It outlines a number of shortfalls at the Transition to Home service including gaps in protocols and new complaints of “poor client hygiene” and “toxic leadership”.

The State Government-commissioned report, released today, calls for urgent improvements, which the government says will take place.

The Transition to Home (T2H) program, run by the Department of Human Services, has been under scrutiny since last year, after InDaily revealed the case of a man – now known as Mr D – who was rushed to hospital from the service in an alleged state of neglect with a severely infected pressure sore.

A subsequent damning investigation by the independent health watchdog uncovered “serious failings” in his care, finding he had an infected pressure wound, appeared to be malnourished and was left to sit in faeces and urine for long periods.

T2H provides step-down accommodation for patients with disabilities discharged from a long stay in hospital but with nowhere to go.

It now operates from two sites – at the Repat in Daw Park and St Margaret’s Rehabilitation Hospital at Semaphore.

Mr D had been residing at the now decommissioned T2H service at Hampstead Rehabilitation Centre.

The State Government launched an independent review into T2H after being elected in March and today Human Services Minister Nat Cook released those findings, vowing to take action to improve the service.

The review – undertaken by Flinders University health expert Associate Professor Christine Dennis and disability and health advocate Greg Adey – found that none of the targeted NDIS practice standards in T2H were fully met.

It did however find they were “partially met”, with the reviewers noting that none were rated as “not met”.

“Where Standards are only ‘partially met’, they are currently low risk, but they have the potential to deteriorate unless effective systems are implemented and monitored,” the report found.

While the expected length of stay for patients at T2H is 90 days, the report found on average they stayed 207 days, with one client residing nearly 18 months – 536 days.

“It’s evident from the escalating number of long stay outliers that barriers to effective and timely discharge pathways need to be addressed,” the review found.

The investigators are calling for a longer-term strategic view for T2H.

“Our opinion is that given an ever-increasing length of stay, there will be a cohort of clients who will remain as very long-stay clients and it is important that their care and services ensures independence is maintained or re-developed and, that the rights of people with disability are continuing to be upheld when working on any policy, procedure or program change,” they found.

“The T2H clients cannot (continue) to live in ‘no man’s land’ as this, in addition to potentially impacting on functional decline, may also impact on their mental health and wellbeing.”

The report said there were 1238 “incidents” internally reported at T2H from September last year to April this year but almost half of those related to clients refusing medication.

From May last year to April this year there were 1829 incident reports including 27 relating to care concerns.

The report stated that while better than a hospital, the T2H service at the Repat “compromises client privacy and dignity”.

“The St Margaret’s living arrangements are of a much higher standard, although a number of shared rooms impact client privacy and dignity,” it found.

Twelve NDIS Practice Standards were assessed for compliance and rated as “partially met”.

They include rights and responsibilities, risk management, quality management, incident management, provision of supports and specialist behaviour support.

The reviewers said staff raised concerns about increased vulnerability of clients when large numbers of complex clients are grouped together.

“Despite raising these concerns, it became evident during the review that corrective actions by management in response to key reports and investigations… lack appropriate timeliness and effective resolution of the gaps and risks that were identified,” they found.

The report says T2H “is strongly supported by the DHS’s comprehensive operational management systems, however there are a number of gaps in key T2H operational protocols”.

It says “several of these are currently being addressed”.

The reviewers found that risk assessments of patients were “incomplete”.

“Intake assessments and checklists being completed by staff are frequently incomplete, inconsistent, undated and contain information randomly noted in the margins of the template,” they found.

The reviewers said an internal audit report from May this year identified that of 20 client files that were reviewed, only eight had risk assessments.

“A number of other risk mitigations were not implemented as per T2H policy, related to completing Positive Behaviour Support Plans and recording of substance abuse issues,” they found.

The report says understanding and application of the T2H intake and eligibility criteria “remains an operational management concern”.

“The revised intake assessment and risk screening protocols are still in draft form, and they require a number of improvements to appropriately address roles, responsibilities and clearly defined processes,” it says.

The report found there had been eight contacts and complaints about T2H raised with the Health and Community Services Complaints Commissioner (HCSCC) over the past 12 months, relating to issues such as poor hygiene, poor wound care, “inappropriate admissions” and lack of proper clinical assessments.

One complaint raised within DHS related to “alleged toxic leadership”.

“The complaint (as per the MySAFETY record) states closed but not resolved. There is no further information,” the report says.

Another complaint highlighted by the reviewers reads: “Poor client hygiene / client left unattended and found by external support worker / negligence. NB: This client had previously been brought to the attention of the Adult Safeguarding Unit (25 March 2022 – 12 days earlier) by SA Police.

“In conversations with the client’s partner it was stated that (he) ‘attempted on a number of occasions to have the matters addressed prior to the Police Report being submitted to no avail’,” the report says.

It says the complaint was referred to the Incident Management Unit for further investigation with the “staff member placed on suspension under investigation”.

DHS told InDaily today the staff member is no longer employed by the department.

Human Services Minister Nat Cook said the government was acting on the review’s findings, including employing extra staff, improving risk assessment and monitoring and delivering ongoing worker training including mental health first aid.

“I’ve long held concerns about aspects of Transition to Home – complaints brought to my attention before and after coming to government showed we need to do better,” Cook said.

“I am working towards an ambitious future where there is no need for a step-down service for NDIS participants leaving hospital, because they will be discharged straight to their home with suitable NDIS supports in place.

“The disability support workers in T2H deal with highly complex circumstances every day and the independent review noted that they are ‘committed to the people they support’.

“I’m confident that the actions we’re taking to address the review’s findings will better support staff to provide a consistent quality service.”

Cook said other actions in response to the latest review include:

• Auditing living environments based on best practice design principles
• Developing a Memorandum of Agreement between the Department for Human 
Services and SA Health to clearly articulate governance and accountability
• Introducing new referral and intake forms
• Carrying out both scheduled and “spot check” audits
• Establishing clearer terms of engagement for NDIS workers who support 
residents onsite

Cook said one of the reviewers – Greg Adey – will be appointed to oversee urgent improvements.

A department spokesperson said: “DHS believes that recommendations for improvement from this review, along with positive action already underway within Transition to Home will address recent concerns raised with the HCSCC.”