and thirdly   this was in the letter issued to the two employees   also during the time the client, Mr Stumpo, visited Afford's respite there were no community activities for him or others, they just stayed in the respite house. 

Now, again, according to your statement, the reportable incident team escalated that to the compliance team, I think shortly after it was received in July 2021, and notification. Just to be clear, and I emphasise it remains open, but you set out in paragraph 81 that the team's investigation has uncovered possible   and I stress possible   breaches of the NDIS Act as follows. Firstly, the NDIS practice standards regarding risk management and support planning, possible breach from   


MR FOGARTY:    what I just described. Do you agree? Secondly, the requirement to notify the NDIS Commission of a reportable incident. And then lastly:

"The NDIS code of conduct regarding the requirement to provide supports and services in a safe and competent manner with care and skill."

Both the first and third of those matters are front and square the sorts of matters that are assessed in a quality audit, correct, because they're parts of the practice standards and parts of the code of conduct? 

MS TAYLOR:  They are at the point in time   

MR FOGARTY:  In time, yeah. 

MS TAYLOR:    that that assessment is undertaken. 

MR FOGARTY:  In   sorry. 

MS TAYLOR:  The code is not, sorry. 

MR FOGARTY:  Code of conduct. 

MS TAYLOR:  So the thing that the quality audit looked to are the practice standards that are relevant and the   and the indicators that support those standards. 

MR FOGARTY:  Okay. And the quality auditing guidelines I think in a sense cross the governance point, aren't they? There's some other documents that assist in   

MS TAYLOR:  The quality audit guidelines are as advertised. They set out the guidelines for quality auditors in undertaking the audit. 

MR FOGARTY:   Alright.  And that's issued by the Commission? 

MS TAYLOR:  Yes, they are a Commissioner's guideline. 

MR FOGARTY:  In September 2021 a section 26 letter was send to Afford by the NDIS Commission. What is a section 26 letter? 

MS TAYLOR:  That's a provision under the reportable incident   incident management and reportable incidents rule, and that section require   enables the Commission to ask a provider certain things. 

MR FOGARTY:  To do? 

MS TAYLOR:  To do, in response to an incident. 

MR FOGARTY:  In this case, the letter, you agree, asked or required of Afford to initiate an internal review of its incident management system to identify any incidents and the letter set out a period from 1 January 2021 to 31 August 2021. 


MR FOGARTY:  That may be reportable incidents and any incidents found to be reportable had to be reported within seven days. Secondly, to provide documentation on how Afford identify and report incidents, and then to provide a list of other forms of information. I won't walk through them all, but training logs regarding supports or, for Mr Stumpo, so this is quite specific to him, corrective actions implemented after the incident to mitigate risks, details of any incidents involving the client regarding choking or near misses since the date of the incident, etcetera. 

The   Afford in October in response to that letter informed the NDIS Commission that in the period, so in answer to the first part, in the period 1 January 2021 to 31 August 2021, an eight month period, it had identified 5,722 incidents of which 267 were notified as reportable incidents to the NDIS Commission, 56 of which were notified late. Do you agree that's in paragraph 91 of your statement? 

MS TAYLOR:  Yes, that's in my statement, yes. 

MR FOGARTY:  Then in November 2021 the Commission asked for some more detail regarding the responses it provided, including around the identified incidents, and the reason being the NDIS Commission said it wanted to better understand the scale of seriousness of those incidents. Given, as I understand it, the   essentially the response from Afford in October has really just been the numbers. Do you agree? 


MR FOGARTY:  Then in December 2021 Afford's client services project manager sought guidance from the NDIS Commission, its reportable incidents team regarding the definition of "missed medication" and you refer to that in paragraph 99 of your statement. 


MR FOGARTY:  Is this a fair summary: that to that point Afford or certainly what was expressed by the client services project manager had considered missed medication was only reportable if it was deliberately not administered? 

MS TAYLOR:  Not as I understand. 

MR FOGARTY:  And in the same correspondence the client services project manager indicated that there would be at least 1500 incidents in which medication had been missed over the last six months, and asked how to deal with them. 

MS TAYLOR:  Over the previous six years, I think in my statement. In paragraph 99. 

MR FOGARTY:  Thank you. That's right. Over the last six years. And asked how to deal with them; is that correct? 

MS TAYLOR:  Yes. Yep. 

MR FOGARTY:  Part of the role of the NDIS Commission, I think you provided evidence before, is to assist with compliance where a provider is asking for that assistance; correct? 

MS TAYLOR:  That's absolutely right. 

MR FOGARTY:  So that request isn't out of the ordinary or something that the NDIS Commission couldn't assist with? 

MS TAYLOR:  No, it's a very regular thing for providers to seek guidance about whether or not an incident is reportable and our staff, we have sensitive material describing what is reportable and what is not. Sometimes to be honest those issues might not be entirely clear and in this instance the organisation quite rightly sought our guidance. We've been engaging with them about things that they haven't reported. So it seems apparent to me that they were taking some caution to make sure that they were reporting the right thing. 

MR FOGARTY:  This is December 2021 last year; correct? 


MR FOGARTY:  At that time the Commission writes back a letter and you've at paragraph 100 extracted part of that or there is a reference to it:

"There are some circumstances where missed medication may not be reportable. However, if a doctor prescribes medication and Afford has responsibility to administer the medication, and failed to do so, this could constitute neglect and therefore is reportable."

In other words, you agree, it doesn't need to be deliberate at all? The miss by Afford or staff? 

MS TAYLOR:  No, it could be neglectful to forget   forget to provide a person with the medication, yes. 

MR FOGARTY:   Does it concern you that as at December 2021 a member of Afford   well, that that question and that guidance was being sought by this provider? 


MR FOGARTY:  Alright.

CHAIR:  Yes, because, missing medication is extremely important? 

MS TAYLOR:  Absolutely. And  

CHAIR:  And is a reportable incident regardless of whether the missing of the medication was inadvertent or deliberate because the consequences can be very severe for the participant? 

MS TAYLOR:  That is   that is correct, depending on the medication and its purpose, that is   that is correct.

CHAIR:  That's correct. 

MS TAYLOR:  I was   I'm concerned about this on two levels, that they were seeking guidance from us about   well, two, three, many levels   seeking guidance from us at this   at this point in 2021 that there had been a number of matters that had been not reported, and   and I've   I formed a view that I still don't think it's clear to me, at least, that there is clarity about what should or shouldn't be reported. 

MR FOGARTY:  And you've expressed that? 

MS TAYLOR:  I've expressed that, yeah. 

MR FOGARTY:  In a recent letter to Ms Toohey, the CEO; correct? 

MS TAYLOR:  Yes, I have, yeah. 

MR FOGARTY:  Alright. Moving on sequentially, February 2022   I withdraw that. In December, so the same month, the NDIS Commission responded and asked Afford to clarify the exact number of incidents of missed medication since 1 July 2018 when the NDIS regime was in place? 

MS TAYLOR:  Mm hmm. 

MR FOGARTY:  The exact number of instances missed that Afford had assessed as meeting the reportable incident threshold and then, lastly, the number of incidents that the identified reportable incidents missed medication relate to. And in February of this year   this is paragraph 104 of your statement   Afford's Chief Operating Officer answered the request and in terms of missed medication incidences since 1 July 2018, so approximately three and a half years, day programs, so I broke it down into day programs, or dating, I should say, 225 is identified, then group home respite, 744. So in total 969. And the letter then identifies all of those as being reportable incidents that should be reported, and then data is given or a response is given in terms of the number of participants affected and in total over the day programs and in group homes and respite 212. You agree with those figures? 


MR FOGARTY:  As provided by Afford? This is February 2022. You referred to a meeting on 30 March between the NDIS Commission and Afford including Ms Toohey, the CEO. This is I think in the following   


MR FOGARTY:    following paragraph. You didn't attend that meeting? 

MS TAYLOR:  No, I didn't. 

MR FOGARTY:  You say in your statement: 

"It was to discuss a range of issues and Afford outlined its operational and governance review, its reform and changes taking place and intended, and it agreed to provide the NDIS Commission with its business improvement plan once approved by the board."

Also, your statement says that it was agreed there would be scheduled ongoing three monthly meetings.

MS TAYLOR:  Yes, that's what I understand was agreed at that meeting. 

MR FOGARTY:  And you're aware one's coming up? 

MS TAYLOR:  I couldn't tell you    that that will happen as agreed. 

MR FOGARTY:  But would you be part of that in your role or not? Are you part of that, I should say? 

MS TAYLOR:  No, I'm not part of that. I would leave that to the branch head   . 


MS TAYLOR:  I've offered separately to meet with the CEO of Afford about my concerns and what form compliance action might take and to discuss that issue. 

MR FOGARTY:   To your knowledge, the NDIS Commission requested that meeting with Afford or was it the other way around? 

MS TAYLOR:  No, I think we requested that meeting. 

MR FOGARTY:  I don't think your statement makes that clear. 

MS TAYLOR:  I might need to confirm that for you. 

MR FOGARTY:  Alright. To your understanding though, was this the   this was the very first time the NDIS Commission had met with any Afford officer face to face about any of the investigations and compliance matters being conducted by it about Afford? 

MS TAYLOR:  I can't answer that. 


MS TAYLOR:  I'd have to presume that given most of our investigations have occurred through the period of the pandemic, that   that there haven't been too many face to face engagements. But I couldn't tell you whether or not some of the engagements that are set out in my statement happened face to face with officers. Of course, there have been various interviews and other things undertaken as part of our investigation. 

MR FOGARTY:  But you haven't been involved in any   any meetings face to face or Zoom or otherwise with   


MR FOGARTY:    the Executive of   Senior Executive of Afford in respect of any of these matters I've been referring to? 


MR FOGARTY:  And just to clarify   forgive me, I can't remember the period, I think it is set out in your statement   you were acting NDIS Commissioner between what dates? 

MS TAYLOR:  From 1 July 2021 till 9 January 2022. 

MR FOGARTY:  Alright. In November 2021 you refer to this at paragraph 117 that:

"The NDIS Commission introduced a new practice standard and quality indicator for mealtime management."


MR FOGARTY:  And that commenced on 13 December 2021. Do you understand what practical effect that would have on service providers like Afford that now a new compliance or a new registration compliance step that they must show in meeting? 

MS TAYLOR:  Yes. So this   this new standard, together with the emergency standard, were introduced around the same time. The mealtime standard, and also in addition to the high intensity   I completely have a blank   high intensity daily personal activity suite of standards around exposure and dysphasia. 

MR FOGARTY:  So there were a number of   

MS TAYLOR:  So there were a number of things. So those mealtime supports came up as a significant contributor to avoidable deaths in the scoping review that the Commission undertook in 2019. Julian Troller did that piece of work for us. It's available on our website and I think the former Commissioner has given evidence to the Royal Commission about it. And mealtime supports is a   as I say, a significant contributor, based on the evidence that   that Professor Troller reviewed from the extensive experience of other jurisdictions prior to our commencement. And, indeed, we have seen that mealtime support issues are significant numbers in our reportable incidents scheme. 

This standard is to give unequivocal instruction, if you like, through a standard about what each participant requiring the mealtime supports from a   from any provider would expect, and the indicators provide the   the guidance along with a whole range of other materials that we've given to the sector and continue to roll out about  how to deliver mealtime supports in a   in a safe manner, particularly for people with more complex support needs. 

MR FOGARTY:  And would you say, given that   what you know, and I accept that it remains open, but Thomas Stumpo matter and indeed in paragraph 24, at least one of incidents of those nine we discussed earlier   in fact two now that I took at it   involve issues around choking at mealtime. That appears to be something that has been an issue for   at least an alleged issue for Afford. 

MS TAYLOR:  They are terrible examples of why this is a significant issue in this sector. 

MR FOGARTY:  Chair, I note the time. Regrettably, I'm not through the course of questions I'd like to ask Ms Taylor.

CHAIR:  Should we continue tomorrow? 

MR FOGARTY:  If that's possible with Ms Taylor? 

CHAIR:  Is that possible, Ms Taylor? 

MS TAYLOR:  I can make myself available. 

CHAIR:  Thank you, we appreciate that. I think that should be done. I think there are a number of issues that emerge from the statement, not to the discredit of Ms Taylor but information that I think needs to be pursued. So we will do that. So we will resume with Ms Taylor tomorrow at 10, and we   is there anything else we need to do now before adjourning? 

MR FOGARTY:  I don't think so, Chair.

CHAIR:  Alright. Well then, arrangements can be made, I'm sure, with the other witnesses who are to appear tomorrow so they know what is likely to transpire as far as timing is concerned. 

MR FOGARTY:  Yes, Chair. I understand a reading of Rachel's statement was the first thing and then Mr Adamson was the only witness otherwise proposed tomorrow. I can make those arrangements, I'd be grateful.

CHAIR:  Alright. We will adjourn now until 10 am tomorrow.