Hints and tips for licensing
These hints and tips are designed to assist non-government organisations with the licensing process being undertaken by the department.
- Why should a care service be licensed?
- Applying for a care service licence
- Service standards - Self Assessment Workbook (SAWB)
- The service standards
- Service standards - process documentation
- Service standards - staff/management awareness
- Service standards - output documentation
- Service standards - stakeholder feedback
- Service standards - key considerations for standard 1
- Service standards - key considerations for standard 2
- Service standards - key considerations for standard 4
- Service standards - key considerations for standard 5
- Service standards - key considerations for standard 6
- Service standards - key considerations for standard 7
- Service standards - key considerations for standard 8
- Service standards - key considerations for standard 9
- Independent external assessments (IEAs)
- Combining licensing process for different service types
- The role of the Community Support Team (CST) and Quality Assurance Operations Unit (QAOU) (formely Licensing Coordination Teams (LCT))
- Lead Zone Process
- Carer approvals
- Determining a licence application
- Screening processes
- Legislative responsibilites of licensees, nominees and directors
- Corporations
- Resourcing implications
- Services not required to be licensed
- Departmental monitoring processes
1. Why should a care service be licensed?
It is a requirement under the Child Protection Act 1999 that care services become licensed. Non-government services that have the primary purpose of providing out of home care to children subject to statutory child protection are required to be licensed.
What are the benefits for a service in becoming licensed?
There are a number benefits to becoming a licensed care services including:
- Ensuring that the delivery of services are reflective of current legislation and policy
- Empowering collaborative relationships between the department and services
- Building the professional capacity of the sector
- Ensuring that service staff and management are well informed of policies and procedures
- Embedding key processes to ensure consistency and efficiency across the non-government sector
- Setting the benchmark for services to strive towards continuous improvement
- Establishing networks and communication paths between services and the community
- Acknowledgment of the achievements of services
- Provides an insight for the department to continually improve our services to children and young people.
2. Applying for a care service licence
Are only grant funded services required to be licensed?
No, if the service meets the scope of licensing it is eligible to be licensed regardless of the type of funding it receives (grant or transitional (PASP)).
How do I know whether the service my organisation provides meets the scope of licensing?
Non-government services that have the primary purpose of providing out-of-home care to children subject to statutory child protection intervention are required to be licensed.
In assessing the primary purpose of the service, the department will consider whether the:
- primary function of the service is to provide a child protection out-of-home care service to children and young people subject to statutory child protection intervention, rather than placements to other target groups, such as homeless young people or people with disabilities
- service is made available specifically for departmental referrals
- majority of placements with the service are child protection placements
- majority of funding for the service is received from the Department of Child Safety.
If you are unsure if your service meets the scope you should contact the Community Support Team at your local Child Safety zonal office.
What do I need to be able to evidence before applying for a license?
You must be able to evidence that you have process documentation (documented policies, procedures, flowcharts etc that describe the process) across all 11 child safety service standards, that your staff and management are aware of the process, and you must have a premise (for residential and coordination point services) and a way to evidence output documentation (records of implementing the processes, e.g. client files).
Am I required to obtain a copy of the certificate of classification and copy of the signed lease as part of my licence application?
Yes, you are required to obtain the certificate of classification if you are a residential service, and it is required by the service's local council. Proof of the exemption is required (ie, email from the council or Zonal advice).
You will also be required to provide a copy of your lease detailing that the lessor is aware of the purpose of use. If the lease does not detail this information, a letter from the real estate or owner of the property is sufficient.
What does being licensed mean for my service?
Being licensed means that you have demonstrated that your service meets the minimum standard for out of home care services.
Being licensed does not guarantee that you will receive funding (recurrent or transitional) from the department or that the zone will place children and young people with your service.
Participating in the licensing process is not voluntary. If you are providing placements to children and young people and you meet the scope of licensing, you must lodge an application.
3. Service standards - Self Assessment Workbook (SAWB)
How does the SAWB assist in developing my service?
Completing a Self Assessment Workbook (SAWB) enables a licence applicant to be confident that they meet the required standards and are therefore ready to progress through the licence application and assessment process.
The SAWB is an internal auditing tool that will assist your service to imbed quality assurance processes in everyday practice. It is a tool which can assist your service to identify your strengths and plan for meeting any shortfalls against the service standards.
Can organisations address specific criteria at an organisational level for multiple service types?
Yes, an organisation can submit one SAWB to address elements of standards that are applicable at the organisational level, as long as the organisation fits within the parameters of the business rules set out in Appendix 5, Out-of-Home Care Services Licensing Manual.
The SAWB must address the three evidence types for these criteria:
- process documentation
- staff/management awareness
- output documentation.
Note: Elements may vary depending on how each organisation operates. Contact your Community Resource Officer (CRO) for assistance with determining which elements can be addressed at the organisational level.
When do I submit my self-assessment workbook to the department?
It is preferred that a draft SAWB be submitted to your CRO prior to formally submitting your SAWB as an attachment to the licence application. This will enable the CRO to review your application and provide you with feedback prior to formal lodgement and the 90-day licensing period commencing.
Can I provide electronic documentation to support my self-assessment?
Yes. After completing the SAWB, services are required to provide copies of the SAWB and their policies and procedures to demonstrate compliance with the service standards. These need to be provided to the Community Support Team as part of the licence application process. To make this process as easy and cost efficient as possible, electronic copies of policies and procedures can be forwarded with your completed SAWB.
Note: All process documents sent to the department will be kept by the Independent External Assessor.
What are the timeframes for completing the SAWB?
Organisations will negotiate this date through the completion of the Licensing Implementation Plan, developed in consultation with the Community Support Team.
For services that are grant funded, the services must have an application properly made or be actively engaged in the licensing process within six months of signing the service agreement.
Who fills in the boxes in the Staff and Management Awareness section of the SAWB marked 'Overview of what was said/assessor's comments'?
The entire workbook including the boxes marked 'Overview of what was said/assessor’s comments' are to be completed by the service. Generally, the first section will include the comments from staff being assessed. The overview section should be a summary of responses with a comment about the responses. Eg, staff demonstrated an adequate understanding of the process, their roles and responsibilities.
Who needs to be involved in the staff management/awareness section of the SAWB?
The staff management/awareness section of the SAWB should reflect that the people who need to know about the standards, policies and procedures do actually know about them. This includes nominees/directors being involved in providing staff management/awareness evidence regarding corporate governance. As part of the independent assessment, all or a sample of staff will be required to be interviewed for assessing awareness therefore, it is essential that all staff and management have participated in this process.
4. The Service standards
Are the eleven (11) minimum child safety service standards applicable to all service types?
Yes. The service standards are applicable to all service types. However, how they apply will depend on the functions that each service provides. Refer to Appendix 3, Out-of-Home Care Services Licensing Manual to identify how the standards apply to the model of your service.
Have the 11 service standards changed since the new licensing process began?
No the 11 standards have remained the same. However, minor changes have been made to the criteria under the standards. It has been necessary to make a small number of changes to:
- accurately reflect their intent
- address instances where aspirational (beyond minimum standards) requirements were included
- to reflect changes to legislation and departmental policy.
The main changes cover:
- blue card and suitability requirements
- informing children and young people about limits to confidentiality
- removing some requirements regarding
- consent to share information
- evidencing training
- carer approvals
- tracking reported harm not arising from the service
- assisting the child or young person to make external complaints.
- reflecting the requirements of the Positive Behaviour Support policy in criteria 2.1.9, 2.2.8, 2.3.2, and 2.3.3.
5. Service standards - process documentation
Where do I list my policies and procedures (process documentation) in the SAWB?
All policies and procedures need to be listed under relevant elements within the process documentation section in the SAWB. The SAWB is broken down per standard, then per element.
I want to make sure that my service's process documentation is consistent with the department's policies and procedures. Where can get I get access to departmental policies and procedures?
Departmental procedures can be found within the Child Safety Practice Manual located in the library section of the department’s website.
If you have any queries about policies on any matter or would like any information about departmental policies or procedures contact your Community Resource Officer (CRO).
6. Service standards - staff/management awareness
What is required to show staff/management awareness of the standards?
Firstly, you are to complete the SAWB. This is your tool to conduct an internal assessment of awareness. Secondly, your staff and management will participate in awareness sessions with the Independent External Assessor. Staff or management who are involved in implementing the process should be able to articulate an understanding of its key features. There is no requirement that staff and management are able to recite procedures or that staff be aware of procedures for which they are not responsible. The questions listed in the SAWB are the questions the IEA will be assessing.
Who will need to participate in staff/management awareness groups conducted by the Independent External Assessor?
The licence applicant must provide a list of all staff (including volunteers, management, directors and the nominee of the service). The Independent External Assessor will select a sample of people from the list to reflect the number of staff, their roles in the service and number of locations (if relevant). Refer to Appendix 5, Out-of-Home Care Services Licensing Manual.
Before the site visit the Independent External Assessor will contact the service to confirm who needs to participate in the groups.
What questions will the Independent External Assessor be asking staff regarding staff/management awareness?
The assessor will be asking questions directly as they appear in the Self Assessment Workbook (SAWB) under the staff/management awareness section.
What if the staff selected by the Independent External Assessor are not available?
If these people are not available, the service will need to discuss this with the assessors prior to the site visit so an alternative arrangement can be made.
7. Service standards - output documentation
What do I do if I can’t evidence some output documentation elements?
You may be unable to evidence some output sections of the SAWB if there are new processes or an event has not occurred. For example, you may not be able to list evidence for client complaints because your service has not had any complaints from young people. For these elements, you are required to indicate that Data is not available by ticking the DNA boxes in the SAWB.
What do I need to provide to evidence output documentation?
You are not required to provide any documentation to the department for output documentation elements. The SAWB requires you to list the evidence relating to each element. The CRO in consultation with your service will complete a Request for Independent External Assessment (IEA) .The document will list the location of your output documentation eg, client files located at Smith Street and staff files located at Jones Street. This evidence will then be assessed by the IEA during the scheduled site visit with your service.
8. Service standards - stakeholders feedback
Do I need to complete stakeholder feedback?
You are required to provide evidence of stakeholder feedback in reference to standards 5, 8, and 9 (client, carer and staff only). These standards explicitly contain a requirement to 'seek and respond' to stakeholder feedback. This can be evidenced by providing records, for example surveys, minutes of meetings or file notes. You are not required to ask the specific questions listed in 'Views of stakeholders' - these are examples only.
Refer to Appendix 5, Out-of-Home Care Services Licensing Manual for further information.
9. Service standards – key considerations for standard 1
What is required to evidence element 1.3.3 cultural awareness training?
This element requires additional evidence to other training related elements. In order to meet this element, the evidence needs to include evidence that:
- The training was focused on cross cultural competencies required to meet the needs of the target group.
- A certificate or equivalent, signed by whoever provided the training, for individual staff.
- A register of training showing who received the training and the date of the training.
- The training provided is a formal training course.
- And either:
- The duration of the training is sufficient to cover the requirements / content of the course, or
- The training is provided by a competent person, for example a trainer who holds a Certificate IV in Training and Assessment, a registered training organisation or an Indigenous person.
10. Service standards – key considerations for standard 2
What does my process documentation need to include for element 2.1.2 – Strengths and Needs Assessments?
The strengths and needs assessment is a process developed by the service and completed prior to the care plan. It is an information gathering and assessment tool. To meet this element the process documentation must include usage of the referral form (and other information obtained prior to and following the placement) as part of the assessment.
For further information refer to the Resource Paper – Standard 2.
What is care planning and how does it differ, and relate to departmental case planning?
The service care plan is a mandatory document for all direct care services which captures the strengths, needs and goals of the child or young person placed and also sets out the plan for how services are to be delivered, monitored and reviewed to the child or young person using the service. The care plan should be informed by the department’s case plan, and needs to be reviewed and updated accordingly.
The services care plan should reflect the statement of standards and the dimensions of need and have clear objectives. Care plans should be current, signed, dated and reviewed to meet the element.
A copy of the departmental case plan is to be provided by the department to the service, for all children and young people in out-of-home care. For further information refer to the Resource Paper – Standard 2.
What is the new Positive Behaviour Support Policy?
The Positive Behaviour Support policy will become effective from 1 March 2009 for departmental staff, foster and kinship carers and direct care staff.
Transitional arrangements will apply for licensed care services to provide for lead in time to amend their policies in line with this policy by 1 July 2009.
A Power Point Presentation on the Positive Behaviour Support Policy will be sent out to Zonal Directors, CSSC Managers and PSU Directors to be forwarded to all staff.
What is required to evidence elements 2.3.3 behaviour management training?
This element requires additional evidence to other training related elements. In order to meet this element, the evidence needs to include:
- The training was focused on positive behaviour support required to meet the needs of the target group.
- A certificate or equivalent, signed by whoever provided the training, for individual staff.
- A register of training showing who received the training and the date of the training.
- The training provided is a formal training course.
- And either:
- The duration of the training is sufficient to cover the requirements / content of the course, or
- The training is provided by a competent person, for example a person who has undertaken the 'transforming care' or 'complex trauma' training provided by Thomas Wright, a trainer who holds a Certificate IV in Training and Assessment or a registered training organisation.
Examples of training include:
- Transforming care,
- Complex trauma,
- Non-violent crisis intervention, and
- Therapeutic Crisis Intervention.
Do I need to provide a Memorandum of Understanding (MOU) with a Recognised Entity as evidence for element 2.3.8 (Records of interagency cooperation)?
No, services are not required to have an official protocol or MOU with other services or the Recognised Entity. To meet the element, your service needs to have a written document showing that a formal relationship or cooperation exists between the service and an Indigenous service. This formal agreement might be:
- bi-lateral (involving only the service and the Indigenous service) and take the form of an exchange of letters or a formal agreement
- a multi-lateral arrangement involving a number of services, including the service and an Indigenous service (eg a document outlining the operation of a network of services)
The Department does not require a formal protocol with the local Recognised Entity.
What is my responsibility after a young person has transitioned from the service (2.1.6)?
Services are required to plan and support the transition of young people with the department. However, you do not need to follow-up up with the young person after they have transitioned from the service as this is the department’s responsibility.
What do I need to include in the matching procedures (2.1.8)?
The process documentation needs to outline how the service matches the young person to the placement. This includes detailing the criteria used in making the matching assessment and is often completed using a checklist. The records need to demonstrate that the process was implemented with the results indicating a 'yes or no' to each of the criteria with details of how the service came to the conclusion objectively. If the service believes (or was told) that there was no other choice but to accept the placement, then this must be recorded. However, you are still required to complete matching and advise the department.
The matching criteria should include:
- Impact on existing placements
- Current staff capacity / availability
- Current support available
- Location of the facility
- Additional support required to meet the needs of the child
- Age
- Gender
- Development
- Cultural factors
For further information, refer to the Resource Paper – Standard 2.
Should my service receive a copy of the department caseplan?
Yes. You are required to have a copy of the case plan to assist in the development of care planning. Please contact your Community Support Team if you are having difficulty obtaining case plans.11. Service standards – key considerations for standard 4
How can I ensure my service's process documentation adequately reflects the requirements of confidentiality?
There are 4 requirements of confidentiality. These areas include:
- Informing the child or young person about confidentiality
- The routine sharing of information within the requirements of the Child Protection Act 1999 (section 187)
- Gaining consent from the child or young person when sharing their information 'outside' the Act
- The limits to confidentiality (exceptional circumstances). Confidentiality is limited by the need to:
- Keep records
- Commit to legislated reporting to the Department of Child Safety
- Share information between the Department and the service or with another organisation when directed by the Department for the safety and well being of a young person and as indicated in the young person's case plan
- Report harm or alleged harm to a young person
- Abide with lawful requests
- Protect the safety and wellbeing of the young person and others.
Also, the forms used by the service for consent and acknowledgement need to clearly identify the situations when information will be shared only after the child or young person’s consent has been provided, and in what situations client consent will not be required or sought.
Refer to Licensing Resource Guide Standard 4 for further information.
How is information about confidentiality provided to young people in a foster care placement and how does the IEA assess this?
Information can be provided to the young person either by the service or the carer. If the carer is providing the information to the young person, the service is required to have processes for supporting the carer to do this correctly and to ensure that service records are maintained to evidence that the information has been provided.
Similarly, when consent is required from the young person to share information, this may be facilitated by the carer with support from the service. If the carer is responsible for this task then there will need to be a process for training the carer to provide the correct information and maintain records of completion.
I am a foster care service, am I required to keep client files in addition to carer files?
Yes. You are required to keep separate client files to those kept for carers for the following reasons:
- If the young person moves placement (both from and within the service) then this information needs to be easily located
- It should be in an easy to access location if the young person requests access to the information or if it is requested through Freedom of Information
- The information needs to be easily returned to the department when the young person transitions or the placement ends.
12. Service standards – key considerations for standard 5
Element 5.3.1 requires me to aggregate, assess and communicate client feedback and levels of satisfaction, what does this mean?
This relates to using the information obtained from client feedback to improve services. Specifically the information obtained through client feedback needs to be:
- collated (often in a register, linking similar themes)
- reviewed – the information needs to be assessed to see what actions may be taken to deal with any issues raised through feedback.
- Communication – this can be done in team meetings, carer home visits etc and ensures that all relevant people are aware of the information obtained and any decision made in response to the feedback, particularly when it relates to positive feedback about a job well done, or things that can be improved in the service.
13. Service standards – key considerations for standard 6
How can I ensure our services process documentation adequately reflects the requirements of preventing and reporting harm, and managing the outcomes of reports of harm?
Key considerations for this standard include:
- Incident reporting policies need to reference section 122 of the Child Protection Act 1999 (standards of care) to demonstrate knowledge in this area and include the definition of harm listed in section 9 of the Act
- Incident reporting policies should also include definitions of events that constitute an incident. As a subset to incidents, there should be definitions and processes for critical incidents and non-critical incidents (including standards of care and harm not arising from services received eg. self-harm and attempted suicide). Under the definitions, services should list what constitutes a non-critical and critical incident (eg. Fell off bike without serious injury - non critical incident, alleged harm by staff or carer - critical incident)
- Incidents include those events that do not occur as a result of services received (e.g., self harm, absconding, harm occurring at a contact visit). These incidents need to be included in the definitions and responded to appropriately.
- Policies and procedures need to clearly describe how the service works with the department during and after an investigation. Policies and procedures also need to demonstrate how support is provided to a child and staff/carer during an investigation and what external support can be accessed. (also relates to standard 9)
- The report provided to the department using the incident report form, or equivalent, needs to include the particulars listed in section 11 of the Child Protection Regulation 2000.
Refer to Licensing Resource Guide Standard 6 for further information.
What is my responsibility in tracking the progress of incidents that I have reported to the department?
You must report incidents regarding children and young people in your care to the department. The department then has 6 weeks to determine if the incident is an MOC and to assess any MOCs and notify you of the outcome in writing by letter. If the service has not received this advice after 6 weeks of notifying, the matter can be considered ‘closed’ and recorded as not being a MOC.
What are the recording requirements for standard 6?
The recording requirement for this standard is that there is a central location where all information on incidents, critical incidents and their outcomes are recorded so they can be tracked and monitored, ie, recorded on a register. Refer to Licensing Resource Guide Standard 6 for further information.
What is required to evidence element 6.3.3 records of training aimed at protecting people using the service from harm and reporting harm?
This element is specifically identified in the standards and requires additional evidence to other training related elements. In order to meet this element, the evidence needs to include evidence that:
- The training was focused on and covers preventing, identifying, reporting, recording and responding to harm required to meet the needs of the target group. This training will fall into two distinct areas, which are:
- How to work with children to prevent and identify harm and risk of harm which may well be provided externally, by a qualified trainer such as a trainer who holds a Certificate IV in Training and Assessment or a registered training organisation, and
- The services processes for reporting, recording and responding to harm or risk of harm, which may well be provided by a member of the services own staff.
- A certificate or equivalent, signed by whoever provided the training, for individual staff.
- A register of training showing who received the training and the date of the training.
- Either:
- The duration of the training is sufficient to cover the requirements / content of the course, or
- The training is provided by a competent person, as indicated above.
14. Service standards – key considerations for standard 7
What are the key components my service needs to include in our process documents in relation to blue card and suitability processes?
Your service is required to have a documented procedure on how and when blue card and suitability checks are undertaken. Once licensed, all applicants for positions within the service are required to have undergone a suitability check by lodging an application for a suitability check (LCS2), or confirmation of suitability (LCS7) to the Department and have a positive outcome before commencing. Staff are also required to have applied for a blue card or have their current blue card validated through the Commission for Children and Young People and Child Guardian prior to commencing. If the applicant has submitted a blue card application but does not have a current blue card prior to commencement or this hasn’t been validated, this can be managed through a risk management strategy, as per the Commission for Children and Young People and Child Guardian Act 2000, until the blue card is issued or validated. All Nominees, Directors and volunteers must have suitability and blue cards issued prior to commencement.
The policy and procedure also needs to contain how outcomes of these checks are managed and monitored, and when renewals are sent.
See section 17 Screening Processes for more information.
What are the suitability and blue card requirements for emergency contractor staff?
The department understands that there may be times when services do not have sufficient staff to cover care and support to young people placed and therefore utilise emergency contracted staff. In order to ensure the suitability of these staff, the service is required to have the following process:
- The service is to implement a risk management strategy
- The worker must hold a current blue card which must be sighted and recorded by the service prior to commencing
- The service is required to contact their CST or Child Safety After Hours Service to obtain departmental history checks before the person commences work to ensure they are not unsuitable. The outcome of these checks needs to be recorded by the service.
What evidence is required to demonstrate compliance with 7.3.5 – records of screening, assessing and selecting carers?
The IEA are looking at the forms (which should be on carer files) to assess the element. If the APPA is not signed by the CSSC Manager prior to the expiry then the carer is not approved and the element is 'not met'.
Do I have to keep records of the selection process for staff after the appointment has been made?
Yes. You are required to keep records of the recruitment and appointment processes for all staff to meet the requirements of this element including:
- How the service generally promotes vacancies
- How the application, selection and appointment process was undertaken
- How the job descriptions and selection criteria are used in the process
What needs to be included in our policies and procedures around the requirements for carer approval?
Your policies and procedures should document how carers are screened and assessed and how they are re-approved. The process should reflect the requirements detailed in the Child Safety Practice Manual. Refer to Licensing Resource Guide Standard 7 for further information.
What are the recording requirements for this standard?
A register, or equivalent, needs to be maintained for suitability and blue card checks, and carer approvals. The registers should include:
- blue card number
- blue card expiry
- date application sent for approval
- verification/authorisation date (if applicable)
- date renewal sent (prior to expiry)
- date application for suitability sent
- suitability outcome date
- suitability expiry date
- Date renewal application for suitability sent (prior to expiry)
A carer approval register should include:
- Carers name
- Type of approval (General or Kinship)
- Approval status
- Approval expiry date
- Date renewal approval lodged (should be the date signed by the CSSC Manager and is required to be before the expiry date).
15. Service standards – key considerations for standard 8
What evidence does the IEA look for in element 8.3.4 – records of reviewing learning and training strategies?
The IEA will review records to ensure that information has been collected on the training and learning strategies within the service. They will also assess whether this information is collated and an assessment undertaken with a summary review statement prepared. If no learning and training needs have been identified services should record that there are no learning and training needs.
The service can not record 'no training needs' for every carer, the service must generate some records of training identified through training assessments conducted by the service with the carer.
16. Service standards – key considerations for standard 9
What is the best way to provide information to carers about complaints and meet element 9.3.7?
The most effective method of providing information to carers is through an induction package. Evidence of providing this information to carers can then be demonstrated through an induction checklist which is signed by the carer and returned to the service.
The induction package can also include information to meet elements 7.3.6 and 7.3.7.17. Independent External Assessment (IEAs)
Can the Independent External Assessor provide advice prior to the assessment?
No. If you have any questions about the process ask your Community Resource Officer (CRO) or contact PeakCare or Queensland Aboriginal Islander Health Council (QAIHC) who assist in supporting services with licensing.
Will volunteers need to participate in the assessment of staff and management awareness?
Yes. Volunteers will be assessed on the criteria relating to the tasks they carry out.
Who pays for casual staff and volunteers to attend IEA?
The organisation is responsible for meeting any costs involved. Any issues should be discussed with the Independent External Assessor, as alternative processes (for example, telelinks) may be possible.
Is the IEA for specialist foster care services and foster and kinship care services the same?
The Independent External Assessment for specialist foster care services only differs from the IEA for foster and kinship care services if the specialist foster care service engages care staff to work directly with children and young people and foster carers (known as direct care staff).
When preparing to undertake the self-assessment it is important to refer to Appendix 3 of the Out-of-Home Care Services Licensing Manual so as to identify which criteria under each standard "things that must be considered" apply to your service model. These criteria will also be assessed by the Independent External Assessor.
What should I expect from an IEA site visit?
The IEA site visit is usually undertaken in one to two days depending on the number of staff, location of premises and the location of files. The site visit enables the Independent External Assessors to sight and assess output evidence and to assess staff and management awareness of relevant process documentation. At the beginning of the site visit the assessor will meet staff to introduce themselves and explain the process and answer any questions. Once the site visit is finalised the assessor will conduct an exit interview and provide a broad overview of the evident gaps in process documentation, staff awareness and output documentation. It is important that key staff from your service attend this meeting.
It is imperative that all relevant staff and management attend the site visit. The department will negotiate appropriate dates with you well in advance to the site visit date. The Independent External Assessor will contact you close to the visit date to negotiate a suitable time for the visit to occur.
Will I receive the IEA report directly from the assessors?
No. The IEA is conducted to assist the department to make a decision regarding the outcome of your licence application. The report is therefore provided to the department.
However, the department will forward a copy of the report to the nominee of the service with an invitation to provide the relevant Zonal Director with a response regarding the findings. Any response you provide will be considered when determining the outcome of your licence application.
Is the IEA report the licensing decision?
No. While all organisations seeking care service licences must meet minimum standards before the department will approve a licence, the IEA report represents only one of a number of assessment processes the department utilises when considering and making a licensing decision. Other measures include assessing:
- that your licence application shows that your service is eligible to be licensed
- your response to the IEA report
- implementation of your action/improvement plan
- the outcome of personal history checks and other information regarding the suitability of persons associated with the service
- information arising from Matters of Concern and case work matters that relate to the service
- feedback obtained from children and young people
- any complaints received by the department in relation to the service.
What happens if we get a 'not met' in the IEA report?
If a service does not meet all of the standards in their IEA report, the service will be given the opportunity to demonstrate they have rectified the issue to meet the standard/s.
For services who have received a 'not met', on any process documentation elements, the service will be given the opportunity to amend the documentation in line with the feedback from the IEA report with support from the Community Support Team and/or Quality Assurance Operations Unit (QAOU). This documentation will need to be reassessed by the IEA.
Once the IEA has agreed that the process documentation meets the standard, the department undertakes a follow-up assessment of staff/management awareness and output documentation (completed by the CRO).
In assessing staff and management awareness elements, the CROs are required to sight qualitative evidence that staff and management have an awareness of the requirements of the element. This is most easily achieved by the service using a survey form with the question listed in the SAWB from that specific element. Relevant service staff and management are then required to respond to the question based on their awareness. All staff should complete this and the CRO will review a sample.
Secondly, the service should assess the responses and complete a synopsis/summary of the responses received including a statement as to whether the element is believed to be met. The CRO will review this document together with the sample of qualitative responses to assess the element.
What are the most common 'not met' areas in an IEA report?
The most common 'not met' areas in IEA reports are in relation to Standard 2 (Responding to the Needs of Children and Young People) Standard 4 (Confidentiality and Privacy), Standard 6 (Protecting the Safety Children and Young People) and Standard 7 (Recruitment and Selection Processes for Staff, Carers and other Volunteers).
For more information on the most common 'not met' areas, or licensing 'hot spots', see sections 8-11 (Key considerations for the standards).
Do I need to complete a contents page when sending documents back for a follow-up IEA?
Yes. You will be required to complete a contents page (Table of Documents) detailing the elements assessed as 'not met'’ with the exact reference to the amendments made to process documentation e.g. amended section 5.3 Policy and Procedures manual page 45. The service will then need to highlight the changes within the document before submitting for the follow-up IEA.
What is the Summary Report?
The Summary Report is the final piece of information completed by the Community Support Team and presented at the State-wide Licensing Panel. This document includes a summary of initially 'not met' elements from the IEA report, details of the amendments made to documentation, updated staff awareness and re-assessed output documentation and the final assessment of these elements made by either the Independent External Assessor or the CST. There are also other appendices of this document which include information about the location of houses (Premise site/coordination applications only), carer approval details (carer and direct care applications only), staff suitability information and details of matters of concerns for the past 12 months. Your CRO may require your assistance in completing these documents.
Can I provide new or revised process documentation to the department or Independent External Assessor after I have submitted my licence application and before I receive the report?
No. As a general rule, any process documentation developed or updated after the licence application has been accepted will not be considered by the IEA.
Of course, you will be expected to amend any process documentation that the IEA determines does not meet the minimum standards. Once the amendments are in place you will need to submit changes to your CRO to enable feedback and progression through the assessment phase. You will also need to ensure that staff and management are aware of these changes, that the change is referenced throughout other interrelated process documentation, and that where possible you provide output evidence.
We have developed new processes consistent with the suggestions in the IEA report. Do we need output evidence to demonstrate this before being granted a licence?
As a general rule, yes. Evidence of output documentation is an integral part of the assessment process. Nevertheless, the department recognises that there are particular policies and procedures that may not be implemented within the assessment timeframe. In these instances you may be able to submit a response of Data Not Available (DNA); however it is recommended that you contact your CRO for assistance when determining which output documents can be omitted.
18. Combining licensing processes for different service types
Can an organisation obtain one licence to cover two services or more?
Yes. An organisation may submit one licence application to cover two services or more in certain circumstances. In general, the services must share the one nominee, group of directors, one coordinator and one set of process documentation. They must be located within the one coordination site and service delivery must be conducted within the boundaries of one departmental zone. If you believe your services may be able to share a licence you should contact your Community Resource Officer (CRO) to discuss.
Will forms or templates be available to help organisations undertake the licensing process?
Yes. All relevant licensing of care services forms and templates are available from your CRO.
Some of the licensing forms and templates are also available on our website.
19. The Role of the Community Support Team (CST) and Quality Assurance Operations Unit (QAOU) (formerly Licensing Coordination Teams (LCT)
How can the CST and QAOU assist my service?
The QAOU have the primary focus on providing high level assistance and support to CSTs and services with progressing through the licensing process.
What type of support can I expect?
The CST can offer advice and feedback on your services licensing submission including general information about commonly 'not met' areas. These key areas are referred to as the licensing 'hot spots' (see 8-15).
What are the Licensing Implementation Plans (LIPs) and Licensing Application Actions Plans?
Licensing Implementation Plans are the overarching agreement between your service and the department around the meeting of key milestones within the licensing process. The plans are designed to assist your service to identify timeframes around each step of the licensing process with a tentative date for assessment of your application.
The Licensing Implementation Plans are signed by the service Nominee or delegate, the CST Manager and the Coordinator of the Licensing Coordination Team.
Action plans are more specific plans that provide suggestions for improvement to your process documentation or application. These are completed after a review has been conducted and may be followed by a meeting between your service and the department to discuss the contents of the action plan. These plans set out the feedback from the CST in relation to each of the elements. It is important to note that these are suggestions only.
20. Lead Zone Process
What does the lead zone process mean for my organisation that has a number of services across zones?
For organisations that have a number of services across zones, the department has developed a lead zone process aimed at streamlining licensing.
The lead zone (CST) will be responsible for coordinating the suitability and blue card applications of the nominee and directors that are across the organisation.
The lead zone will also be responsible for checking the process documents for the first application/s.
The process aims to ensure that organisations are receiving consistent information from the department and provides a central contact point for all licensing queries.
What does the lead zone process mean for my organisation/service that is only in one zone?
The lead zone process does not apply to your service if the service is only in one zone. You will only need to work with the CST in the zone your service is located within.
21. Carer Approvals
Will my licence be granted if there are foster carers without current approval?
No. A requirement of the standards is that the service has approved foster carers. The service is required to evidence this in the LCS1 - Application for a Care Service Licence for an application to be accepted as properly made.
22. Determining a licence application
How long does the department have to process and determine an application for a care service licence?
The department has 90 days once an application for a licence (LCS Form 1) has been determined properly made.
Can the 90 day licence application period be extended?
Yes. If the department needs more time to consider an application or the service needs additional time to rectify areas where the Independent External Assessor has identified non-compliance, the 90-day timeframe can be extended. The extension must be agreed to, in writing by our department and the licence applicant before the initial 90 days expires.
The department's policy position is that an extension can only be granted for an additional 90 days.
Note: Only one extension can be granted for any licence application.23. Screening processes
What screening is required to be completed for staff, carers and volunteers of a licensed care service?
The nominee and all staff (including administration staff), volunteers, carers, directors and board members are required to undergo a working with children (blue card) check and a suitability (personal history) check. The working with children check is conducted by the Commission for Children and Young People and Child Guardian and involves a detailed check of criminal history, including any charges or convictions. When the person has been assessed as eligible, they are provided with a blue card which is valid for two years. Personal history checks refer to a domestic violence, traffic and child protection history check which is conducted by the Department of Child Safety. If the applicant is approved, they are provided with a Notification of Suitability which is also valid for two years.
My service is currently licensed under the previous licensing regime. Can a nominee or director take up their position prior to receiving outcomes of suitability and/or blue cards?
No. A nominee or director must have an outcome of suitability and hold a current, valid blue card before they take up their position.
Can service managers and staff members start work in a licensed care service while they are waiting for the result of their blue card application?
Yes, as long as the manager and/or staff member has received notification of suitability from the department's Central Screening Unit and has applied for a blue card. The service must also have a documented risk management strategy. Examples of risk management strategies include:
- not working alone with children
- having strong, confirmed references
- conducting criminal history checks.
Can a volunteer start work in a licensed care service if they have only applied for a blue card?
No. The Commission for Children and Young People and Child Guardian Act 2000 states that a volunteer must have a blue card before they can be engaged in regulated employment. A volunteer must also be determined 'suitable' by the department’s Central Screening Unit prior to commencing with a licensed service.
Where can I find a blue card application/authorisation form for nominees/directors?
Blue card forms for nominees and directors are available on our website.
Where can I find a blue card application/authorisation form for staff/volunteers?
Blue card forms for staff and volunteers can be found on the Commission for Children and Young People and Child Guardian (CCYPCG) website.
When do nominees, directors, service managers, staff and other volunteers need to complete an LCS Form 7: Confirmation of suitability?
Any person who has received a letter of suitability from our Central Screening Unit after 30 May 2006 and is commencing work as a nominee or director in a different licensed care service, should submit an LCS Form 7 (rather than LCS Form 2).
These licensing forms and templates are available on our website.
Does a person engaged by a licensed care service need to have another suitability check conducted by the department, if they shift employment from one licensed care service to another?
A 'Notification of suitability' letter issued by the department’s Central Screening Unit after 31 May 2006 is valid for two years. If a relevant person has received a letter from the department’s Central Screening Unit on, or after 31 May 2006 they still need to confirm their suitability using an LCS Form 7 prior to commencing with the new service.
What form is used by nominees, directors and staff to advise about changes to personal circumstances?
Under sections 141C and 141H of the Child Protection Act 1999, if there is a change in the personal, criminal or child protection history of a nominee, the nominee must immediately inform the Department of this change.
Similarly, under sections 141D and 141I of the Act, if there is a change in the personal, criminal or child protection history of a director or staff member, the person must immediately disclose this to the nominee who in turn must notify the Department of this change.
To advise the Department about changes in personal, criminal and child protection history, nominees, directors and staff of a licensed care service, are required to use the Licensing of Care Services (LCS) form 6, which is available on the Department’s website or from the relevant Zonal Community Support Team.
Can the nominee delegate tasks such as the verification of identification of staff on an LCS form 2?
Yes, the nominee can delegate a task if appropriate. However, the responsibilities of the nominee pursuant to the Child Protection Act 1999 cannot be delegated. Therefore, if a nominee delegates tasks in relation to their responsibilities under the Act, they would need to sign off on the completion of their tasks as they are ultimately responsible for such matters. (See below)
24. Legislative responsibilities of licensees, nominees and directors
Chapter 4 of the Child Protection Act 1999 (the Act) and part 2 of the Child Protection Regulation 2000 (the Regulation) directly relate to licensing of care services. Licensees, nominees and directors associated with licensed care services are required to abide by and fulfil certain responsibilities under this legislation.
They must also comply with Part 6 of the Commission for Children and Young People and Child Guardian Act 2000.
Please refer to the Resource Guide for Licensees, Nominees and Directors.
25. Corporations
The Child Protection Act requires organisations to be a corporation in order to be licensed. Does it matter what type of corporation my organisation is?
To meet the requirements of Section 125 (1) (a) of the Child Protection Act 1999, organisations applying for a care service licence must be incorporated under:
- Associations Incorporations Act 1981 (Queensland)
- Religious, Education and Charitable Institutions Act 1861 (Queensland)
- Co-operatives Act 1997 (Queensland)
- Corporations Act 2001 (Commonwealth)
- Aboriginal Councils and Associations Act 1976 (Commonwealth)
- Corporations (Aboriginal and Torres Strait Islander) Act 2006 (Commonwealth)
- Local Government (Community Government Areas) Act 2004 (Queensland)
- recognised under the Community Services (Torres Strait) Act 1984 (Queensland)
- recognised under the Aboriginal Communities (Justice and Land Matters) Act 1984 (Queensland)
- an incorporated local government authority
- an organisation with non-profit objectives incorporated by an Act of Parliament and approved by the Minister
26. Resourcing implications
How are the service standards related to the service agreement and departmental funding?
Demonstrating compliance with the service standards is a requirement of the service agreement.
27. Services not required to be licensed
My organisation is funded by the department to provide an out-of-home care service and a child protection counselling service. Do both services need to be licensed?
The licensing process only applies to out-of-home care services. Support services, including counselling services, are not required to be licensed. However, the department will be introducing a Quality Assurance Strategy for all funded services in the future.
28. Departmental monitoring processes
What happens once I am licensed?
Once your licence is granted by the Zonal Director you will be required to participate in the monitoring process for the duration of the 3 year licence.
How will licenses be monitored by the department?
The department's Quality Assurance Branch is working closely with the Community Partnerships Branch to establish a combined monitoring process. Monitoring activities for grant funded and licensed care services will be combined where possible and will include:
- quarterly service meetings
- scheduled service site visits.
If my service is licensed do I still need to complete annual performance reports with the department?
Yes if grant funded. Performance reporting for grant funding purposes remains unchanged.
- Last updated
- 17 July 2009