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Public hearing 26 - Homelessness, including experience in boarding houses, hostels and other arrangements, Parramatta - Day 5

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CHAIR: Good morning, everybody. Welcome to this, which is the fifth and final day of the 26th Public Hearing of the Royal Commission into Violence, Abuse, Neglect and Exploitation of people with disability. And this hearing is concentrating on the experiences of People with Disability who have been homeless or are at risk of homelessness in a variety of settings. I wish to commence, as always, with an Acknowledgment of Country. On behalf of the Royal Commission I wish to acknowledge the Dharug people, the traditional custodians on which the hearing is taking place. And we pay our respects to their Elders, past, present and emerging. We also pay our respects to all First Nations people who are attending the hearing in person today or who may be following the hearing on the live stream.

Yes, thank you. Yes, Ms Eastman. 

MS EASTMAN: Thank you, Commissioners. Good morning, Commissioners, and good morning everybody following the Royal Commission proceeding, be it in the room or online. So, Commissioners, we start this morning with Georgia Wilson. She's going to tell you her story and the story of her mother, and then after Georgia has finished her evidence, we will then turn to hear some evidence about the Quality and Safeguards Commission. It will be the first opportunity for the Royal Commissioners to hear from the new Commissioner, Ms Mackey, and Ms Samantha Taylor, who have you heard from on a number of occasions, will return. 

And then after we have completed the NDIS QSC evidence, we will then turn to Victoria, and you will hear from two officials from the Victorian Government responsible for the regulation of SRSs and broader housing policy. For those following the proceedings, we hope we will probably conclude today around 3 or 3.30. So, Commissioners, I would like to introduce to you Georgia Naomi Wilson. She is in the hearing room, and I think the first thing you need to do is take the oath. 

CHAIR: Ms Wilson, thank you very much for coming to the Royal Commission to give evidence today. Thank you also for the statement that you have prepared, which each of us has read. We are very grateful for the assistance that you are providing to the Royal Commission. If you would be good enough to follow the instructions of my associate, who is located over there, he will administer the oath to you.



CHAIR: Thank you very much Ms Wilson. Just to explain where everybody is, you may already know, Commissioner Galbally, whom you can see on screen, is joining the hearing from Melbourne. Yes, she just waved, and you waved back.  Commissioner Ryan is here on my left. 


CHAIR: And I'm the Chair of the Royal Commission and, of course, Ms Eastman is in the same room, and I will ask Ms Eastman now to ask you some questions. 

MS EASTMAN: Just before I do that, so Ms Wilson is also represented, and I will just ask Ms Almond to announce her appearance. 

MS ALMOND: Thank you, Ms Eastman. 

CHAIR: There you are. 

MS ALMOND:   May it please the Commission, I, Elise Almond, appear on behalf of witness Georgia Wilson. 

CHAIR: Thank you very much. 

MS EASTMAN: We have to do a few formalities so can I confirm you are Georgia Naomi Wilson. 


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


MS EASTMAN: And you prepared a statement for the Royal Commission? 


MS EASTMAN: And I know you have had a chance to look at the statement again, but everything in the statement is true; is that right? 

MS WILSON: Yes, it is.

MS EASTMAN: You want me to call you Georgia this morning. Is that okay?


MS EASTMAN: Now, Georgia, your Statement is about your mum, Kaye Alice Wilson. 


MS EASTMAN: And it's about the time she spent in a Supported Residential Service, an SRS. 


MS EASTMAN: And she passed away on 13 April 2020. She was 65 years old, and she was living at an SRS. At the time of her death, she had lived at the SRS for about three months. 


MS EASTMAN: So before we start, can I express our condolences for the loss of your mother. 

MS WILSON: Thank you. 

MS EASTMAN: We know, from what you've told us, you loved her very dearly and she's still in your heart. 


MS EASTMAN: And today we wanted to make sure that we don't just talk about your mum, but this is her story as well as your story; is that right? 

MS WILSON: Yes, that's very important. 

MS EASTMAN: And we have agreed that we are going to see how we go, but if any time you need to have a break or you just feel you need to have a sort of moment to yourself, can you let me know and we can do that. 

MS WILSON: Yes. Thank you. 

MS EASTMAN: Alright. So, before I ask about your mum, can I do a little bit about you? 


MS EASTMAN: So you're 40 years old. Is that alright to say that? 


MS EASTMAN: And you live in Victoria? 

MS WILSON: Yes, I do. 

MS EASTMAN: And you have five children?

MS WILSON: Yes, I do. 

MS EASTMAN: Your eldest is 21. 


MS EASTMAN: And you have a beautiful little baby. 


MS EASTMAN: And your baby is here with you   not in the hearing room? 

MS WILSON: Yes, she is, yes. 

MS EASTMAN: And you are also a person who lives with disability? 


MS EASTMAN: You have an acquired brain injury? 


MS EASTMAN: And you tell us in the Statement how that came about as a young person as a result of a motorbike accident. 

MS WILSON: Yes, when I was 2 years old. 

MS EASTMAN: Yes. And you have also had some mental health struggles in your life? 

MS WILSON: Just around my mum, yes. 

MS EASTMAN: And you remember your mum used to say to you that, "the system doesn't look after those of us with disability, Georgia."


MS EASTMAN: And that's really stuck with you. 

MS WILSON: It has, yes. 

MS EASTMAN: And that's one of the reasons why you wanted to share your mum's story today at the Royal Commission. 

MS WILSON: Of course. Yes. 

MS EASTMAN: Okay. Do you mind if I ask you some questions about your mum? 


MS EASTMAN: So she was born in New Zealand? 

MS WILSON: Yes, she was. 

MS EASTMAN: And she's part Tongan? 


MS EASTMAN: And she moved to Australia when she was about 22? 


MS EASTMAN: And that's because she's a beautiful singer and she wanted to pursue her singing career? 

MS WILSON: Yes. She was amazing. 

MS EASTMAN: What can you tell us about her singing and her career as a singer? 

MS WILSON: She was so gifted and an amazing singer, had an amazing voice, and she really took off in New Zealand and came here to make the big time. And she was almost there. She did a lot of recordings for a lot of artists and wrote a lot of songs that artists have used and   yes. 

MS EASTMAN: Was music an important part of your life growing up? 

MS WILSON: It was huge. Every day, mum would have music on. Every day. Like, life wouldn't be the same without it. 

MS EASTMAN: And you have still got some recordings of your mum? 

MS WILSON: Yes, I do 

MS EASTMAN: So you are able to watch them and listen to music?


MS EASTMAN: Does music sort of help you feel better in yourself as well? 

MS WILSON: Yes. It really grounds me, yes 

MS EASTMAN: Can I ask you now a little bit about your family? 


MS EASTMAN: So your mum had been living in Australia for a few years and she was diagnosed with schizophrenia? 

MS WILSON: Yes, she was. 

MS EASTMAN: That diagnosis arose when your brother was quite young; is that right? 

MS WILSON: Yes, he was a baby. 

MS EASTMAN: And in term of what you remember about your mum when you were a child is that she had some struggles from time to time, didn't she? 


MS EASTMAN: But she was still the super woman to you? 

MS WILSON: She was my queen. 

MS EASTMAN: And you watched your mum over time in terms of her own mental health, and it did go down a little bit? 


MS EASTMAN: And there was a period where you and your brother had left home, you had grown up and you thought she was sort of suffering empty nest syndrome? 


MS EASTMAN: But you felt really that for her to be alone was really affecting her mental health; is that right? 

MS WILSON: Yes, I did. 

MS EASTMAN: And when you and your brother had left home, your mum changed where she lived a few times. Is that right? 

MS WILSON: Yes, she did. 

MS EASTMAN: So, she lived in different places in Melbourne? 


MS EASTMAN: And some of them were private rentals? 


MS EASTMAN: And she lived in some social housing flats? 

MS WILSON: Yes, she did. 

MS EASTMAN: And for a while she lived in a mental health hostel? 


MS EASTMAN: And that followed coming out of hospital for some treatment. Is that right? 


MS EASTMAN: Okay. And then your mum lived with you. She came to live with you? 

MS WILSON: She did, yes. 

MS EASTMAN: Can you tell us about what it was like with mum coming to live with you? How many kids did you have at this stage? 

MS WILSON: I had four. 

MS EASTMAN: Four. Okay. So, your mum is coming in. You have got four kids. How did that all go? 

MS WILSON: Good. Mum was my   you know, very supportive. She loved family. She was always around anyway, like, regardless of where she lived. Helping me and supporting me. And I was the same for her. So, we were kind of like two peas in a pod, me and mum, in the way we supported each other, and she loved it. She loved being around her grandchildren and, you know, helping me and just being a mum. You know, just being that nurturing, caring person that she was. Yes. 

MS EASTMAN: The house started to get a little bit cramped? 

MS WILSON: It did, yes. So, mum was living with me for about six to seven years, and from what I learnt of her mental illness as she got older, it became harder for her to sustain her life in certain circumstances, and one of them was living around my boys who were now teenagers. And she didn't like the ruckus, the, you know, teenage life and so she   we   we had made the decision, so me and my brother and my mother and her mental health workers, that maybe it would be best for her to move into another facility. 

MS EASTMAN: Can I jump in at that point. So, this was around the time that your mum was in her early 60s? 


MS EASTMAN: And when she was about 62, 63, she became an NDIS participant? 

MS WILSON: Yes, she did. 

MS EASTMAN: And she had some support workers to   


MS EASTMAN:   assist her in terms of supporting her decision making but also assisting her in terms of where she might want to live? 


MS EASTMAN: Okay. So, your mum had made it pretty clear that while she loved you dearly, she needed her own space? 


MS EASTMAN: And her idea was that she wanted to live in something that really felt like a home. She didn't want to live somewhere that felt like an institution? 


MS EASTMAN: Is that right? 


MS EASTMAN: Okay. And it was important to her that the doors would not be locked so she could come and go as she pleased and that there was no curfew? 

MS WILSON: Yes, that she had that independency that she wouldn't have had if she had gone to a hospital based facility. 

MS EASTMAN: So she didn't want to go to hospital. So, a hospital facility. She didn't want to go into aged care, did she? 

MS WILSON: Aged care was an option, but because of the NDIS and her still being on Disability Support Pension, we thought that a facility would be more around her needs. 



MS EASTMAN: Now, at this time, had you ever heard anything like an SRS?


MS EASTMAN: And you had ever seen an SRS? 


MS EASTMAN: And no one in your family had ever lived in an SRS? 


MS EASTMAN: But your mum's health worker suggested that she move into an SRS, and you took your mum to have a look at one? 


MS EASTMAN: And we are not going to name the particular place. 


MS EASTMAN: And you remember her saying "it's perfect for me."? 

MS WILSON: She loved it. 

MS EASTMAN: What did she like about it? Purple walls. What else did she like? 

MS WILSON: She loved it because it was in the   it was close to the city and mum was a city girl at heart, and she loved the big lights and the   the flashiness of it all. So   and it was close to everything. So, amenities and things that she could just go for a walk down the road and she would be   everything was   and the facility itself, mum loved her bedroom, she loved the garden. She was really comfortable in that facility. 

MS EASTMAN: Yes. And were you happy about her moving into the SRS at the start? 

MS WILSON: Yes, at the beginning. 100 per cent. If mum was happy, I was happy. 

MS EASTMAN: Okay. And so you met the manager of the SRS? 

MS WILSON: Yes, I did. 

MS EASTMAN: And you remember him telling you that your mum was going to have her every day needs supported   


MS EASTMAN:   while she was living there. She would have three meals a day, morning, afternoon tea? 


MS EASTMAN: She would have medical care, appointments with the GP who would visit the SRS twice a week. And assistance with self-care? 


MS EASTMAN: And he also told you that the residents would be provided with excursions and daily activities? 


MS EASTMAN: Alright. Now, just let me ask you this, can you remember, in terms of your mum being on the NDIS, did she have a particular organisation that helped her with her supports? 

MS WILSON: Yes, she did. 

MS EASTMAN: And they were different to the people who operated the SRS? 

MS WILSON: Yes, they were.

MS EASTMAN: Is that right? Okay. But the manager from the SRS said these are the things we can do to support your mum? 


MS EASTMAN: Okay. And your mum was required to pay approximately $490 per week? 


MS EASTMAN: For her accommodation and daily support. And where did she get the money to pay that? 

MS WILSON: She had a Disability Support Pension. 

MS EASTMAN: So her pension was   

MS WILSON: All of her pension went. 

MS EASTMAN: Did she have any money left over after that? 


MS EASTMAN: Now, in the Statement that you have given to the Royal Commission you remember the manager insisting at the SRS   


MS EASTMAN: Insisting on seeing your mum's NDIS plan, and he said to you "it's all about money, money, money."  Why do you remember that? 

MS WILSON: It makes me quite sick to talk about this now because at the time, I thought it was weird, just dark joke of his. But I remember him asking me on the day of my mum's arrival, he said "hey Georgia, do you have the NDIS papers."  And I said, "no, not on me."  I said, "they are still at home. Would you like me to bring them?"  He goes, "oh yes, they are very important."  And I kind of found it strange that they would be important since mum had, like, an NDIS card, she had other things that were NDIS related. And I said, "why are they so important?" Like, I didn't understand. And he looked at me and he said, "money, money, money" and he rubbed his hands together. And I thought   that's a bit strange. Like, my mum is not a pay cheque. Like   but yes.

MS EASTMAN: So, that conversation you still remember really clearly, don't you? 

MS WILSON: 100 per cent, yes. 

MS EASTMAN: Now, it was hard for you to accept that somebody else would be supporting and caring for your mum, but you put your trust in that SRS? 


MS EASTMAN: And you relied on what the manager told you about what was going   

MS WILSON: Yes, I did. 

MS EASTMAN:   to be done to support your mum? I know you feel very guilty about that now. So, can I ask you some questions in terms of what happened once your mum moved in? 


MS EASTMAN: So you helped your mum move in around February 2020? 


MS EASTMAN: And you helped to set up her room? 


MS EASTMAN: Feeling comfortable. And in terms of being able to contact your mum at the SRS, you were given the office phone number? 


MS EASTMAN: And   but you didn't have any after hours number? 

MS WILSON: No, there was no emergency number or   yes. 

MS EASTMAN: And your mum had a mobile, but she wasn't the best with the technology, was she? 


MS EASTMAN: So you wanted to make sure you had a landline number that you can call? 

MS WILSON: Yes. Yes, I did. 

MS EASTMAN: And when she moved into the SRS, there were about 27 other people living there? 


MS EASTMAN: And your mum was, you thought, probably the oldest person there? 

MS WILSON: Yes, she was. 

MS EASTMAN: But she had her own room? 


MS EASTMAN: And her room had both a shower and a toilet? 


MS EASTMAN: And she had an emergency buzzer in her room if something happened to her? 


MS EASTMAN: And the manager said to you, if anything goes wrong or she needs help, she can just buzz? 

MS WILSON: And he made it clear that someone would be there instantly for her care. 

MS EASTMAN: Now, when your mum moved in, did you know how many people actually worked at the SRS? 

MS WILSON: No. I wasn't   all I was told by the manager was that there would always be someone there 24/7 for the residents. 

MS EASTMAN: But over the time your mum was there, you only ever saw two people there? 


MS EASTMAN: The manager and the cook. Is that right? 


MS EASTMAN: Now, not long after your mum moved in, say, about a month or so, you started to sort of have some concerns? 


MS EASTMAN: And you went to visit your mum and you took your then 8 year old and 6 year old son and daughter with you? 


MS EASTMAN: And something happened that was quite scary. What do you want to tell the Royal Commission about what happened on that day? And if you don't want to talk about it, tell me. I can do it, but I thought you might want to tell the Royal Commission that. 

MS WILSON: Yes. So, I had taken my children that day to visit mum. It was a Sunday. And we had gone to visit grandma like we normally did, and we were sitting outside in the communal backyard area. Now, in the backyard area, there are two entrances to get to the backyard. One is from where the bedrooms are, and the other is from a communal lounge room. And we were sitting outside, and my mum had told me that there was a racist resident there. And about two seconds later she had hunched over and had this really angry, scared look on her face. And I looked behind me and I said, "mum, is that him?" And he was a guy, maybe in his early 40s, and he had approached us, and he looked at my mum and he said, "I see you bought your fucking ghetto with you today, Kaye" and I looked at this man, and I said, "what did you say to my mother?" And he walked inside, through the bedroom area of the entrance. At this point, he had come back out two minutes later, and he said to my mum, "I'm going to fucking kill you, Kaye. I'm going to do exactly what you did to her. I'm going to rape you and I'm going to fucking kill you." 

MS EASTMAN: You were absolutely terrified, weren't you? 

MS WILSON: I was livid. My children were extremely traumatised by seeing this, seeing this man talk to grandma in such a way. My daughter was screaming. Mum said   mum was so calm though. And she said, "don't worry about him. He has issues. Take the kids home. They can't be around this." 

MS EASTMAN: And there were no staff around at the time? 

MS WILSON: No, there was nobody. 

MS EASTMAN: Well, there was a couple of other of the men who lived there? 

MS WILSON: Residents. Residents there, yes 

MS EASTMAN: And they said, "look, we will look after your mum."? 

MS WILSON: Yes, so we walked inside, and I said, while I was walking with mum inside I said, "where is the manager? Is there anyone here?" And the two male residents that told me that they would look after my mother said, "he's never here." 

MS EASTMAN: You did speak to the manager the next day? 

MS WILSON: Yes, I did. I called him first thing in the morning. 

MS EASTMAN: And the manager told you that the man who had sworn and threatened your mother had been admitted to hospital? 

MS WILSON: Yes, he did. 

MS EASTMAN: And that he wouldn't be returning to the SRS? 

MS WILSON:  Yes, he did. 

MS EASTMAN: So that incident started to be that change for you of, "I'm not quite sure this is the best place for my mum."  Is that right? 

MS WILSON: Yes. I said to mum at the time, I said "come home with us. It's not safe here." And she said "I'm fine. I'm fine. They will look after me" and she was referring to the residents there. And she said, "the manager will be back" and, you know, "I'm fine, I'm safe". 

MS EASTMAN: Now, I want to ask you about something that happened around 14 March. This is about six weeks into your mum being there. 


MS EASTMAN: So around 8.30 at night, you got a call from the cook at the SRS. 


MS EASTMAN: To say your mum had been taken by ambulance to hospital and she was having breathing difficulties? 


MS EASTMAN: And the cook said that your mum seemed to be okay, but she couldn't tell you anything about it? 


MS EASTMAN: So, you had to then chase up and see what was happening with your mum at the hospital. Is that right? 

MS WILSON: Yes. Yes. 

MS EASTMAN: And you found out that your mum was in the emergency department and on oxygen? 


MS EASTMAN: And that she had had an obstruction to a   a cardiac obstruction that affected her breathing.

MS WILSON: A pulmonary obstructive, yes. 

MS EASTMAN: So your mum had to spend a bit of time in hospital?


MS EASTMAN: But hospital is not your mum's favourite place, is it? 

MS WILSON: No, no. 

MS EASTMAN: So she got quite anxious about being in hospital? 

MS WILSON: She did, yes.

MS EASTMAN: And she actually wanted to get out of hospital and go back to the SRS; is that right? 


MS EASTMAN: So when your mum came out of hospital and back to the SRS, did you help her with that sort of move back? 

MS WILSON: Yes, with the transition, of course. I was there first thing on the Sunday morning, 15 March. And, yes, I   I said to the doctors   they said, "if your mum refuses to stay here, we can't force her." 


MS WILSON: So they had told me strict instructions to give to the manager of the facility regarding her   her ongoing healthcare. 

MS EASTMAN: Yes. So, just pausing there. So, the hospital said, "we can't make your mum stay."?

MS WILSON: “We can't”, yes. 

MS EASTMAN: But if she is to go back to where she lived   


MS EASTMAN:   she had to be strict on her medication? 


MS EASTMAN: And be supported in terms of when she took the medication? 

MS WILSON: Yes. And what type of medication it was, that they were going to administer it through an IV in hospital over two days, but because mum had refused admission, it could be given to her through a tablet. 

MS EASTMAN: So when your mum got back to the SRS, the only person around was the cook? 


MS EASTMAN: And you wanted the mobile number for the manager so you could give some instructions about what your mum needed to do? 

MS WILSON: Yes, yes. So I walked up to the cook, and she couldn't understand a word I was saying. And she said, "go into the office and write it in the manager's diary everything the doctor told you to tell   to tell him and I will let him know first thing in the morning."

MS EASTMAN: Okay. Just for   many people will remember, the 14th of March and what happened in the following week in March 2020 was pretty big, because the country went into lockdown about 10 days later. 

MS WILSON: Yes. Yes. 

MS EASTMAN: And one of the real concerns for you was, given your mum's health, returning to the SRS and the first lockdown starts in March 2020, you were not able to visit your mum? 


MS EASTMAN: And all you could do was talk to her on the phone; is that right?


MS EASTMAN: And in   so just let me know how we are going, if you need a break. You got a call on the 5th of April from your mum, and you said she felt really upset and panicked. And that the SRS manager had threatened her. That's what she told you? 


MS EASTMAN: And she had been accused of putting sanitary pads in the communal toilet and creating a plumbing issue? 


MS EASTMAN: And as far as you knew, your mum was not using any sanitary pads at aged 65? 

MS WILSON: No, and there had already been two plumbing issues previous to that week. So, at this point, the manager was extremely angry with whoever it was that was doing it, but he accused my mother. 

MS EASTMAN: You couldn't get there to see your mum or see what was going on? 


MS EASTMAN: Alright. About a week later   we are now at 13 April 2020. What I might do is just walk through this Georgia, and if at any time you want to jump in or say anything, let me know. So, Commissioners, on 13 April Georgia says this: 

"Shortly after midday I received a call from a Senior Constable who worked for [REDACTED] who let me know that my mother had passed away that morning and I needed to visit the SRS to identify her body. I called Joe..."

That's your brother: 

"...on the way to the SRS. We assumed mum had passed peacefully in her bed during the night. In this conversation, Joe and I agreed that it would be undignified for mum to have an autopsy given her mental health struggles and poor interaction with doctors during her life. When I arrived at the SRS, I was asked by the police to put on full protective gear because we were in lockdown. I mentally prepared myself for the long walk to my mother's room, where I assumed she would be. But immediately when I got inside the police started saying, 'are you ready?'"

MS WILSON: Are you ready. 


"I turned the corner, and I could see my mum's body through the sliding door to the back courtyard. Lying on the concrete, just outside the dining room in the communal area, and she was covered by a tarpaulin. I was appalled. Nobody had thought to move her to a bedroom or to place her anywhere less public or more dignified. Mum had not been respected or dignified by being left on the ground. The police lifted the tarpaulin so I could formally identify her. 

When I saw her face, she looked like she was in tremendous pain, and I will never forget that look. The police told me she had been found dead at 10.30 am on the backyard couch, which was next to where she had been lying on the ground. They said the paramedics arrived at approximately 10.45 am but had moved mum from the couch to the ground to perform CPR. The paramedics attributed her death to natural causes, so they did   it did not need to be reported to the coroner. They explained that I had the option of reporting her death if I thought it was suspicious."



"But that I would need to fill out a tonne of paperwork if that's something I wanted to do, and I felt completely overwhelmed just after identifying my mother's body."



"And I wasn't in the right mindset to think about paperwork. At the time, I had no reason to feel suspicious, so I decided not to do that." 

Okay. Just pausing there. 

MS WILSON: I just wanted to say that when the police had asked me whether I thought my mum's death was suspicious, I found that extremely odd, given the fact that we were in lockdown. So, we weren't sitting inside the facility. I was outside the front on a plastic chair and the   just   the whole environment of it just seemed odd. Really off. And, yes, when they said, "if you find your mum's death suspicious, we have a tonne of paperwork for you to fill out", I didn't know what that   what that meant. Like, what would I have to fill out? Would it   what questions would be on it? What would   I didn't know what I   you know, have to do. So, I didn't do anything at the time. 

MS EASTMAN: I think, Georgia, fair to say you were absolutely in this state of shock? 


MS EASTMAN: So you had to attend to what happened next with your mum? 


MS EASTMAN: To organise a funeral? 


MS EASTMAN: To collect her belongings? And you wanted to sort of sort out what was going on? 

MS WILSON: Well, mum didn't have a funeral until a year later when my brother could come from New Zealand. 

MS EASTMAN: You have told us in the Statement   and you have given us a note   that you got an email from the funeral home? 

MS WILSON: Yes, I did.

MS EASTMAN: Who came to take your mum's body, and they   can I read this? This is how they described your mum: 

"Physically, Kaye was very dirty. Dirt or similar under all nails, across hands, legs, neck and face. In addition to Kaye's   Kaye's long hair was matted. Kaye's clothing was old, stretched, one foot had multiple socks and there was a hole in the bottom of her shoe. Both her feet felt very wet, and Kaye had strong body odour."

So, Georgia, that for you to hear someone describing your mum with that lack of dignity is something that has driven you to do the steps that you've taken, to come and speak to the Royal Commission, and I'm going to ask you about some of the things that you did in terms of taking this to the government regulators to find out what happened. Is there anything you want to say at this point? Or just take a deep breath. 

MS WILSON: At that point in time, I had already put in a formal complaint with the Department of Health and Human Services. But I was going purely on intuition. I didn't have any facts. All I knew was my mum was on the couch, paramedics has moved her, and put her death down to natural causes. So when I received that report that was   yes. That was something else. 

MS EASTMAN: Had you ever heard of anybody called NDIS Quality and Safeguards Commission? 


MS EASTMAN: Have you ever heard of that body? 


MS EASTMAN: So you did want to find out what happened to your mum. 


MS EASTMAN: And some of the steps you took included speaking to the GP? 


MS EASTMAN: And the GP told you your mum hadn't been taking the medication? 

MS WILSON: Yes, and I had been told she did take the medication by the manager the day after I had left the note. 

MS EASTMAN: Yes. You wanted to find out what did the paramedics actually do. So, you wanted to get information about the paramedics reports? 

MS WILSON: Which I did. 

MS EASTMAN: Yes. And, as you said, you raised it with the Victorian Department? 


MS EASTMAN: And a year later   so we're up to April 2021   

MS WILSON: Can we   

MS EASTMAN: Is there anything in between there? 

MS WILSON: So, okay, yes. So, the Department were in line in doing a full investigation on the facility in September 2020. 


MS WILSON: And all I had at that point was the doctor's word that mum didn't take the medication and the report that I had from the funeral director. In November of 2020, I received two copies of the paramedics reports. And on those reports, they both stated that my mother was sitting on the ground, not on the couch, deceased for two and a half hours before they arrived. So, she was never on the couch. They didn't move her. And her death could not be determined because of the amount of time she was lying there, so she needed to go to a coroner. But I was told she didn't. 

MS EASTMAN: So, Georgia, it's been difficult for you to actually find out what happened? 

MS WILSON: Yes. But I had sent these documents to the Department of Health and Human Services, trying to be as transparent as I could be during the whole investigation process. 

MS EASTMAN: But it was about a year later   so April 2021. 


MS EASTMAN: You still hadn't received any formal indication of what enforcement activities might be happening for the SRS, and you decided to send a follow up email. The day after the anniversary of your mum's passing, you got a call from a regulatory officer who told you that the investigation was now closed. And she told you that fortnightly auditing systems had been ordered for the SRS. And the regulatory officer   so this is what you say in your Statement: 

"The regulatory officer indicated to me that they would have never have known about what happened at the SRS if I did not make a complaint."



"I said something like, 'SRS accommodation is under your umbrella. What do you mean you wouldn't have known?' And the regulatory officer indicated to me, nothing further could be done by the Department and that her hands were tied."

That didn't stop you. You sent a follow up email two days later   that day or so, and then two days later you got an email from the Department. Do you want me to read what that says? 



"The regulatory compliance and enforcement team investigated your complaint and substantiated the following allegations. " 

First dot point: 

"The SRS failed to notify you of Ms Kaye Wilson's deteriorating condition when she allegedly declined additional support for her care."

Second dot point: 

"Ms Kaye Wilson's physical appearance was not adequately addressed while residing at the SRS."

The third point: 

"Following her passing, Ms Kaye Wilson was covered and left in the communal area at the SRS, and this did not afford her adequate dignity. As discussed, concerns relating to the cause of death or if Ms Wilson's death was preventable are not within our scope to investigate."

So you got that email. You then tried to contact the regulatory officer by phone and email to do a follow up meeting, and you didn't receive a response to that request. 


MS EASTMAN: Has anyone from the government contacted you? 


MS EASTMAN: Do you know anything more about what happened to the investigation beyond what's set out in the email? 


MS EASTMAN: Has anyone given you any advice about what further steps, if any, you could take? 


MS EASTMAN: And has anyone offered any apology to you about the circumstances of your mother's passing at the SRS? 


MS EASTMAN: Has anyone from the SRS contacted you to express any apology or provide any explanation? 


MS EASTMAN: Can I ask you about the impact of your mother's death and your concerns for the future? And I think you have said to us, Georgia, that you don't want anybody else to be this situation you've been in. 


MS EASTMAN: You have felt not only the circumstances of learning of your mother's passing and how you were treated on that day, but also what's happened in that time since has left you devastated and hopeless that the Victorian Government did not do an investigation that achieved better outcomes, and you feel anger and despair that other SRS residents may continue to experience neglect at the SRS. Is that right? 

MS WILSON: Can I just say   


MS WILSON: Yes, about that, I put all of my trust in that manager. All of my trust in the Victorian Government to do what's right. The manager lied, plain and simple. Now, what sort of   what   I'm trying to get my words. 

MS EASTMAN: That’s okay. 

MS WILSON: What does that paint, what picture does that paint when we as a society put our trust in these people to do the right thing, that's their job, and they don't do it. And my mother dies as a result of that neglect? 

MS EASTMAN: Now, having known nothing about SRSs   you now know a bit about SRSs. 


MS EASTMAN: And you've got some recommendations you want to share with the Royal Commission. 


MS EASTMAN: So, if you have still got your statement with you and you turn over to about page   top of page 14. Do you want to read these out to the Royal Commissioners or tell the Royal Commissioners what your recommendations are? 


MS EASTMAN: And I will get to you just cover what's on   so the Commissioners have got a copy of your statement. But I think people will be interested to hear, what do you think needs to happen? 

MS WILSON: Yes. Modification of the current regulations allowing for one to 30 staff to resident ratio in SRSs. A significant increase should be implemented to the amount of staff required, especially in the case of residents with mental disabilities. A ratio akin to one to 15 would be far more appropriate. 

MS EASTMAN: Implementation of universal auditing systems for SRSs involving regular audits on, at a minimum, quarterly basis but ideally a bi monthly basis. And each audit there needs to be a thorough check of the practices of the SRSs and the welfare of the residents. That's the second one. Over to you on the third one. 

MS WILSON: Yes. Implementation of a system of audit and accountability for the Department of Family, Fairness and Housing to ensure that any investigations being conducted into SRSs are done so properly, fairly and with a satisfactory outcome favouring public interests. 

MS EASTMAN: And the next one? 

MS WILSON: Implementation of greater restrictions on access to NDIS funds by SRS managers and care providers to prevent these funds being claimed by SRSs or caregivers who are abusive or neglectful. Thorough checks into practices of SRS managers or a care provider should be conducted before they are granted access to residents' NDIS funds. 

MS EASTMAN: Okay. And you have said you think there are many other aspects of the Australian disability system that need to change, but I'm just going to read the final two paragraphs, and then the Commissioners might want to ask you some questions: 

"My mother's disability did not make her lesser. And she should have been treated as a valuable human being, as all people with disability are. I feel that the SRS treated my mother as a number and a pay cheque. Based on my experience, I feel the Australian disability system treats people with disability without dignity, respect and humanity, and the government departments which are supposed to be there to investigate and prevent such mistreatment cannot be trusted to do their jobs correctly. This is not right. We need to do better. The administrative system within the disability sector ironically doesn't seem to be looking after those with a disability. So who is going to listen to me?"

Georgia, thank you for sharing your story and Kaye's story, for speaking so powerfully and being a powerful advocate for your mother. I think the Commissioners might have a few questions for you. 

CHAIR: Thank you. Do you mind if I ask my colleagues if they have any questions to put to you? 

MS WILSON: Yes, that's fine. 

CHAIR: Thank you. I will ask Commissioner Galbally first. 

COMMISSIONER GALBALLY: Thank you, Georgia. I just wanted to ask you, do you think SRSs should continue at all with those large numbers   you know, what's your perspective on their going on? 

MS WILSON: Yes, I don't   I don't think that staff to resident ratio is right. Given that in SRSs it's so broad in the sense of anybody with a disability, be it mental or physical, is allowed to live there, but it's one to 30 people. And that is an extremely hard task for anybody to do. It doesn't excuse it, but I think that it   if we can't do better in that ratio of making more staff present for these people, then why do we have these facilities at all? 

COMMISSIONER GALBALLY: Would you have liked other options to have been suggested when your mum wanted to, you know, move out and   for all the reasons you describe. Like a rental next door or a granny flat or something that might have been more   

MS WILSON: Appropriate. 

COMMISSIONER GALBALLY: Yes. And no one offered those things, I gather? 

MS WILSON: No. So, my mum couldn't live independently. Just   

COMMISSIONER GALBALLY: With her NDIS package to help her, yes. 

MS WILSON: Well, maybe that could have worked. But that was never brought on to the table. So, yes, but in hindsight that   yes, that would have been a great idea. 

COMMISSIONER GALBALLY: Thank you very much and thank so you much. It was very moving and my condolences too, of course. 

MS WILSON: Thank you so much. 

HIS HONOUR: I will ask Commissioner Ryan if he has any questions. 

COMMISSIONER RYAN: Thank you, Georgia, for coming to the Royal Commission. Obviously, my sincere condolences on the loss of your mum, who is clearly a special person to the world, given her capacity to sing and to improve people's lives. But look, I just wanted to ask, do you have any idea how your mum came to choose the SRS as an option? Was she able to explore other options? How did she get to find out about it and move there? 

MS WILSON: So we had about three or four appointments with her care team to discuss living arrangements and what sort of possibilities there were in the sense of aged-care, SRSs and things like that. And that's how we came to the conclusion of an SRS being more to suit her needs individually. 

COMMISSIONER RYAN: Who were the aged-care team? Were they hospital people or   

MS WILSON: She was involved with a mental health care team who were providing her support as well as the NDIS. 

COMMISSIONER RYAN: Did have a support coordinator from the NDIS? 

MS WILSON: No, not yet. Not at that time. 

COMMISSIONER RYAN: People have come to the Commission, you might have been aware of their evidence, where they describe SRSs as being like dumps, really, that you could smell how bad they were, that they were unclean and unkept, that there was broken furniture and broken facilities around the place. Would you care to comment on the condition and the hygiene of the SRS that your mum lived in generally? 

MS WILSON: I didn't really see anything that was hygienically out of sort, no. 

COMMISSIONER RYAN: And did your mum ever comment on the food that she received? 

MS WILSON: Yes, the   mum was a vegetarian so her diet was limited in the SRS. There was only one cook, and so mum would usually just get either soup from a cup or, like, egg   and egg on toast. That was her dinner on a daily basis. 


MS WILSON: Yes. Yes. 

COMMISSIONER RYAN: Thank you for coming to the Royal Commission. They were all the questions that I had but thank you for coming. It's an important story and I'm glad we heard it. 

MS WILSON: Yes, it is. 

CHAIR: Ms Wilson, I too thank you for coming to the Royal Commission and telling your story and your mother's story. I extend my sympathy to you too for the loss of your mother. I think that you have sought to honour your mother by coming here and telling us of her story, and you have done that. And we are very grateful for sharing your experience. I know it's not easy to do that. But you have done that, and we have learned from it. So, thank you so much for sharing that experience, your experience and your mother's experience with it. 

MS WILSON: Thank you. 

MS EASTMAN: So thank you, Georgia. And, Commissioners, could we have a short break of about 10 minutes? 

CHAIR: It's now just after 20 past 10. We will resume at 10.35. 

MS EASTMAN: Thank you.



 <RESUMED 10:38 AM

CHAIR: Yes, Ms Eastman. 

MS EASTMAN: Thank you, Commissioners. You will see that we have with us Samantha Taylor, who has appeared previously at the Royal Commission, and I think for the first time Tracy Mackey. So, I think they both have got to give their oath or affirmations and then I will introduce them and then we will deal with their written evidence. 

CHAIR: Yes. Thank you very much, Ms Taylor and Ms Mackey, for coming to the Royal Commission to give evidence. In your case, Ms Taylor, thank you for returning to the Royal Commission for another appearance. Just to let you know where everybody is, Commissioner Galbally, whom you can see on screen, is joining the hearing from Melbourne. Commissioner Ryan is on my left. Of course, Ms Eastman is in the hearing room. If you would be good enough to follow the instructions of my associate, who is located to my right, he will administer the oath or affirmation, as the case may be, to each of you. 



CHAIR: Yes, thank you, Ms Eastman. 


MS EASTMAN: Ms Mackey, can I start with you. Your name is Tracy Anne Mackey? 

MS MACKEY: It is. 

MS EASTMAN: And you've prepared a statement for the Royal Commission, dated 8 August 2022. 


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


MS EASTMAN: And I think I just mentioned to you, I am now aware you have a corrigendum to that statement with some corrections to paragraph 58 and 72; is that right? 

MS MACKEY: That's correct. 

MS EASTMAN: Alright. I think, Commissioners, you also have a copy of those amendments so I'm not going to spend time reading them out. But, Commissioners, we might include corrigendum in the bundles.  So with the combination of the corrigendum and the 8 August, the contents of your statement are true and correct? 

MS MACKEY: That's correct. 

MS EASTMAN: Now, I wanted to just   before I come to you Ms Taylor, Ms Mackey this is the first time you have appeared at the Royal Commission; is that right? 

MS MACKEY: That's right. 

MS EASTMAN: And you have been appointed the Quality and Safeguards Commissioner; is that right? 

MS MACKEY: That's right. 

MS EASTMAN: When did you take up that appointment? 

MS MACKEY: I took up that appointment on 10 January this year. 

MS EASTMAN: And in terms of the seven months since have you had the role of NDIS Commissioner; you tell the Royal Commission that you have initiated a Future State program of work to facilitate the maturing of the NDIS Commission's operations. Can you tell us just briefly what does this involve? 

MS MACKEY: Sure. So, as everyone is aware, the Commission is still a very young organisation, being only four years old, and certainly in the first four years, much effort and concentration has been on transitioning in all of the jurisdictions, which has been done in a staged way to allow the Commission to build up its capacity and functions, which are outlined in the Act and the Rules. And it’s now time for us to very much turn our attention to what the arrangements need to look like and how we will operate as a regulator going forward. 

So, we need to mature our approach as a regulator, and that's something that we are doing in tandem with the sector, who also newly regulated. So, it's a journey we have all been on. So, in terms of the Future State, what we have been working on is making sure we have got all the right pieces in place, for example, we have just launched our very first strategic plan, which gives you a sense of how young we are as an organisation, so that was only launched last week. 

And we have been talking a lot about how we move from start up to scale up, which is how you would expect any organisation to be in its early years. So there's lots for us still do, to make sure that we fulfil all of our functions in the best possible way. And we will continue to be an organisation very much focused on how we can improve over time the way in which we undertake our responsibilities. 

MS EASTMAN: Thank you. And you have set out in your statement   and I won't trouble you with these paragraphs   your relevant professional background. But I wanted to ask you this: Has any of your professional background involved working with the international human rights regime at all and the relevant human rights instruments? 

MS MACKEY: So when I worked for the Department of Families, Human Services   sorry, Families, Communities   FaHCSIA   I can't remember what the acronym stands for anymore. It was quite some time ago. 

MS EASTMAN: I might just ask you to slow down a little bit as well. 

MS MACKEY: Okay. So FaHCSIA, it was a Commonwealth department. I worked in what was the Office for Women, and we had quite a broad range of responsibilities, including those that related to a rights   the rights arrangements internationally. 

MS EASTMAN: And, as you are aware, the Convention on the Rights of Persons with Disabilities is a core aspect of the work of the NDIS Commission. What's your experience working with the CRPD? 

MS MACKEY: So I have certainly worked in human services for most of my career across all of the different domains, from children to people with disabilities, carers and refugees, and all of those have involved having an understanding of the arrangements around rights. I mentioned the Office for Women work in particular because it was a very strong and probably the dominant part of that work. 

MS EASTMAN: Forgive me for interrupting   and I may   my question may not have been clear, but just specifically, the Convention on the Rights of Persons with Disabilities. What has been your experience working with that convention? 

MS MACKEY: So in terms of working with that convention, I have worked in the disability space and been on boards that have   or organisations that deliver disability services. So, I have an understanding of the Convention professionally. I also have a brother that has a disability, and he has had that since he was born. He's my younger brother, and I have travelled through life understanding the challenges and the rights that he has and advocated and worked alongside others to try and ensure his rights. So, I have a personal understanding as well. 

MS EASTMAN: Are there any particular rights in the CRPD that directly inform the work you are doing in relation to the sort of future strategy? 

MS MACKEY: So there's quite a few, and I don't have the Convention in front of me so I'm not going to reference particular paragraphs. But certainly as we've been undertaking the work on the Future State, Department depending on what stream we are doing, we have been thinking very carefully about rights. For example in the strategic plan, there are only three focus areas. The first of those focus areas is the rights of people with disability. So, that is very much framing how we are thinking about our responsibilities and how we are taking forward our role as a regulator. 

MS EASTMAN: In terms of using the CRPD on a day-to-day basis in the work that you do, how do you use the CRPD? 

MS MACKEY: I think it depends on the work that is happening. It's quite a broad question. So, in terms of how we use it, if we are doing policy work, we are certainly engaging with others and seeking advice about how we would look at the particular conventions and how we would play that out. I have certainly got an active conversation with Mr Ben Gauntlett in terms of his view on the rights element and, in fact, we are pursuing some work together around that. I also meet with stakeholders, particularly advocates and representative organisations where a significant part of the issues that we canvass is around rights. And I do meet with participants very regularly and, again, we are certainly engaging in a conversation which is about rights. 

I would say that we don't just talk about rights in such a   in the rights   by referring to rights. We talk a lot about choice and control and what that means in terms of choice and control and what expectations people should have. 

MS EASTMAN: Well, it has to be choice and control about the content of particular rights. Isn't that   you agree with that? 

MS MACKEY: Sorry, say that  

MS EASTMAN: It has to be choice and control and not just in an abstract sense, but choice and control with respect to the exercise of rights, the protection of rights and the fulfilment of rights. Do you agree with that? 

MS MACKEY: Absolutely. 

MS EASTMAN: And how or where do we see in the work of the NDIS Commission that connection between choice and control on the fulfilment, protection, choice, exercise of rights? 

MS MACKEY: It would play it out in a range of levels. So, at the policy level, we are certainly considering rights as a very strong input to the way in which we are positioning things. Right down to how we are operationalising things. So, when we are looking at our internal policies and procedures and the processes we have in place, we certainly think about rights very carefully. And I would like to give an example of that. So, we have just gone through a process with our   that our Complaints Commissioner has taken the lead on, where we have looked at whether or not we have got the settings and the processes right about the way in which we deal with complaints when they come in, and also really taking the next step about maturing our processes around intake and then triaging information that we get into the Commission. 

MS EASTMAN: I might ask you some questions about that in a bit more detail. So, in the material   

MS MACKEY: Sorry could I just add that the other layer where rights is incredibly important is the decisions that we are taking as part of our business each and every day. So, it's certainly an active conversation and consideration in the way in which we are undertaking those decisions. 

MS EASTMAN: Right. So, in the material that the Royal Commission was asked to consider for this hearing, there were a number of statements prepared by your predecessor, Mr Graeme Head. Have you had an opportunity to read those statements? 

MS MACKEY: I have looked at those statements. They are   there are quite a number, so I don't purport to be an expert on all aspect of those statements. 

MS EASTMAN: And have you been following the proceedings over the past few days here at the Royal Commission? 

MS MACKEY: I followed the last couple of days. 

MS EASTMAN: When you say, "last couple of days", which days? 

MS MACKEY: So yesterday and most of Wednesday. 

MS EASTMAN: Alright. But you didn't see any of the evidence on Monday and Tuesday? 

MS MACKEY: I did not. 

MS EASTMAN: Has anyone briefed you or kept you up to date with what occurred? 

MS MACKEY: Yes, they have. 

MS EASTMAN: Okay. Alright. Ms Taylor, sorry to keep you waiting. Welcome back to the Royal Commission. So, you have prepared a statement for the Royal Commission also dated 8 August. Have you got a copy with you? 

MS TAYLOR: I do, yes. 

MS EASTMAN: And you have also provided us a corrigendum dated 31 August, and that makes some amendments to paragraph 39 of your statement. 

MS TAYLOR: Yes; that's right. 

MS EASTMAN: I think it seems to be just a reference to   

MS TAYLOR: That's right. It's a document. 

MS EASTMAN:   a document. And at the time you made your statements on 8 August, were the contents true and correct? 

MS TAYLOR: Yes, they were. I have an update, though. 

MS EASTMAN: Well, let's just do it bit by bit. 

MS TAYLOR: Certainly. 

MS EASTMAN: I'm only asking you to take yourself back to the 8 August. When you signed the statement, was it true and correct at that time? 


MS EASTMAN: Now, I understand you want to give the Commission an update in relation to one aspect of your statement. Is it convenient to do that now? 


MS EASTMAN: Alright. What would you like to tell the Commission and which paragraph would you like to update? 

MS TAYLOR: In paragraph 49, I make reference to two confidential exhibits, and I mentioned that at that time that I submitted the statement, the action that they relate to remains underway. I just wanted to let the Royal Commission know that one of those matters has been determined, and that involves the refusal of an application for registration. 

MS EASTMAN: Right. So   and that relates to the entity referred to? 

MS TAYLOR: One of the entities referred to in the confidential exhibits, yes. 

MS EASTMAN: Yes. Alright. Now, you are giving your evidence together, and it may be that there there's a question that I ask you that relates to topics that cover both of your evidence, or it might be separate. I will take my lead from both of you about who might respond. 

CHAIR: Ms Eastman, just before you commence that process, I notice, Ms Taylor, that you have now been appointed to the role of Strategic Advisor. 


CHAIR: Was there a position of Strategic Advisor before you were appointed to it? 

MS TAYLOR: I don't know that that's a question for me. It's a matter for the Commission. 

CHAIR: Did it exist? 

MS MACKEY: No, it didn't. 

CHAIR: Right. Well, can someone   I don't mind which one of you. What's the point of a Strategic Advisor? 

MS MACKEY: So, we had   it was timely a number of months ago when we had a   several significant initiatives underway   one of which is own motion inquiry, which is the first own motion inquiry that we have undertaken as a Commission   to look at whether or not we had the resource settings at the right level levels. There are   along with that own motion inquiry, there are a number of other strategic pieces of work that we wanted someone at a senior level to take carriage of, and Ms Taylor was best positioned to be able to take carriage of the work that we anticipated in that space. So, she has moved into the Strategic Advisor role. 

CHAIR: Thank you. 

MS EASTMAN: I want to start by just ensuring the Commissioners can get a little bit of an update in terms of what the NDIS Commission has been doing. Mr Head told us about the review undertaken by Mr Alan Robertson following Ann Marie Smith's death and some recommendations made by Mr Robertson. And he told us with respect to recommendation 4, which was a recommendation that until the NDIS is amended to provide for the NDIS Commission to establish its own equivalent state and territory Visitor Schemes that the Commission would continue to support the state and territory Community Visitors Schemes, and that was in the context of some evidence concerning the situation in South Australia. Can you tell us what is the current situation in relation to the NDIS Commission with respect to the establishment of a Community Visitor Scheme? 

MS MACKEY: So we continue to work with states and territories where they have an equivalent scheme in place. And for those that do, we have clear arrangements about how we work with each other. I'm conscious that you heard from the Victorian lead of their Community Visitor Scheme yesterday, and certainly we have regular and ongoing engagement. 

MS EASTMAN: Has there been any steps taken to develop a national scheme? 

MS MACKEY: There's a review of the National Quality and Safeguarding Framework. That review was due at the end of last year but will be undertaken, I understand, as a part of the broader NDIS review that the Government has indicated it will proceed with. And as part of that review   because the Framework includes consideration of a Community Visitor Scheme and those arrangements, they will be considered as a part of that process. 

MS EASTMAN: Alright. One of the other recommendations which Mr Head told us about arose from the Safeguarding Task Force Report. So, that was the South Australian model that indicated that participants and their families are unclear about how to raise matters of concern with the Commission and the Commission does not   routine not undertaken proactive inspections to vet the performance of service providers. So, Mr Head told us that some of those contentions were not correct. But I wanted to ask you, in terms of participants and their families having some clarity about how to raise matters of concern with the Commission, what steps have   if any, have been taken since the recommendations in the South Australian Safeguarding Task Force Report? And if you have got Mr Head's statement with you, this is the statement from 14 May 2021 at page 65, paragraph 265. 

MS MACKEY: I might just have a go at answering the question.

MS EASTMAN: But if you wanted to check it, that's where it comes from. 

MS MACKEY: So, there is quite a bit of work underway. That has been underway for some time both prior and after the evidence which Mr Head gave with regard to that. We have arrangements in place to work with our consultative committee to ensure that the kinds of initiatives that we are putting in place to assist people to be able to make complaints and raise issues with us are improving all the time. We have also funded, through grant programs, organisations to assist participants and those that support participants to make it as easy as possible and as supportive as possible for them to be able to make complaints and raise issues. 

And, in fact, one of the things that I talk about all the time when I meet with stakeholders is how can we make it easier and what else can we do? We are still seeing a growing number of complaints come in each month, so we know there is room in terms of people being able to raise issues and we would always encourage people to raise issues with us. 

MS EASTMAN: Were you here this morning when Georgia gave her evidence? 

MS MACKEY: I watched that this morning, yes. 

MS EASTMAN: And you heard her say she had never heard of the Commission. You heard that? 

MS MACKEY: I did. 

MS EASTMAN: And she hasn't made a complaint to the Commission? 

MS MACKEY: She hasn't made a complaint, as far as we were aware. 

MS EASTMAN: I am not asking you to comment on her case in particular, but thinking about her circumstances, would you expect someone like Georgia should know that there is a body called the NDIS Commission? 

MS MACKEY: We would certainly like people to become more and more familiar and comfortable and confident that there is a place for them to raise any issues they might have with regard to the delivery of NDIS services and supports. 

MS EASTMAN: Just taking Georgia's example   and tell me if this is the case   does the NDIS Commission have material that's available in, for example, an SRS which it might be a poster   and I think posters is one of the measures that Mr Head told us about, but just some information. A poster, a brochure. Do they exist in SRSs? Do you know? 

MS MACKEY: So there is certainly that information   that collateral available for any service type, and we would encourage providers to make that information available. We have also worked quite closely, particularly for SRSs in Victoria, with the Human Services Regulator in terms of their communication and the information that is available. We have been working quite closely with them for quite some time in terms of that provision of information. The other thing we are doing quite proactively is working with the NDIA about how we can join up and make sure that when people first receive a plan, when they make changes to a plan, that they get joined up information about what to do. 

MS EASTMAN: Doesn't that already happen? 

MS MACKEY: So they get information about the plan but in terms of information from us at the same time, that hasn't necessarily been what has occurred in the past. So, that's a really important step to take to make sure people are receiving that information at the same time. 

MS EASTMAN: What do you think, having listened to Georgia's evidence this morning, would need to be done at a very practical level to ensure people in Georgia's circumstances would even know about the NDIS Commission? 

MS MACKEY: I think we need to continue to do what we have been doing in terms of putting as much information out there as possible. But we also need to make sure that we are sharing information about how easy it can be. So, we don't need an enormous amount of information to begin to look at a particular issue. So, we do want to build people's confidence that we can actually start to explore and investigate at a very early stage rather than waiting for something to happen. And we are absolutely open to any other suggestions that others might have. In the meantime, we will continue to work with a range of other regulators, particularly in a jurisdiction like Victoria where there are multiple regulators that are in the space of, for example   

MS EASTMAN: I do want to ask you about that too. 

MS MACKEY: The residents of SRSs. So, we will continue to work with them to make sure there's information. But we want to try make it easy for people and not be the ones trying to get a person to determine which is the right regulator. So   

MS EASTMAN: Well, they have got to know the regulator exists, and that was the issue for Georgia. She wasn't even at the   she wasn't even at the point of deciding which one would I go to. She didn't even know there was a NDIS Commission. 

MS MACKEY: Perhaps I heard a little differently. I heard Georgia indicating that she did go to the Victorian Government. 

MS EASTMAN: She did. 

MS MACKEY: Because that's who she understood as the regulator, and that is absolutely correct. 

MS EASTMAN: But not on the basis of there being a choice knowing you exist as well. 

MS MACKEY: As I indicated, I think it's really   if a participant or their support person wants to go to any regulator and make a complaint, we have got really good arrangements in place by which we can refer and make sure that that ends up in the right place, if it's not with us. So, I just want them to make the call or go online and let someone know that something is happening. 

MS EASTMAN: And the next matter Mr Head dealt with in his statement back in May last year, was Recommendation 7 of the Robertson report, and that concerned information. So, the recommendation was: 

"The Commission must at all times be able to know whether a person is or is not an NDIS participant. The Commission should also have readily access to information held by the NDIA concerning what supports a participant is receiving and the provider of such reports. The Commission should not depend on providers to provide it with such information only after a request."

So, Mr Head gave us some information about the sharing and the Commission having access to the NDIA's PANDA system and for the Commission to be able to access that system remotely. Can you tell us what improvements have been made to respond to Mr Robertson's Recommendation 7? And, again, if you need to look at Mr Head's statement   and, Commissioners, it's page 69 at paragraph 273. And, Commissioners, in your Hearing Bundle, this statement is behind tab 18. Ms Taylor, this might be an area for you. 

MS MACKEY: Yes. Just before Ms Taylor starts, the statement I have from Mr Head at that time doesn't have a page 73. So, I'm not sure I've got the right one in front of me. 

MS EASTMAN: Those who are   it's paragraph 273. Yes. Page 69. 

MS MACKEY: My statement only goes to paragraph 261. 

MS EASTMAN: There's a lot of people in the room and a big trolley of documents, and I will make sure that you have got the Hearing Bundles. Okay, Ms Taylor. Thank you. Help me on the information. 

MS TAYLOR: So, since Mr Robertson handed his findings to the former Commissioner, and, indeed, in the lead up to that, there has been a considerable amount of work done with the NDIA to give us access to information that they hold about participants and, indeed, providers on a number of levels. You mentioned Mr Head's reference to the PANDA system. That is in place and available to staff in a select way. 

We are very careful to provide access to information that is necessary for people to verify that someone is, in fact, an NDIS participant, but also to protect the privacy of NDIS participants by not giving staff access unnecessarily to information about them. So, we do have access to that system and our staff use it. We have also made significant changes to our operating system where we now have a participant view tab, and that allows us to   use NDIA data which is provided to us separately to the PANDA system on a fortnightly basis to data match the participant in our Commission operating system with NDIA data on the basis that their data is the primary information of   you know, the source of truth about the circumstances of an individual. 

MS EASTMAN: Can I jump in there. To the extent you've got information through the NDIA, you have to rely on the accuracy of the NDIA's records. Is that right? 

MS TAYLOR: We validate   we can match across. So, so we don't   we don't abandon any information that we might collect through our functions about an individual. We do seek to validate that information to see if we, you know, can   can match. And there are data exchanges for the purposes of updating particular fields, if that's necessary. It's important that that happens through the moment of a person's engagement with the scheme as a whole. 

However, often in the course of our particular functions   and I think this is what Mr Robertson was getting to   we can   we do get information about an NDIS participant through a provider. That provider may provide a significant amount of support to a person or a very small amount of support to a person. We would obtain that information through the record of a reportable incident, for example. We might also get information about a person through a complaint. 

Now, because anyone can complain to us and because, as I mentioned just now, a person's engagement with the Scheme can be significant or of a lesser nature, we can't always rely on the identifying information or, indeed, people's assessment through a provider or a complainant who might not be terribly familiar with the person to rely in full on the information they give us about that individual, which is why we have the verification of participant data through the NDIA sources. 

MS EASTMAN: Is the Commission confident that it will be able to pinpoint all NDIS participants? 

MS TAYLOR: Well, where they have come to our attention, we   we did an extensive validation exercise of the participant information that was in our   our Commission operating system around the beginning of last year when we   when   you know, we were doing the matching and, yes, it was very   very strong validation capability. So, yes, we are pretty confident, yes. And, as I say, we retain the record that we have, in any case. So, if it should arise that we need to engage with the agency to be clear whether or not someone is or isn't   so I mentioned that we get their data every fortnight, for example. 

If someone were to come to our attention through   by approaching us with a complaint or through an incident and they were not part of the set because they were a recent participant whose plan maybe not had been initiated or approved at the point the data transfer happened, we do have protocols where we can engage directly with the NDIA to just be sure and those   and, of course, the real time access to the PANDA system is a critical back stop for us to be able to have that confidence. 

MS EASTMAN: Okay. The things I need to ask you about today are very much focused on the SRS. But just a few questions about some issues that arose at the early part of the hearing where we heard some experiences of people who have been homeless or at risk of homelessness. And did you follow Lisa Short's evidence earlier this week? 

MS TAYLOR: I followed part of it; I can't say that I saw it all. 

MS EASTMAN: Right. And so she told us   and I will just use rounded up figures   that in terms of NDIS participants who identify as being homeless   and I think it was for the sort of last calendar year   it was just over 1,000. But combine that with people who identified at the risk of becoming hopelessness, it was just over 6,000 people. To what extent do people who are homeless or at risk of being homeless come to your attention?  Is it only through a service provider or a complaint? So what   what's the situation for the Commission in relation to any oversight of people who are homeless or at risk of homelessness? 

MS TAYLOR: So I can see the Commissioner would like to say something. So, if I can just maybe talk from an operational perspective before Ms Mackey comments. We don't need to wait for a complaint or even an incident to be aware of a particular person. We get information from the NDIA, and we also might get information that doesn't necessarily come to us as a complaint from other regulators and from advocacy organisations who may have concerns. 

And we have   we have protocols with the agency to then work through with any   you know, regulatory intelligence or whatever it is that you might like to call it, what role we might have in engaging with a participant where there might be an issue with the support or service in the NDIS that they are receiving. And, similarly, the agency will consider whether or not there are issues that they need to pay attention to as part of their role in supporting a participant, for example, with an adjustment to their plan to address a particular issue or gap. 

So, those protocols are used every day. From the point of view of a person who is homeless or at risk of homeless   I am aware that the agency does   they do have a flag for risks around   

MS EASTMAN: Does the Commission have a flag for homelessness? 

MS TAYLOR: We are developing a flag around participants that are at risk in the context of the Commission's functions, but the NDIA's flag is present in the data that we receive from them, and I mentioned the participant view that we have in our Commission operating system. That includes the NDIA's flag, and homelessness is   is one factor, or potential risk of homelessness is one factor. There are a number of other personal factors that would   that would be present in that flag and that   the access of our staff to that flag is important when we do get a complaint, for example, about somebody and we   our staff can then see in the participant view that   that there may be information that the NDIA has about that individual which   at a very, very high level; I just don't want to give the impression that we hold significant information about a person be where we don't have their agreement to hold it   but it is a flag which generally says there are considerations that might need to be   

MS EASTMAN: Can I jump in there. If the flag's there and a participant is either homeless or at risk of homelessness, is that   does that trigger anything within the Commission either to do a sort of closer look at who the service providers may be around a person with that flag? 

MS TAYLOR: It would   it would trigger consideration by our staff when they were dealing with a matter about that person   for example, an incident that might be reported to us or a complaint that might come from anybody   that there are particular issues they need to keep in mind in dealing with that issue. So, for example, in someone who might be homeless or at risk of homelessness, that might suggest to our complaints officers, if someone were raising an issue about somebody, that there might be more creative ways they might need to take to maybe make contact with that person, to   for example, we get complaints coming through mental health officers and so forth who might say "I'm a bit concerned about this person."

MS EASTMAN: Can I just jump in there. I mean, it's   creative is one way, but if somebody is at risk of homelessness and the cause of that magnified risk is the treatment of a service provider, is there any system within the Commission that would prioritise a person at risk of homelessness for your urgent intervention? So it's a little bit different to creative ways, but actually, like, what do you do? 

MS TAYLOR: Thank you for clarifying that in the question. Because if   if the   if the situation was arising because the homelessness potential was the result of an action by a person   a provider who was delivering NDIS supports or services, then that would be a relatively clear matter for the Commission. And we   we do receive complaints about those circumstances. We do receive incident reports about that where people may be at risk of losing their accommodation because of the actions or indeed even the failings of   

MS EASTMAN: Is that cohort prioritised in terms of action in either responding to a complaint or   I'm going to ask you about the regulatory actions in a minute, but in terms of the regulatory actions is someone at risk of homelessness prioritised in terms of any steps you can take with a service provider? 

MS MACKEY: So the work I referenced before about looking at how we do intake and triage is to make sure that we have got those settings right. That we are not just prioritising on the basis of particular boxes or flags, that we are actually looking at the circumstances of that person and whether or not there's an imminent issue that   something that's either already happening or something that's imminent and likely to have quite a significant consequence. So   and we are using that to escalate the activity that we take, putting the person first in terms of making sure they are safe and in the   the area where it might be about somebody's change in circumstances, that might lead to them becoming at risk of being homeless, then we will work really closely with the NDIA and, where we need to, other service providers to ensure. 

MS EASTMAN: If a person is at risk of being homeless because   I want to take a hypothetical   their service provider says "we are going to evict you. You can no longer stay here" should the Commission be the first place where a person goes for assistance? 

MS MACKEY: The Commission can absolutely be the first place that they go for assistance. And I'm certainly aware of a number of those particular situations where we have acted the same day to try and make sure that that person has a place, and certainly what we do is, as I said, put the person first and look at their circumstances, and then we will do what we need to do if there's a requirement look at the compliance and the   any regulatory activity around the particular provider. So, we put the person first in terms of resolving the imminent issue. 

MS EASTMAN: That's a good step into just touching and reminding the Commissioners of the Commission's particular functions as a regulator. So, the relevant legislation says the Commission has the following functions: Core functions, registration, reportable incident functions, complaint functions and behaviour support functions. The core functions are identified as upholding the rights of and promoting the health and safety and wellbeing of people with disability who receive supports or services, including those under the NDIS. Right? 

MS MACKEY: That's right. 

MS EASTMAN: And then other core functions are to develop the policies and the framework to support the regulatory arrangements. So they can be advice, education, things of that kind; is that right? 

MS MACKEY: That's correct 

MS EASTMAN: I'm not going to read out the whole of section 181E. In terms of the way in which the Commission performs its functions, you have got some statutory requirements in relation to registration and dealing with reportable incidents and responding to complaints. Is that right? 

MS MACKEY: That's right. 

MS EASTMAN: And in terms of translating those core functions into something substantive, are we right in understanding that the Commission works with the legislation, a suite of policies, which include a code of conduct. So you work with a code of conduct? 


MS EASTMAN: And a range of other rules, including provider registration and practice standards. So all of these matters together set out the expectations that you have of service providers with respect to the standards that have to be met and the expectations of those receiving services as to what's going to happen in the way in which they receive their services, the quality of those services and what to do if something goes wrong. If I have missed anything tell me. 

MS TAYLOR: The two primary regulatory tools are the code of conduct and the registration function. The code applies to any provider and any worker, in fact, who is delivering an NDIS support or service. 

MS EASTMAN: So that includes both registered and unregistered? 

MS TAYLOR: Any person. Any person. It's   yes. And registration applies to those providers who are registered, and it attracts a range of other obligations. And you mentioned the   some of the other functions such as behaviour support and reportable incidents, and those relate to providers who are registered. I would say, though, that we   we do have a set of practice standards which, while relevant to the gateway of registration and for the ongoing   or for making a registration determination because providers need to be assessed against those practice standards, and then for monitoring compliance against them. 

They are practice standards which we consider to be a guide available to any provider who might be delivering supports or services, although we, of course, in terms of our regulatory tools for noncompliance, would not rely on them in the case of an unregistered provider. But they provide a good overview of about how to deliver the quality support to a person with disability. 

MS EASTMAN: So with respect to this core function of upholding rights, promoting health, safety and wellbeing of people with disability who receive supports and services, there is a number of sort of regulatory actions that you can take. Is that right? So one is an investigation. 


MS EASTMAN: You can investigate. Is there an own motion power to investigate or does that depend on a complaint? 

MS MACKEY: We have an own motion power as well. 

MS EASTMAN: And is the report undertaken by Mr Robertson an example of an own motion investigation? 

MS MACKEY: No, it's not. 

MS EASTMAN: Is that a different part of the function? 

MS MACKEY: That's a different part of the function and so we only have one own motion inquiry and that's underway at the moment. And I would say it's not just the compliance actions either where we have regulatory tools. You know, some of our best regulatory tools   and you can look at really good regulators, particularly in the human services spaces   use education and information and building and understanding within the regulated community as the requirements as really important levers to lift quality and what is delivered. So in addition to our compliance type tools like investigations and penalty infringement notices and so forth, we also have those other tools. 

MS EASTMAN: So investigations is one. Compliance action is another? 


MS EASTMAN: And in terms of compliance management, does that require a complaint to be made to trigger off compliance actions? 

MS MACKEY: No, it doesn't. 

MS EASTMAN: Right. In terms of a compliance action you can initiate your own investigations, is that right, to look at compliant issues? 

MS MACKEY: We can, and we also use reportable incidents as another tool or input. But where we have information that causes us to consider whether or not a provider, registered or unregistered, is not   is operating inconsistent with the code of conduct, then that's when we can look at that activity. 

MS EASTMAN: So, the other stream on the reportable incidents is there is a requirement for service providers to report? 

MS MACKEY: If they are registered. 

MS EASTMAN: So unregistered service providers don't report reportable incidents. But registered do. There's a gap there, isn't there, in terms of reportable incidents?

MS MACKEY: I'm not sure I would characterise it as a gap. There are different arrangements for registered and unregistered providers. 

MS EASTMAN: Let me just use, like, an example. Say if a person dies when they are an NDIS participant, that the death of a person is a reportable incident; is that right? 

MS TAYLOR: The death of a person with disability is reported where the death occurs in the course of delivering a support or service. The function around reportable incidents applies to registered providers, largely because of the reasons for the obligation to be registered. So, I think it is important to say that there are certain classes of support or activities in the NDIS where a person must be registered in order to deliver those supports. And those, in the design of the framework, which as we've given evidence to the Commission before about, was established in the early part of the establishment of the NDIS, really, the Quality and Safeguards Framework was a policy position determined in 2017 by all Australian governments and   and the risk around   registration is really designed to ensure that providers who are delivering supports such as those which will result   excuse me   require the use of a restrictive practice, for example, or particular new elements of the scheme, such as Specialist Disability Accommodation, require a registration. And there is a   the reason for that is to require particular obligations such as reportable incident   

MS EASTMAN: Can I just tease this out so I can understand it as I practically   let's take Georgia's example. So, she's told us that her mother was an NDIS participant living in an SRS, and she told us that the supports were not provided by the SRS but provided by others. So, her mother passes away, while she is an NDIS participant. Should her death have been reported? 


MS EASTMAN: Why not? 

MS TAYLOR: Not necessarily. The death of her mother   and you know, I have to also   I would really like to extend my condolences to Georgia. That evidence was extraordinary for her to give. 

MS EASTMAN: Why? Her mother's died. She's an NDIS participant. 

MS TAYLOR: The way the statute operates is that the death of an NDIS participant is reportable to the regulator where the death occurs in the course of delivery of an NDIS support or service by a provider that is bound to report that incident because they are registered. The death of an NDIS participant is   is also advised to the National Disability Insurance Agency who   who, in fact, receives   although I could not speak to the mechanism   advice about the death of NDIS participants in the broad. Because many NDIS participants pass away for a variety of reasons and do so separately to any engagement they might have with anything that they might be accessing through the NDIS. 

MS EASTMAN: So what would have had to have been different for, in Georgia's mother's case, for her mother's death to become a reportable incident under section 73Z(4) of the Act and make its way   that report to make its way to the Commission? What would have had to have been different? 

MS TAYLOR: So the Commission receives many reports of   through the reportable incidents function of the deaths of people with disability who might pass away, for example, in an accommodation setting while receiving supports in that setting. For example, Supported Independent Living arrangement. In terms of your question about what would have had to have been different in the circumstances for Georgia's mother, the SRS proprietor or that business or, indeed, any other organisation coming in to provide supports into that accommodation might have been providing her with very significant amounts of support. There would have been a relationship, perhaps, between the support and her death. That could have been because someone, for example, might have been due to come and provide her with some personal care support and had become aware of her death. And they might then report that death to us. 

MS EASTMAN: As I said, I'm not asking you what happened in her case, but it just has got a flavour of sort of slipping between the gaps, either because you happen to have that connection with the service provider at the time or you don't. Is there a risk in the current regime of people like Georgia's mum slipping between the gaps? 

MS TAYLOR: My understanding is that incidents are also reportable to the Human Services Regulator and that   and that, I understand, but I did   yes, I might need to check this   includes the death of people who pass away while living in an SRS. Now, where you do have regulators who might have an interest in a particular situation where that situation might   no one has to   has to be absolutely clear in a referral to another regulator, for example, about having a concern about someone's circumstance, but it's not inconceivable that, in that situation, if the Human Service Regulator in being informed of Georgia's mother's death had have had some concerns about a relationship between her supports in the NDIS or, indeed, a failing in those supports   of course   that they might refer to us a concern and we would then work with them or work independently to explore those issues. 

MS EASTMAN: Right. Mr Head told us on 11 February 2020 in his statement   and, Commissioners, this is behind tab 15, page 11, paragraph 52   that the Commission's compliance and enforcement options are as follows. So, can I just run through these and check that this is still the case. Number one: education, persuasion, and compliance support. Still used? Monitoring and investigation. Sanctions, including compliance notices; enforceable undertakings; infringement notices; injunctions; variation, suspension or revocation of registration; banning orders; and civil penalties. So, does that remain the case? Ms Mackey, you've said in your Statement that you're keen for the Commission to do more in relation to compliance action. Is that right? 

MS MACKEY: That's correct. 

MS EASTMAN: And in terms of the way in which you can exercise the powers to give effect to it, the Commission also has powered under the Commonwealth Regulatory Powers (Standard Provisions) Act. Have you heard of that? 


MS EASTMAN: And that allows the Commission to exercise a range of powers, including obtaining warrants. Is that right? 


MS EASTMAN: And also being able to enter premises? 

MS MACKEY: Where we go through a process to be able to do that. We don't have a power of entry as a regulator. 

MS EASTMAN: So have you ever had to take steps to get access to enter a particular premises? 

MS MACKEY: I believe we have. 

MS TAYLOR: Yes, we have. We have exercised those powers. 

MS EASTMAN: And part of the approach to the compliance action is the recent development of the NDIS Commission Compliance Strategy, Supported Residential Services in Victoria, and you have both got a copy of that. And, Commissioners, you should have this behind tab 7 in the bundle. So, Ms Taylor, is this the product of the work that you have been doing? 

MS TAYLOR: Yes, it is. 

MS EASTMAN: And would it be your view that there really is no place for Supported Residential Services in Australia for people with disability? Would you have reached that conclusion? 

MS TAYLOR: No, I have not reached that conclusion. 

MS EASTMAN: You haven't. Is it your view or have you reached the conclusion that the SRSs need significant improvement for them to be safe places for people with disability to live? 

MS TAYLOR: I haven't reached that conclusion because I don't know enough about the hundred and however  


MS TAYLOR: I understand that there's a different number but   

MS EASTMAN: That's what's in your document at page 6   

MS TAYLOR:    the point in time of an evolving strategy. And I understand action has been taken to close a couple perhaps more recently. But I'm not aware of the full spectrum of those   those facilities. I'm not aware personally of any particular issues apart from those issues where we have been working with the Human Services Regulator or where we, through the normal course of our functions, have issues raised. 

MS EASTMAN: Should you know? Should you know more about the SRSs? 

MS TAYLOR: Well, so if I can maybe contextualise this strategy. It's   it is clear that there is a   the reason for this strategy document, which is a   you know, it's an internal document which is designed to really guide our staff in their engagement with others and the Human Services Regulator is one, the NDIA is another, and the Public Advocate in Victoria is also a very significant connection for us. That there are clearly issues that create the potential for risk. 

MS EASTMAN: Right. So, can I take you   it's page 5 of the document: 

"The NDIS Commission is aware of and responding to the following types of issues impacting NDIS participants living in SRSs."

The first one:

"Financial exploitation, where the SRS operator uses NDIS funds as well as the payment already made by the resident from their pension to pay for the same supports or provides no services after depleting the person's NDIS plan."

That   that causes a concern to the Commission, does it not? 

MS TAYLOR: That's why it's referenced in the strategy. And   but I   can I just say that these are examples in the strategy of issues that we have received through complaints or other intelligence. 

MS EASTMAN: Yes, you say that. 

MS TAYLOR: And that does not relate   you have asked me a couple of questions which are about SRSs in the broad. And I   I feel it's important to say that these are issues that have come up not necessarily and certainly not in our   in our understanding about SRSs in the broad. 

MS EASTMAN: Another concern is: 

"Trading of residents between SRSs or entities associated with SRSs where the value of their NDIS plan makes these residents..."

And these are your words: 

"...lucrative for unscrupulous operators. And that includes relocating residents to private accommodation which does not have the oversight of the Victorian regulator."

What happens with those NDIS participants? Do you treat them as having the flag of being homeless or at risk of homelessness. Do they trigger off some particular flag for the Commission? 

MS TAYLOR: These are examples of issues that have come to us through our complaints function as allegations or issues that have surfaced around SRSs. And this strategy is designed to make sure that our staff understand the need   the particular risks that might be present or may be present for residents of SRSs. 

MS EASTMAN: The third one is complex business networks. 

MS MORGAN:   The witness hadn't finished, and Ms Mackey may have wanted to say something then, Ms Eastman. 

MS EASTMAN: Well, what I might do, is I will read through all seven and then if there is something you want to say that is referable to the point, we will do that. So, the first is financial exploitation. The second is trading of residents between SRSs. The third is: 

"...complex business networks established by SRS operators to operate collectively providing a range of supports and services and duplicating costs already met by a participant where the relationship between these businesses is not transparent to a resident."

The fourth: 

"Poor or non-existent record keeping by SRS operators. And that results in a lack of transparency. It also limits the information available to regulators."


"Residents being limited in their choice of other providers and the ability of other providers to deliver supports in SRSs, or significant conflicts of interest between SRS operators and other providers involved in the person's support."


"Coercion of residents, particularly those at greater risk of such practices due to cognitive impairment."

And seventh: 

"The lack of skills and competency of the SRS workforce to deliver NDIS supports and services to the level required by residents."

And in terms of the NDIS participants who live in SRSs, 30 per cent of all SRS residents are NDIS participants. And your data indicates that they are disproportionately   in terms of the general cohort   people more likely to have psycho social disability, intellectual disability, and 11 per cent of that are a group of participants have acquired brain injury or stroke. So when you look at the cohort of the NDIS participants, who live in SRSs, would you agree with me 30 per cent is a very substantial component of all SRS residents? 

MS TAYLOR: Absolutely. That's why we have a strategy.


MS MACKEY: Can I just  

CHAIR: Sorry, I do think that Ms Mackey wanted to say something. So, we will give her the opportunity to do so. 

MS MACKEY: Thank you. I wanted to say that the contextual piece that Ms Taylor was referencing is actually quite critical in this. We started the evidence earlier this morning by talking about rights. And what we are very conscious of as a regulator is that participants have a right to choose. And so while we might have views   and I heard views expressed yesterday about whether or not people should be choosing an SRS   people do choose SRSs and a range of those SRSs   like, we are making a leap from there are issues with some of them and we can look at any other accommodation types and find very similar issues across all of those accommodation types. So, I don't think it's fair and reasonable to suggest that because this exists in one part of the SRS sector that we should be making a significant jump into a sense that all SRSs operate in a way that is unscrupulous and   

MS EASTMAN: I'm not suggesting that. 

MS MACKEY:    to participants. 

CHAIR: I don't think anybody suggested that. 

MS EASTMAN: I'm not suggesting that. But, Ms Mackey, you say in your statement: 

"Living in an SRS may be attractive to some participants because SRSs are regulated under the Victorian SRS Act and overseen by the Victorian Regulator."

What's your evidence to support your opinion that living in an SRS may be attractive to participants because it is regulated under Victorian law? That is paragraph 52 of your statement. 

MS MACKEY: I had an opportunity to talk to an SRS resident. I wasn't seeking out an SRS resident. I was actually visiting an employment service, and in the course of having a conversation with her, she was very open with me that she lived in an SRS. And she chose that   well before the NDIS Quality and Safeguards Commission was in place, and part of the reason why she indicated she chose that is because the government had   she didn't use the word visibility, the government looked after her in that. So, she   that was certainly part of the decision making. And we are conscious that there are a range of other   

CHAIR: Sorry, you are talking about someone who made a decision before the NDIS came into force. What's that got to do with what they currently are   

MS MACKEY: I'm sorry, before the NDIS Commission was established four years ago. 

CHAIR: Yes. So what's that got to do with our current discussion? Of course she would want the Victorian Government to be the regulator. There was no other option. 

COMMISSIONER RYAN: Ms Mackey isn't the issue   

CHAIR: Sorry, would you like to answer that? 

MS MACKEY: I was just picking up the point Ms Eastman was raising in terms  

CHAIR: Alright. I suggest perhaps we just continue with Ms Eastman at the moment. I will have some questions later. 

MS EASTMAN: So are we right in understanding that the opinion you expressed in the first sentence of paragraph 52 is based on speaking to one participant? 

MS MACKEY: No, it's not. 

MS EASTMAN: What is the other evidence other than the one participant that you say living in an SRS may be attractive because it's only regulated under Victorian law? 

MS MACKEY: Because there are a range of other accommodation types that don't have the protections that are afforded to those residents in SRSs. So, SRSs in Victoria have a process around registering, and they have a regulator   and I'm sure you will have lots of questions for the regulator about how they are regulating, but they do have a regulator and they do have oversight. So, it's helpful that there is another layer of oversight that doesn't exist in other accommodation types. 

MS EASTMAN: You also say in that paragraph: 

"Equally, participants who have resided in an SRS may be more comfortable remaining in this style of accommodation as it suits their preferences and needs." 

What's the basis for making that statement? 

MS MACKEY: We know that participants make choices about their accommodation for all different reasons. We have heard from a number of lived experience witnesses that I have heard in recent days where they have made choices about where they have chosen to reside based on, for example, the   their congregate style of living in terms of not being isolated alone, the level of support they get, because they need some supports for daily arrangement. There are a whole lot of reasons and that that is consistent with what we hear from participants. They make choices. There are also   there is something to be said around the referral patterns from a range of other mainstream services and a range of specialist services into SRSs as an option for people who might require those types of supports. 

MS EASTMAN: In terms of the risk to NDIS participants, your strategy identifies a number of risks to those participants, does it not? 

MS MACKEY: Yes, it does. 

MS EASTMAN: And those risks are specific to life in an SRS as opposed to different forms of accommodation; is that right? 

MS MACKEY: I would say a number of them are not specific to SRSs. We see that in a number of other   you know, services that are supported and accommodation options that are delivered. 

MS EASTMAN: One of the risks is the similarity between supports provided by the SRS and the NDIS make the boundaries between these systems unclear and unduly complicated for residents to navigate. That's quite SRS specific, is it not? 

MS MACKEY: Absolutely. That's why I just mentioned that some of them are applicable in other service types, not all. 

MS EASTMAN: If there is a lack of clarity in the boundaries of the different regulatory systems, and thinking about the cohort of the NDIS participants who live in SRSs, that creates a significant risk for those residents, does it not? 

MS TAYLOR: If I can just maybe address that question. But first just make the point that there are   there are a number of circumstances in which the supports that are delivered in one system and those that are delivered in the NDIS overlap or might be unclear, and this strategy I think, if I recall, makes the point that that navigation   the navigation between those systems should not be the responsibility of the person with disability to navigate. 

Residential Aged Care, of course, where we do have a number of NDIS participants living in residential aged care facilities is another example. And I guess in both situations, this one and in that similar situation of residential aged care, the references Ms Mackey was making earlier about the way in which we share information with other regulators and determine between us who is best placed to take action, depending on the nature of the circumstance that's arising for the person is   

CHAIR: Could you please state very succinctly the point you are trying to make? Because we are taking quite a long time to get to the point. Can you just tell us what it is you are trying to say? 

MS TAYLOR: Certainly. I don't think it matters. Where there is more than one regulator involved, it's a matter for us to determine who is best placed to take action. That's the point I'm trying to make here. 

MS EASTMAN: But isn't the point that while there are two regulators deciding who is going to take action, that the person whose rights and interests are part of your core functions can slip between the gaps? That's the risk, isn't it? 

MS TAYLOR: Well, it could be a risk if we take too long, but in the circumstance where we are working with someone who might have complained to us that they think they have paid twice, then we will work on that   and engage with that person without having to wait to determine whether or not the Human Services Regulator is going to do something. It's much at the pointier end of what I'm talking about. It doesn't stop either of us delving into issues with that person, working with that person or trying to resolve the issue between that person and that operator. 

MS EASTMAN: Your strategy says that the lack of clarity exposes residents to risk from unscrupulous operators who may continue to charge residents for supports that they are funded for by the NDIS but also overlapping. That's what you identify the risk   unscrupulous operators. 

MS TAYLOR: Well, it would be unscrupulous for someone to deliberately do that, absolutely. 

MS EASTMAN: If the operators are not only accommodation providers but they are also registered or unregistered NDIS service providers, that's an area that you can take action, is it not? 

MS TAYLOR: If   yes, if they have not done the right thing. I mean, look, we heard   I did hear part of the evidence from Wintringham the other day, for example, where they are an SRS operator, they are delivering NDIS supports as part of their business and, you know, they are quite clear. So, we would   if someone was concerned about that being an issue and there was a lack of clarity about how that operator was describing or delivering those supports, then, yes, absolutely we would pursue that and seek a resolution to it. There might be situations like the evidence given by Wintringham where it's completely transparent and not something that we would have a concern about. 

MS EASTMAN: Right. The strategy says: 

"It's not reasonable for residents of SRSs to have to navigate this complexity without assistance to understand their rights and guidance on where to get help and when they require it." 

I asked you earlier about what the Commission does to provide information to people in the SRSs. And I asked you whether, for example, you had posters or the like. Having identified this as part of your strategy, what does the NDIS Commission do to address navigating the complexity, so residents understand their rights and they have guidance on where to get help when they require it? 

MS TAYLOR: If I can start on that, one of the things that we are doing is visiting a number of SRSs. Our Victorian team is going to a number of SRSs, starting with those where we   we think there are issues. We might have had a complaint from someone or we might have had a referral from the Office of the Public Advocate to talk to residents to help them understand that we are there, and they will do that sequentially as part of this strategy and have been for   for many, many, many months to make sure people are aware of our existence if they need us and what we can do to assist them. And we also have a broader campaign that is accessible for people with disability, our Speak Up campaign, which, as Ms Mackey said, we have collateral that can be provided to residents to help them know how – how to get in touch with us. 

MS EASTMAN: Is this part of what's on page 9 of the strategy under the heading Proportionate to Risk: 

"to continue on site visits, activities by NDIS compliance officers to target SRSs with a higher risk factor. And the progress and expansion of education activities."

MS TAYLOR: Yes, in part, yes. 

MS EASTMAN: Sorry, can I ask you, are they directed as SRSs as providers or are they directed to residents to understand their rights? 

MS TAYLOR: They are directed to both. It's important that we engage with residents as well as with proprietors so that they are aware that   for example, if they are not a registered provider, contemplating delivering NDIS supports or services, that they understand what obligations come with that and   and what we might be wanting to talk to them about if they are   if we hear concerns about that. 

MS EASTMAN: Looking at the regulatory approach that's set out at page 8 and following in the strategy, are we right in understanding that the regulatory approach is to use all of the tools available, but is it fair on my reading to say that the emphasis seems to be very much on building capacity in this sector? So, improving the services rather than a compliance model of imposing sanctions or suspending or cancelling registration? 

MS MACKEY: A significant avenue that we go down all the time is to try and improve quality. So, we do want to take a proactive stance in terms of going into particular sectors, particular service types and trying to get a lift in the quality of what is delivered in those supports and services. Until we do some of this work, we won't have a good sense of what the type of compliance action we might take. So, we haven't got, for example, any targets in here about what type of compliance action we might take because we need to look at what we learn going in and out of services, as we get more information from participants. And then that will inform any compliance action that is required. So, it's not that there won't be compliance action and that's not the focus; it's that we can't determine what that is before we have actually focused in this way. 

MS EASTMAN: The Royal Commission asked you in the preparation of your statements the number of times any specified compliance or enforcement activity was undertaken by   against an NDIS provider or an SRS proprietor or an entity associated with an SRS proprietor. So, you recall we asked you that question. 


MS EASTMAN: Ms Mackey, you have answered that in various places between paragraph 40 and 45. Tell me if my understanding is correct. There has been one suspension of registration. Is that right? 

MS MACKEY: We haven't prepared the information in that way in terms of a table with figures 

MS EASTMAN: I know. And what I'm trying to do is, having read your statement, to distil what I think to be the compliance actions taken. So, one suspension of registration. Is that right? 

MS MORGAN:   Could I just object at this moment just because the question at the moment, Chair, doesn't take into account the definition captured by the notice issued by the Royal Commission and the reference to that in Ms Mackey's statement a bit earlier than paragraph 42. I think it appears in paragraphs 35 to 37. 

MS EASTMAN: Have a look at your statement. 

CHAIR: I'm sorry, just let me   

MS EASTMAN: Do you want to read what's there? 

CHAIR: Just let me have a look at that. 

MS EASTMAN: Chair, I'm trying to distil what's actually happened in terms of the numbers of things. 

CHAIR: Yes, I rather thought that Ms Eastman wants to ascertain what the actual position is. I'm not sure definitions necessarily come into it. So, if the questions can be framed by reference to the actual action, as Ms Eastman identifies the action in her question, we should be on reasonably safe ground. 

MS EASTMAN: Let's do it this way   there have been no banning orders made, have there? 

MS MORGAN:   I'm sorry, Chair, could I just explain. 

MS EASTMAN: We can't have it both ways. 

MS MORGAN:   Could I just explain. 

CHAIR: Yes, Ms Morgan. 

MS MORGAN:   Thank you, Chair. Ms Eastman introduced this line of questions using a defined term and   

MS EASTMAN: Which is? 

MS MORGAN:   It's just gone off the transcript but it's the entity associated with an SRS provider which is a very broad definition in the notice that was issue, and if the question is more direct about an SRS provider as opposed to an entity associated with an SRS provider, I think Ms Eastman will get the answer she's looking for. 

MS EASTMAN: I'm asking   

CHAIR: I rather thought Ms Eastman was doing that as a matter of precaution but no doubt she can narrow it in the way that you have suggested, and we will get to the point. 

MS MORGAN:   Thank you, Chair. 

MS EASTMAN: Alright. So, paragraph 40 of your statement, Ms Mackey. You talk about a suspension of registration. 


MS EASTMAN: There has been one suspension of registration that you have identified for the Royal Commission. Is that right? 

MS MACKEY: In the time period specified?


MS MACKEY: And at the point of drafting the statement. 

MS EASTMAN: Now, that suspension   

CHAIR: Ms Mackey, you don't need to look at your counsel in order to answer the questions. Alright. 

MS EASTMAN: In terms of that one suspension, that was in relation to Grace Disability Services; is that right? 

MS MACKEY: That's right. 

MS EASTMAN: And, Ms Taylor, you have dealt with a chronology in relation to that matter in your statement. 

MS TAYLOR: Yes, I have. 

MS EASTMAN: And the suspension was overturned, was it not, following a review? 

MS TAYLOR: There was a decision by a delegate in the Commission to suspend an entity, and that entity   Grace Disability Services   and that entity, after the suspension period had ended under the Act   the Commission can suspend an entity in its registration for a period of up to 30 days. That suspension period had ended. The entity sought a review of the decision to suspend, and the reviewer decided to uphold the review. 

MS EASTMAN: And what was the reason the reviewer upheld the review? 

MS TAYLOR: So, in my statement, I set out what I understand to have   

MS EASTMAN: I don't want you to go through. You can just go straight to the punch line on it. There is a reason. You have said this, if you want to look at paragraph 39. You have said the essence of it. What was it? 

MS TAYLOR: It was because the entity that had been suspended was not the entity that the Human Services Regulator had taken their action on, and the decision to suspend was an action related to a registered provider who had a very close affiliation with the entity that the Human Services Regulator had taken action against and was intended to be protective in that   in that context. 

MS EASTMAN: Why did the Commission suspend the wrong entity in the first place? Why did that occur? 

MS TAYLOR: Well I don't think   

CHAIR: Sorry, stop. Stop. 

MS MORGAN:  Chair, I just object to that. 

CHAIR: Why? 

MS MORGAN:   What does that mean, the wrong entity? The entity that the HSR identified? 

CHAIR: I would have thought it meant that the Commission obviously intended to suspend the registration of an entity that was responsible for certain conduct. And on the appeal process or review process, someone decided that the Commission had actually directed its attention to a different entity. That's, I think, what Ms Eastman was asking. Why did that happen? 

MS MORGAN:   And that what's not the way it was put, Chair, and if   the matter can be put   

CHAIR: Let's put it that way. 

MS MORGAN:   Thank you, Chair. 

MS EASTMAN: Thank you, Chair. I'm grateful for the assistance 

MS TAYLOR: So the entity that was suspended was an entity that we registered and, of course, you know, you can only suspend a registration of entity that is registered. But had very close affiliations with the entity that the HSR had taken action against. I do think it is unfortunate that the   that the suspension didn't make that relationship clear. My understanding in the review was that the decision was taken to   to uphold the review because the entity   because it had not been made clear in that suspension that the reason was that it was a related entity about whom we had concerns about continuing to   to operate, because of the nature of the findings of the HSR. That was entity where the key personnel were the same as the entity that the HSR are taken action against. It was also an entity which had as part of its registration the SRS as an outlet within its own registration, so whilst I think there were certainly issues with the drafting of that suspension, the intent was the right intent, which was protective in the context of an entity that we   we had a registration over. 

CHAIR: Thank you. 

MS EASTMAN: Alright. Now, look, Ms Mackey, at your paragraph 41, are we right in understanding that of all the points raised there, there are 11 references to conducting an investigation or undertaking or having completed compliance activity, compliance monitoring activity, compliance and investigation activity. You use a range of different expressions. I want to bring them together. So, 11 references to that. 

MS MACKEY: I haven't counted them, but I understand that would be about the number. 

MS EASTMAN: Alright. And in terms of those 11 areas of activity, have they focused on 11 different providers?

MS MACKEY: So, they focused on different entities, and this is where we had quite a bit of trouble pulling this together because we don't have a fulsome view of the related entities in all cases. 

MS EASTMAN: Why not. Why not? 

CHAIR: Let Ms Mackey finish. 

MS MACKEY: So, for example, you asked about banning orders and in the   the questions that came to us for   for this submission, you asked about related parties including family members and so forth. We don't necessarily have visibility of all of the workers in an SRS and all of the family members related to those workers and understand whether or not we have actually banned a related party who may or may not have been involved in that particular SRS.

So, it's very difficult for us to draw a line on who is and who isn't a related party, given how broad the definition was. So, what we have provided you is, where we are certain it is an SRS, we have given that information. 

MS EASTMAN: Why   why don't have you this information? 

MS MACKEY: I don't think it would be fair and reasonable for us to understand the family relationships of every employee in all services, for example   I know there is a range of examples that we could give in terms of the way in which the definition was very broad and   

MS EASTMAN: Don't you need   don't you need this information to be able to discharge your functions and exercise the powers that you have in relation to compliance? 

MS TAYLOR: We   we certainly do need to understand affiliations to a degree. And   so I   I   we spend an awful lot of time and have very good intelligence networks associated with our registration function as well as those that emerge through investigations that we undertake. I think what both Ms Mackey and in my statement are referring to is that in the definition, whilst we could tell you that none of the actions that are on our public register, for example, relate specifically to an action related to an SRS, we could not in all honesty, using the definition that the Royal Commission had provided us with, guarantee that those actions, although not related to SRSs, did not relate to a person who was not, for example, related to a worker in an SRS. It's simply   

MS EASTMAN: Can I   doesn't this, in a sense, invite the very people you describe as unscrupulous SRSs to actually set up arrangements and organisations   in the way they organise their business and it slips through the regulatory scheme? 

MS TAYLOR: Can I give you an example, perhaps, to illustrate the complexity for us in our statements but I would also like to go back to the issue of networks. A relative or spouse of any person who would be captured by the definitions above, for example, where a person who is an employee or a contractor of an SRS proprietor, to know whether or not someone was relative or spouse of someone who was a volunteer working for an SRS at any particular point in time would not be intelligence that we would gather on a regular basis. 

And I do not   I don't think, in all honesty, would come to the issues that I think you are wanting to hear from us. We are simply trying to illustrate that, in that definition, that created a complexity for us. If I can go to the second thing that I said I would about networks and how important they are to us, it is incredibly important for us, and we do actively, throughout most of our functions, maintain records and go down paths to identify where there are affiliations between entities that may be registered or not registered, or other businesses, as part of our   our daily work. 

That can occur in our registration. So, for example, when we   we register and   or when an entity seeks to be registered with us they are required to give us the key personnel that are associated with that   the entity seeking to be registered. That   what key personnel is defined as is set out in our rules. Our staff look through ASIC, a range of other records, other regulators records to ascertain connections both within our systems and in other regulators' systems about those individuals. 

We connect and we maintain that information for the purposes of connecting up with our investigations. It's very rich information. We even go so far, can I say, of when we might seek further information around a registration or in the course of an interview, we might seek references, for example, and we look for affiliations with referees. 

So our regulatory intelligence function is incredibly broad, but I think our   our difficulty as witnesses here today to   to give the Royal Commission an absolute guarantee about how we maintain information about, for example, a relative or spouse of a volunteer in our SRS is simply not possible. And not the nature of information that we would ever hold as a regulator. 

MS EASTMAN: Dr Pearce said yesterday that there are now   she described as sort of pop-up SRSs. So they may not be registered SRSs even if they are required to be and that there may be NDIS participants living in these pop up arrangements. But no one is able to get in them, I think, was her expression to actually check. So, I'm asking you these questions in terms of understanding what type of information you collect. So, if there are these elaborate structures or that they are going under the Victorian regulatory arrangement, what is the Commission's responsibility? 

MS TAYLOR: Well our responsibility is about NDIS supports and services and   

MS MACKEY: So, if something was to occur in one of those other pop-ups that Ms Pearce revered to, we could certainly look into that, treat it like we would any other accommodation type. So the fact that something is an SRS, for us, isn't a defining point. What we are interested in is whether or not the safeguards and quality of supports and services that are being delivered to the participant is in place and what we need to do to assure that. So, we are quite agnostic to the accommodation, whether another someone is living in their own home, right through to living in some kind of   group situation. 

CHAIR: Can we just go back to something fairly basic. Do I understand from your evidence that the concept of a registered NDIS provider, as far as you are concerned, is the corporate entity, assuming there is a corporation, that provides the services of and applies to be register as an NDIS provider? 

MS MACKEY: Yes. And  

CHAIR: Sorry, the answer is yes. 

MS MACKEY: Individuals can also register. I just wanted to   

CHAIR: Sorry? 

MS MACKEY: Individuals can also register. Be registered providers. 

CHAIR: That's my point. 


CHAIR: What do you do about the individuals behind the corporation? In the old language of corporations law, behind the corporate veil. What do you do to ensure that the actual individuals who are using these corporate entities   and they may be using many of them for all sorts of reasons, some legitimate, some not. What do you do to make sure you capture them? 

MS MACKEY: So we do capture the individuals and that's part of the registration process. As Ms Taylor was mentioning, we do collect quite a lot of intel around not only the entity, but also about the individual  

CHAIR: Do you require them to be registered as NDIS providers if they are, for example, directors or, if you had sufficient information to make the judgment, shadow directors of a corporation? 

MS MACKEY: Yes, so they are part of a consideration of suitable persons when we look at the registration. So we do look at the individuals, and the registration will not occur without looking at   

CHAIR: The registration of what or whom will not occur? 

MS MACKEY: So it could be an entity. So it could be a corporate entity, or it could be an individual. So an individual. 

CHAIR: I'm not sure   either I haven't made myself clear or you haven't followed me. If a corporation applies   because a registration depends upon an application being made; correct? 


CHAIR: If a corporation applies, I understand that you seek to find out who is the director or directors, and you make some inquiries about the suitability of the directors. I understand that. Do you also seek to have the directors registered in their own individual capacities as service providers? 

MS TAYLOR: No, we do not. 

CHAIR: Why not? 

MS TAYLOR: The Act does not require that. The Act  

CHAIR: Does it empower that? 

MS TAYLOR: No, the   the requirement to be registered is in certain situations that are set out in the Act and Rules. 

CHAIR: I'm looking at them and it's not obvious to me that it doesn't require it, because an NDIS provider can include someone who provides certain services. It all depends upon what you mean by "provide". But if someone who is an individual who happens to be a director or an employee of a corporation is actually providing services, albeit through a corporate entity, that person may well require registration, at least as I read the Act, in order to operate within the framework of the NDIS Act. Has anybody thought about that? 

MS TAYLOR: If they are operating independently of the corporation or entity that's registered, even if they are affiliated with it, and they are delivering supports to people whose plans are managed by the NDIA or   

CHAIR: I'm not talking about necessarily operating independently. Even as part as a corporate entity, has anybody looked at whether that person may require to be registered? 

MS TAYLOR: Well it's certainly not my understanding that the Act requires that, Chair. 

CHAIR: No. Maybe someone should have a look. 

MS EASTMAN: Just a couple of final things. I'm conscious of the time. 

CHAIR: Yes. 

MS EASTMAN: You have told us in your statement, Ms Mackey, since the 30 June this year there have been four refusals of registration. Are you able to assist us in terms of the circumstances, without identifying   so four refusals of NDIS providers that are also SRS providers. Is that right? 

MS MACKEY: At the time of drafting this submission, it was correct. I would have to take on notice the details around those refusals. 

MS EASTMAN: And since the 30 June, the Commissioners commenced compliance and enforcement action against two   what you describe as relevant service   NDIS providers. Are they also SRS proprietors or operators? Or are they NDIS providers who provide services to participants who happen to live in SRSs? 

MS MACKEY: They are either SRS operators or have a relation to the SRS operator. 

MS EASTMAN: Alright. My last question is this: You can receive complaints from anyone can't you?

MS MACKEY: That's right. 

MS EASTMAN: And some of those complaints can be from family members who may have lost a family member who has passed away or has suffered an injury. Is that right? 

MS MACKEY: Absolutely. 

MS EASTMAN: And the nature of the investigation and action taken can be to impose, for example, some sanction on the service provider? 

MS MACKEY: That's right. 

MS EASTMAN: To what extent do your powers extend to requiring a service provider to make redress to either the individual participant or the participant's family members? If you made a definition of redress, I'm happy to go into that but do you understand what I mean? 

MS MACKEY: I do understand what you mean and what I was going to say is we   we have a number of parties that are speaking with us at the moment about whether or not our powers extend in that way. So, we are currently considering   it doesn't immediately appear so, but we are looking at whether or not there is any room in that space. 

MS EASTMAN: Do you have a view on that, whether the NDIS Act empowers the Commission as part of its compliance powers to order a service provider to make redress? 

MS MACKEY: I would like to consider the information that we have got being gathered and developed at the moment before I have a view. 

MS TAYLOR: If I could add to that, there   not in the circumstance that you just described, a death, but the complaints powers are quite strong and   and in the course of managing a complaint where it's clear there are issues where a provider needs to   redress is one   

MS EASTMAN: I'm only on redress. I'm not talking about, improvement, but just redress. 

MS TAYLOR: We have used powers, though not to the level of that, to get people compensation for   for a wrongdoing. So   and we have used those powers quite effectively for good outcomes for people where they have sought something similar. 

MS EASTMAN: Ms Mackey, would it be your view that it would be preferable that there be an express provision in the legislation to enable the Commission to require a service provider which has not upheld the rights of a person with disability who's an NDIS provider that you can require the provider to make redress in whatever form might be appropriate? 

MS MACKEY: I'm not sure at this stage, given the work that we are doing, whether or not that's required. 

MS EASTMAN: But an amendment to the legislation to make it absolutely crystal clear that the Commission has the power to do that. That would be of assistance, would it not? 

MS MACKEY: I'm certainly not in favour of us continuing to make the legislation any more complex than it already is. I'm very conscious of the participants and many of whom really want us to simplify rather than make more complex the arrangements. So   it's not yet my view. 

MS EASTMAN: Where, then, do participants and/or their families go to seek redress if their rights as NDIS participants have not been upheld by the conduct of service providers? Where do they go? 

MS MACKEY: As I said, we are currently looking at that issue, and as soon as we have more to say, we will say more on the matter. 

MS EASTMAN: Where do they go now? If they are not with you, where do they go? 

MS MACKEY: I am aware there are parties that have taken legal recourse in terms of the provision of services and supports to either themselves or those they are related to. 

MS EASTMAN: Thank you, Commissioners. 

CHAIR: Thank you. The document that Ms Eastman has been asking you about, that is, the NDIS Commission Compliance Strategy   SRS Services in Victoria, that is an internal document as I understand it. It bears the date or a version date as at July 2022. When was the first iteration of that document prepared? Do you know? 

MS TAYLOR: There was a first iteration. There has been a series of iterations earlier in this year. I couldn't give a date, Chair, but there were some draft documents given to me. 

CHAIR: But the first iteration was some time this year, 2022. 


CHAIR: Alright. That's all I need to know at the moment. And what prompted that document to be   what prompted the preparation of that document? 

MS TAYLOR: I think in my evidence I'm talking about the fact that I had conversations and we had been talking within the organisation because we had seen a growing number of issues coming to us through complaints and in our engagement with the HSR about the need to have some more targeted attention around SRSs, that was a kind of   came to our attention, can I say, around the time of the major outbreak in Victoria in 2020. The COVID outbreak.

CHAIR: Alright. Well, that answers  

MS TAYLOR: And then through 2021. 

CHAIR: That answers my question. Thank you. Do you agree that the provisions relating to the reportable incidents, or what are reportable incidents, is a very important mechanism for you to be able to determine if something was going wrong as far as NDIS participants are concerned? 

MS MACKEY: It is a very critical part of our functions 

CHAIR: The Reportable Incidents Framework operates only in relation to registered NDIS providers; is that correct? 

MS MACKEY: That's right. 

CHAIR: We know that 30 per cent of the residents in SRSs are NDIS participants. Correct? 

MS MACKEY: That's right. 

CHAIR: We also know that SRS providers do not, by reason of that, have to be registered as an NDIS provider. Correct? 

MS MACKEY: Sorry, can you just   

CHAIR: Someone operating an SRS does not have to be registered as an NDIS provider? 

MS MACKEY: That's right. 

CHAIR: However, they can also be an unregistered NDIS provider, can they not? 

MS MACKEY: They could be.

CHAIR: If they are an unregistered NDIS provider and something goes wrong with the resident at the SRS who is also being provided by the SRS provider with NDIS services, there's no requirement for reportable   to make a reportable   a reportable incident? 

MS MACKEY: Not a reportable incident, but there is a requirement for them to operate consistent with the code. 

CHAIR: I'm sure that's right. Yes, indeed. 

MS MACKEY: Which includes coming to us when something goes wrong. 

CHAIR: Has anybody given consideration to extending the reportable incident requirement to unregistered NDIS providers? 

MS MACKEY: We started work earlier this year, when I started my tenure, about how we might evolve the broader registration arrangements and, therefore, including the responsibilities that go with being a registered provider and thinking very carefully about how we might respond. There's a range of issues that sit in that registration space that need careful consideration. 

CHAIR: Does that mean the answer to my question is yes? 


CHAIR: It will be a good idea, wouldn't it? 

MS MACKEY: We need to   the challenge that we have is visibility of all providers and understanding what they need to do in terms of those reportable incidents. So, we do need to look at it as a whole in terms of across the registration responsibilities and arrangements. 

CHAIR: I understand that. But it's rather difficult from the point of view of the people who receive services and who, by definition, if we are talking about reportable incidents, have suffered or experience something that is unfortunate that may range from death to a failure to administer medication on the appropriate day   it's rather unfortunate that there isn't an obligation upon people who are providing NDIS services to let you know that these things have happened. 

MS MACKEY: I agree. 

CHAIR: And, therefore, you need to do   somebody needs to do something about it. 

MS MACKEY: As I said, we have certainly raised this as part of the work we are doing on registration because   

CHAIR: If someone looks at the Act, they may find that the Act authorises regulations that would allow you to do exactly that. 

MS MACKEY: There are certainly   there is   the authority that sits in the Act is broader than how we currently operate so we are very conscious that there are arrangements that we could take that fit within the current Act. So, we   that's why we are delving into a number of issues including registration to look at what we can do and then, you know, as a second step what might need to change in the legislation. 

CHAIR: Inventive legal minds might point out all sorts of possibilities under this legislation. 

MS MACKEY: We have had a range of suggestions. 

CHAIR: Alright. Thank you. Commissioner Galbally, do you have any questions? 

COMMISSIONER GALBALLY: One question would be that, while it wouldn't deliver everything, you know, would it be   would you be supporting the separation of accommodation from service provision as a requirement to reduce risk? And I understand the complexity of all the interconnected entities and, you know, that they're set up with different names but still as a beginning point, would it be a good idea that accommodation and service provision are not delivered by the same entity? I would just like your comment on that, thanks. 

MS MACKEY: I think what we have learned from a number of incidents that have occurred is that safeguards are   work best when there are a range of safeguarding mechanisms in place, so, therefore, you have a range of providers and supports providing those services. But we have also learnt from what we collected over last four years that simply separating the provider of accommodation and supports does not necessarily, you know, lead to a better quality or outcome or safeguarding for that individual. 

So, it's not as clear cut as saying separation is the answer. There are circumstances in which the provision of both works quite well for a whole range of circumstances and characteristics, and equally there are circumstances where it doesn't work well. I think part of what we have to do   and we've done this, for example, in a range of SIL settings, is look at what are the practical mechanisms we can put in place and require of providers to try and clarify who's providing what, to try and provide certainty that it's at a level of quality that is required. They are the kind of things that I think are much more helpful in the space. 


MS TAYLOR: If I could add to that, thinking about the system in the broad, people   people choose and for some people with disability, choosing somebody who may be providing them with accommodation to also deliver their supports makes sense in terms of their particular circumstance. The issue for us is how we put protections around   available to those people who do make those choices where   and particularly focus where there might be risks. 

And I think the evidence that the Commission has given previously, particularly in response to the Robertson review, is about the protective mechanisms we need to have in place so that NDIS participants can make choices freely and have   and have us available or mechanisms available to assist them if they need. But the first principle of choice   and this is why, I think, in   if we take the example of Robertson where Mr Robertson in response to   as part of his review into the death of Ms Smith, and particularly the regulatory response of the Commission, he, for example, indicated that the Commission should take steps to remove the obligation   or the choice of a person to choose to have a sole worker delivering their support. 

We consulted with people with disability and a number of parties about that, and there was a very strong view that that should not be a binary position, and that that option should be available to people if they choose it. But that the mechanisms that   what the Commission should put in place are mechanisms to reduce significantly any risk that might present by putting additional obligations on providers where people make those choices. 

CHAIR: I think that's an answer to the question. Yes. Commissioner Galbally, do you have another question? 

COMMISSIONER GALBALLY: My only other question was regarding your comment, Ms Mackey, about education and information. And just coming backing to the Workforce Capability Framework where I notice homelessness is one of the areas in complex, challenging or changing circumstances. And I just wondered how much that's penetrated that Capability Framework and whether SRSs would be aware of it, for instance, and how far it's reached, because it's a good   well, a valuable resource but how far has it gone? 

MS MACKEY: So, we agree the Capability Framework is a really valuable resource. It's relatively new and we are just in the process of rolling out a number of tools for service providers and individual workers to make it easy for them to engage with the Capability Framework. So, that there's a   if you like a schedule of work that's happening around building people's awareness that the Capability Framework exists and how and which they can engage with it. We are also actively considering, with our regulator   very much our regulator hat on how we use the Capability Framework across the board, so for registered and unregistered providers. How do we start to point to   here is the expectation and this is the guide around the expectation. 


CHAIR: Commissioner Ryan. 

COMMISSIONER RYAN: Thanks. There will be some people that would regard SRSs, because of their scale and size and staffing and the inability of residents to choose who they live with, and yet they have got to share very intimate spaces with them, they take the view that they are ultra vires of Articles 19, 22 and 28 of the Convention of the Rights of People with Disabilities. They clearly are notorious in terms of their risk. 

CHAIR: Is there a question? 

COMMISSIONER RYAN: The question is, how is it possible for an SRS to get   or an entity associated with it to get in NDIS registration without very, very significant capability building prior to that happening? I think a lot of people are asking how that happened. 

MS TAYLOR: I can   so registration, gaining registration, providers will, you know, apply for a class of supports that might not actually be about delivering supports in a   in an accommodation setting. SIL, for example. Wintringham talked about how they are registered to deliver support coordination, for example. So, it depends on what someone's registering for. In the context of SRSs that are registered by the Commission, the majority of those   those entities transitioned to the Commission as registered entities prior to our commencement, and they have been going through a repeat   you know, a re registration process where they have sought to continue to be registered. And they have to meet the same thresholds that any registered provider delivers   has to demonstrate, depending on the nature of the supports that they are applying to be registered for. 

We don't   as part of that registration, the standards do not look at the setting, per se, and make a judgment about the setting. They look at how the standards are   are applied in the context of delivering the supports that the provider has been registered for. I know that's not a particular answer to your question, but it's a description in the broad of the way in which the function operates. 

COMMISSIONER RYAN: So it's likely that many of the SRSs became registered entities by virtue of the fact they were providing disability services prior to that, is it? 

MS TAYLOR: I couldn't say, Commissioner, how they became originally registered. The   there were arrangements in Victoria, as I understand in every jurisdiction, around registration into the NDIS where   yes, prior to our establishment. And they may have been funded, for example, by the Victorian Government for other things in that example. They might have registered as new entities when the NDIS started earlier than our commencement. 

COMMISSIONER RYAN: Well, I think you would agree that it's   I mean, 43 years ago every government in the country agreed that large residential centres should close. And there are many, many aspects of SRSs that look very similar to large residential centres. Do NDIS registration requirements or the code or practice standards need to be adjusted to prevent NDIS participants in exercising their choice or control from the unintended consequences of allowing the establishment of new forms of congregate accommodation which don't operate according to the convention or assisting existing models being sustained by virtue of the fact that they are receiving funding under the NDIS? Do we need to look at something? Because it looks to me this is a broken model which needs to either be significantly reformed or abolished all together. 

MS TAYLOR: Well, we understand that the Victorian Government   and sure it's a good question to put to those officials   is reviewing SRSs and their   their place in the Victorian accommodation market. It's probably an appropriate thing to do. Certainly, you know, as you and I know from previous experience in our work in past lives in New South Wales, significant reforms around these kinds of settings was undertaken by the state government as part of a whole suite of looking at issues around tenancy and affordable accommodation for people on very low incomes, and particularly people who are pension dependent. 

COMMISSIONER RYAN: Did you hear the evidence of a person called 'Colin' earlier about   in our inquiry into homelessness where he talked about the services he received from his service coordinator, and they didn't appear to be very good. A lot of people have come to the Commission with complaints about service coordinators, that they don't seem to know   they don't have enough information about the system to help them navigate it. They don't respond promptly to requirements. Do you think it's time to have some sort of strategy to educate and have service coordinators better understand their role? 

MS MACKEY: I didn't hear that   the witness 'Colin' that you referred to. But I have heard from many that we need to be much clearer around what we do in terms of support coordination, if that's what you are referring to. 

COMMISSIONER RYAN: That's what I mean, of course. 

MS MACKEY: And we have actually   it's part of the work that Ms Taylor will undertake in her new role. We are looking at doing a piece of work, quite a detailed piece of work, possibly in the form of an own motion inquiry looking at those particular arrangements. 

COMMISSIONER RYAN: Thank you, Mr Chair. 

CHAIR: Thank you. I do have one more question for you, Ms Mackey. You have been in the job for seven months, a pretty big challenge. The Commission has been going for three and a half years. I don't expect you have to have read everything that your predecessor provided in the form of statements or the transcripts, but have you taken steps to determine what the Commission has learned or should learn from the   your Commission has learned from the work of this Royal Commission over its three and a half years so far? 

MS MACKEY: Yes, and certainly as part of my introduction to the organisation, I was also made aware of work that had happened prior to my commencement, and we continue to look at proceedings and learn and think about what actions that we might need to take and what work we need to do. So, we are certainly drawing in the information. 

CHAIR: Is there some formal process in place to ensure that whatever is coming out of this Commission, for example, in the form of reports on particular hearings, that that is taken into account and brought to the attention of relevant decision makers within your organisation? 

MS MACKEY: Absolutely. And, again, part of the establishment of the Strategic Advisor role was to look at the work of the Royal Commission and other inquiries and reviews to draw it into the organisation and think about, as I said, having that focus on continuingly improving and ensuring that we are doing our functions to the best of our ability. 

CHAIR: Very good. Thank you. Now, I should ask Ms Morgan if she wishes to ask any questions from the witnesses. 

MS MORGAN:   Thank you, Chair. No questions from me. 


CHAIR: Ms Eastman, I realise we are a little behind time. What should we do now? 

MS EASTMAN: Yes. It's 20 to 1 now, and I'm conscious that our interpreters will require a break. I had suggested that we have an early lunch, but I'm told lunch is not available until 1 pm. So we could have a short break of five minutes or 10 minutes and then resume until 1, have a shorter lunch. Or, alternatively, if everybody can wait, maybe we should have lunch now and return, say, at   what do you want to do? 

CHAIR: I think it will be better to have   to have a break now for lunch, only because of my back. 

MS EASTMAN: I'm conscious we have had a long run. 

CHAIR: And then we can resume after lunch so some of us have had a chance to walk. 

MS EASTMAN: Can we come back at 1.30? 

CHAIR: Yes, let us break for lunch now and resume at 1.30. 



CHAIR:  Ms Bennett.

MS BENNETT:  Commissioners, the next witness is Mr Anthony Kolmus, and he appears remotely.

CHAIR:  Yes, we can see you, I think.  In the distance.  Thank you, Mr Kolmus, for coming to the Commission remotely, as it were, to give evidence and thank you for the extremely detailed statement that you prepared plus the annexure thereto, which we have read.  Thank you very much.  If you would   just to explain where everybody is, Commissioner Galbally   I assume you can see her on a screen   she is joining the Royal Commission hearing from Melbourne.  Commissioner Ryan is on my left.  I'm the Chair of the Royal Commission.  We have Ms Bennett in the same room, and Ms Bennett, once she returns to the counsel's whatever it is, will ask you some questions.  In the meantime, I will ask you to follow the instructions of my associate who will administer the affirmation to you.  Thank you very much.


CHAIR:  Thank you very much, Mr Kolmus.  I will now ask Ms Bennett to ask you some questions.


MS BENNETT:  Good afternoon, Mr Kolmus.  Can you hear and see me properly?


MS BENNETT:  Thank you.  You are the Director of the Human Services Regulator Unit; is that right?

MR KOLMUS:  That's right.

MR BENNETT:  And what is the name of the Department of which you are a part?

MR KOLMUS:  It is the Department of Families, Fairness and Housing.

MS BENNETT:  From a state perspective, you are effectively, along with your unit, the regulator of SRSs; is that right?

MR KOLMUS:  That's right.

MS BENNETT:  And they are regulated primarily under the SRS Act and the SRS Regulations.  Do you know what I mean when I am referring to those pieces of legislation?

MR KOLMUS:  I do, yes.

MS BENNETT:  Now, most SRSs are pension level SRSs, are they not?

MR KOLMUS:  The majority are, yes.

MS BENNETT:  And that means that residents of those SRSs pay 85 to 95 per cent of their income and all of their Commonwealth rent assistance to the SRS proprietor; is that right?

MR KOLMUS:  That's right.

MS BENNETT:  And in addition to that, many receive what we have called SAVVI or PLP funding from the state government; is that right?

MR KOLMUS: That's right, yes.

MS BENNETT:  And most residents in pension level SRSs have a disability.  Is that right?


MS BENNETT:  You tell us in your statement that the figure is 79 per cent.  And I understand that figure to be higher in those pension level SRSs that receive SAVVI or PLP funding.  Is that right?

MR KOLMUS:  I think that's correct, yes.

MS BENNETT:  Mr Kolmus, do you know what the largest number of residents is in a single SRS in Victoria?

MR KOLMUS:  The largest capacity for an SRS in Victoria, I think, is just over 80.

MS BENNETT:  And do you know if there are 80 people resident at that SRS?

MR KOLMUS:  As of a few weeks ago, we had cause to be in touch with that SRS.  I think they had about nine vacancies.

MS BENNETT:  So there are 71 people presently resident in that SRS?

MR KOLMUS:  Approximately, yes.

MS BENNETT:  And there could be 80.

MR KOLMUS:  There could be 80, yes.

MS BENNETT:  And there is no limit, is there, on the number of people who could be resident in an SRS?

MR KOLMUS:  Yes. The limit is set by the registration criteria. So, each SRS is registered for a specific number of beds.

MS BENNETT:  Yes.  And is there a limit in the Act or the Regulations as to how many the SRS could be registered to receive?

MR KOLMUS:  No.  No, there's not.  No.

MS BENNETT:  And the SRS that has 80 residents, is that 80 rooms or 80 residents?

MR KOLMUS:  I would have to take that on notice and check.  I don't know.

MS BENNETT:  It could well be a number of the people in that SRS are sharing rooms.  Is that right?

MR KOLMUS: That's right.  It could be.

MS BENNETT:  Quite common for people in SRSs to share room; is that right?

MR KOLMUS:  It's not uncommon. That's right.

MS BENNETT:  Do you know precisely how many people are living in an SRS today in Victoria?

MR KOLMUS:   Not precisely.  The most recent figure we have had, which we are not sure if it's 100 per cent accurate, but it's a little over 3,100.

MS BENNETT:  So how do you know how many people are in SRSs at any given time?

MR KOLMUS:  We don't, necessarily.

MS BENNETT:  I see. You know the maximum number that could be in SRSs; is that right?

MR KOLMUS:  That's right. Yes.

MS BENNETT:  And the maximum numbers as at today could be 4,000 in Victoria; is that right?

MR KOLMUS:  That's right yes.

MS BENNETT:  No, my learned colleague Ms Eastman recently took some witnesses to a document called the NDIS Commission Compliance Strategy   Supported Residential Services in Victoria.  The Commissioners will find this in folder B2 at tab 7.  Have you seen this document before this hearing?

MR KOLMUS:  No, I haven't.

MS BENNETT:  Were you involved in consultations with the NDIS Commission about the formulation of this strategy?

MR KOLMUS:  I was aware of this strategy, and I was aware that there was a paper being developed and a piece of work being developed by the NDIS Commission with regards to SRSs, but I wasn't   other than conversations we have on a regular basis regarding specific matters, we weren't involved specifically in the development of this strategy.

MS BENNETT:  You will notice that there are numbers at the top right hand corner of that document, and they have four digits at the end, 0001 and so on.  Could you go to 0006.  And you will find there the paragraph above the dot points commences with the words:

“The NDIS commission is aware of and responding to the following types of issues impacting NDIS participants living in SRSs through the management of complaints it has received or compliance and investigation activities. The first is, the financial exploitation where the SRS operator uses NDIS funds as well as payment already made by the resident from their pension to pay for the same supports or provides no services at all after depleting the person's NDIS plan.”

Mr Kolmus, are you aware of that issue impacting on SRSs in Victoria?

MR KOLMUS:  We've had allegations made or concerns raised that people who are in receipt of an NDIS package and who live in an SRS, yes, are paying both SRS fees for supports and may also be being charged for NDIS supports for those same type   the same supports.

MS BENNETT:  There is the potential for substantial overlap, would you agree, between the supports provided that an SRS proprietor is required to provide and the supports which might be provided under NDIS funding.  Do you agree with that?


MS BENNETT:  Could I ask you to say yes for the transcript?


MS BENNETT:  Thank you.  Would you agree that that is financial exploitation of people with a disability?

MR KOLMUS:  If it's occurring, yes, it would be.

MS BENNETT:  Yes.  And that would be a matter of substantial concern to you, if it were occurring?

MR KOLMUS:  Yes, it would be

MS BENNETT:  And what steps have you taken to investigate whether it is occurring?

MR KOLMUS:  So whenever we hear about   whenever we receive concerns regarding matters of that description, we usually contact either   both the NDIS Commission and potentially the NDIA as well.  We don't have access to the NDIS documents, but we do have access to the ongoing support plan that's developed for SRS residents, and we would normally share that with   well, we would work out with the Commission in particular who is best placed to investigate the issue, depending on the particular circumstances of that issue.

MS BENNETT:  Mr Kolmus, I'm talking to you, though, about a systemic problem across the SRS sector.  Are you aware of the extent of this potential exploitation across the SRS sector in Victoria?

MR KOLMUS:  In terms of numbers of complaints about this specific issue, we actually haven't had that many.  We've had a few.  But it certainly hasn't been what I would consider a systemic issue, per se. So, it's been, off the top of my head, maybe 10 to 20 complaints regarding that. But that's   

MS BENNETT:  From different SRSs?

MR KOLMUS:  Not   not that many SRSs.  No.

MS BENNETT:  So the Public Advocate has raised this concern with you, has she not?

MR KOLMUS:  Yes, we've talked about it with the Public Advocate yes.

MS BENNETT:  And she has   she's raising a broad and systemic concern there, isn't she?


MS BENNETT:  And the   I'm sorry.

MR KOLMUS:  I was just going to say, I mean, she's certainly concerned that it could be. We don't have evidence at this stage how broad it is or how broad a concern it is.

MS BENNETT:  It is your responsibility, isn't it, to identify how widespread this conduct is, isn't it?

MR KOLMUS:  Yes.  And, to that end, we have sought information and received information from the NDIA in terms of all of the SRSs that receive   where payments for NDIS supports are being provided to someone living within that SRS.  But in terms of the number of actual complaints about that activity, like I said, it's actually not that many to date.

MS BENNETT:  I'm asking, Mr Kolmus, about the proactive steps that you as a regulator are taking to identify and then prevent exploitation. So, as I understand your evidence, you've sought information from the NDIA about NDIS participants living in SRSs.  Is that right?

MR KOLMUS:  That's right, yes.

MS BENNETT:  And do you also cross reference the place of business or the identification of NDIS providers with SRS providers?

MR KOLMUS:  We've provided information to the NDIS Quality and Safeguards Commission regarding   so we've had discussions with the Commission on a number of occasions about exactly that issue, about trying to identify and match up SRS proprietors with the NDIS registered providers.  And we have provided information to the Commission with details of the SRS, their address, the registered proprietor of the company that's in charge of the SRS and company numbers so that they can try and align that.  It's proven to be much more difficult than anticipated, because the NDIS registered providers are often completely separate companies that aren't necessarily or overtly have any obvious connection to the SRS companies.

MS BENNETT:  So returning to my original proposition to you, which was that this was a matter that fell within your scope as a regulator, why is it something that you are sending off to the NDIS rather than investigating yourself?

MR KOLMUS:  Well, it actually affects both of us.


MR KOLMUS:  So it's   it's   from an SRS perspective, if it is the SRS proprietor that is charging for both, then, yes, it falls into our remit.  And the idea of asking the NDIA for   where NDIS funds were going to was so that we could have a sense of which SRSs could this potentially be happening with.  But it's also an issue for the Quality and Safeguards Commission in terms of the provision of NDIS supports and how they line up.

MS BENNETT:  So my question is directed to you as the regulator in Victoria.  Is   are you taking in any proactive steps to identify where there is this   this potential for the exploitation of people with a disability through this double dipping?

MR KOLMUS:  You could.  Like I said, by knowing which SRSs have NDIS packages being paid into them, that gives us a potential line of sight of where it could be occurring.  We also, through complaints that are referred to us from the Commission, that also gives us an idea of   of where that issue might be occurring.  But short   like I said, we don't have access to NDIS plans.  So we can view SRS ongoing support plans that are developed for people, but we don't automatically have access to NDIS support plans to be able to line the two documents up and compare them.


MR KOLMUS:  So it's very much   at this stage, it's very much a case of identifying issues as they occur so whether it's through support coordinators raising concerns with us, whether through complaints to the Quality and Safeguarding line, whether it's families bringing concerns to us about a potential double up, that would typically then enable us or give us a line of sight into issues.

MS BENNETT:  Is it fair to   as a matter of fairness to you, Mr Kolmus, is it right to say that the orientation of your office, your unit, is that it is, at present, reactive to complaints and issues as they arise rather than proactively trying to track this down?

MR KOLMUS:  In relation to this specific issue? 


MR KOLMUS:  Yes, I   to a degree, yes.

MS BENNETT:  The second dot point is:

The concern regarding the trading of residents between SRSs or entities associated with SRSs where the value of the NDIS plan makes these residents lucrative for unscrupulous operators.  This includes relocating residents to private accommodation which does not have the oversight of the HSR."

That being your unit.  Are you aware of this issue?

MR KOLMUS:  Yes.  Yes.

MS BENNETT:  And do you consider that a risk to people with a disability who presently reside in SRSs?

MR KOLMUS:  If they are in receipt of an NDIS package, it can be a risk, yes.

MS BENNETT:  Is it a risk to them that they are moving out of a system that has the oversight of your unit?

MR KOLMUS:  It depends where they go. So it depends whether the accommodation they are going into has some form of regulatory oversight or not if   yes.

MS BENNETT:  So are you aware of the issue of what the Public Advocate yesterday referred to as pop up SRSs?

MR KOLMUS:  Yes, I am.

MS BENNETT:  This is really related to that issue, isn't it?

MR KOLMUS:  It can be.  Yes. That's one type of accommodation that people might relocate to, either by their choice or   yes.  That will be relocated to, yes.

MS BENNETT:  Well, pop up SRSs would be an unregistered SRS, would it not?

MR KOLMUS:  If   if it isn't   it if it hasn't applied for registration with us then, yes, it would be an unregistered   well, not quite as simple as that.  It would be an   it would be a disability service.  If   if someone with a disability is relocated to another form of accommodation, so a shared rental house, for example, that may or may not be an unregistered SRS, depending on the nature of the supports being provided and if they are not receiving disability supports, per se, and not paying a board and rent component on top of the NDIS package, then it's not necessarily an unregistered SRS.

MS BENNETT:  So the   a premises where accommodation and personal support of some kind are provided for a fee, that is a supported residential service, isn't it?

MR KOLMUS:  If there's a fee from their personal income as opposed to from their NDIS supports then, yes, typically that would be a very strong indicator that it's an unregistered SRS.

MS BENNETT:  So there's a distinction, is there, between where the funds for the personal support come from. So, where they come from individual income stream, it might be an SRS.  Where they come from the NDIS to the participant, to then be disbursed  


MS BENNETT:    that is different.  Is that your evidence?

MR KOLMUS:  That's right, yes.

MS BENNETT:  And is that   do we find that in the Act, that distinction?

MR KOLMUS:  Well, the SRS Act was   was promulgated well in advance of the NDIS, so it's not in the NDIS   sorry, the SRS Act.  I don't know if it's in the NDIS Act, but in order for it to be   in order for it to be considered an SRS   and the SRS   the SRS Act is a bit unusual in that it defines an SRS by what it's not rather than what it is.  But typically, like I said, if someone is paying out of their own pocket a board and lodging fee of some description to receive supports in an accommodation setting, then typically that would be a very strong indicator that it is an SRS, yes.

MS BENNETT:  Is that   is that position in relation to   the relevance of NDIS funding as to whether or not it's an SRS   is that a position that's been developed by your office?

MR KOLMUS:  Not by   well, no, not by my office, per se.  If   if the person is only receiving supports that are funded through the NDIS, then, from our perspective, it wouldn't wouldn't   really wouldn't qualify as an SRS.  It would be a disability service where supports are being funded through the NDIS supports like a   what would typically be considered a disability service.

MS BENNETT:  Alright.  I'm going to just read out the balance of the dot points in that document I was just asking you about to get your views as to whether these are prevalent concerns that your office responds to:

"Complex business networks established by SRS operators to which operate collectively providing a range of supports and services and duplicating costs already met by a participant, where the relationship between these businesses is not transparent to a resident.

Poor and non existent record keeping by SRS operators, resulting in a lack of transparency for residents about what they are are paying for and limiting the information available to the regulators to pursue lines of inquiry.

Residents being limited in their choice of other providers and the ability of other providers to deliver supports in SRSs, or significant conflicts of interest between SRS operators and other providers involved in a person's support.

Coercion of residents, particularly those at greater risks of such practices due to cognitive impairment.

And, finally, the lack of skills and competency of the SRS workforce to deliver NDIS supports and services to the level required by residents."

Now, these are all matters that have been drawn to your attention in the past, are they, Mr Kolmus?

MR KOLMUS:  If we can take   if we can go through each one, perhaps, rather than an overall summary. So, the complex business networks, that is an issue which we have heard about both in relation to SRS proprietors who have multiple companies and/or NDIS registers providers who have multiple companies. So, yes, that is an issue.  As to whether the residents would typically understand the connection between those companies, I imagine there are times when they don't but I can't speak, obviously, for every situation.

Poor or non-existent record keeping by SRS providers.  Typically, the supports that are to be provided to any person within an SRS are normally documented or are documented in the ongoing support plan.  That is a legislative requirement that's to be developed by the SRS.  I   certainly the quality of those support plans, like the rest of the sector, varies.  Some are very good and provide a really good level of detail about the supports being provided.  Others are not as good. So, that's   that can be an issue.

Residents being limited in their choice of other providers.  That can be an issue.  Different SRSs have approached that differently.  Some SRSs absolutely have a number of different NDIS providers coming into their SRS to deliver NDIS supports, and it's completely up to the client.  Others have taken a view where they do have an NDIS-associated company and have made it clear that their strong preference is that people use that company, and we have had to step in a couple of times to make it clear that people do, in fact, have a choice about where they   where they get their NDIS supports from.  That can vary in terms of clients who move into an SRS and whether they are informed of that upfront, as opposed to clients who already live in an SRS who might then receive NDIS supports and what level of choice they have about those supports.

Coercion of residents   yes, unfortunately, coercion of residents does seem to take place in some situations, and certainly we took regulatory action against a provider just recently, and that was one of the reasons we took that action, because we believed that was happening.  The lack of skills and competency of the SRS workforce to deliver NDIS supports.  The SRS workforce doesn't by definition provide   necessarily provide NDIS supports. So, there may be some situations where SRS staff, where they're not rostered for the SRS, would be rostered to deliver NDIS supports.  That's possible.  But SRS staff are delivering   typically are delivers SRS-related supports, and NDIS-related supports should theoretically be delivered by a separate group of staff.

MS BENNETT:  Yes, okay.

MR KOLMUS:  But sometimes the two   you might use the same staff member so long as they are not on the roster at the same time for both the NDIS and the SRS.  Yes.

MS BENNETT:  So and   would you accept that there have been concerns or complaints about the lack of skills or competency of the SRS workforce to deliver SRS supports?

MR KOLMUS:  Yes, there have been concerns about that yes.

MS BENNETT:  So there have been   is it fair to say, Mr Kolmus, there have been a number of concerns raised   a large number of concerns raised from a number of quarters about substantial issues about the quality and efficacy of SRS properties in Victoria.

MR KOLMUS:  As a sector?

MS BENNETT:  Yes, as a sector.

MR KOLMUS:  Yes, as a sector, there has certainly been fairly broad criticism of the sector.  I think, like any sector, there are some SRSs are better than others. So I don't   I don't think you can necessarily   or we can necessarily take the point that all SRSs are a concern.  But as a sector absolutely, it is   has had numerous criticisms of how it operates. 

MS BENNETT:  And there are substantial concerns across the sector into matters that go directly to the safety of people with a disability living in an SRS.  Is that fair?

MR KOLMUS:  There are definitely safety concerns in relation to some SRSs within the sector, and that's been borne out in some cases that we've   we've had to deal with.

MS BENNETT:  I should say the safety and support of people with disability.  Is that understood to be encompassed within that question?  Yes.  Let me ask again.  Is it fair to say that there is a substantial concern across this sector for matters which are relevant to the safety and support being given to people with a disability in SRSs.  That's fair?

MR KOLMUS:  As a broad general view of the efficacy of the sector, yes, that would be fair.

MS BENNETT:  And is it likewise fair, Mr Kolmus, that the complexity of the resident profile   of the presenting resident profile has increased over time in the SRS sector?

MR KOLMUS:  I've only been in position for just coming up to three years.  My sense from talking to colleagues, from different reports and information I read would be, yes, that would be my sense is the complexity of clients is increasing.

MS BENNETT:  So of all of these issues and concerns that you are aware of, can you tell us   and tell the Commissioners   what are the regulatory response   I'm going to go through the regulatory responses at your disposal. So, you have the power to issue an infringement notice.  Is that right?

MR KOLMUS:  That's right.  Yes.

MS BENNETT:  And how often is that used?

MR KOLMUS:  We haven't yet used the infringement notice.

MS BENNETT:  So you have had that in your toolbox since 2010; is that right?  I mean you as in the unit has had that in its toolbox since 2010?

MS BENNETT:  The Department has had that as a tool in its regulatory toolbox since 2010, yes.

MS BENNETT:  And it's never once had an incident where an infringement notice might have been appropriate?

MR KOLMUS:  I   I can't comment for the period prior to 2019. I'm not aware that they have. But I can't comment specifically for the period prior to September 2019.

MS BENNETT:  Well, alright, has it been   would you consider that to be a fairly important tool, infringement notice tool?

MR KOLMUS:  It's one of a number of tools that   that the Act provides for.  I think the aim of any regulator is to bring or to keep regulated entities in compliance.  An infringement notice is one of those tools, absolutely, but there is also a range of other tools that can be just as effective in terms of bringing providers into compliance or ensuring compliance, yes.

MS BENNETT:  Right. You can issue a compliance notice.  Is that right?

MR KOLMUS:  That's right yes.

MS BENNETT:  You tell us in your statement that they were not in   in much use prior to 2018.  Is that right?

MR KOLMUS:  Yes.  Prior to 2018   and, again, I'm relying on information from colleagues and reports.  Prior to 2018, whilst I understand that there were some regulatory sanctions used in the years between 2010 and   and, really, 2019, for the most part, the regulatory approach was to provide support and guidance to SRS providers to assist them to reach compliance, and that was usually in the form of either advice or guidance letters, etcetera.

And I think in 2018, the unit   which had just been formed at that point, the unit I'm now in charge of   began using compliance instructions which is still a   an administrative tool. So, it's not a statute in the Act.  We first began using compliance notices in early 2020.

MS BENNETT:  Alright.  Do you consider   is that a regulatory action, a compliance notice?


MS BENNETT:  So that triggers   when you issue a compliance notice, you inform the NDIS that you have done that?



MR KOLMUS:  No.  Not necessarily.  If it specifically relates to an issue that we think is of relevance to the NDIS, then, yes, we will let them know   the Commission know, but the vast majority of them don't necessarily relate directly to NDIS provided supports.

MS BENNETT:  Your evidence earlier was that it's difficult for you to have insight into when an NDIS provider is involved.  Is that not the case?

MR KOLMUS:  If   if the support is actually being delivered by an NDIS provider then, typically, we can work that out.  But   and a compliance notice is issued to an SRS proprietor where we believe that they haven't met their legislative obligations in relation to the SRS Act, per se. So, what they should be doing in terms of delivering the SRS and supports within that, as opposed to any other type of support.

MS BENNETT:  So when do you inform the NDIS of concerns that you might have as a regulator?

MR KOLMUS:  If   if we   if in the course of investigating an issue that we think might warrant a compliance notice or something more, if we believe that there is an NDIS support element to it, that's when we would let the Commission know. Because sometimes it's quite clearly an issue that's confined to the SRS and the types of   or the obligations the proprietor has under the SRS and has nothing to do with an NDIS element at all.

MS BENNETT:  So who is making that judgment?   Is that you or an authorised officer?

MR KOLMUS:  It would typically be a combination of an authorised officer along with   we have a management structure above them between myself and the authorised officers.  And then if it was a particularly serious issue or widespread issue, then it would be brought to my attention.

MS BENNETT:  And that's the   in the evaluative judgment of the authorised officer to bring it to your attention?

MR KOLMUS:  Or the   so we have a Director of Compliance.


MR KOLMUS:  We have a State Wide Manager of Regulatory Compliance Enforcement who also has a significant role in overseeing SRSs.  And we have two Managers, one for the south and east, and one for the north and west. So, that's the line management structure that sits above the authorised officer.  Compliance notices have to be signed off by the Director of Compliance or myself. So, any   any authorised officer that was recommending a compliance notice be issued, they have to document the reasons why they believe it needs to be issued, the evidence of that gathered, and relevant information that's put in a brief up to   

MS BENNETT:  Just pause.  I'm sorry to interrupt you, Mr Kolmus. I'm just conscious of the time and I understand the point so thank you.  How many authorised officers do you have in the unit?

MR KOLMUS:  Currently, we have about 21.

MS BENNETT:  21.  And they are responsible for regulating all 114 SRSs. Is there any else involved in going out to see SRSs?

MR KOLMUS:  They are the main people that would go out to see SRSs.  We have a different team that's involved in the registration of SRSs.


MR KOLMUS:  So they hold that function, and the authorised officers in   primarily spend most of their time regulating, SRSs, but as a regulator, I'm also responsible for two other Acts of Parliament. So, they also do spend some time in relation to, for example, the Disability Act and occasionally issues arising in relation to the Children, Youth and Families Act.

MS BENNETT:  Does an authorised officer visit every SRS every year?

MR KOLMUS:  That would be the aim.  It doesn't always happen.

MS BENNETT:  Does an authorised officer set foot in an SRS every six months?  I'm sorry, every 18 months.  Every 18 months?

MR KOLMUS:  Again, that would typically be the plan, but that can depend on   if we have priority issues come up or priority investigations that require a much more intensive input or much more resource intensive input, then that would take priority over a visit to a   what we consider a low-risk SRS, for example.

MS BENNETT:  So you've got   do you have 21 full-time equivalent staff or 21 staff?

MR KOLMUS:  No, I have approximately 45 FTE.


MR KOLMUS:  Across.

MS BENNETT:  Across, and then for authorised officers carrying out the regulation of SRSs in Victoria, you have 21.  Are they 21 full time equivalent?

MR KOLMUS:  A few part timers but they are probably about 19 FTE.

MS BENNETT:  Okay.  Let's call it 20 people regulating 114 SRSs 


MS BENNETT:  And when a substantial regulatory response is called for, that will divert resources from the other SRSs; is that right?

MR KOLMUS:  That's right, yes.

MS BENNETT:  Mr Kolmus, is it   is 20 people enough to regulate these environments?

MR KOLMUS:  I think, like any regulator out there, if someone offered me more resources, I wouldn't say no.  I think that the challenge for government is to decide how much they invest in regulating services as opposed to actually delivering services that are required on the ground. So, it's   it's a   it's the proverbial how long is a piece of string.

MS BENNETT:  Well, no, we've got a very specific sector here with very specific problems that we have gone through and identified.  In light of those problems, Mr Kolmus, are the 20 people you have on the ground sufficient to respond in a way that is proactive and responsive to the needs of people with disability?

MR KOLMUS:  At the moment, I would have to say that we are probably being more   less proactive than I would ideally like.  I think   having said that, I think for the most part we are across the key issues arising.  We are able to deal with those.  But, yes, in an ideal world, I would want to be a little bit more proactive than we currently are 

MS BENNETT:  Not the ideal world, Mr Kolmus. The world we are in, you're able to   is it the case that you are able to respond to issues as they arise but not to proactively go out and find the problems?

MR KOLMUS:  We can do some of the latter.


MR KOLMUS:  But not as much as we would like to.

MS BENNETT:  Yes. So, fair to say   well, right.  We have had some evidence, Mr Kolmus, that there is a risk that SRSs can't operate in a way that is both ethical and viable.  Have you heard that evidence?

MR KOLMUS:  I've heard evidence that   where people have expressed the view that their SRS is not viable.


MR KOLMUS:  Basically I think I have heard in relation to specific SRSs.  I can't say I've heard that in relation to SRSs across the board.

MS BENNETT:  Alright. So, you've heard it said that it is not possible to operate, I should say as a matter of fairness, a pension level SRS in a way that's viable.  Is that   you've heard that evidence?

MR KOLMUS:  I've heard that in evidence, yes.

MS BENNETT:  And have you heard that concern expressed elsewhere?  Is the first time you are hearing that concern this week, Mr Kolmus?

MR KOLMUS:  No, no it's not.

MS BENNETT:  You have heard it before from others.  Is that right?

MR KOLMUS:  Yes.  And certainly it's a view that it's   it's an issue that we ourselves are contemplating on a regular basis.

MS BENNETT:  How does it arise in the context of regulation?

MR KOLMUS:  Because one of the   so, for example, one of the registration criteria for an SRS is that they have the financial capacity to operate an SRS, that they actually have the means to   to run SRS. So, on occasion, we have reason to   to be concerned about whether, in fact, that's the case and that might come through if an occupancy level is particularly low or maintenance of the site is not being kept as much as we would expect.  Then we might have reason to be concerned that, in fact, the SRS is struggling financially.  And if that's the case, we can ask for what's called a registration statement whereby we seek a range of information about the operation of the SRS, including financials, to assess whether, in fact, it is   continues to be a going   or continues to be viable.  Yes.

MS BENNETT:  Does an SRS that is struggling with viability, does that give rise to a risk that it will cut corners?

MR KOLMUS:  Yes, it could do, 

MS BENNETT:  And does it give rise to a risk that it will seek out new and inappropriate revenue streams?

MR KOLMUS:  It would put more pressure on them to think about a wide range of   of revenue streams. Whether they are all inappropriate or not is another issue, but certainly it would put increased pressure on them to find other   and try to engage with other revenue streams yes. 

MS BENNETT:  Is it something that informs your approach to the regulation of this space?  So do you avoid taking regulatory steps that might impact on an SRS's viability?

MR KOLMUS:  No. So, we   if an SRS is struggling financially, we may well be aware of it, but we wouldn't take that into account in terms of if we felt we needed to take regulatory action in relation to that SRS, then that action would be taken.  If   if the action we took   say, for example, if we have   in a couple of instances, we have suspended admissions to an SRS, which has a potential financial impact on that SRS.  If we already had concerns about the financial viability of the SRS, then that would be something we would monitor perhaps even more closely, depending on how long a suspension remained in place, etcetera.

MS BENNETT:  You say at paragraph 63 of your statement that:

"The power to suspend admissions has been used sparingly.  The power has the benefit of preventing a non compliant SRS from taking on and providing substandard care to any additional residents.  However, it also gives rise to a potential increase in risk to residents in an escalation of substandard care through impacting on the financial viability of the SRS, which can in turn cause a risk to resident health and safety if a proprietor chooses or needs to reduce costs.  For that reason, I would typically I only consider using a suspension of admissions in the narrowest of circumstance of a compliance issue being serious enough to outweigh the latter risk."

Mr Kolmus, aren't there other options to ensure the safety and services to the people living in the SRS to   in a non-compliant SRS?

MR KOLMUS:  So, typically, if   when we identify non-compliances within an SRS, the first option   unless it is particularly serious and we think that there's evidence that warrants jumping to the more significant forms of regulatory intervention, typically, the first forms of regulatory action we would take would either be compliance instruction or, more commonly nowadays, a compliance notice, which basically instructs the proprietor as to where we believe them to be non-compliant and gives them a timeframe to bring themselves back into compliance.

In almost all cases, with the exception of two that I think I mentioned in my statement, in almost all cases, those compliance notices have, in fact, resulted in SRS proprietors addressing the noncompliance involved and becoming compliant again.  So that's typically the most common form of regulatory action we would take.  Where   in the two instances where I used   I referred   I engaged suspension of admissions, it was where either the compliance notices were partially met or there were significant delays in meeting them or we felt that the proprietor wasn't making in good faith efforts to address the compliance notices. So, any suspension of admissions was used to escalate the action and becomes more of a sanction rather than just remedial notice.

MS BENNETT:  You gave some evidence   you gave some evidence earlier there are concerns around the quality of ongoing plans   ongoing care plans.  Is that right?

MR KOLMUS:  That's right.  Yes.

MS BENNETT:  So every resident must have an interim plan within 48 hours of arriving at SRS and an ongoing plan within 28 days.  Is that right?

MR KOLMUS:  That's right.

MS BENNETT:  And they are intended to set out the care needs of that person who is to be a resident of the SRS? 

MR KOLMUS:  That's right.

MS BENNETT:  And then the SRS must provide that care.  Is that right?

MR KOLMUS:  That's right. 

MS BENNETT:  And, indeed, it's an offence not to provide that care. 


MS BENNETT:  Now, who writes the plans?

MR KOLMUS:  It would usually be the staff within the SRS.

MS BENNETT:  And do they have any   do they necessarily have any clinical training?

MR KOLMUS:  The majority of SRS staff would not have clinical training, per se.  When you say "clinical", do you mean like as in medical, etcetera, or?


MR KOLMUS:  Yes, no, the majority of SRS staff would not have clinical experience or training.

MS BENNETT:  And the SRS staff who prepare those plans, they are then kept at the SRS and are they reviewed by your staff?


MS BENNETT:  And so   

MR KOLMUS:  Well   

MS BENNETT:  What process do your staff go through?  Your authorised officers attend the SRS, they ask to see the plans.  Do they then consider the content of the plans against the needs of the individual?

MR KOLMUS:  We don't know every individual within   within all of the SRSs. So, we don't know on a person-by-person level the details of each person's support needs.  What we look for in a plan is does it cover off the care areas that someone's likely to need support in?  Does it detail, you know, medical referral?  Does it detail the types of support that might be required, including other contacts that the person might have, whether it's GPs, whether it's community health services or mental health services? So, what we would look for is, is the plan representative of the type of information you would expect to see for people living in an SRS.

MS BENNETT:  You provide a template plan, don't you, on your website? You provide a template care plan, don't you? 

MR KOLMUS:  We do, yes.

MS BENNETT:  And that has boxes with each of the content requirements that the SRS is required to fill.  Is that right?

MR KOLMUS:  That's   that's a guide based  


MR KOLMUS:    on our    interpretation of the legislation.  So it's not compulsory that they use that template but that is a good   we consider it a good guide, if they are using something similar to that, then, typically, that plan would be acceptable.

MS BENNETT:  So as long as each box is filled, it would probably be pass the test.  Is that fair?

MR KOLMUS:  It will depend on the quality of information in   in each area of the plan.

MS BENNETT:  But no one is checking to see if that information bears any resemblance to the needs of the resident at the SRS?  The actual needs of the person with a disability?

MR KOLMUS:  Like I said, we don't have a line of sight of the needs of the 3,000 people currently living in SRSs. So, no, we can't compare it to the actual needs of people living at that SRS.  Like I said, what we look for is a plan that seems to cover off the range of support needs for   that you would typically expect a plan to include.

MS BENNETT:  So there's no mechanism anywhere in the system for   to ensure that the plans are adequate or comprehensive or even appropriate.  Is that fair?

MR KOLMUS:  We   we can check in terms of the comprehensiveness of them in terms of the range of supports that might be covered off in the plan, but I think if what you're asking is can we be 100 per cent confident that the plan relates directly to the support needs of each and every person, no, we can't.

MS BENNETT:  Not 100 per cent, Mr Kolmus, to any extent.  You know nothing about the needs of the individual resident at the time that your staff are reviewing the plans.  Is that right?  You've never seen them.  You've never seen the medical certificates.  You are just looking at the support plan created by the SRS provider.  Isn't that right?

MR KOLMUS:  Yes.  Taking into account authorised officers, because the authorised officers will often   you know, they become quite familiar with SRSs and the people living at them.  So they will broadly   they wouldn't   again, they wouldn't know individual needs, absolutely, but they   with years of experience, you tend to know the types of things that you might look for in a plan.  But, no, in terms of the individual needs, no.

MS BENNETT:  And wouldn't SRS providers come to know what sorts of things pass muster in these audits? 

MR KOLMUS:  They may, yes. 

MS BENNETT:  That's a risk, isn't it?

MR KOLMUS:  Potentially.  Yes.  I   I guess  

MS BENNETT:  And what   sorry.

MR KOLMUS:  Yes, if you work on the basis that   that the SRS proprietors are fundamentally only ticking the boxes, so to speak, but, again, we get a sense, you know, through our engagement with proprietors, through our contact through different reports that come in, through incident reports that come and in how proprietors are dealt with, we develop a sense   and we have a risk rating system for proprietors which gives us an idea of which are the ones that, in our view, seem to be absolutely trying to do the right thing and in the most part are doing the right thing.  Which are the ones that we are not as confident about, based on a whole range of information that comes into our office about the performance of the proprietor. So   and that would inform how closely we need to look at plans or other documentation within an SRS, yes.

MS BENNETT:  I would like to suggest to you, Mr Kolmus, that the person with a disability is not at the centre of that process, the document is.  Is that fair?

MR KOLMUS:  By virtue of the fact that we don't know the individual clients across the board, that's a reasonable assertion to a degree.  But, like I said, the idea of the plan is to bring that focus on to the person.  Yes.

MS BENNETT:  What are the qualifications of your authorised officers to be making the assessments?

MR KOLMUS:  Many of have worked in   some of them have worked in clinical settings previously. Some of them have worked in regulation in other areas. Some have worked in disability services in the past and so have brought those skills across to   to the current role.  We have a pretty broad range of authorised officers.

MS BENNETT:  Is there any minimum requirement?

MR KOLMUS:  There's no minimum qualification, per se. It's   it's   a lot of it is based on experience and depending on the roles they previously held and ability to inquire, to know   to be able to develop a   a   you know, how to use information to bring a picture together that gives them an idea of whether an SRS is operating as it should or not.  Yes.

MS BENNETT:  In the context of the pop up housing that we were discussing earlier, you have the power to seek a warrant to search a premises to determine if it is an unregistered SRS; is that right?

MR KOLMUS:  That's right, yes. 

MS BENNETT:  Is that a power you have ever used?

MR KOLMUS:  Yes, we used in in relation to a currently ongoing matter where, through concerns raised by a local community, we were made aware of a   a house operating in Melbourne where people were being supported.  It seems like they were people with disability. We were able to establish and gather enough information to warrant   or to establish the grounds for a search warrant, which we then issued to the proprietor to gain entry to the premises 

MS EASTMAN:  Mr Kolmus, have you watched the evidence this week?

MR KOLMUS:  I've seen a number of witnesses, yes.

MS BENNETT:  Yes.  Did you see the state of 'Bel's bedroom?  Could I ask the operator to show it. This was taken from an SRS last month.  Is this consistent with your expectations of the sector?

MR KOLMUS:  The bed is a concern, I would have to say, in terms of the standard cleanliness of the bed.  The rest of the room and the size of the room is   is   I don't know if that picture encapsulated the whole room or not.  In terms of the general tidiness of the room, I know that people who live in SRSs are typically reasonably independent.  They will often require some levels of support, but they also have the right and the skills to operate or live their lives reasonably independently. 

So, often they make choices about how they was their rooms to be, which wouldn't necessarily be what I would look for.  But it's   there's a fine line there between what   at what point does the proprietor have an obligation to step in and ensure that the room is safe and clean, as opposed to the client's right to   to   "well, this is how I want my room.  I'm paying for this room and this is how I'm comfortable in terms of what I want the room to be."

MS BENNETT:  Does this room raise concern for you as a regulator of this space?

MR KOLMUS:  Yes, it does, in relation to the standard of the mattress, absolutely.

MS BENNETT:  That's the only two matters in those two photographs that causes you concern?

MR KOLMUS:  Like I said, I would want to see how big the actual room is, but the standard of the mattress would be my main concern, yes.

MS BENNETT:  Can I bring the photos down.  Can I add this is a person who has cleaning and assistance with room cleaning written into her SRS care plan and has substantial NDIS supports for the same thing.  Do these photographs raise concerns for you around those issues?

MR KOLMUS:  Again, it would depend on what choice the resident has had in whether that's how she wants her room to be or whether she is comfortable with that or not. If she is wanting a much cleaner room and that's not being delivered to her, then absolutely that's a concern.  But there are a number of people who live in SRSs who   like I said, who make choices about how they their rooms, which I wouldn't make that choice, but they have.

MS BENNETT:  An NDIS participant and an SRS resident would be paying for assistance to clean their room and would be paying for assistance from the NDIS and that would still   and is your evidence that if they have denied entry to the room, then that would be a concern, but if they haven't, then it would be a concern.  Is that fair?

MR KOLMUS:  Denied entry or denied access   denied people being able to clean the room.  In either situation, what   if the room was of a real concern, so it was potentially dirty or unhygienic, if the client was still refusing to allow people to clean her room what I would expect would be that there will be in her support plan or in the support strategy somewhere, I would expect that the proprietor   I don't have any control over the NDIS supports but I would expect the proprietor to have some sort of plan in place as to how do you encourage the person to   to take better   better care of their room, better care of their health, etcetera, and make them aware of the potential concerns. So, that's what I would expect.  The difficulty   and I'm aware of a number of situations where clients have made it very clear they do not want SRS proprietors cleaning their room, and that has absolutely presented issues, but the proprietor, likewise, is in a position where they can't force their way into the room, can't   that would present other issues as well if they forced a paying client to allow them to take over the room to clean the room, etcetera. So, there's a fine balance to be struck now.

MS BENNETT:  Alright.  You heard the evidence   did you hear the evidence of Georgia this morning?

MR KOLMUS:  Yes, I did.  Yes.

MS BENNETT:  Have you ever written to Georgia to express any concerns about the way in which her complaints were managed?

MR KOLMUS:  No, I haven't.

MS BENNETT:  Do you in any concerns about the way that her complaints were managed?

MR KOLMUS:  Yes, if   I guess I begin by saying first, you know, that whole circumstances was incredibly unfortunate, and I completely understand George's level of distress about both, obviously, her mum's death and obviously the circumstances in are raised in relation to it.  It was a particularly messy manner in terms of the information we   we were getting, in terms of   and the contradictory information we were getting.  And even at the end, I think Georgia mentioned that she had had a phone call from a regulatory officer saying   or, in fact, an email, I think, explaining to her the outcome of the investigation.  Yes, there's a point at which an investigation closes, but in that particular matter, I think we could have done better.

MS BENNETT:  Alright.  Have you ever told her that?

MR KOLMUS:  No, I haven't.  No.

MS BENNETT:  Do you think you ought to tell her that?

MR KOLMUS:  Yes.  That would be a fair point yes.  Now that I   yes.  Yes.

CHAIR:  In paragraph 165 of your statement, you refer, I think, to this matter.  I'm not going to refer to the name of the institution or the SRS, but you say that, after referring to the circumstances, which one can readily understand extraordinarily distressing to the family members, the proprietor was issued with a compliance instruction regarding the action or lack of action taken to preserve the dignity of the deceased.  What would a compliance instruction do in that situation?

MR KOLMUS:  So, just to be clear, one of the corrections in my statement was, in fact, in the end, the proprietor wasn't issued a compliance instruction.  What happened in that situation was that the authorised officers conducting that investigation made recommendations regarding what they thought should happen.  And one of the things that should happen was a compliance instruction be issue to the proprietor based on the management of the person's   of the deceased's body.  When   when   you have heard earlier to the line management structure, when we looked at the actual Act and the obligation of the proprietor, it actually wasn't a breach of the Act, per se. So, there was no   there was no legislative breach that we can evidence in that situation.  Incredibly unfortunate, and   and I   I   like I said, I completely understand that if it was my parent   or I’m sure in Georgia's case she made it very clear this morning in her statement that she found it really distressing that her mum was   her mum's body was left on the ground.  But in and of itself, that did not warrant   or did not constitute a breach of the Act. So   

CHAIR:  But section 7 sides out the principles:

"Residents of supported residential services have the same rights and responsibilities as other members of the community and so on.  The following principles apply:  Individual rights of residents should be respected by recognising a resident's right to, among other things, dignity and respect."

Now, I appreciate that the resident had died but why does that prevent   preclude a breach of the Act if the service provider, the SRS, manifestly breaches the dignity and respect that ought to be accorded to every human being in the way they have treated this person who had died?

MR KOLMUS:  To some degree   and, again, this is just an unpleasant situation all round.

CHAIR:  No, we understand that.  But I'm just trying to understand why there is no breach of someone's obligations    

MR KOLMUS:  The view we formed was that the fact that the person was deceased technically meant they were no longer a resident.

CHAIR:  I see.

MR KOLMUS:  And also they were on the ground   my understanding is   and this is where some of the contradictory information came to the fore.  My understanding is they were on the ground to   for the ambulance and paramedics to assist them, to work with them.  The police   I think it was either the police or the proprietor then covered the body, and that was where Ms Wilson identified her mum.  We certainly, at the time and since, we have talked about whether there should have been an expectation that someone would have moved the body, for example, to a bedroom.  I think in situations like that, sometimes people can be unsure of, are they allowed to move a body in a situation like that or not?

CHAIR:  That's a rather different matter.  What you are saying is that since the resident had died, she was no longer a resident; therefore, there was no obligation to preserve her dignity or autonomy in the way in which her body was to be treated, notwithstanding she had died within the accommodation and under the care of the SRS. That's the point you're making.

MR KOLMUS:  As   as awful as that sounds, yes. 

CHAIR:  Well, I wonder whether that's a possibly disputable interpretation of the legislation, but we won't pursue that any further.

MS BENNETT:  Thank you, Chair. It might be a convenient moment for me to have done what I ought to have done at the start of the session, which is to   reading the corrections to Mr Kolmus' statement.  Mr Kolmus, you made a statement to the Commission in response to a notice.  You would like to change the following paragraphs.  At paragraph 165, we've just been looking at, where the words:

"However, the resident was placed there by Ambulance Victoria, not the SRS".

You would like to delete those words. And then in the penultimate line of that paragraph   sorry, I will withdraw that. And then where the paragraph goes on to say:

"The proprietor was issued with a compliance instruction."
You would like to change that to be:

"The proprietor was not issued with a compliance instruction." 

MR KOLMUS:  That's right.

MS BENNETT:  And at paragraph 177, where it says:

"In May 2019, the Human Services Regulator Unit learned whilst undertaking an inspection at..."

CHAIR:  A particular SRS.


“...a particular SRS of an alleged sexual assault..."

You would like to delete the words "whilst undertaking an inspection at" and then the following three words.

MR KOLMUS:  That's right. Yes.

MS BENNETT:  And then finally, at paragraph 178, where the words   where it says:

"It was noted that the procedure had conducted his own investigation of the matter and when asked to do so..."

You would like to add the words after the word "asked":

" Human Services Regulator Unit staff."

Is that right?


MS BENNETT:  With those changes, Mr Kolmus, is your statement true and correct?

MR KOLMUS:  It is.  I am able to provide an update that's relevant to annexure 4, so in relation to SRS C.

MS BENNETT:  I think we will seek that if it becomes necessary, Mr Kolmus.


MS BENNETT:  Commissioners, those are the matters I seek to raise with Mr Kolmus this afternoon.

CHAIR:  Alright. Thank you very much, Ms Bennett. I will start by asking Commissioner Ryan whether he has any questions to put to you.

COMMISSIONER RYAN:  I just take you to the evidence that we received about pop up and unregistered SRSs.  Have you done any   have your officers done anything in regard to exercising your powers to determine whether or not any   whether or not you have any unregistered SRSs that haven't been registered and that have you taken action to see this they become registered?

MR KOLMUS:  Yes. So we   we have two matters currently active.  One that we've been dealing with now for a number of months where we have absolutely formed the view that the accommodation   the accommodation setting in question is an unregistered SRS.  We have   that's the one where we conducted a search warrant to establish that, in fact, it was an unregistered SRS.  We have since suspended admissions at that site, so the person is, by law, not able to take any further clients into the site.

We have also worked with the Office of the Public Advocate   there is one client currently remaining in that site, and we have worked with the Department of the Public Advocate in relation to guardianship arraignments for that person so that hopefully that person can be supported to decide whether he wants to continue to live at that site or move out.  If he was to move out, then there will be no further clients living there.  We   that will remain an ongoing investigation even if that happens. So, we   we are currently considering what plan of action we are in a position to take in relation to that matter 

The second issue that we currently have, I think Dr Pearce mentioned it yesterday.  Two houses that we were recently informed about, I think, in Preston and Reservoir, I think, if I am correct, where it appears they may be an SRS.  We literally found out about this   I think it was last week.  We have reached out to the local council, to see whether those properties are on their owner, which they are. So, the local council is aware of the properties and is currently dealing with the landlord.  We are currently gathering new information from State Trustees about what types of fees the clients living there are paying because, as I said earlier, that can be an indicator, potentially of an unregistered SRS. We will also be reaching out to the NDIS Commission and probably the NDIA to find out whether anyone in either of those houses are receiving NDIS supports, because if they are, then clearly they have a disability of some kind, and there is every chance that, in fact, it's not just a living arrangement but, in fact, supports are being provided.  That provide us with   if we can't get consensual entry to the property, that will provide us with the basis to get a search warrant to search both properties and that would help us establish whether or not it is an established SRS.

COMMISSIONER RYAN:  Do you think there is only two or do you think there is a lot more to find?

MR KOLMUS:  I think there could well be more.  Whether they are unregistered SRSs or whether they're NDIS or disability supports that have been initiated or established in the community where people are receiving NDIS supports but not necessarily paying funds from their personal income, that's what we need to work out.

COMMISSIONER RYAN:  Presumably, these pop up residences get   find residences either by advertising or indicating in some way that they have a service to provide.  You probably would have a better idea of how they do that than we do.  Do you interrogate those sources to see whether or not people are seeking residents in   and seeking to find residents and follow those up?

MR KOLMUS:  Typically, how   I'm not   like, I could be wrong.  I'm not aware that they do advertise, per se, often because they are often very small companies that don't necessarily have web presence or the like.  They might be an individual person who thinks that it's okay to set up a support facility like that.  Typically, where we hear about them from is the issue that Counsel Assisting referred to earlier where you might have   a nominal NDIS provider approach, for example, an SRS and encourage, induce a person to move into their accommodation that they run.  Typically, those types of concerns will be raised with us as a regulator, either by the proprietor or by people associated with the client.  And that is normally then how we would work out that   or identify that, in fact, there is an issue there.  The other piece of work we have begun contemplating, but it literally is in its infancy, is how you would compare data across local councils, the NDIS and NDIA and our own data as to where addresses where NDIS, for example, supports are being delivered into. So, there's clearly someone with a disability in those sites, and whether raises alarm bells for whether it might, in fact, be some form of pop-up disability service.

COMMISSIONER RYAN:  They are things you could do.  I guess I was asking you, do you do that and are you following it up with staff?

MR KOLMUS:  At the moment, most of our effort is, again, responsive in relation to issues of concern that we hear and sharing of information with the NDIS Commission or information from them to us and the NDIA.  And, certainly, it's an issue that, as we hear about it more often, we are having to contemplate whether it's something we can actually proactively address.

COMMISSIONER RYAN:  So the short answer is, no, you're not yet.

MR KOLMUS:  No, not yet 

COMMISSIONER RYAN:  That will save a lot of trouble.  You said the NDIA gave information about the number of SRSs which have received payments for NDIS supports that are being delivered to someone living within the SRS.  Would you be able to provide the Royal Commission with the numbers   not the, obviously, the details of the addresses but the numbers of the 117 odd SRSs you've got that are in this situation, that you would be monitoring how many, you know, are   

CHAIR:  Again, I think if there is to be a request for further information, the appropriate course is for that to be done through Counsel Assisting and the   

COMMISSIONER RYAN:  I was just asking whether he could.

CHAIR:  I know, but I think the better thing is for this to be done through Counsel Assisting.

COMMISSIONER RYAN:  Finally, look, I think you have heard in the evidence before the Commission we have had a number of SRS residents from a variety of different SRSs tell us that they have been routinely hungry, cold, and living in unhygienic conditions, one of which the resident told us that she was angry about those conditions.  Would you say that the regulation activity that you are conducting overall is in any way sufficient to prevent those things from being almost routine in SRSs, that people are hungry, cold, or living in putrid conditions?

MR KOLMUS:  Yes, I do think our regulation is   is effective in reducing that to a smaller number of SRSs.  That   

COMMISSIONER RYAN:  What would you regard as a small number?

CHAIR:  Please let him finish.  Yes, please go ahead.  Finish your answer, please.

MR KOLMUS:  So, for example, the evidence given to date, so particularly in relation to, for example, Hambleton House and Gracemanor and Sydenham Grace, that's three SRSs that we have then taken action against.  We had been closely monitoring but we have also now have taken action against to close them down so that that those proprietors are no longer in the field.  As I said, whenever we receive complaints and through both unannounced and announced inspections, we monitor generally the performance of SRSs. So, I think the examples that have been given in evidence, I'm not sure we can necessarily assume that that's representative of all SRSs.  I think the examples relate to the absolute worst of the SRSs that we have now removed from the sector.

COMMISSIONER RYAN:  So you are telling us they are just a rogue few and everything else is fine?

MR KOLMUS:  I'm not necessarily saying everything else is fine, but I think that the conditions experienced   and, unfortunately, the conditions people experienced in Hambleton House and at the other two SRSs I think are far worse than what you would typically see in an SRS.


CHAIR:  Thank you.  Commissioner Galbally, do you have any questions?

COMMISSIONER GALBALLY:  My first question is why have the numbers of complex people in SRSs increased? Why are they now more complex, in your opinion?

MR KOLMUS:  This is going to be somewhat of an anecdotal answer.  My best guess would be that the NDIS has given people with a disability other options that, prior to the NDIS, they never had.  And I think particularly disability providers who were able to provide supports to people with relatively low support needs have taken up that option, and people have been able to take up those supports in other settings. 

Similarly, the advent of My Aged Care and more flexible aged care supports, I think has also reduced the of people who are frail aged that have previously used SRSs, perhaps more so in the above pension sector   part of the sector than at the pension level.  So I think what that's meant is that the people primarily coming through are people referred from   and I know that referrals, I think, from hospitals are one of the main referrals and from community mental health centres. 

So, I think it's for people with those types of supports that perhaps aren't always picked up in some of those other settings or people who, yes, just aren't eligible for some reason or another for those settings are coming through into SRSs.  I think that's why that's happening.

COMMISSIONER GALBALLY:  We won't go further on it but it's surprising to me that if they are complex, they are not picked up in the   in the   under the NDIS, if they are under 65, but we will just leave that one.

With paragraph 34 and the accommodation and personal support standards, is this   are the   do the authorised officers assess the SRSs according to these standards and so do they talk to residents in doing that?  Do they actually meet with residents in their visits and ask them about these standards, about, you know, healthy food and fruit?  We've heard this week about food, and you've made the point that that's restricted to a few, but are these checked thoroughly with residents across the SRSs?

MR KOLMUS:  There's a number of areas   yes. In a word, yes. So, the standards are one of the main criteria that authorised officers would check when they go out to an SRS, because they are quite prescriptive about what's expected in the SRS.  There is also other particular areas of   you know, the ongoing support plans, medication, those other areas that the authorised officers would check.  Yes, they certainly, when they do visits, whether it's a proactive visit or an an unannounced visit, they will certainly also speak to their residents of their experience in living with the SRS.

COMMISSIONER GALBALLY: So they would ask   I will leave it after this, but will they ask them about whether they are cold at night and cold on weekends because the heating is turned off?  Like, would they ask specific questions, you know, addressing some of the concerns Commissioner Ryan raised about making sure those issues are picked up and then reported on?  And then would you demand compliance so there is fruit and veg and it's warm on weekends and warm at night and clean sheets, and would that be something you would follow up?

MR KOLMUS:  Yes. They are the types of conversations that, yes, I would expect the authorised officers would be having with clients in terms of what's   and again, you know, what people's experience of the SRS, what's their experience of living there, and across a range of areas because that can also vary, obviously, from person to person.  But it's the types of questions that I would expect authorised officers are putting to people in terms of their experience of living and then matching that back to how does that relate to what we know.  Because the resident may not necessarily be aware of what the legislative obligations are. So, we have to then match that back to those.

COMMISSIONER GALBALLY:  And their reports are written up. 


COMMISSIONER GALBALLY:  So their reports are thoroughly written up?

MR KOLMUS:  Absolutely. Yes.


CHAIR:  Sections 79 and 80 of the Act contemplate that a proprietor can manage the money of the resident with the written consent of the resident.  Does the regulator keep track of what happens, as far as control of money is concerned?  How often it happens and whether the SRS is complying with the requirement to keep records and so forth?

MR KOLMUS:  Yes.  That is absolutely an area.  Not many SRSs take that responsibility on, because there is a fair bit of compliance requirements that comes with it.   But it's absolutely an area, because of the obvious risk involved in terms of handling people's money   like, I know for a fact we just recently spent a significant amount of time in one SRS in regional Victoria where we specifically audited their management of clients' money, and that's continues to be an ongoing issue. So, yes, it's an area that   because the Act is quite restrictive about it, if you were going to manage a client's money, it needs to be with consent. There are reports you need to provide.  So we would look at is that actually in place.

CHAIR:  How do you determine whether the consent is informed?

MR KOLUMS:  That's a much trickier question.  Usually, that will be in conversation with the client and/or particularly if we have had concerns raised by family of a client or an advocate.  But that is absolutely   a trickier thing to sometimes pin down, yes.

CHAIR:  On the face of it, it's a rather odd situation that a private corporation or individual running an SRS for profit and being paid by the resident has authority to control   that's the language of the Act   the resident's money.  You would think it is a situation fraught for a potential for abuse.

MR KOLMUS:  I think it is certainly a situation that poses   if not monitored, that poses obvious risks.  I agree.  I presume the people   you know, in the drafting of the Act, they envisaged that there are a number of people who might in fact choose to live in an SRS or end up maybe not having many options as to where they live who end up living in an SRS who actually do need support with their money in order to make the most of it. So I think it was probably envisaged that where they don't have an administrator or don't have a family member who can do that for them, another fallback is the proprietor with requirements associated with that in terms of how they actually go about doing that.

CHAIR:  Yes.  Thank you.  Alright.  I take it there's nothing further at the moment.  We are going to adjourn in a moment?


CHAIR:  Or are we going to go straight into something else?

MS BENNETT:   Yes, thank you, Chair.  We do need to have a break.  We have been imposing our interpreters quite enough today.  So if we could have a few minutes before we finish the final witness.

CHAIR:  Okay.  Alright.  Well, in that case, thank you very much, Mr Kolmus, for coming to the Commission to give evidence and for the detailed statement that you have provided.  We appreciate the assistance you have afforded to the Royal Commission.  We will now take a break for, what, 10 minutes?  It's now 3 o'clock.  We will resume at 3.10.




CHAIR:  Yes, Ms Bennett.

MS BENNETT:  Thank you, Commissioners.  The last witness today is Ms Sherri Bruinhout.

CHAIR:  Thank you very much, Ms Bruinhout, for coming to the Royal Commission to give evidence.  All the way from Melbourne I understand.  If you would be good enough to follow the instructions of my associate, who is located over there, he will administer the affirmation to you.


CHAIR:  Ms Bruinhout, just so you know where everyone is located, Commissioner Galbally, whom you can see on the screen, is in Melbourne and is joining the hearing remotely.  Commissioner Ryan is on my left.  I'm the Chair of the Royal Commission, and Ms Bennett, who you can see, is Senior Counsel Assisting, and I will now ask Ms Bennett to ask you some questions.


MS BENNETT:  Thank you, Chair.  Ms Bruinhout, you have made a statement to the Commission; is that right?

MS BRUINHOUT:  That's correct. 

MS BENNETT:  You have made that statement recently and save for a cross referencing error of a typographical nature in paragraph 85, is the contents of that statement true and correct?

MS BRUINHOUT:  Yes, it is.

MS BENNETT:  Thank you.  Ms Bruinhout, can you tell the Commissioners your current role and where it sits within the Department?

MS BRUINHOUT:  Sure.  I'm the Executive Director of Homelessness and Housing Supports at Homes Victoria which is a   a unit within the Department of Families, Fairness and Housing in the Victorian State Government.

MS BENNETT:  And I'm now going to ask you some questions about pension level SRSs, and I will use the shorthand SRS when I'm referring to that group of accommodation.  You would accept, Ms Bruinhout, wouldn't you that SRSs continue to accept high levels of referrals from acute health and mental health sectors as well as from homelessness services.

MS BRUINHOUT:  Yes, they do.

MS BENNETT:  That's one of the main contributing factors to the population of people presently resident in SRSs.

MS BRUINHOUT:  To people currently being accepted into SRSs.


MS BRUINHOUT:  I would say, though, that there are some long term residents in SRSs that perhaps haven't come from those pathways.

MS BENNETT:  Yes.  But the needs of SRS residents are becoming increasingly complex; is that right?

MS BRUINHOUT:  Yes, in line with as we are seeing more complexity across a lot of human services, yes.

MS BENNETT:  Yes.  And that adds to the financial and staffing pressures on SRS proprietors; is that right?

MS BRUINHOUT: I would agree with that.

MS BENNETT:  And in the absence of additional income to support residents, their increasingly complex needs threatens the viability of SRSs and impacts outcomes for residents.  Do you agree with that?

MS BRUINHOUT:  So, let me just say that back to you. So, the increasing complexity has an impact on revenue and staffing?

MS BENNETT:   Adds to the financial and staffing pressures that are on SRS proprietors.  Do you agree with that?


MS BENNETT:  And in the absence of additional supports, the increases complexity of needs threatens both the SRS's ongoing viability   do you agree with that?


MS BENNETT:  And it impacts on the outcomes for residents; is that right?

MS BRUINHOUT:  Yes.  I would agree with that.

MS BENNETT:  And by the outcomes of residents, you mean the level of services and safety of residents themselves.

MS BRUINHOUT:  I would say the care that's appropriate to meet their individual needs.

MS BENNETT:  That is what is being impacted upon?


MS BENNETT:  The level of care is being reduced?

MS BRUINHOUT:  Potentially, yes.

MS BENNETT:  Now, you would agree that the majority of SRSs rely on government subsidy assistance.  Is that right?

MS BRUINHOUT:  It depends what you call government subsidy assistance.  They take their revenue from particular people that are predominantly receiving a subsidised income from government, but also most pension level SRSs receive some sort of government subsidy as well.

MS BENNETT:  Would you accept that the majority of SRSs   pension level SRSs would not be viable without that government assistance?


MS BENNETT:  And those subsidies are inconsistently applied at the moment; is that right?

MS BRUINHOUT:  I wouldn't say inconsistently.  They are constantly applied within the policies that   that have been established, and they are consistently applied across two different programs. So within the guidelines of those two programs, they are applied.  But the two programs are different.

MS BENNETT:  Yes.  Would you agree that the subsidies are inconsistently applied based on historical decisions that have been made by the department over time?

MS BRUINHOUT:  I would say that they are consistently applied as per the program guidelines as they were established at the time. I'm not trying to be irritating, I just   I think that's   it's a distinction from what you are proposing.

MS BENNETT:  I might return to that.  The effect, though, of the way in which government subsidies are provided is that the funding available is not efficiently or effectively distributed to ensure the optimal impact on SRS viability.  Do you agree with that?


MS BENNETT:  Could I take you to your document, which is at VIC   I won't ask you to   I won't bring it up on the screen.  This is the project request for the NOUSE Group dated 8 April 2022.  Do you have that with you?


MS BENNETT:  Could you go to page 2?  Can you see the paragraph there starting with the words "the majority of SRS rely." 


MS BENNETT:  Can you read that paragraph to yourself?  I will read you the second   I will read you the paragraph:

"The majority of SRS rely on this government subsidy assistance, an average of $137,000 each SRS per annum, to be financially viable.  In the context of government investment in housing assistance, these subsidies are inconsistently applied based on historical decisions.  This means that funding available is not efficiently and effectively distributed to ensure optimal impact on SRS viability."

That's your document isn't it?

MS BRUINHOUT:  That is my document.

MS BENNETT:  It's recently written?

MS BRUINHOUT:  Yes, it is.

MS BENNETT:  It's accurate, isn't it? 

MS BRUINHOUT:  Within the context that this document was written, it is accurate.

MS BENNETT:  Yes, and your previous answer, to that extent, was not accurate. 

MS BRUINHOUT:  No. I would say if we are talking about broad statements regarding SRS, this is a document that looks particularly at the viability and a cost benefit analysis of the funding decisions that   and the funding guidelines as they stand for two programs.  The previous comments about have the guidelines   have the   has the funding been distributed consistently, I still stand by my statement that they were consistently delivered at the guidelines.

MS BENNETT:  No, no, I was on to the next point, which is that the funding available is not efficiently and effectively distributed to ensure the optimal impact on SRS viability.  You would agree that's the case?

CHAIR:  Ms Bennett, perhaps just a little slower.

MS BENNETT:  I'm sorry, Chair.  You would agree that's the case, wouldn't you?

MS BRUINHOUT:  In the context of doing a financial impact statement, absolutely, yes.

MS BENNETT:  Yes.  The Department continues to identify market trends and risks within the sector that impact on outcomes for residents.  You agree with that?

MS BRUINHOUT:  Are you still reading?

MS BENNETT:   I'm just asking you the question.  Has the Department been identifying market trends and risks within the sector that impact on outcomes for residents?

MS BRUINHOUT:  That's correct, but within the scope   are we still talking about this document?

MS BENNETT:   I'm just asking you the question more broadly. I'm just asking you the question.


MS BENNETT:  Is the Department aware that there are market trends and risks within that sector that impact on residents?


MS BENNETT:  And when we are talking about impact on residents there, we are talking about the impact on the standards of care that they receive in the SRS environment?

MS BRUINHOUT:  To meet their individual need, yes. 

MS BENNETT:  So those are risks to people in that environment?

MS BRUINHOUT:  They can be risks, yes.

MS BENNETT:  And the people within that environment are   for those receiving SAVVI funding or PLP funding, they are 93 and 95 per cent, respectively, people with disabilities; is that right?

MS BRUINHOUT:  That sounds about right, yes.

MS BENNETT:  Well, I   


MS BENNETT:  It is in your statement, but I   you're saying that's close enough.

MS BRUINHOUT:  It sounds right.

MS BENNETT:  Yes.  There have been an acceleration of closures in the SRS sector; is that right?

MS BRUINHOUT:  That's right.

MS BENNETT:  And that's because of the non viability of the SRS model as it presently stands in the pension level; is that right?

MS BRUINHOUT:  There is you a few drivers for that but you could summarise it as being a viability issue, yes.

MS BENNETT:  And that has created what you describe in this document as:

"A complex risk matrix of issues evolving within the SRS sector that has created a high risk environment to government, including high profile cases of regulatory noncompliance, a lack of service coordination and support, contributing to poor resident outcomes, and costs associated with relocating an escalating number of complex residents as a result of increasing market failure."

That's what you've written in the document and that's your experience, isn't it?

MS BRUINHOUT:  Yes, that has been the case in a small number of SRSs, yes.

MS BENNETT:  What is the risk to government?

MS BRUINHOUT:  Government has an obligation, as you have heard from Mr Kolmus, in terms of a regulatory oversight, but that's not in scope for this document.  The risk to government is that, at the moment, SRSs   sorry, pension level SRSs can accommodate up to 4,000 quite vulnerable Victorians.  There is a risk to government that those vulnerable Victorians need adequate care to meet their needs.  There is also a risk that   that the viability of this sector would need to be met by other means should this sector be not continued.

MS BENNETT:  Is the risk to government that it will have to provide for some 4,000 people if this sector doesn't continue?

MS BRUINHOUT:  That could be a risk to government.

MS BENNETT:  Is the government propping up this sector for that reason?

MS BRUINHOUT:  I wouldn't characterise it that way, Ms Bennett.

MS BENNETT:  The risk to   this document refers to, towards the end of that paragraph, a lack of service coordination and support, contributing to poor resident outcomes.  Again, can we take that to be a reference to reduced resident support?

MS BRUINHOUT:  When we are talking about coordinated support, we are talking about a changed environment where NDIS, aged care packages, mental health recommissioning   this is a changed environment.  We're being able to ensure that those supports are coordinated for residents have to have the best outcome.

MS BENNETT:  Isn't the greatest risk here to the residents, not to the government?

MS BRUINHOUT:  I think you will see, to be fair, through this document that is at the centre of  

MS BENNETT:  That is my question, though.  That is the key risk here, isn't it?

MS BRUINHOUT:  It should be, yes.

MS BENNETT:  Yes.  It is the key risk, isn't it?


MS BENNETT:  Now, the   you say on the following page that the rapidly increasing rate of voluntary and involuntary closures of SRS indicate that the current funding model is unsustainable and putting vulnerable people at risk, further compounded by a tight property market and poor availability of private market housing. So, is it   is it the position of you and your Department that this model is not viable as it presently stands?

MS BRUINHOUT:  My view is that it would be very difficult for a pension level SRS to be viable without some form of government subsidy.  And I think it would be fair to say that government is sufficiently concerned about that to have commissioned this review to look at exactly those issues.

MS BENNETT:  So what is the present plan to meet the risk that is presented by the rapidly increasing rate of voluntary and involuntary closures?

MS BRUINHOUT:  So it's a very big question, Ms Bennett. So, we are looking at this review to ensure that the 13 odd million dollars that is currently spent in pension level SRSs is used to the best effect to support outcomes for vulnerable Victorians.  It also sits within a range of government initiatives over the last couple of years that looks at housing stress in Victoria and looks at the availability of community and social housing in Victoria and public housing in Victoria that sits within a suite of broader reform initiatives to   to address housing shortages.

MS BENNETT:  Is Victoria the provider of last resort for people with disability   a housing provider of last resort for people with a disability in Victoria?

MS BRUINHOUT:  When you say is Victoria a   

MS BENNETT:  Is the State?

MS BRUINHOUT:  The State of Victoria?

MS BENNETT:   Yes, is it?

MS BRUINHOUT:  The provider of last resort?  I'm not sure what you mean by that.

MS BENNETT:  Well, if a person has been evicted from an SRS, they have a disability and there is nowhere else to go, does the state step in?

MS BRUINHOUT:  If someone is experiencing homelessness in Victoria, then there is a   the specialist homelessness sector, which the Commissioners heard about earlier this week, absolutely steps in to provide assistance to people experiencing homelessness.

MS BENNETT:  Yes.  And so is there an expectation that SRSs will be providing that support instead of the state or that the SRS   sorry, let me go back.  Are the SRSs the step before the state will intervene to protect people at risk of homelessness?

MS BRUINHOUT:  I don't think that's a fair characterisation.  I think that there's a continuum of housing responses for vulnerable Victorians.  Some of those have   for people who require support, some of them are independent housing options that have carers come in and out, and some are supported residential services, and SRS is one of those housing options.

MS BENNETT:  So of the housing options that provide support, the state provides SDA housing?  Or what housing is provided with support for people with disability?

MS BRUINHOUT:  SDA and then other NDIS funded accommodation.  There is also   the Commissioners heard earlier this week about other Housing First type models, particularly for people with disability.  You heard Wintringham talking this week about some of their common ground style models of accommodation.  So there is a variety of options that are available.  Are they enough to meet everyone's needs?  Probably not, but there are a variety of options. 

MS BENNETT:  I see.  Excuse me for one minute.  Commissioners, in light of the time, those are the questions that I have for Ms Bruinhout.  And the Commissioners may have some questions.

CHAIR:  Very good.

MS BENNETT:  If it please the Commissioner.

CHAIR:  Commissioner Galbally, do you have any questions?

COMMISSIONER GALBALLY:  My question is around the SRS model, that I'm very struck and I just want to check if I'm correct, but there doesn't appear to be any capacity building or developmental function in living. Like, you can't cook.  You can't   you can't even eat between meals and afternoon tea. So, you can't even use your own judgment to select something to eat.  You know, you have somebody to change a bed.  Are you given assistance to learn how to do that?  Like, I'm just sort of   it seems people are there and there's no sort of vision for where they might be. So, there's no sense of interim even about them.  But I might be wrong about that.  I've just   that's what I have picked up, that there's just no development coming from them.

MS BRUINHOUT:  Commissioner Galbally, I think SRS are a pretty broad church.  And I think the service or practice model   I think there is what, a hundred and now fourteen SRSs across Victoria.  There is probably about 114 different service models.  In some SRSs, food is readily available, snacks, fruit bowls are available to residents between structured meal times.  In other SRSs, you will see as an attachment in my statement there is a few million dollar a year going to support coordination functions.  They can run activity groups within the SRSes.  So they are a health practitioners and social workers so they go in and they run living skills activities and they run excursions.  They go fishing, they do all kinds   those sort of activities.  So, by and large, yes they are a   a facility for people with   who need daily support care.  But I think that to say that there would be no sort of living skills enhancement or development wouldn't be true across the board.

COMMISSIONER GALBALLY:  Would you pick up which ones do have   you know, quite a commitment to improving daily living skills?  You know, self care.  And I would very much like to see those reports.  But I will leave that again, of course.  Thank you.

CHAIR:  I think Commissioner Galbally means she should leave that to Counsel Assisting.  Thank you.  Commissioner Ryan.

COMMISSIONER RYAN:  Could I ask some questions about the proposed review or the review that's underway by the NOUSE Group.


COMMISSIONER RYAN:  You have indicated some of the lines of inquiry.  One of the lines of inquiry doesn't seem to include compliance with the Convention on the Rights of People with Disability.  I mean, there are plenty of people who would suggest that because people don't have choice of who they live with and that creates problems for people, and they don't have sufficient choice and control in how they run their lives, that they are segregated from the community, that that model does not comply with the Convention of the Rights of People with Disability.  Shouldn't that be one of the lines of inquiry as well?

MS BRUINHOUT:  So, yes, in Victoria all of the programmatic funding and guideline has to comply with the Victorian Charter of Human Rights which is   has very similar conventions. So, yes.  Within   so in any review, in any changes that might be recommended to the SAVVI or PLP program, we would have to comply.  I think it's interesting, though, to be thinking about how we use government funding to bring that sort of client centred experience into SRSes as much as we can. So, putting aside the regulatory aspect, but really investing in being able to   so, for example, some of that funding can be used for what's called a single room supplement. So, people who aren't able to share with other people but where there might only be a twin room available   

SPEAKER:   But because have you said that    

CHAIR:  I think we have got interference from the rest of the hotel.  However, I did hear what you said.

MS BENNETT:  It seems to have resolved.

MS BRUINHOUT:  I can keep going, but if that answers your concern about the charter.

COMMISSIONER RYAN:  I'm still not clear whether the Convention on the Rights of People with Disability is a critical part of that review.  If compliance with that is a critical part of the review.

MS BRUINHOUT:  It's not an explicit part of the review but any action that we take as a result of the review would have to be in line with the Charter.

COMMISSIONER RYAN:  Why?  If it's not an explicit part of the review?

MS BRUINHOUT:  So the review is to bring recommendations to government.  Any   any implementation of changes, because we are a government department, has to be compliant with the Victorian Charter of Human Rights. 

COMMISSIONER RYAN:  Okay.  You have given details of who the stakeholders that have been consulted, and they range from SRS providers, partnership managers, supporting connections workers, Human Service Regulator staff, Community Visitors, area mental health staff, and homeless services workers.  There's a group of people pretty much missing from that, isn't there?  People with disabilities and advocacy organisations and so forth. Was there any attempt to make sure that there's a broader consultation on that?  Residents of SRSs, for example?

MS BRUINHOUT:  Yes, no, thank you for asking.  At the time we wrote that, we didn't have ethics clearance, so it wasn't included.  It has subsequently been included.  The NOUSE Group who was commissioned to undertake the review for us has been talking to both present and past residents.  They have also interviewed Dr Pearce, who you heard from yesterday.  The Community Visitors programs, as well as two other advocacy groups.  And also   thank you very much   using the lived experience from this Commission as part   as feeding into the review as well.

COMMISSIONER RYAN:  Is there any option for public submissions to this review?

MS BRUINHOUT:  Not at this point in time.

COMMISSIONER RYAN:  Would that be a good idea?

MS BRUINHOUT:  It would be something I would be happy to consider.

COMMISSIONER RYAN:  Thank you, Mr Chair.

CHAIR:  Thank you.  Do SRSs have any equivalent in any other Australian jurisdiction, to your knowledge?

MS BRUINHOUT:  That's a bit out of my remit.  I'm not entirely sure.  I think   I mean, we heard from Mr Lipmann yesterday that, generally, where there's a gap in the market the market fills a gap. So, it would not be a surprise to me to learn that there are other SRS style facilities in other jurisdictions.

CHAIR:  What underlies that question is really what led to them in the first place and how they have survived in the current environment which has been radically altered by the introduction of the NDIS.

MS BRUINHOUT:  So, Chair, the SRSs kind of existed as a bit like room and board, and then in the 80s, with de institutionalisation, they became a much more sort of supported room and board, if you like, and then lead into a   being a Supported Residential Service.  And they sort of plateaued a little bit and they had a fairly structured business model and a fairly structured   to Commissioner Galbally's point earlier, sort of fairly structured support model and then practice model.  We have seen that fundamentally change over the last probably 10, 15 years   10, 12 years as the affordability of housing has become more and more difficult, and different support models becoming   giving much more choice and control of   instead of those sort of large congregate settings. So, we are really seeing what was quite a stable private for profit business sector now undertaking some pretty radical change.

CHAIR:  Your statement provides a very comprehensive account of the multiple pieces of legislation in Victoria that might be relevant to accommodation for people with disability.  What's the difference between a rooming house, under the Rooming House Operations Act, and an SRS?

MS BRUINHOUT:  That's interesting, isn't it?  So, a rooming house is where there's four or more bedrooms   four or more separate tenancies that are occupied on a property, and it's covered by the Rooming House Act and there's tenancy rights.  An SRS, you enter into an accommodation and support fee structure. So   so in a   

CHAIR:  Sorry to interrupt, so that includes not just the accommodation but some support services.

MS BRUINHOUT:  So SRS is a   yes, you give a fee in return for accommodation and a support plan.

CHAIR:  So what's the difference between that and an SRS?

MS BRUINHOUT:  So that's what I'm saying an SRS is.  I beg your pardon. So, a rooming house, you just have a tenancy agreement.

CHAIR:  It's just the accommodation?  There is nothing, I take it, to prevent the rooming house operator becoming an unregistered NDIS provider and providing services for one of the tenants who is occupying a rooming house?

MS BRUINHOUT:  That's when it gets into Mr Kolmus' area to determine whether or not that is a accommodation and support for a fee or if that is a rooming house with a separate support arrangement   supported independent living, for example.

CHAIR:  But it shows the boundaries are a bit porous, doesn't it?

MS BRUINHOUT:  Chair, I think that there are opportunities for improvement in that area.

CHAIR:  Yes.  Alright.  Thank you very much, Ms Bruinhout, for coming to the Commission and giving evidence and for your statement.  We appreciate your assistance.  Thank you.  If you would like to step down, that's fine.

MS BRUINHOUT:  Thank you.


CHAIR:  Yes, Ms Bennett.  I take it there are some directions?

MS BENNETT:   Yes, Commissioner.

CHAIR:  And have they been circulated to parties who have been given leave to appear?

MS BENNETT:   Yes, Commissioner.

CHAIR:  And nobody has expressed any profound disagreement.

MS BENNETT:  No, profound disagreement, Chair.

CHAIR:  In that case, I will read the directions that are proposed, and if any representative has any objection to any part of it, they can indicate.  Otherwise, I will make the directions that I read out.  The proposed directions are as follows:

(1) Any witness who took questions on notice during this hearing should provide his or her answers in writing to the Office of the Solicitor Assisting the Royal Commission by 30 September 2022.  The answers should be targeted and concise and not address additional or unnecessary matters. Counsel Assisting the Royal Commission may tender those responses into evidence.

(2) By 14 October 2022, Counsel Assisting the Royal Commission will provide a list of documents, all documents she wishes to tender into evidence, including responses to questions on notice on a confidential basis to the parties with leave to appear at this hearing. 

(3) Parties with leave to appear should advise the Office of the Solicitor Assisting by 21 October 2022 if they wish to suggest any additional documents for tendering by Counsel Assisting.  At the same time, they should identify any parts of the documents to be tendered that they consider need to be removed before the documents are made public with reasons.

(4) Counsel Assisting will tender those documents into evidence which she considers appropriate and will do so in chambers by 28 October 2022.

(5) Counsel Assisting the Royal Commission will prepare written submissions following the hearing by 4 November 2022.  These submissions will be provided on a confidential basis to parties with leave to appear and may be provided on the same basis to any witness or recipient of a procedural fairness letter from the Office of Solicitor Assisting the Royal Commission in preparation for this hearing.

(6) Any responses to Counsel Assisting's submissions should be sent to the Office of the Solicitor Assisting by 2 December 2022.  Those responses should be concise and should not include any additional evidence.

In the absence of any disagreement with those directions, they are the directions that I make.  Ms Bennett, is there anything else from you?

MS BENNETT:   Only to thank the legal representatives for the parties and those who have appeared this week for their assistance.  Otherwise we have nothing further for the Commissioners.

CHAIR:  Alright.  Thank you.  Thank you very much.  I should make this statement about protection of witnesses in order that it be reinforced.  The Royal Commission has been very greatly assisted at this and previous hearings by evidence from people with lived experience of disability.  Hearing evidence from people with disability is essential if we are to understand fully the issues that are the subject of our inquiry.  We continue to encourage members of the public to come forward and share their stories.

In our engagement with various members of the public, a number have expressed concerns about being identified and the potential effect talking with the Royal Commission may have on them.  I would like to remind everybody who is following the Royal Commission in one form or another that under section 6M of the Royal Commissions Act, it is a criminal offence for any person to cause or inflict any violence, punishment, damage, loss or disadvantage to any person for or on account of reasons that include the person having given evidence to the Royal Commission.  It is important to appreciate that the Royal Commission will, if necessary, take steps within its powers to ensure that witnesses and those engaging with us are protected in accordance with the Royal Commissions Act or indeed the common law.

I won't take up additional   any significant additional time in concluding this hearing, but I do want to express the thanks of the Commissioners to all those from the Royal Commission and who are assisting the Royal Commission in the preparation for and the conduct of this hearing.  As I have remarked on many previous occasions, these hearings are extraordinarily complex to organise, to prepare for and to conduct.  And we are always grateful for the extraordinary support we receive from staff and others who have been involved in preparation for and conduct of the hearing.

It obviously would not be possible to conduct these hearings without that support and assistance and the great skill and dedication that are shown by the members of staff and others who have contributed.  I mention particularly the Office of Solicitor Assisting, all those within the Royal Commission who have been responsible for the logistics and organising the hearing, which is a process of considerable complexity, to the staff from the Policy Team who have helped prepare the hearing and to inform the hearing and to enable it to be conducted as efficiently and as effectively as it has been.

To the counsellors who provide invaluable support to the people with lived experience of disability, from whom we have heard this week.  Their role, which is behind the scenes, is nonetheless of critical importance to the conduct of these hearings.  We could not hear from people with disability about their own experiences without the support that they receive from the counsellors who show enormous skill and empathy in providing that support.

We express our appreciation, as always, to the Auslan interpreters. On the whole the average speed of talking in this hearing hasn't been quite as extreme in other hearings, but still they operate with remarkable efficiency in translating the spoken word into Auslan.  To Law In Order, the people who provide the IT support that enable us to operate in this way, our thanks as always, and to the staff who provide support to the Commissioners, thank you too for the work that you do and the support that you have provided.  And, of course, to the Official Secretary, who is the eminence grise behind the entire operation.

I do want to express our particular appreciation to the witnesses who have appeared who have lived experience.  I refer to 'Charlotte'; to 'Dawn'; to 'Jack', who I see is here again today; 'Colin'; Nik Moorhouse, 'Claudia', 'Jacob', 'Bel', Georgia Wilson, and to the witnesses who gave evidence via pre record, Christmas, William, 'Dave', Denise.  This hearing has been quite extraordinary for the evidence that has been given by the witnesses who have lived experience of homelessness, or have had experience of being under threat of homelessness, and the evidence that they have given to the hearing is of the utmost importance to the work that we now have to do in compiling the record of their experiences in formulating recommendation to be included in the final report.

We are deeply grateful to them for having given their evidence.  We know that it's not particularly an easy thing to do, and we hope that the experience of giving evidence has been something that they can take considerable pride in and that has been something that they will look back on as a very worthwhile exercise from their point of view.  I do want also to express appreciation to the various witnesses from a variety of sources who have given evidence to us during the course of the week and for the very detailed statements that have been provided.

That material is, of course, of extreme importance to our work.  It provides the basis for understanding how the various systems that we are looking at actually work in practice and what perhaps needs to be done in order to fulfil   so we can make recommendations that fulfil our Terms of Reference which, as you know, concentrate on the need to protect people with disability, from violence, abuse, neglect and exploitation and that can lead to a more inclusive society that minimises the prospect of any such abuse, violence, neglect or exploitation occurring. So, our thanks to everybody who has given evidence, everybody who has participated in the preparation for and conduct of the hearing.  We are indeed most grateful to all of you.

The next hearing will take place in Perth.  This will be Public Hearing 27 and it will deal with issues involving the experiences of people with disability in the criminal justice system, with particular reference to circumstances in Western Australia, but perhaps not exclusively to circumstances in Western Australia.

So we shall now adjourn, and the Commission will resume with Public Hearing 27, which is to start, as I recall, on 17 September.  Is that right?  17th I think yes.  19th.  19 September.  Alright.  Don't rush to Perth until 19 September.  Okay.