Mamre Association is a Brisbane based non-profit organisation supporting families that have children with a disability.

Mamre believes that people with a disability and their families can have rich, full and meaningful lives within their communities and is committed to working with families in partnership to inspire, embolden and empower towards a better future.

Rachel Drew, Director of Mamre shared her experiences in preparing for and going through the HSQF audit process.


Hi I’m Rachel Drew Director of Mamre.

We were given a lot of really, really good information and that was really helpful. I think the thing though too was that I had just finished, I had been working in Child Safety just before coming back to Mamre and just before the trial so my head was kind of full of it anyway because the Child Safety processes were just unbelievably complex so when I got the information for the HSQF to me it just seemed really straight forward.

I really loved the fact that there were six standards and they were kind of… the indicators seemed to be, I suppose broader in that you could actually respond to them with more scope rather than just trying to tick one particular box, so you could actually be a lot more articulate against the different indicators under each service standard. So I didn’t, I mean, did I find it onerous? I think it was actually probably simpler in some ways than the previous framework because of that, the indicators were broader so you could actually give more information without feeling that you were just trying.. you weren’t going to get to the point. If that makes sense.

So it was more holistic I suppose. So it wasn’t that I was just trying to fit information into pre-determined boxes but they were broad enough that you know, you could actually give a broad process but also I was interested in, with the HSQF the different streams although we only fit the disability stream not the other streams of it.

I used that toolkit, as in I used the self-assessment workbook and that was the best thing I could have done. Because even though the standards were quite broad, or the indicators were quite broad, it still gave me a sense of exactly what they needed to know. So I found the workbook really critical to the process and I still use it.

So every time we come up for an audit, like we’re coming up for one in June I actually start from scratch again. I compare the last workbook to this latest workbook and see where we’ve developed or changed or grown. So I would recommend that people use that because it’s actually very easy to follow and it gives you some very clear examples about some of the things the auditors are looking for. And it also helps you work out what you need to identify for continuous improvement and then you can actually jot that, you assess whether or not you’ve met the standard but you can put areas for improvement and that goes on your continuous improvement plan.

So that was really critical and I would highly recommend that people, particularly people going through it for the first time, to use that. But as I said I just use it anyway.

I thought the preparation time was less under the HSQF than the other system and again I think it’s because, well obviously because there’s six standards and .. you know when under the ten standards you were always  trying to second guess yourself as to where information needs to go because the indicators were really quite similar. Whereas with the HSQF you could actually see the difference between the different indicators and it was clearer to work out where you needed to put particular pieces of information.

So that was really good and I don’t think it took as long to prepare because if you use that workbook it gives you the foundation of what documents you need so you’re not trying to second guess yourself as to what the auditors would want to see. Because the way the book’s set up you actually name all the documents that support, that kind of backs you as evidence. So you’re not trying to guess what the auditors want to see. So overall I found the HSQF process simpler, clearer and less onerous really.

We’ve had a couple of policy changes and this is what I’ve appreciated actually. The auditor recognized that we didn’t have two different levels. One being general incidences, and one being critical. So therefore our incident processes were just saying you’ve gotta report an incidence and this is the process. So he fed that back to us and then talked through how we could resolve it. Which was really helpful. It wasn’t like it was “look you’ve got this wrong”, he also said legislation now is a critical incident needs to be reported immediately, as soon as it’s safe to do so and within 24 hours.

So we had a really good discussion about what constitutes a critical incident and we ended up making a decision that we would treat all incidences as critical because to try to, like what’s really distressing for me, might not be for somebody else. So we then amended our policy that it’s basically anything that happens, anything that could be considered an incident, has to be reported immediately within 24 hours with a written incident report within three days. So that was helpful and we changed our policy there. So everyone’s just on, no-one’s walking around going well what was critical, what wasn’t, you know. So that was really clear.   

A couple of other things they had picked up over the time, like we had forgotten to update our policy around the new workplace health and safety. It wasn’t the legislation, it was the Act. So he picked up on that.

I think we had a really comprehensive policy structure anyway and we had done a lot of work on that a number of years ago. He, they have all commented on the level of standard that all the policies are and the fact that every single person in Mamre, families as well, receive annually all the policies and procedures that’s relevant. So we’ve got those practices in place anyway.

Some of the other things though that kind of had been picked up are things like just the importance of recording process. So things like our continuous improvement plan. So that’s a fairly active document, what isn’t active in that at the moment for us is the reporting of that within the leadership team so that’s something, and that’s just an internal thing we’ve just got to get better at. But I think certainly what it’s done for me is raised the consciousness of how important really documentation and processes are when, I’m not a process person but I’ve really come to respect and see the value in it particularly now with the size of the organization. If you didn’t have those in place and in some ways the framework to you know checking yourself against it would just disintegrate into chaos.

So I’m not even going to pretend that I know everything and so that’s delegated and if there’s anything like one of the standards is around individual need, Julie gets very heavily involved in that as do her staff. And so they then see the linkages, so if people can’t actually see how it links to the bigger picture they’re not going to be interested. And I don’t care who you are, I don’t think quality, quality sits with every single person in the organization, in any organization.  And the only way for people to understand that is if they’re involved in the actual doing of it not just me standing there telling people why it’s important but when they can see the linkages that people are more vigilant about it. So I think that’s really important that… I mean the only time that I ever got anyone in to help with it… we don’t have a quality manager in Mamre. As I said, it’s up to all of us. But there was one time we had a… I got somebody in to help and it was to do the trial. And the reason I did that was to see if that was a good way of working and also my capacity at the time. And I also didn’t want, because it was a trial, I didn’t want that to impact on the other staff. 

So we got somebody in, but again I think that well, it was fine, and it was really helpful but at the end of the day it still needed everybody to participate in some way or another so I think that that’s a learning. And look, maybe if Mamre got a lot bigger we’d have to look at someone who you know who kind of takes over that, but I feel really strongly that we are all responsible for quality and that we are all responsible for following process in Mamre, whatever that process may be. So I guess that’s sort of how I feel about it and that’s the only way I think that you can build it into the culture of the organization.

So we now have, like I have no hesitation in saying I completely trust the staff that if there is an incident, or negative feedback, or you know a complaint, I would know about it because everybody sees that it’s not about blame, it’s about continuous improvement. And I think that’s a really important key that you know we all stuff up, the worst thing that Mamre could ever do is have a culture of sweeping it under the carpet. Let’s get it out, let’s address it, let’s learn from it and move on. So I suppose that’s just my approach to it and I know that’s the approach of every other manager in the organization that’s how they see leadership, but also quality. There’s consequences for that.

I’d say that’s the biggest benefit for us is clarifying and realizing the importance of process. Certainly, you know, when I’ve talked to, like there are times when I’ve talked to auditors about what Mamre wants to do. So I remember before the trial or no round the time of the first certification I talked to the auditor about a particular hosting arrangement Mamre was thinking about and I found that was great because the auditor could then go, you know could sort of give some feedback about that, but in the context of process. So they could say Ok so if you’re going to do this it needs to be reflected in your processes and don’t forget to look at your policy and don’t forget da de da de da… and then put it down, not as a recommendation, but as Mamre is considering this the next audit will need to check.

I think too, I remember we used to have an incident folder, we’d put the incident reports in there and I think this is some time ago it came up well you don’t have a register for your incidents and at the time I’m thinking well, why would you need that, I couldn’t understand it. But anyway we developed this register and what it did was, it highlighted a pattern in particular incidences and it sounds weird, but the pattern was, that people didn’t know how to fill out the incident form because we were getting you know these incidences come through I’d put them on the register and it was like incomplete information, so there was all this sort of follow up that I’d have to do.

So what we then did was, we thought this is actually a problem and it’s obviously, it’s not one person, it’s several, so we then conducted training in incident reporting and then we included it in our orientation processes a lot stronger than it used to be. Not that it took over, I mean our orientation is not two weeks of back care or workplace health and safety. Most of is around our values and our philosophies, but that there are key policies that need to take some focus and that was an improvement from just a suggestion of having an incident register. So I think that I could have boo-hooed that but I think we’ve got to try you know different things that auditors suggest that these people see a lot of, you know, experiences of organizations so they come with a level of wisdom and I think that we have to really recognize that.

The other thing too, that has happened I notice and it really only dawned on me a couple of months ago. I was in the kitchen and a couple of the key workers came in and they were talking about a particular policy, and I said to them you know, oh are you talking about da de da, and they went yeah this is the policy that we talked about in our meeting this morning. And every single week those key workers look at a policy and see how it relates to their work and I think that’s phenomenal that they are now in a pattern of doing that. So every single week someone picks a policy and they go through it and then they try to apply that in their practices, or look at how they are applying it in their practices.

And that’s what I mean by the culture. It’s not that the staff are all policy driven, they’re not, but they have a very high level awareness of what our policies are. And I think what it does, it actually sets them free in a sense that they know their scope. They know what to do if something happens. They know what decisions they can make or when they need support. So that’s about how we’ve built it into the culture of the organization. Now I haven’t done that, I mean the other managers have done that and the team leaders but it’s because they’ve seen the value that this whole thing of quality is everybody’s responsibility.          




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