AUSTRALIAN GOVERNMENT'S COMMUNITY LEGAL SERVICES PROGRAM

SERVICE STANDARDS RESOURCE KIT

Service Standards Manual

The Kit comprises the following resources:

• Introduction - purpose of the Kit
• The Service Standards - lists the nine service standards and describes the structure of a service standard
• Procedures Guide - step-by-step guide to developing procedures and compiling documentation
• Mock Audit - Examples of completed working documents 
• Audit Guide and working documents - step-by-step guide to conducting a Service Standards Audit assessing the documentation and writing up the Report
• Conclusion - important points to remember

Introduction

The Service Standards Resource Kit has been developed in conjunction with the National Association of Community Legal Centres and State/Territory Program Managers (SPMs). The purpose of this Kit is to provide information on the processes involved in preparing for, and undertaking, a Service Standards Audit.

It is recognised that each Centre is unique and that it should strive to comply with the Service Standards in a manner that is relevant to its size and type. There is also no expectation that all Centres will show compliance in the same way. However, there may be some similarities amongst Centres that are of a similar size, location or function.

We are aware that some centres have already developed some or all procedures. These Centres are encouraged to contribute their examples for posting on this web site, enabling those Centres in need of assistance to view these examples and consider them when formulating their own procedures.

Contributions to the web site may be forwarded to the Australian Government's Community Legal Services Program or The National Association of Community Legal Centres at julie_bishop@fcl.fl.asn.au. The suitability of a contribution will be considered prior to posting on this web site. The Kit will be updated regularly.

We have tried to keep the Kit simple. However, if you have any queries please contact the Australian Government's Community Legal Services Program, your SPM, via e-mail or the National Association of Community Legal Centres at julie_bishop@fcl.fl.asn.au.

The Service Standards

The Community Legal Service Standards were developed following discussions between practitioners, centre coordinators and volunteers, together with the Australian Government's Attorney-General's Department, State/Territory Program Managers and NACLC.

Clause 12 of the Service Agreement relating to the provision of community legal services provides that the Australian Government may undertake service standards audit with the organisation during the term of the agreement to ensure compliance with the service standards.

There are nine standards:

1. Information and referral
2. Provision of advice
3. Casework
4. Community Legal Education
5. Law Reform and Legal Policy
6. Accessibility
7. Organisational Management
8. Management of Information and Data
9. Assessing Client Satisfaction and Managing Complaints

Structure of the Standards:

The Standard is a statement of principle or practice required.

Each standard is broken down into attributes and elements.

'Attributes' are the concrete evidence required to show compliance with that Standard.

'Elements', or 'processes', of each set of Attributes are the individual bits of evidence.

Click here Word | PDF to see a graphic of this structure.

Procedures Guide

The Procedures Guide provides information on developing procedures to meet the Service Standards. You should plan to start compiling documentation for the Service Standards several weeks in advance of the audit date. The Service Standards Checklist (SS 1) Word | PDF | HTM can help you with this. See also Mock Audit.

You may already have one or more procedures manuals. Alternatively, you may operate a service where staff know the procedures but nothing, or very little, has been written down. Procedures need to be documented for Centres to be able to comply with the Service Standards.

In order to work out what you already have written down and what is missing, you can carry out a Preliminary Audit. By using the Service Standards Checklist (SS 1) you can record the location of procedural documentation that you already have and indicate what, if anything, is missing. Whilst performing your preliminary audit only the 'Documented Evidence' column in the Service Standards Checklist (SS 1) would be used. This column allows you to record the location of the relevant procedure. This may not be just a page number, but a section number and/or chapter heading.

The Service Standards Checklist can also be used later at the Audit Stage. See the Audit Guide.

If you have ascertained that some procedures are not yet documented, you can use the Procedures Sheet (SS 2)Word | PDF | HTM provided here as a template for writing up your procedures. Whilst uniformity is not mandatory it will assist you later on in the audit process. It is also a good idea to keep everything in one manual. Note that some procedures may relate to more than one standard/attribute/element.

Each piece of documentation should indicate:

• title of Procedure eg - 'Referrals to other Community Legal Services'
• Service Standard & Attribute number to which it applies eg '1.1.3'
• a description of the task or process
• staff /organisation position responsible for the task or process, including supervision if applicable, and
• timeframes, checks and/or controls as relevant.

Audit Guide

Audit Dates must be set by agreement between the Centre and the SPM.

For the purposes of the SPM Participant Audit, the Audit Date will be deemed to be the date of the staff interviews.

The Audit process will vary slightly according to whether the SPM is participating in the audit or it is a Self-Audit.

The following steps provide an overview of the steps required to conduct an Audit.

For a Self-Audit, it is recommended that you appoint a person within your organisation to coordinate the Audit. This 'Audit Coordinator' will instigate and organise the Audit including:

1. Ensuring that all documentation is readily available
2. Making staff and volunteers aware of the Audit
3. Making sure key staff are available to be interviewed on the Audit Date
4. Making a room or an area available to conduct the Audit
5. Locating documented procedures and noting them on the Service Standards Checklist
6. Identifying relevant members of staff/volunteers/management committee who are responsible for each procedure on the Service Standards Checklist
7. Analysing documents to see whether or not they comply with procedures and then recording results on the Service Standards Checklist (SS 1)Word | PDF | HTM 
8. Conducting Staff Awareness Interviews and recording results on the Service Standards Checklist (SS 1)Word | PDF | HTM 
9. Recording findings on the Service Standards Report Detail (SS 3)Word | PDF | HTM and the Audit Report Summary (SS 4)Word | PDF | HTM . See also Mock Audit
10. Forwarding a copy of the Audit Report to the State Program Manager within 30 days of the Audit Date. (The Audit Report should comprise SS 4 and an SS 3 for each Service Standard which is either not met or not fully met), and 
11. Undertaking actions to ensure future compliance.

1. A person is nominated to coordinate the audit with the SPM
2. The Audit Coordinator negotiates a day for the SPM centre visit and a due date for materials to be provided to SPM. Note that the day the SPM visits the Centre will be deemed to be the audit date
3. The SPM will send a confirmation letter to the Centre, including a request for interviews with a sample group from administrative staff, those providing legal services (employed and/or volunteer) and members of the management committee (categories and minimum numbers)
4. The Audit Coordinator will ensure that the following materials are provided in advance to the SPM (to be received at least 10 working days before the audit date):
   1. The Service Standards Checklist (SS 1)Word | PDF | HTM with the name of the Audit Coordinator, document references and staff responsibilities completed, and 
   2. Documented procedures.
5. The Audit Coordinator arranges for relevant staff/management committee members to be available for interviewing on the Audit Date
6. The Audit Coordinator ensures that staff to be interviewed are aware of the existence and location of particular procedures
7. The SPM will conduct interviews at the Centre and may wish to clarify some of the documentation with the Audit Co-ordinator
8. The SPM will analyse the results and, if required, seek further information
9. The SPM will provide a report to the Commonwealth and the Centre within 30 days of completion, and 
10. If applicable, the Centre will undertake actions to ensure future compliance and provide a plan to the SPM for achieving full compliance.

Centres need to meet two requirements in order to comply with Service Standards:

• Documentation - possess documented procedures which demonstrate the attributes, and
• Staff Awareness - that people in the organisation (including employees, volunteers and management committee members) are aware of procedures referred to in the attributes.

During the audit process the Service Standards Checklist (SS 1)Word | PDF | HTM can be used for either a Self-Audit or SPM Participant Audit, to determine:

• whether a documented procedure exists, and
• whether staff (ie relevant legal/para-legal/volunteer/management committee members) are aware of those procedures. The Service Standards Checklist (SS 1) can also be used earlier, during the Preliminary Audit, and as a reference when writing up procedures. See also Procedures Guide

All Service Standards are listed in the Service Standards Checklist (SS 1), together with necessary attributes and elements for each standard.

The first column, headed Documented Evidence, is used to record the location of the relevant procedure. This may not be just a page number, but a section number and/or chapter heading. A tick, cross or question mark in the next column indicates whether the procedure or documentation exists, does not exist, or is unclear.

The column headed Staff Awareness, is used to record the staff position responsible for the procedure. A tick, cross or question mark in the next column indicates whether the interviewee has shown awareness of the procedure, is not aware of the procedure, or whether it is unclear.

The column headed Auditor's Comments, is used to make notes as required.

See also Mock Audit

At this stage the Auditor should have a reasonable understanding of the Centre's procedures. Questions can now be prepared for the Staff Interview. The Auditor should interview a range of people, from different areas across the organisation, based on who is responsible for a particular procedure. Interviews can be performed either one to one, or with a cross section of staff. In terms of staff awareness of the procedures, the Auditor will want to carry out brief interactions with some staff and, where relevant, interested volunteers, to gauge the level of awareness of the procedures. This does NOT mean that staff require a capacity to memorise all the procedures. This interaction can occur in the context of some brief discussions with the use of a simple survey process.

Questions should be of a general nature, to allow staff to provide a full explanation. Questions that elicit an explanation are better than those that get a 'yes' or 'no' response. For example, 'what do you do if someone comes in asking for some information' requires the interviewee to provide an explanation. A question such as 'do you do conflict checks?' will likely draw out a response of, 'yes'. In essence, the best questions start with 'how', 'who', 'what' and 'when'.

Clause 12.1 of the Agreement states that results of a Service Standards Audit are to be provided to the State Program Manager in the Service Standards Audit Report in accordance with Schedule 12.

The Service Standards Audit Report is in two parts:

• Service Standards Report Detail SS 3 Word | PDF | HTM
• Service Standards Audit Report Summary SS 4 Word | PDF | HTM.  See also Mock Audit

Your findings must be recorded on the Report Detail Sheet (SS 3)Word | PDF | HTM , noting requirements met and/or any discrepancies. Attribute numbers should be recorded in the right-hand column in the appropriate section depending on whether an Attribute:

• Has been fully met
• Has been met with completion of work underway, or
• Has not been met.

This is determined by considering whether or not:

• The procedure/s are observable
• The procedure/s are understandable, and
• Staff in the organisation are aware of the procedures referred to in the attributes.

For an Attribute to be fully met a procedure or document should have a title or heading, delegated staff responsibility to carry out each task, timeframes and control points and proven staff awareness of the procedure. (It is recommended that staff interviews be undertaken after you have finished locating and examining the documentation.)

For an Attribute to be met with completion of work underway, documentation will show a clear plan or timeframe for developing documented procedures, show that the Centre has the capacity to deliver on the plan, and the capacity to make improvements.

The Attribute has not been met if neither 1 nor 2 apply.

If the results of the Audit show that your Centre has not complied with, or is not fully compliant with, one or more of the Service Standards, they must include:

• reasons for non-compliance
• a proposal for actions, and 
• a timetable to achieve full compliance within six (6) months of the date of the Service Standards Audit Report Summary.

The Audit Coordinator should discuss, with relevant staff, the aspects that require attention. It may be a good idea to assign the work to an individual or group. It is recommended that the people assigned to address the shortfall in compliance are clear on what is required.

Where the Centre is unable to achieve compliance within the proposed timeframe, the SPM will assist the Centre to achieve full compliance and may participate in subsequent audit processes until such time as the Centre becomes fully compliant.

The Audit Report Summary is the compilation of the nine completed Service Standards Report Detail sheets.

As indicated, the Centre will have the opportunity to include any comments it wishes on the nature of the Self Audit and its outcome, in the Report.

Two signed copies of the Report will be compiled - one for the Centre, and one forwarded to the SPM within 30 days of the date of the Audit.

Mock Audit

A mock audit is presented here.  The examples given show how the auditor has completed the working documents for this audit.

• SS 1 Word |PDF |HTM
• SS 3 Word |PDF |HTM
• SS 4 Word |PDF |HTM

Conclusion

1. Settle on a date for your first audit and advise your SPM as soon as possible
2. Nominate a service standards and audit coordinator
3. In advance of the audit date use a plan to ascertain what Attributes you can already comply with (fully or partially) and what you still need to do to comply with all Service Standards
4. Keep all your evidence in the same format and in the same place, or make a record of where it is all located
5. Use the working documents to assist you at every stage.  See Mock Audit.  Blank printable versions follow:
1. Service Standards checklist (SS 1)Word | PDF | HTM
2. Procedures Sheet (SS 2)Word | PDF | HTM
3. Report Detail Sheet (SS 3)Word | PDF | HTM
4. Audit Report Summary (SS 4)Word | PDF | HTM
6. Seek help from NACLC and your SPM to develop your procedures and by networking with other centres.
7. Make sure that Centre staff is fully aware of the audit and the Staff Awareness Interviews, and 
8. If the audit finds that your Centre has not fully complied with the Service Standards, develop a plan for working towards full compliance.

We hope that the Service Standards Resource Kit will be a useful tool for you. If you wish to make any comments or suggestions about the Kit, we would welcome your feedback.