Investigate an unauthorised restrictive practice

What is going on

On 25 August a worker at the Geelong short term accommodation locked the front door overnight to stop a participant leaving. There was no authorisation for this in the participant's behaviour support plan, so Willow notified the NDIS Quality and Safeguards Commission as an unauthorised restrictive practice. The Commission has now asked for the investigation outcome and corrective actions. The worker says the participant had walked onto the road the previous night and that no one had told them what to do. The behaviour support practitioner from Wattlebird Behaviour Services is available on Thursday. Daniel Nguyen wants findings that are fair to the worker, honest with the Commission and useful for the team.

Your brief

Lead the investigation into the incident, establish what happened and why, decide whether the practice was a restrictive practice and whether it was authorised, identify the system failures that left the worker without guidance, and produce corrective actions and a response to the Commission.

Work through it

You do not need to do it all. Doing a few of these will show you what the work is like. Your ticks and notes stay on this device.

• Read the Safeguarding, Abuse and Neglect Prevention Policy and the restrictive practice section of the Person-Centred Practice and Rights Policy and set out the test for an authorised restrictive practice.
• Read the Responding to and Reporting Abuse, Neglect and Reportable Incidents Procedure and confirm the notification timeframe was met using the Incident and Hazard Register entry.
• Plan the investigation: list the records to review in the Progress Notes and Case Log and the Roster and Shift Log, the people to interview and the questions for the worker and the participant.
• Review the participant's behaviour support plan summary and the progress notes for the week before the incident, and identify what strategies were available and what was missing.
• Meet the behaviour support practitioner and record what the interim behaviour support plan will include, including any proposed regulated restrictive practice and the authorisation pathway.
• Write findings on the balance of probabilities covering the worker's actions, the handover and training gaps, and the environmental factors, using neutral language.
• Draft corrective actions with owners and dates, including training, handover changes and environmental controls, and record them against the incident in the Incident and Hazard Register.
• Draft the response to the NDIS Commission for the Quality and Safeguarding Manager's review and a summary for the participant and their family.

What someone in this role would produce

• Investigation plan
• Findings report
• Corrective action plan recorded in the Incident and Hazard Register
• Draft response to the NDIS Commission
• Summary for the participant and family