Service Standards Audit Checklist

When conducting a Service Standard Audit the SPM will assess the Centre against ten requirements. This may be done through information
provided as part of the NACLC Accreditation process in consultation with the CLCNSW Regional Accreditation Co-ordinator (RAC) via the
provision of the Accreditation External Assessment Report, Workplan and Evidence Pack and/or independently of the NACLC Accreditation
Scheme.

The ten Service Standard requirements pertain to:

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
10. Aboriginal Cultural Safety Standard

Under each of these ten service standards the following information/documentation is required by the SPM for audit purposes:

1. Informational & referral:

Referral to other community legal service providers:

 Documented policies/procedures for making referrals to other community legal service providers (these procedures must establish the
appropriateness of any referral).
 A maintained up-to-date contact list of relevant community legal service providers.
 That an annual check is undertaken to ensure that the relevant community organisations and practitioners have the capacity to provide a
service to the referred person.

Referral to legal aid, private practices or other agencies:

1
  Documented policies/procedures for making referrals to Legal Aid NSW, private practices and other agencies (these procedures must
establish the appropriateness of any referral).
 Policies/procedures must prevent any actual or perceived conflict of interest in making a referral.
 Policies/procedures must provide at least two referral options to clients when more than one option exists.
 A maintained up-to-date contact list of Legal Aid NSW offices and relevant private practitioners.

Referral to other community services:

 Documented policies/procedures for making referrals to other community services (these procedures must establish the appropriateness
of any referral).
 A maintained up-to-date contact list of relevant community service options.
 Information pamphlets or other printed information should be provided to people whom are being referred & should be evident in
community legal service provider offices.

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

2. Provision of advice:

 Documented policies/procedures for the provision of advice which include:

o The completion of advice sheets/records

o Advice is recorded appropriately and limitation dates identified
o Advice is checked, where appropriate
o Conflict of interest issues are identified/avoided
o Ensures client confidentiality

2
 o Provides information to clients in relation to duties of disclosure, the type/purpose of client information collected/used

 Documented policies/procedures which deal with circumstances where staff and/or volunteers are unable to provide advice, which
includes:

o Informing clients of areas in which advice cannot be provided

o Provide appropriate referral options, if available, in accordance with the Standards for Information and Referral (Standard 1)

 The Centre has cover under a current certificate of professional indemnity insurance

 The Centre operates under a current unrestricted practicing certificate

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

3. Casework:

 Documented policies/procedures for performing casework which include:

o The completion of case records

o Instructions, advice and limitation dates are recorded
o Conflict of interest issues are identified/avoided
o Advice is checked, where appropriate
o Ensures client confidentiality
o Provides information to clients in relation to duties of disclosure, the type/purpose of client information collected/used

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

3
4. Community Legal Education:

 Documented procedures for performing CLE which include:

o Identifying CLE priorities and objectives, in partnership with community input/ need
o CLE is appropriately evaluated, with stakeholder feedback and outcomes/objectives assessed

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

5. Law Reform & Legal Policy:

 Documented policies/procedures covering the development of law reform and legal policy initiatives which include:

o Planning of law reform/ policy priorities

o Considers external stakeholder input
o Law reform and policy initiatives are appropriately evaluated, with stakeholder feedback and outcomes/objectives assessed

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

4
6. Accessibility:

 Documented policies/procedures in relation to ensuring the service is accessible and appropriately targeted which includes consideration
of:

o Client characteristics/ community diversity

o Setting appropriate criteria for accepting clients
o Communicating with clients who experience language difficulties
o Ensuring the service is physically accessible
o Avoiding discrimination/ harassment
o Providing a flexible mode of service delivery
o Adequately promoting the service

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

7. Organisational Management:

 Documented policies/procedures which ensures the service has appropriate organisational management structures including, but not
limited to, that the Centre:

o Promotes community involvement, including volunteer involvement

o Undertakes required financial management/reporting

5
 o Appropriately trains, manages and supervises staff and volunteers
o Identifies/manages risks associated with the provision of legal services
o Plans/implements and monitors service delivery

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

8. Management of Information & Data

 Documented procedures in relation to the management of information and data which include:

o Data is collected accurately

o Data is secure and used appropriately
o Data is regularly backed-up from all computer systems and stored at an off-site location
o Off-site data is regularly updated and appropriate for use in the event of on-site data loss
o Paper documents/files are securely stored for the required statutory period and accessible

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

9. Assessing Client Satisfaction & Managing Complaints:

 Documented policies/procedures in relation to collecting client feedback which includes:

6
 o Assessing satisfaction with services provided
o Client feedback can be provided in a confidential manner
o The service ensures ongoing consideration of client feedback
o That staff are aware of procedures for collecting client feedback

 Documented procedures in relation to managing client complaints that are accessible, that ensure all complaints are considered
appropriately and properly documents a complaint process in a written format for clients.

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

10. Aboriginal Cultural Safety Standard

 Documented policies/procedures in relation to ensuring Cultural Safety and Awareness in working with Aboriginal and Torres Strait
Islander communities and people which include:

o Documented procedures to ensure cultural safety across all services and activities and at all levels of the organisation
o Formal and informal processes are in place to identify and understand legal and social needs of communities within the catchment
area
o The organisation is connected to the local Aboriginal and Torres Strait Islander communities, families and people, with formal
consultation processes functioning to inform strategic planning and service delivery
o Employment and retention strategies for Aboriginal members of staff
o Regular training and professional development in the areas of Aboriginal Cultural Awareness and Cultural Safety for all Management
Committee members, staff and volunteers
o The internal areas of the Centre, and the outside of the building and surrounds, where possible, are welcoming, culturally sensitive
and create culturally safe environments for clients and staff
o Evaluation of cultural safety and responsiveness strategies

7
The Aboriginal Cultural Safety Standard Checklist outlines key evidence indicators that will be used to assess compliance with this Standard.
The SPM will assess the community legal service provider’s progress towards compliance with Standard 10 using the Aboriginal Cultural Safety
Standard Checklist. It is expected that Centres demonstrate adequate progress against the requirements of this new Standard by 15 April 2016.
The CLC Program will be assessing each Centre’s progress against this standard, with an expectation that Centres will be able to demonstrate
compliance with Aboriginal Cultural Safety Standard requirements from 1 July 2016.

 Attribute Element/Process Documented Evidence Yes/No or ? Staff Awareness Yes/No or ? Auditor’s

(reference) (staff position Comments
responsible)

Notes:

1) The appropriateness of all documented procedures must be assessed against the size, nature and locality of the service being provided.

2) The SPM does not require separate documents for each component procedure, a single manual or document covering various procedures
is acceptable, provided each procedure is clearly identifiable.