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Disability support provider quality of care and risk management (11HDC00384)
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(11HDC00384, 24 June
Disability support provider ~ Systems issues ~ Staff
training ~ Hazard identification ~ Incident reporting ~ Risk
management ~ Culture of compliance ~ Rights 4(1), 4(4)
A man with Attention Deficit Hyperactivity Disorder, an
intellectual impairment, and behavioural issues, was attending a
work skills programme run by a disability support provider when he
was involved in an accident in which he was injured.
On the day of the accident the man, who was known to staff for
his distractibility and poor attention to instructions, was
assigned an activity that involved working with tools and
machinery, including power saws. It was the disability support
provider's policy that there needed to be a minimum of two staff to
attend and supervise that activity when clients were involved, and
that only staff and clients who had completed training and passed
certain safety assessments could participate in the activity and
use power tools. The two supervising staff and the man had not been
adequately trained to use tools and machinery, including power
At mid-morning, the man had an accident when the power saw he
was using became entangled in his overalls. It was decided that it
was not safe for the man to continue using the power saw, and he
was asked to perform a different activity. A short time later, one
of the two staff assigned to supervise the man and two other
clients, was called away. The man started the power saw again but
the remaining staff member did not intervene. The man sustained an
injury when he was cutting through a wooden plank.
It was held that the disability support provider did not have
rigorous assessment and review processes in place to assess the
man's suitability to take part in the assigned activity. The risks
attached to the activity had not been appropriately identified and
responded to, and staff were not adequately trained and supported.
It was also held that there was a culture of non-compliance with
the disability support provider's policies, particularly its
policies relating to supervision requirements, training, hazard
identification and incident reporting. The disability support
provider's documentation also fell below expected standards. The
disability support provider did not provide services with
reasonable care and skill and that minimised potential harm to the
man, and therefore breached Rights 4(1) and 4(4). The disability
support provider was referred to the Director of Proceedings.
The man's care manager breached Right 4(4) of the Code because
she failed to assess the man's suitability for the activity and
failed to adequately reassess his suitability for the activity when
potential risks were identified.
The activity co-ordinator also breached Right 4(4) of the Code
because he did not fulfil the obligations set out in his job
description or the disability support provider's policies, and made
a number of errors of judgement. In particular, the activity
coordinator allocated the two supervising staff members to work on
the activity using power saws with the man when neither the man nor
the two supervising staff members had met all the required
competencies for that activity.
The supervising staff member who was present when the accident
occurred also made a number of errors of judgement in that he did
not take appropriate action to mitigate the risk to the man
following the first accident and did not respond appropriately to
the risk posed when the man started up and began using the circular
saw for a second time after having been instructed not to use it.
For those errors, the supervising staff member failed to take steps
to minimise harm to the man and breached Right 4(4).