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Shared living arrangements for people with disability have been in the spotlight for many years. In January, the NDIS Quality and Safeguards Commission presented a Report and Action Plan for its first inquiry, which focused on supported accommodation. The Commission noted that one of the key aims of the Inquiry was to "identify modes of best practice for the delivery of supported accommodation” in order to inform the Commission’s work with providers.
It’s important to note the definition of supported accommodation used in the inquiry. The focus was congregate living, often called “group homes”. The Commission then narrowed this definition further to support and accommodation provided under NDIS-funded Supported Independent Living (SIL) and Specialist Disability Accommodation (SDA). The report noted that these services generally include three or more people with significant support needs living together and receiving support from an organisation. More importantly, the Inquiry was not focused on individual independent living options or shared living in family situations.
The Inquiry collected data from 7 of the larger NDIS SIL providers, who, due to their considerable market share of supported accommodation (18% of NDIS participants receiving SIL across Australia), were viewed as representative of the wider sector. The Inquiry explored reportable incidents and complaints, conducted a detailed analysis of policies, procedures, and systems, and undertook direct engagement with people across these group homes and stakeholders representing their interests and those of the sector.
The key findings of the inquiry were listed as follows:
- There is a need for specific regulation of group home settings to enhance the quality and safety of these settings for people with disability
- Greater engagement with people living in group homes is required to support their exercise of choice and control
- The attitude and aptitude of the workforce drives a high number of the issues evident in group home settings
- The interaction of SIL and SDA arrangements affects the ability of people with disability in supported accommodation to make changes to their living arrangements
- We need to better understand the supported accommodation market and how people interact with it, including by improving the collection, monitoring, and analysis of relevant data
- The interface with health and the supported accommodation system is not effective for many people living in these settings
The Commission’s action plan includes commitments and key initiatives to achieve longer-term outcomes to improve the NDIS, to amplify the voices and maximise the experience of people with disability, and to improve the quality and safety of SIL.
Two decades working in the sector has left me with no doubt that the experiences of people with disability, both with and without funding from the NDIS, need to be significantly improved. This social reform will require a coordinated effort from multiple government departments and significant investments in the sector to continue to create innovative supports and services. It must also be shaped by a clear understanding of how everyday language, attitudes, and practice continue to exclude people with disability from their own lives.
The Commission Inquiry is a step in the right direction in understanding how practices and structures can have a detrimental impact on the way people with disability can exercise their human rights. It is also a clear reminder that every provider in this space needs to take accountability to ensure that it continuously strives for better and ideally best practices in designing and delivering these services. However, any Inquiry and its findings can only be as good as the assumptions and limitations behind it. After reading the report, I am left with some questions. Let’s explore them now.
1. Was the definition of supported accommodation useful?
The Inquiry used a narrow definition of supported accommodation, limiting the scope to “group homes” of people funded under SIL:
"Just about every NDIS participant living in a group home receives SIL in their NDIS plans. Some people with disability may live in group homes but not receive SIL in their NDIS plans, for example, children and young people who are NDIS participants and may be in out of home care or voluntary out-of-home care arrangements."
There has been significant energy from NDIS over the past two years in the home and living space, including the introduction of Individualised Living Options (ILOs) and the blurring of boundaries between how support in the home is funded. In 2022–23, it is common for people who may once have been eligible for (and are perhaps even receiving) a specific support type, to now have their new home and living funding noted as Flexible Core.
In fact, most SIL funding is made at the category level and can be claimed under any number of support types, depending on the needs and wishes of the participant. This relaxing of firm boundaries and definitions of supports in the home is driving innovation and challenging previously held beliefs that people with disability will be shaped to fit a type of predetermined service or support model. In this new definition of home and living, supported accommodation or the traditional “group home” may have an assortment of people living together: some funded under SIL, some with some Flexible Core, and some with ILOs while they build the skills to move on to the next step in their journey.
With the NDIS looking to the future and focusing on funding needs across life stages, not the cost of a type of support, is it still relevant to use a narrow focus to evaluate services when we are not using a narrow focus to create them? In addition, what are the implications for reforms linked to this limited definition?
2. How do service providers highlight risk and underfunded supports?
Recently, the NDIA has removed the ability of providers to contribute to funding discussions and will often cite “insufficient evidence” in response to requests for higher intensity supports or lower ratios in SIL. However, providers in this space need to respond to support coordinators, families, and specialists who cite risk and duty of care to apply significant pressure to provide higher ratios. This tension, coupled with the significant changes in home and living funding, has prompted a clear need for greater synergy between the NDIA and Commission in assessing support needs and the funding that is granted. This can help ensure that the safety of residents informs funding decisions.
One mechanism that providers can still use to highlight issues in support provision is incident reports, which in some cases can prompt investigation into support needs and are recognised by the NDIA as evidence. The report noted that larger configurations of people in supported accommodation generally resulted in higher rates of incident reports. In many cases, these incidents were related to specialised support needs, particularly medication and mobility. It was also noted that these settings were likelier to have much higher rates of reportable incidents associated with falls and seizures or near misses related to equipment use. Interestingly, there has also been a correlation between larger configurations of people and the NDIA funding lower support ratios, presumably because the ability to share reduces costs.
The report noted inconsistent approaches across all seven providers regarding what constituted a reportable incident, with some providers submitting incidents that were “out of scope”. The Commission noted that it would look to address this inconsistency. It also mentioned “issues with the capacity of providers in making necessary adjustments to supports needed to address the risk of harm".
Incident reports can also be used as evidence of the success of support approaches. The Inquiry found the following:
"There were examples given to the Inquiry about people who had been successful in moving into independent settings and a corresponding reduction in incidents affecting them and their former co-residents. However, there were also examples where, after living in a more independent arrangement over time, the corresponding reduction in support needs led to reconsideration of their SIL arrangements, making the more independent placement unsustainable within the funding available."
The NDIA has removed the direct line of communication for providers to report support needs. The Commission may also reduce the issues a provider can submit based on what is “in scope”. What mechanisms will exist for providers to report or respond to concerns?
3. Can we ignore the history and evolution of supported accommodation?
The Royal Commission has highlighted abhorrent stories of violence, abuse, neglect, and exploitation of people with disability and rightly increased expectations, guided by the Quality Safeguard Practice Standards, that this behaviour will be rectified. Organisations are continuously redesigning their operations, risk approach, and support on the ground to respond to any quality and safety issues.
This inquiry used complaints about supported accommodation services to highlight how people in these settings are often dependent on others to raise issues on their behalf. The following data was included in the Inquiry:
- “Of the complaints examined through the Inquiry, only 3% had been made by people with disability themselves. This compares with a typical range of 23–29% for all complaints received by the NDIS Commission made directly by a person with a disability.
- By contrast, the proportion of complaints made by family members or friends of people living in supported accommodation provided by the 7 providers was 40%. This compares to a typical range of 15–22% of all complaints that are made directly by a family member or friend of a person with a disability to the NDIS Commission.”
The sector must address barriers for people with disability in raising concerns about their support or expressing their needs. However, when we make assumptions from data, it is also essential to do that in the context of the history of the people involved. In addition to frameworks that shift provider behaviour, there must also be investment in supporting families and stakeholders of participants to understand the changes that need to be made to align with contemporary practice and a human rights-based approach. This is even more important if the person has “legacy supports”, as many of these people will have moved from institutions with the promise to their families that they would remain safe and secure in these environments and receive these supports for the rest of their lives.
At the current time, this education is generally left to the provider and as such raises conflict and promotes the destruction of formal and informal relationships. Surely there is a need to focus on this tension rather than simply tightening compliance requirements.
This article has only started to unpack the complexity of the issues raised by the Commission and I encourage you to check it out yourself here.
