Draft Strengthened Quality Standards Guidance

Put in place strategies that support tailored care for each older person.

Partner with older people when developing and reviewing their care and services plan (Outcome 3.1). Include in the plan how your aged care and services are going to be tailored and safe for the older person. This includes identifying, documenting and accommodating each older person’s:

• background
• gender identity, such as gender diverse or transgender
• sexual orientation
• culture and beliefs  
• language and communication needs and preferences
• life experiences. It’s important to try and understand each older person's life experiences and how this can affect them. A life experience can be a single event at a particular time or a long period in an older person's life. Life experiences can include family, friends, career, meaningful activities and trauma.

Keep in mind an older person’s diversity when considering daily activities like food preferences (Outcome 6.2) and community-based activities (Outcome 7.1). If the older person identifies as Aboriginal and/or Torres Strait Islander, you need to record this information with their consent (Outcome 2.7). If an older person has a diverse background, tailor their care and services plan to make sure that their aged care and services are respectful and safe:  

• spiritually
• socially
• emotionally
• culturally  
• physically.

It’s important to make sure you respect older people’s privacy through this process (Outcome 1.2).

Identify if the older person is vulnerable. For example, an older person may be more at risk if they:

• live on their own  
• live in rural or remote areas without many service options  
• are socially isolated or don’t have close relationships  
• have few or no family or friends who ‘check in’ on them
• have a cognitive impairment and might have difficulty problem solving or advocating for themselves  
• have difficulty communicating or expressing themselves
• have a history of complex trauma
• are not very mobile
• show clinical frailty
• are dependent on their carer or only have one carer.

Make sure their care and services plan explains how you will address these circumstances and needs. Do this in partnership with the older person, their supporters and others involved in their care and services with their permission.

Make sure older people receive quality care and services based on their care and services plan. This includes any clinical care, palliative care and end-of-life care (Outcomes 3.2, 5.4 and 5.7).

Deliver aged care and services that:

• meet older people’s needs, goals and preferences. For example, for older people living in a residential care home, make sure food, drinks and the dining experience meet their needs and preferences (Outcomes 6.2, 6.3 and 6.4).
• improve people’s quality of life
• help people to do what they want to do. For example, if an older person wants to go for a daily walk but is finding this difficult because of their health, look at how care and support can help them achieve their goals and move safely. This could include allocating a worker to assist or supervise the older person, providing mobility aids such as a four-wheel walker, or offering a wheelchair for part or all of the walk.
• help older people to maintain and improve their physical, mental and cognitive function by encouraging them to use their skills and strengths. In some cases where older people have experienced a loss or reduced function, getting function back may not be possible. If this is the case, aged care and services should help them to maintain their current function. The guidance for Outcomes 3.1, 3.2 and 5.4 has more information on how you can support older people’s reablement and maintenance of function.
• meet older people’s cultural needs and preferences, are culturally safe, responsive and suitable for older people with diverse backgrounds (Outcome 3.2).  
• are trauma aware and healing informed. Make sure that workers understand different types of trauma and how this can affect older people. Older people may have past experiences of trauma that aren’t included in the care and services plan or that the older person doesn’t want to share. The older person may show signs that they have past experiences of trauma. Workers should be aware of these signs and deliver trauma aware and healing informed care. Make sure trauma aware and healing informed care is part of your systems and processes.  
• recognise the rights and autonomy of older people. This includes their right to intimacy, sexual and gender expression.
• are informed by contemporary, evidence-based practices.
• help older people to develop relationships and social connections. Older people who identify as Aboriginal and/or Torres Strait Islander may need extra support to stay connected with community, culture, Country and Island Home. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on how you can help support older people with their daily living.
• match what you have agreed to with the older person during assessment and planning. They also need to be included in their care and services plan (Outcome 3.1).  

Partner with older people to deliver quality care and services (Outcome 2.1). Make sure they:

• receive critical information about their aged care services (Outcome 3.3). Find out the older person’s language and how they need and prefer to be communicated with. Provide them with information in their language and that meets their communication needs and preferences. Include critical information in care statements.
• receive planned and coordinated care and services (Outcome 3.4). This includes where there are multiple health and aged care providers, supporters, family and carers involved in delivering aged care services, such as during transitions of care. This may include hospital-in-the-home arrangements where an older person receives acute care in either their home or residential care home. During transitions of care, you are responsible for making sure there is effective communication processes, and the older person receives continuity of care. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on how you support older people with transitions.

There may be situations where an assessment of an older person’s care needs are beyond what you are required to deliver to them under your legislative obligations and registration conditions. You are at all times expected to partner with the older person, registered health practitioners and allied health professionals to support them to access the aged care and services they need. You should be clear in your communication about what can and cannot be provided as part of your agreement to provide care in line with your legislative obligations. 

Make sure workers have the time, support, resources and skills to plan for and deliver safe, quality and person-centred care

Provide your workers with guidance and training on how to deliver safe, quality and person-centred care for each older person (Outcome 2.9). This needs to be in line with:

• the workers’ abilities and qualification
• the organisation’s policies and procedures
• contemporary, evidence-based practice
• the workers’ roles and responsibilities.

Make sure workers understand how to:

• create professional and trusting ongoing relationships with older people
• tailor aged care services to each older person’s needs, goals and preferences
• deliver care that is culturally safe, trauma aware and healing informed.

The guidance for Outcome 2.8 and Outcome 2.9 has more information on workforce planning and worker training.

Monitor how you plan for and deliver aged care and services to make sure older people’s needs, goals and preferences are at the centre all services and decisions you make.

To check if you’re providing tailored care for each older person, you can review:

• each older person’s care and service documents. For example, care and services plans and progress notes (Outcome 3.1).
• complaints and feedback you’ve received (Outcome 2.6a and 2.6b)
• information about incidents and near misses in connection with the delivery of aged care services (Outcome 2.5).

Look for situations where:

• older people have not felt safe, welcome, included or understood
• you haven’t met an older person’s communication needs and preferences
• you have delivered aged care services in a way that isn’t culturally safe, trauma aware or healing informed
• you or your workers haven’t respected or recognised an older person’s rights or autonomy.

Also, talk with older people, their supporters, families and carers about the aged care services they receive. Ask them if there are any services that they’re not currently receiving that they would like to. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure. This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system and open disclosure.

Put in place a system to recognise, respond to and stop abuse and discrimination from happening. This also applies to violence, racism, neglect and exploitation.

Integrate this system with your systems for:

• providing safe and quality care and services (Outcome 2.3)
• managing incidents (Outcome 2.5)
• managing feedback and complaints (Outcome 2.6a and 2.6b)
• worker training (Outcome 2.9).

Be clear about how your organisation:

•    uses systems and processes to stop abuse and discrimination from happening
•    identifies cases of abuse, discrimination and neglect
•    investigates and addresses these issues, to reduce the risk of them happening again
•    monitors and evaluates how effective steps to respond to cases of neglect are
•    encourages older people to provide feedback and complaints following your feedback and complaints management system (Outcome 2.6b).

Make sure workers follow the Code of Conduct for Aged Care. This will help your organisation and workers to:

• support an older person’s right to personal choice, dignity and respect
• promote kind, honest and respectful behaviour
• protect older people from harm.

Report any serious matters or situations where older people have been harmed or were at risk of harm by following the Serious Incident Response Scheme (SIRS) process.

Make sure workers get informed consent from the older person or their substitute decision-maker when responding to situations that involve abuse or discrimination (Outcome 1.3).

Older people may experience complex family dynamics that workers may become aware of. If complex situations put the older person’s safety and wellbeing at risk, they need to:

• escalate these concerns
• follow the organisation’s risk, incident and information management systems (Outcomes 2.4, 2.5 and 2.7).

Put in place strategies that maintain the personal privacy of older people.

Make sure these strategies:

• meet the older person’s needs, goals and preferences (Outcome 1.1)
• are part of the organisation’s information management system and clinical information system (Outcomes 2.7 and 5.1).

Have a process for providing intimate personal care or treatment, such as help showering. During your assessment and planning (Outcome 3.1), work out when and how an older person receives intimate personal care or treatment. This needs to be:

• based on the older person’s needs and preferences
• done in private and in a sensitive way
• done in a culturally safe, trauma aware and healing informed way (Outcomes 1.1 and 3.2)

Where an older person’s needs or preferences are different to the organisation’s usual approach, document this in the older person’s care and services plan (Outcome 3.1). For example, if the older person prefers to shower only when a family member is there to help them and this isn’t on a regular day. Make sure you follow the older person’s care and services plan when delivering aged care services (Outcome 3.2). This will help to make sure their care is consistent.

Personal privacy also includes the older person’s personal space and the things they own.  

Make sure workers have the time, support, resources and skills to treat older people with dignity, respect and privacy.

Give workers guidance and training on how to deliver aged care services that respect older people’s dignity and privacy (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• treat older people with kindness, dignity and respect
• recognise and respect the relationship between older people, their supporters, family and carers
• respect the privacy of older people. This includes their home and the things they own. It also includes their information and the things they discuss with you during care.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor how you plan for and deliver aged care services to make sure older people are treated with dignity, respect and privacy.

To check if your organisation and workers are treating older people with dignity, respect and privacy, you can review:

• older people’s aged care services (Outcome 3.1). For example, care and services plans and progress notes.
• complaints and feedback (Outcome 2.6a and 2.6b)
• information about incidents and near misses (Outcome 2.5).

Look for situations where:

• older people haven’t been treated with kindness, dignity or respect
• the relationships between older people, their supporters, family, and carers haven’t been recognised or respected
• the personal privacy of older people hasn’t been respected.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them how workers treat them and their family. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure. This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system and open disclosure.

Put in place a system to provide information to older people.

Integrate this system with your organisation’s:

• information management system and clinical information system (Outcomes 2.7 and 5.1)
• communication system (Outcome 3.3)
• risk management system (Outcome 2.4).

Make sure the system for providing information to older people includes information about how you support them to make informed choices. This includes information about dignity of risk and positive risk-taking. Risks are considered ‘positive’ if they encourage an older person’s independence and improve their quality of life.

Make sure the information you give to older people is current and accurate. Make sure you share information in a timely way with older people and others involved in their care and services, including:

• supporters of older people
• family
• carers
• workers
• registered health practitioners and allied health professionals.

You need to share information in a way that meets each older person’s language and communication needs and preferences (Outcome 1.1). This may include using:

• simple, plain language and avoiding medical jargon
• inclusive formats to give older people information if they have communication barriers, such as using large text or images
• language services. For example, interpreters and translators for older people:
  • from culturally and linguistically diverse (CALD) backgrounds
  • from Aboriginal and/or Torres Strait Islander backgrounds
  • who are deaf, hard of hearing or deafblind.

Make sure older people understand the information you give them. Give them time to think about the information if they need it. This will help older people, their supporters and others they may want to involve, such as family and carers, to make informed decisions about their aged care services. 

Put in place a system to get informed consent from older people.

You need a system that clearly explains:

• situations where you need to get informed consent. You need to get informed consent before an older person receives a clinical care treatment, procedure or other intervention. This includes changes to their aged care services. For example, when:
  • there are changes to fees and charges they have agreed to in the past (Outcome 1.4)
  • you need to collect use, store, or share older people’s information (Outcomes 2.7, 3.1, 3.3, 3.4 and 7.2)
  • you’re considering clinical interventions such as restrictive practices or escalating an older person to medical or emergency services (Outcome 3.2).
• how to find out if an older person needs help to make decisions. This system needs to explain how the older person can be supported if they need it. This includes access to advocates they want.
• how you support older people to make informed choices and take positive risks
• how you support older people with dignity of risk (Outcomes 3.2 and 5.4). This includes risks that may be harmful to them, such as smoking.
• how you explain dignity of risk and how it’s understood by the older person, their supporters and others they may want to involve, such as family and carers.
• where older people haven’t given you informed consent. You need to explain the steps workers should take to understand why and if the organisation can provide more support to help the older person make a decision. Depending on the conversation, document this in your information management system (Outcome 2.7).

The guidance for Outcomes 3.2 and 5.4 has more information on dignity of risk and decision-making.

The guidance for Outcomes 6.1 and 6.2 has more information on dignity of risk for eating and drinking. This includes eating and drinking with acknowledged risk (EDAR).

Make sure that your systems for planning and delivering aged care services include the right people. This means making sure that you think about all people who the older person wants to be involved in the decision-making process.

When doing assessment and planning, including comprehensive care planning (Outcome 5.4) and advance care planning (Outcome 3.1), use the systems for planning and delivering aged care services to:

• find out if an older person needs support to make decisions. Document this information. Help the older person get the support they need to make, share and take part in decisions that affect their lives. If the older person wants an advocate to support them, help the older person find an advocate.
• identify which supporters, family and carers the older person wants to be involved in making decisions. Make sure:
  • all relevant people are involved in future decisions
  • substitute decision-makers are only asked to make health, medical, residential and other personal (but not financial or legal) decisions for an older person if they lose their decision-making capacity
  • you keep records.
• find out the older person’s needs, goals and preferences, so they can take positive risks. This supports the older person’s independence and quality of life. Make sure that dignity of risk is clearly shared with and understood by older people and those making decisions.
• monitor changes to the older person’s quality of life. Take steps to manage and resolve any issues. Document this information in the older person’s care and services plan and progress notes.

Older people in residential care homes need different processes for assessing, monitoring and supporting their quality of life to people receiving home care. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on how you can support an older person’s independence and quality of life.

Systems for planning and delivering aged care services need to be clear on what an organisation defines as a decision. This will depend on the type of aged care services you deliver. This helps workers, older people, their supporters and others they want to involve, understand when to follow your process for making decisions. For example, when the organisation or workers need to have formal conversations with older people or their substitute decision-maker or both.

The guidance for Outcomes 3.1 and 5.4 has more information on assessment and planning.

Make sure workers have the time, support, resources and skills to help older people to make decisions about their aged care services.

Give workers guidance and training on how to support older people to make decisions about their aged care services (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• use the organisation’s systems to share information with older people
• get informed consent from the older person
• involve the right people in making decisions
• correctly document each of these steps.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor how you deliver aged care services to make sure workers help older people to make decisions about their aged care services.

Make sure your workers are following your:

• information management system (Outcome 2.7)
• clinical information system (Outcome 5.1)
• communication system (Outcome 3.3).

To check if workers are helping older people to understand their dignity of risk and make decisions, you can review:

• older people’s aged care services (Outcome 3.1). For example, care and services plans and progress notes.
• complaints and feedback (Outcome 2.6a and 2.6b)
• information about incidents and near misses (Outcome 2.5).

Look for situations where workers haven’t:

• supported the older person to make informed choices or decisions
• supported the older person with dignity of risk
• provided information in a way the older person can view or understand.

Also, talk with older people, their supporters and others they want to involve, about the aged care services they receive (Outcome 2.1). Ask them about how workers have supported them to make choices. Ask them if the information workers have given them has been in a way they can view and understand. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure. This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Use your communication system to help older people understand the agreements they are entering into, including the fees and charges for aged care services (Outcome 3.3).

Give information about agreements to older people before they enter into any agreements. It can also be before they start receiving care, whichever happens first. For example, give them information about:

• any agreements they will have to sign before receiving care or services
• any situations where a change needs to be made to a current agreement
• the terms and conditions about their rights and responsibilities, including in relation to personal possessions
• the aged care services you will provide
• fees and other charges they need to pay.

Include information about fees and other charges in agreements and invoices.

This information should help the older person exercise autonomy and make an informed decision about whether to enter into an agreement (Outcome 1.3).

Give older people, their supporters and others they may want to involve, such as family and carers, time to understand the information you have given them (Outcome 1.3) before they enter into any agreements or start receiving care. In particular:

• make sure workers give older people enough time to consider their options when entering into a new agreement. They also need to do this when the organisation makes changes to the prices, fees and payments.
• give older people time and support to ask for external advice if needed.

Help the older person, their supporters and others they may want to involve, understand the information you have given them so they can exercise autonomy and make informed decisions (Outcome 1.3). Consider each older person’s language and communication needs and preferences (Outcome 1.1). For example, use plain language, large text, images, or have a conversation with them directly. Check to see if you need to use interpreters or translators.

Make sure workers check that the older person, their supporters and others they may want to involve, understand the information they have given them.

The guidance for Outcome 3.3 has more information on using the communication system.
 

Put in place a system to manage prices, fees, invoices and payments.

This system needs to include processes to make sure that:

• the prices, fees and chargeable items specified in agreements and shown on invoices are accurate and transparent. This means invoices need to show the aged care services given to the older person. For example, invoices need to be itemised so the older person knows exactly what you’re charging them for. Make sure charges follow the older person’s agreement.
• you give invoices to older people, or people responsible for paying them, in a timely way
• you give invoices to older people in a format they can understand clearly. Consider older people’s language and communication needs and preferences (Outcome 1.1). Make sure that if they need any other support to understand this information, you document this in their assessment and planning (Outcome 3.1).
• you tell older people and those involved in their care when issues in invoices are found. Make sure you address these in a timely way and where needed, give refunds to older people (Outcome 3.3).
• you investigate any issues. Resolve any system issues to stop any overcharging or undercharging from happening again.

Do regular checks to make sure invoices are accurate and any issues with agreements can be found and resolved in a timely way.

Give older people or people responsible for paying invoices ways to give feedback or make complaints if they have been given incorrect charges (Outcome 2.6b). Don’t rely on older people to make complaints about incorrect charges. Instead, have strong systems in place to make sure billing is accurate at all times. These systems should also allow you to monitor complaints and record how you managed them.
 

Make sure that your system for getting informed consent from older people includes situations where fees and charges have changed (Outcome 1.3).

Use the system for getting informed consent when there are changes to:

• an older person’s aged care services
• fees and charges they have agreed to in the past.

Get informed consent from the older person before making any changes. This is so you can encourage them to choose freely and with dignity of risk (Outcome 2.1). This makes sure that you record changes about the older person when making decisions about their aged care services. This means you will be able to find records of care or financial changes that may affect the ability of older people or their supporters to pay the agreed fees.

The guidance for Outcome 1.3 has more information on informed consent and decision-making.
 

Make sure workers have the time, support, resources and skills to use the systems for agreements, invoicing and payments.

Give workers guidance and training on how to prepare invoices and agreements that are clear and easy for the older person to understand (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• workers’ roles and responsibilities.

Make sure workers understand how to:

• give older people prices, fees and payments:
  • that are sufficient, accurate and transparent
  • in a timely way
  • in a way they can view and understand.
• give older people enough time to think about their options before making decisions
• let older people know about any changes to fees and charges they have agreed to in the past
• get informed consent from the older person before you make any changes to fees and charges.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.
 

Monitor the use of your systems for agreements, invoicing and payments and how well they work.

Check if your workers are following your systems for agreements, invoicing and payments (Outcome 2.9).

To check if workers are supporting older people to understand their agreements, invoicing and payments, you can review:

• older people’s aged care services (Outcome 3.1). For example, care and services plans and progress notes.
• complaints and feedback (Outcome 2.6a and 2.6b)
• information about incidents (Outcome 2.5).

Look for situations where older people have had issues with differences in their:

• agreements
• the aged care services they receive
• fees.

Also, talk with older people, their supporters, families and carers about the aged care services they receive (Outcome 2.1). Ask them if workers have given them information about their agreements and fees in a timely way and in a way they can view and understand. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find issues or ways you can improve though your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure. This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Partner with older people in the governance, design, evaluation and improvement of quality care and services.

Partner with a diverse range of older people to understand their needs and preferences. This includes older people who:

• use, or can use, the service
• are Aboriginal and/or Torres Strait Islander persons, including those from stolen generations
• are veterans or war widows
• are from culturally, ethnically and linguistically diverse backgrounds
• are financially or socially disadvantaged
• are homeless or at risk of becoming homeless
• are parents and children who are separated by forced adoption or removal
• are adult survivors of institutional child sexual abuse
• are care-leavers, including Forgotten Australians and former child migrants placed in out-of-home care
• are lesbian, gay, bisexual, trans, transgender, intersex or other sexual orientations or are gender diverse or bodily diverse
• are living with disability or mental illness
• are neurodivergent
• are deaf, deafblind, vision impaired or hard of hearing
• live in regional, remote or very remote areas
• are living with cognitive impairment including dementia
• are represented by the Consumers and Families Panel (Outcome 1.1).

You can do this by:

• talking with older people, their supporters and others they want to involve about their needs, goals and preferences
• providing opportunities for older people to take part in your Consumer Advisory Body or other similar committees
• holding forums or feedback sessions
• using surveys
• promoting the use of your complaints and feedback system.

Use the feedback from older people to:

• tailor information to older people’s needs and preferences (Outcome 3.3). Consider the language and communication needs and preferences of older people (Outcome 1.1).
• design and improve the quality, safety and inclusion culture and quality system (Outcomes 2.2b and 2.3)
• design aged care services to make sure they:
  • centre around the needs and preferences of older people (Outcomes 1.1 and 3.1)
  • are accessible, appropriate and culturally safe for people from diverse backgrounds, including Aboriginal and/or Torres Strait Islander peoples
  • meet all relevant cultural needs (Outcome 1.1)
  • meet the needs of older people living with dementia, disability, mental illness or cognitive impairment.

You can also talk with relevant community organisations, advocacy services and spiritual and community leaders to support older people with diverse needs. For example, you can connect older people with local services and community groups that are relevant to them.
 

Support older people to take part in partnerships.

Put in place strategies to support workers to partner with older people. For example, strategies or supports that educate and guide your workers to:

• inform older people about how they can take part in partnerships
• encourage older people to contribute their ideas. For example, if they:
  • are less inclined to speak up
  • live with dementia, mental illness or disability
  • are affected by trauma.
• help older people contribute their ideas in a way they feel comfortable with. These can be:
  • one-to-one chats
  • anonymous feedback boxes
  • other ways that suit them.

Monitor processes for partnering with older people and how well they are working.

To check if you’re partnering with older people well, you can review:

• older people’s aged care services documents (Outcome 3.1). For example, care and services plans and progress notes. Make sure you include feedback from the older person when you develop their care and services plan.
• participation and feedback of older people involved in committees such as your Consumer Advisory Body
• the number and type of actions and improvements that you’ve made as a result of partnering with older people
• complaints and feedback from older people (Outcome 2.6) about:
  • whether the partnering process works for them
  • whether the partnering process is improving quality care and services
• incident information (Outcome 2.5).

Also, talk with older people, their families and carers about the aged care services they receive. For example, ask them:

• if they feel included in the governance, design, evaluation and improvement of aged care services
• if they feel that you and others listen to their feedback
• if they have any suggestions to improve these processes.

These conversations can help you with continuous improvement actions and planning (Outcome 2.1).
 
Assess if workers are following your quality system (Outcome 2.9). You can do this through system reviews and quality assurance.

If you find any issues or ways you can improve through your reviews and quality assurance, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

You will know things are going well if older people say that they are confident that they feel:

• safe to speak up
• feel heard.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Report concerns about the organisation’s culture of quality care and services.

Regularly report quality performance information and performance monitoring to the governing body (Outcome 2.3).

Gather and report information about your organisation’s quality, safety and inclusion culture (Outcome 2.3) and provide this to your governing body to support their strategic and business planning for workers. This information can come from:

• feedback and complaints from workers (Outcome 2.6a)
• older people’s aged care service documents (Outcome 3.1)
• results from evaluating workers’ performance and how well they’re using the quality system (Outcome 2.9).

Review this information to encourage continuous improvement in how you and your workers deliver aged care services in your day-to-day operations.

Make sure workers follow the Code of Conduct for Aged Care. This will help your organisation and workers to:

• promote a safe and inclusive environment
• protect older people from harm.

Talk with workers to:

• leverage their expertise in delivering quality aged care services to older people
• find out their needs for safety, health and wellbeing. Prioritise and monitor the safety, health and wellbeing of your workers. Do this by following the governing body’s strategic and business plan. For example, identify instances where you haven’t met workforce health and safety needs. This can include one-off occurrences or organisation-wide issues. You may find this through feedback and complaints from workers (Outcome 2.6a). Report this to the governing body.

The guidance for Outcome 2.8 has more information on supporting and maintaining a satisfied and psychologically safe workforce.

Resolve issues in a timely way by using the processes in your:

• incident management system (Outcome 2.5)
• risk management system (Outcome 2.4)
• feedback and complaints management system (Outcome 2.6a).
   

Report concerns about the organisation’s culture of quality care and services.

Regularly report quality performance information and performance monitoring to the governing body (Outcome 2.3).

Gather and report information about your organisation’s quality, safety and inclusion culture (Outcome 2.3) and provide this to your governing body to support their strategic and business planning. This information can come from:

• feedback from older people with specific needs and diverse backgrounds, their supporters, families and carers (Outcome 2.6b). This can also include feedback from Consumer Advisory Bodies
• older people’s aged care services documents (Outcome 3.1).

Review this information to encourage continuous improvement in how older people receive aged care services in your day-to-day operations.

Report any serious issues or situations where older people have been harmed or were at risk of harm by following the Serious Incident Response Scheme (SIRS) process. For example, situations such as negligence need to be:

• communicated to the relevant Consumer Advisory Bodies
• reported to the governing body.

Talk with older people to find out their needs for physical and psychological safety, health and wellbeing. Prioritise and monitor the safety, health and wellbeing of the older people you are delivering aged care services to. Do this by following the governing body’s strategic and business plan. For example, identify instances where you haven’t met older people’s health and safety needs. You may find this through feedback and complaints from older people, their supporters, family, carers and others (Outcome 2.6b). Report this to the governing body.

Resolve issues in a timely way by using the processes in your:

• incident management system (Outcome 2.5)
• risk management system (Outcome 2.4)
• feedback and complaints management system (Outcome 2.6b).

Put in place a quality system that supports you to deliver safe and quality care and services.

Make sure this system supports safe and quality care and services that centres around older people’s needs.

Put in place a quality system that explains:

• who’s accountable and responsible for specific tasks
• ‘what good looks like’ for your organisation and range of services. This includes identifying key performance indicators (Outcome 2.8)
• how you will monitor performance in line with what the governing body expects
• how you will monitor quality to make sure you achieve outcomes of the Quality Standards
• how you will report the results of monitoring activities in a way that supports you with continuous improvement and practising open disclosure. This includes how you will share this information with older people and your governing body.

Where relevant, use your quality system to make sure:

• you deliver safe and quality care and services to older people. This means care that is person-centred, culturally safe, trauma aware and healing informed (Outcome 1.1). Provide this in line with the organisational governance and quality system frameworks.
• you give older people current, accurate and timely information about their aged care services. Make sure this information is easy to understand and supports the older person to make informed decisions (Outcome 1.3).
• older people give informed consent when you need it. For example, before a treatment, procedure or intervention (Outcome 1.3)
• prices, fees and payments are accurate and transparent for older people (Outcome 1.4)
• you support older people to take part in partnership activities (Outcome 2.1)
• workers have the necessary skills, qualifications and competencies to perform their role (Outcome 2.9)
• your aged care services assessment and planning processes are working (Outcome 3.1 and Outcome 5.4)
• your processes to coordinate aged care services are working (Outcome 3.4)
• older people receive aged care services in a physical environment that is safe and supports their needs (Outcomes 4.1 and 4.1b).

You should also use your quality system to:

• recognise, stop and respond to discrimination, abuse and neglect (Outcome 1.2)
• manage organisational risk (Outcome 2.4)
• record, investigate, respond to and manage incidents and near misses that happen while delivering care and services (Outcome 2.5)
• receive, record, respond to and report on feedback and complaints. Use this to support you with continuous improvement (Outcome 2.6a and 2.6b).
• analyse risks and their causes
• securely manage records (Outcome 2.7)
• put in place workforce planning strategies (Outcome 2.8)
• care for older people living with dementia (Outcome 3.2)
• communicate structured information about older people and their aged care services (Outcome 3.3)
• prevent and control infection (Outcomes 4.2 and 5.2)
• support the appropriate use of personal protective equipment (Outcome 4.2)
• put in place the clinical governance framework to drive the safety and quality of aged care services (Outcome 5.1)
• integrate clinical information into nationally agreed electronic health and aged care digital records (Outcome 5.1)
  • For regional and remote providers, limited access to internet and infrastructure may affect digital maturity. These providers should consider strategies to make sure they’re working towards putting in place a digital clinical information system.
• support the safe and quality use of medicines (Outcome 5.3)
• monitor and continue to improve the food service (Outcome 6.1)
• have services and supports for daily living that improve the quality of life of older people (Outcome 7.1)
• transition older people to and from hospital, other care services and stays in the community (Outcomes 7.2 and 3.4)
• measure against Quality Indicator data.
   

Use your quality system to report quality performance information.

Report quality information to the governing body. Also report this information to older people and their supporters.

Make sure you write and distribute reports in line with the governing body’s expectations and directions. This also includes monitoring the performance of any associated providers.

Make sure reports clearly explain the results from performance monitoring, including where:

• things have gone well
• things have not gone well
• you will make changes to make sure similar situations don’t happen again.

When things go wrong, you need to practise open disclosure (Outcome 2.3). This means you should:

• be open about what’s gone wrong
• acknowledge that something has gone wrong and the affect it has had on the older person receiving care
• apologise for what has gone wrong
• put in place strategies in partnership with older people to mitigate the risk of things going wrong again
• monitor and evaluate strategies to mitigate risk
• share this information with older people, their supporters and others they may want to involve, such as family and carers.

Use this information to develop strategies to stop things going wrong again. You should include processes to investigate what has gone wrong in your organisation’s clinical governance framework (Outcome 5.1).
 

Put in place strategies to help workers use the quality system.

Put in place policies and procedures that support the use of your quality system. Make sure these are:

• current and informed by the latest contemporary, evidence-based practices
• regularly reviewed
• clear and accessible for workers and relevant people.

Provide workers with guidance and training on how to use the quality system. This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand:

• their role in the quality system
• how to use the system to tailor and improve aged care services for older people.

The guidance for Outcomes 2.8 and 2.9 has more information about workforce planning and human resource management.
 

Monitor how well you use your quality system.

Regularly review your quality system to make sure it works well. Look for ways to improve the system.

To check if your quality system works well, you can review:

• older people’s aged care service documents (Outcome 3.1). For example, care and services plans and progress notes. This makes sure aged care services meet the needs and preferences of the older person.
• complaints and feedback (Outcome 2.6a and 2.6b)
• risk and incident information (Outcomes 2.4 and 2.5)
• Quality Indicator data
• worker performance and how well they’re using the quality system. You can do this through quality assurance and system reviews (Outcome 2.9).
• policies and procedures.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). For example, ask the older person if any issues they’ve raised have been recognised and addressed. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Analyse the service’s quality data to:

• identify organisation-wide issues that need resolving. To help with this, it’s useful to compare actual performance against expected practice. If actual performance falls short of planning targets, you may need to act. This may include asking for additional investment from the governing body.
• identify and resolve any issues that aren’t organisation-wide. For example, if a particular worker or older person needs more targeted support.

If you find any issues or ways you can improve your quality and safety culture, you need to report them. This way, issues are addressed promptly. Report this information to the governing body and the Quality Advisory Committee. 
 

Put in place a risk management system.

At a minimum, make sure your risk management system has clear and documented processes and roles and responsibilities on:

• managing risks to:
  • older people
  • workers
  • your operations
  • business continuity
  • emergency and disaster management (Outcome 2.10)
  • emerging infectious diseases (Outcome 4.2)
  • your information management system (Outcome 2.7) including data and digital records, such as cyber security risks.
• how to:
  • identify risks
  • assess risks
  • document risks
  • manage risks
  • review risks.
• the strategies to manage the risks you identify. Include how you:
  • prevent risks
  • control risks
  • minimise risks
  • eliminate risks.
     

Use your risk management system to identify, manage and review risks.

Have clear processes to:

• identify and escalate risks. Escalate new risks straight away as you identify them. You should use your broader performance monitoring to inform this (Outcome 2.3). In particular, reviews of feedback and business data such as incidents and near misses. The risk management system needs to encourage you to report and escalate issues. This makes sure you can deal with key risks promptly. This may mean you need to escalate certain risks to the governing body. Risks found through this process include any risks that can harm the organisation and its people. For example, risks to safety, older people, finances and reputation.
• assess risks. Once you identify risks, do a ‘risk assessment’ to check if there’s a chance of a negative outcome and how severe that outcome would be. Document the risk assessment and use it to see if you can do an activity or take more actions to minimise the risk. You can also use a risk assessment to prioritise actions. In some cases, you may need a more detailed risk assessment. For example, an older person who is receiving aged care services delivered in a home or community setting will need a risk assessment of their home environment when they start to have services in their home. You should also do this risk assessment regularly to help identify possible risks to the older person or workers in the home (Outcome 4.1a).
• manage risks. Allocate actions and resources to minimise risks. Act to eliminate risks where possible. Use ways to control and minimise risks if you can’t eliminate them. Act to stop risks from happening again. This is particularly important if the risk is ‘high’. Actions may be related to key business goals, like workforce planning (Outcome 2.8). They could also relate to outcomes of the Quality Standards (Outcomes 5.4, 5.6 and 4.2). For example, using personal protective equipment to reduce the spread of an infection.
• monitor risks. Gather and analyse data to make sure you continue to prevent or minimise risk as much as possible. Identify and address organisation-wide issues (Outcome 2.3).

Have at least one organisation-wide risk register and periodically review it for new and emerging risks and those already identified for any change in circumstances. If the organisation has multiple sites and locations, you may need a risk register for each one. You may also need to complete a separate assessment for high-risk activities. 
 

Put in place strategies to help workers manage risk well.

Put in place policies and procedures that support you to use your risk management system. Make sure these are:

• current and informed by the latest contemporary, evidence-based practices
• regularly reviewed
• clear and accessible for workers and relevant people.

Provide workers with guidance and training on how to use the risk management system (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• workers’ roles and responsibilities.

Make sure workers understand:

• their role in the risk management system
• how to use the system to manage risks when delivering aged care services to older people. For example, how to report a risk.

The guidance for Outcomes 2.8 and 2.9 has more information about workforce planning and human resource management.
 

Monitor how well you use the risk management system.

Regularly review your risk management system to make sure it works well. Look for ways to improve the system.

To check if your risk management system works well, you can review:

• older people’s aged care service documents (Outcome 3.1)
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5)
• worker performance and how well they’re using the risk management system. You can do this through quality assurance and system reviews (Outcome 2.9).
• policies and procedures.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them if they feel their provider engages with them to identify, manage and review their risks. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance on Outcome 2.3 has more information on monitoring the quality system.
 

Put in place an incident management system.

At a minimum, make sure your incident management system outlines:

• clear and documented processes, roles and responsibilities on how you:
  • acknowledge incidents
  • record incidents
  • assess and investigate incidents
  • respond to incidents
  • manage incidents
  • resolve incidents
  • learn from incidents, to prevent or reduce future incidents from happening again.
• categories to define an incident. Be clear about what an ‘incident’ or ‘near miss’ includes. This definition needs to be clear about what an incident is in the context of the organisation’s scope of services. Include situations that have, or could, cause harm to a person. The categories need to be in line with the Serious Incident Response Scheme (SIRS). They also need to include harm or possible harm to:
  • an older person
  • a member of their family
  • a worker
  • another person providing aged care services.

Incidents can be clinical or non-clinical. Incidents can also relate to worker safety.
 

Use your incident management system to report and respond to incidents.

Have clear processes to respond to each type of incident that can happen when you deliver aged care services. Outline who needs to be involved and the timeframe when you need to carry out key activities. Key activities can include reporting, investigations and sharing information.

Incidents that you need to report include near misses, as well as incidents that:

• have happened
• are alleged or suspected, even if you can’t confirm the incident.

Serious incidents must be reported following the Serious Incident Response Scheme (SIRS) process. These are incidents where older people have been harmed or were at risk of harm.

Have clear processes to record and report different types of incidents. Include:

• who reports incidents
• how to document an incident report
• what level of detail to put into an incident report
• how to submit the incident report
• how long you have to submit an incident report.

After an incident:

• be clear who is responsible for deciding on immediate actions to keep older people and workers safe
• review an older person’s care and services plan if an incident involves them (Outcomes 3.1 and 5.4)
• investigate the cause of an incident. Make sure incidents are investigated. This is to find and manage the underlying cause of an incident and prevent it from happening again. Be open about the outcome of the investigation. Share this with the older person, their supporter, families and carers if the older person chooses to.
• look for trends to find organisation-wide issues and ways to improve and communicate changes to workers and older people. Do this as part of your broader performance monitoring activities (Outcome 2.3). For example, an organisation-wide issue could be:
  • aspects of care which aren’t delivered well. These may suggest that your organisation needs additional worker training.
  • older people regularly fall in a particular spot at the service delivery location and you need to redesign the area to be safer.
• use your incident management system to monitor and review the strategies you have to manage the cause of the incident and the risk of it happening again.
• report incidents to the relevant regulator. You may also need to report incidents to other authorities in line with your state or territory legislation.

If you receive a complaint after an incident or near miss, integrate this information with your feedback and complaints management system (Outcome 2.6a and 2.6 b).

Have an incident reporting form and incident register. Record key information about each incident that has happened.
 

Put in place strategies to help workers manage incidents well.

Put in place policies and procedures that support you to use your incident management system. Make sure these are: 

• current and informed by the latest contemporary, evidence-based practices
• regularly reviewed
• clear and accessible for workers and relevant people. 

Provide workers with tools, guidance and training on how to use the incident management system (Outcome 2.9). This needs to be in line with: 

• the organisation’s policies and procedures
• workers’ roles and responsibilities.

Make sure workers understand: 

• their role in the incident management system
• how to use the system to manage incidents when delivering aged care services to older people. 

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and human resource management.  

Monitor how well you use the incident management system.

Regularly review your incident management system to make sure it works well. Look for ways to improve the system.

To check if your incident management system works well, you can review:

• older people’s aged care service documents (Outcome 3.1)
• complaints and feedback (Outcome 2.6)
• information about incidents
• worker performance and how well they’re using the incident management system. You can do this through quality assurance and system reviews (Outcome 2.9).
• policies and procedures.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them if they feel their provider supports them to report incidents and involves them in finding ways to reduce incidents. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their supporters and others they may want to involve, such as family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place a feedback and complaints management system that encourages and supports workers to make complaints and give feedback.

Make sure your feedback and complaints management system outlines:

• clear and documented processes, roles and responsibilities on how feedback and complaints from workers are:
  • received
  • registered and acknowledged
  • recorded
  • investigated
  • responded to
  • managed
  • resolved
  • reported on
  • learnt from to improve aged care services.
• how you will encourage and support workers to provide feedback and make complaints. This includes providing access to advocates and external services to support raising and resolving complaints and feedback. This also includes offering different ways workers can share this information with you.
• how you keep feedback and complaints confidential, if this is what the worker wants. This needs to be in line with your information management system (Outcome 2.7). Make sure:
  • workers do not face retribution because they give feedback or raise a complaint
  • you make efforts to reduce administrative burden
  • you resolve all feedback and complaints
  • you identify any patterns or trends.
• how you can escalate feedback and complaints in a timely way
• how you can access information about external complaints and feedback mechanisms
• processes to collect, store, use and disclose any information related to feedback and complaints from workers, with their informed consent. This needs to be in line with your information management system (Outcome 2.7).
• how you can provide positive feedback to encourage and strengthen good practices you observe
• what feedback or complaints need to be recorded. Make sure the system describes any situations where you don’t need to record feedback or complaints. For example, if the worker chooses not to have the feedback recorded.
• any feedback or complaints that you need to respond to. Include:
  • who you should involve in this process
  • timeframes
  • situations where you need an investigation, such as after an incident or near miss (Outcome 2.5).
• how you discuss and resolve complaints. You should do this in consultation with the worker who made the complaint. 
• how you analyse and resolve complaints and feedback. Focus on identifying any trends or organisation-wide issues during performance monitoring. For example, aspects of care which aren’t delivered well may suggest that your organisation needs additional worker training (Outcome 2.3).

The feedback and complaints management system should also provide guidance and information on how to practise open disclosure (Outcome 2.3) when things go wrong.

Use your feedback and complaints management system to acknowledge, manage and respond to feedback and complaints from workers.

Have mechanisms to give feedback and make complaints that work well for workers. This means that these mechanisms are accessible, prompt and fair for workers.  These can include:

• formal complaint and feedback channels
• the complaints escalation process
• anonymous surveys or questionnaires
• feedback forms
• worker forums or feedback panels
• regular individual and/or team meetings
• union representation.

Consider the different ways workers would like to give feedback and make complaints. This can include sharing information verbally, in writing, digitally, openly, confidentially and anonymously. Make sure these options are available within your mechanisms for giving feedback and making complaints.

Also, consider the needs and preferences of workers. Facilitate access to supports such as advocates and services to support raising and resolving complaints and feedback during this process, if they want it.

If you find issues or ways you can improve through this process, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with workers.
• put in place strategies to mitigate the risk of things going wrong again.

Collect and look for trends in your complaints and feedback data from workers to find organisation-wide issues and ways for the service to improve. Do this as part of your broader performance monitoring activities (Outcome 2.3). Report these outcomes to the governing body and workers.

Have a feedback register to monitor feedback and complaints from workers

Monitor how well you use the feedback and complaints management system to manage feedback and complaints from workers.

Regularly review your feedback and complaints management system to make sure it works well for workers. Look for ways to improve the system.

To check if you’re managing feedback and complaints well, you can review:

• complaints and feedback
• incident information (Outcome 2.5)
• feedback meeting minutes and records.

You will know things are going well if workers say that they are confident that:

• their complaints had been closed out appropriately in a timely manner
• they feel heard.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Put in place a feedback and complaints management system that encourages and supports older people and others to make complaints and give feedback.

Make sure your feedback and complaints management system outlines:

• clear and documented processes, roles and responsibilities on how feedback and complaints from older people and others are:
  • received
  • registered and acknowledged
  • recorded
  • investigated
  • responded to
  • managed
  • resolved
  • reported on
  • learnt from to improve aged care services.
• how you will encourage and support older people, their supporters, family, carers and others to provide feedback and make complaints. This includes empowering older people and others to access language services, advocates and external services for raising and resolving complaints and feedback. This also includes offering different ways older people can share this information with you and your workers.
• how you keep feedback and complaints confidential, if this is what the older person wants. This needs to be in line with your information management system (Outcome 2.7). Make sure:
  • older people or others do not face retribution because they give feedback or raise a complaint
  • you make efforts to reduce administrative burden  
  • you resolve all feedback and complaints
  • you identify any patterns or trends.
• how you can escalate feedback and complaints in a timely way
• how you can access information about external complaints and feedback mechanisms, including the Serious Incident Response Scheme (SIRS)
• processes to collect, store, use and disclose any information related to feedback and complaints from older people with their informed consent. This needs to be in line with your information management system (Outcome 2.7).
• how you can provide positive feedback to encourage and strengthen good practices you observe
• what feedback or complaints need to be recorded. Make sure the system describes any situations where you don’t need to record feedback. For example, if the older person chooses not to have the feedback recorded.
• any feedback or complaints that you need to respond to. Include:
  • who you should involve in this process
  • timeframes
  • situations where you need an investigation, such as after an incident or near miss (Outcome 2.5).
• how you discuss and resolve complaints. You should do this in consultation with the older person and others who made the complaint. Communicate with older people in a way that meets their needs and preferences. Consider their:
  • spoken language
  • culture
  • medical conditions, including cognitive ability
  • needs and preferences (Outcomes 1.1 and 3.3).
• how you analyse and resolve complaints and feedback. Focus on identifying any trends or organisation-wide issues during performance monitoring. For example, aspects of care which aren’t delivered well may suggest that your organisation needs additional worker training (Outcome 2.3).

The feedback and complaints management system should also provide guidance and information on how to practise open disclosure (Outcome 2.3) when things go wrong.
 

Use your feedback and complaints management system to acknowledge, manage and respond to feedback and complaints.

Have mechanisms to provide feedback and complaints that work well for older people, their supporters, family, carers and others. This means that these mechanisms are accessible, prompt and fair for older people. These can include:

• formal complaint and feedback channels
• the complaints escalation process
• anonymous surveys or questionnaires
• feedback forms
• the Serious Incident Response Scheme (SIRS) process
• through a Consumer Advisory Body.

Consider the different ways older people would like to give feedback and make complaints. This can include sharing information verbally, in writing, digitally, openly, confidentially and anonymously. Make sure these options are available within your mechanisms for giving feedback and making complaints.

Also, consider the language and communication needs and preferences of older people (Outcome 1.1). Facilitate access to supports such as advocates and language services during this process, if they want it.

If you find issues or ways you can improve through this process, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

Collect and look for trends in your complaints and feedback data from older people, their supporters, family, carers and others to find organisation-wide issues and ways for the service to improve. Do this as part of your broader performance monitoring activities (Outcome 2.3). Report these outcomes to the governing body and older people.

Have a feedback register to monitor feedback and complaints from older people and others. 
 

Put in place strategies to help workers use the feedback and complaints management system well.

Put in place policies and procedures that support and encourage using your feedback and complaints management system. Make sure these are:

• current and informed by the latest contemporary, evidence-based practices
• regularly reviewed
• clear and accessible for workers and relevant people (Outcome 2.7).

Provide workers with guidance and training on how to use the feedback and complaints management system. This needs to be in line with:

• the organisation’s policies and procedures
• worker's roles and responsibilities.

Make sure workers understand:

• their role in the feedback and complaints management system
• how to use the system to manage feedback and complaints you receive when delivering aged care services to older people.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and human resource management. 
 

Monitor how well you use the feedback and complaints management system to manage feedback and complaints from older people and others.

Regularly review your feedback and complaints management system to make sure it works well for older people and others. Look for ways to improve the system.

To check if you’re managing feedback and complaints well, you can review:

• older people’s aged care service documents (Outcome 3.1)
• complaints and feedback
• incident information (Outcome 2.5)
• worker performance and how well they’re using the feedback and complaints management system. You can do this through quality assurance and system reviews (Outcome 2.9).
• feedback meeting minutes and records.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). For example, ask them if they know about the ways they can make a complaint or give feedback on their aged care services. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

You will know things are going well if older people say that they are confident that:

•    their complaints had been closed out appropriately in a timely manner
•    they feel heard.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place an information management system to manage records.

Put in place a system for managing information, including the clinical information system (Outcome 5.1), that:

• gives workers and others such as visiting registered health practitioners and allied health professionals, agency workers and approved providers access to the right information at the right time
• enables older people, supporters and others they want to involve, to access the information they need to receive quality care and services
• makes sure stored information is accurate and complete. This also applies to information that’s shared between services that provide support to the older person such as telehealth services.
• makes sure that you get informed consent (Outcome 1.3) to collect, use and store older people’s information. You also need informed consent to disclose older people’s information with other people or organisations. This includes assessment information. If an older person withdraws their consent, record and communicate this.
• integrates information from different sources where needed, such as information from hospitals
• manages cyber security risks (Outcome 2.4)
• has enough data storage for the records you need to keep.

The information management system, including the clinical information system, should be digital where possible. This will be specific to each provider. There should always be ways to access critical information when digital systems are offline. For example, you can:

• put in place processes to make information available offline
• put in place processes to record clinical information on paper during internet or power outages. 
   

Use your information management system to record information.

Use the information management system to make sure you securely manage any records at the service. This should be in line with your state or territory legislation and applicable privacy laws. Use the information management system during processes, systems and strategies to do with:

• choice, independence and quality of life (Outcome 1.3), transparency and agreements (Outcome 1.4). Make sure information about the older person’s care, services, and agreements and care commencing (whichever comes first):
  • is current, accurate, timely and easy to understand
  • supports the older person to make informed decisions
  • is accessible by workers
  • helps workers to partner with older people to make informed decisions based on accurate and timely information.
• human resource management (Outcome 2.9). Store information from possible candidates and existing workers accurately against their profile.
• assessment and planning (Outcome 3.1). Each older person’s care and services plan needs to include information about the risks associated with the delivery of aged care services. It also needs to include how workers can support older people to manage these risks (Outcome 2.4). Make sure you securely store information from assessment and planning and risks and use it to inform the systems for:
  • comprehensive care (Outcome 5.4)
  • safe and quality use of medicines (Outcome 5.3) and antimicrobial stewardship (Outcome 5.2)
  • clinical safety (Outcome 5.5)
  • infection prevention and control in the environment (Outcome 4.2) and when you deliver clinical care services (Outcome 5.2)
  • palliative care and end-of-life care (Outcome 5.7)
  • food, drink and the dining experience (Outcomes 6.1, 6.2 and 6.4).

Put in place a clinical information system. This should be digital if possible. Use it to record and manage older people’s clinical information. For example, transitions of care (Outcome 3.4), assessment and planning (Outcome 3.1) and medication management (Outcome 5.3). This will help you to deliver safe and quality care and services. Where possible, the clinical information system should also record Quality Indicator data. The guidance for Outcome 5.1 has more information on the clinical governance framework.

Workers need to monitor and record each older person’s preferences, function and changes during activities of daily living. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on supporting older people with activities of daily living.

During transitions of care, make sure you give timely, current and accurate information about the older person to supporters, health professionals and organisations involved in the older person’s care, in addition to others the older person may want to involve, such as family and carers. Make sure you provide this information with the older person’s informed consent. The guidance for Outcome 3.4 has more information on coordinating aged care services. For providers delivering aged care services in a residential care homer providers, the guidance for Outcome 7.2 has more information on transitions.

For providers delivering aged care services in a home or community setting, information about the older person’s care, such as nutritional needs or activities of daily living, can be stored in the clinical sections of your database. This doesn’t need to be a dedicated clinical information system. Make sure information about a person’s safe delivery of aged care services is assessed and those involved in their care can access it. This includes associated providers.
 

Put in place strategies to help workers use the information management system well.

Make sure all workers and others involved in the older person’s care can access your information management system. Make sure their access to your system is appropriate to their role. This includes any system workers or others, such as Commission Quality Auditors, use. This also includes any policies and procedures. Check with workers and others that they can access the information management system. If they can’t, make sure you give them access.

Make sure policies and procedures support people to use your information management system. Make sure these are: 

• current and informed by the latest contemporary evidence-based practices
• regularly reviewed
• clear and accessible for workers and others involved in the older person’s care and services.

Provide workers with guidance and training on how to use the information management system (Outcome 2.9). This includes training to support digital skills if needed. This needs to be in line with: 

• the organisation’s policies and procedures
• workers’ roles and responsibilities

Make sure workers understand:

• their role in the information management system
• how to use the system to safely manage information about older people and their aged care services.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and human resource management.

Monitor how well you use the information management system.

Regularly review your information management system to make sure it works well. Look for ways to improve the system.

To check if you’re managing information well, you can review:

• older people’s care and service plans (Outcome 3.1)
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5)
• worker performance and how well they’re using the information management system. You can do this through quality assurance and system reviews (Outcome 2.9).
• policies and procedures.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their supporters and others they may want to involve, such as family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place a workforce strategy.

To develop an effective workforce strategy, make sure you understand and assess the needs of older people receiving care and the business. This will help you make sure there are enough workers and a good mix of qualified workers to provide safe and quality care and services.

Make sure your workforce strategy includes processes to:

• identify the skills, qualifications and competencies your workers need to deliver safe and quality care and services. Make sure these relate to what older people receiving care need, want and can expect under the Statement of Rights. It’s important to understand older people’s clinical needs (Outcome 5.4). This includes the supports they need to eat and drink safely (Outcome 6.4). Workers’ skills and competencies must meet these needs.
• screen and hire sufficient numbers of suitably qualified and competent workers. Potential candidates should only be hired if you can confirm they can deliver quality and safe aged care services. You can assess this through a pre-employment validation process as part of your human resources management system (Outcome 2.9). These can include background checks, processes to confirm education, qualifications (relevant to their role) and employment history, reference checks, and competency and skill-based tests. Review any history of complaints, incidents or other feedback relating to the worker to understand if there are any issues in their ability to deliver tailored care for each older person. If you find any issues through your reviews and assessments, assess if you can fill a candidate's gaps in skills with training (Outcome 2.9). However, these processes do not apply to any workers listed on the Aged Care Banning Orders Register, as they must not be hired regardless of their competencies.
• identify the number and mix of skilled workers you need to provide the care and services that meets the older people’s needs (Outcome 2.8) and meets your legislative obligations. To do this, consider:
  • the number of older people you’re caring for
  • the specific needs of the people under your care. This includes their clinical needs (Outcome 5.4). It also includes their emotional, spiritual, cultural and psychological needs (Outcome 1.1).
  • the number and mix of current workers along with the skills and services they can deliver
  • support diverse workers. For example, sexual and gender diverse, culturally and linguistically diverse, and Aboriginal and/or Torres Strait Islander workers.
  • review rostering processes. Make sure these processes support flexible working for directly employed workers.

Make sure enough workers are available at times when older people need more support. For example, during mornings, bedtime and mealtimes. Also, try to maximise worker continuity (Outcome 3.2). Follow processes to:

• meet your legislative obligations. For providers delivering aged care services in a residential care home, this includes requirements for a 24/7 registered nurse on-site and care minutes responsibilities. It is important you engage with and provide information to workers on how planning and rostering will achieve or exceed these minimum requirements.
• mitigate the risk and impact of workforce shortages, absences or vacancies. Make sure:
  • you maintain relationships with aged care hiring agencies and labour hires
  • workforce needs are met on an ongoing basis. This is important when preparing for busy periods
  • you consider the use of digital platforms to meet workforce needs.
• use direct employment where possible and minimise the use of contractors such as agency workers. This can help continuity of care. Only use contractors when workers who are directly employed aren’t available. If you need contractors, aim to roster the same contractors for the older person unless the older person has asked not to. Complete competency checks in line with your policies and procedures. Properly induct and monitor the contractor (Outcome 2.9).  

Document your workforce strategy. Have key initiatives to make sure you meet workforce needs. How you document this needs to be based on how complex the organisation is and its context. For example, some organisations can build these processes into risk management systems (Outcome 2.4) and rostering processes. More complex organisations may need to build this into strategic business planning (Outcome 2.1).
 

Put in place strategies that promote a healthy and safe workforce.

When developing these strategies, consider:

• feedback mechanisms, such as worker surveys
• worker health and safety risks that you’ve identified through your risk management system (Outcome 2.4).

To find these risks, analyse the incidents recorded in your risk management system (Outcomes 2.4 and 2.5). Make sure these strategies outline how you will support a healthy and safe workforce. You can do this by completing risk assessments in situations that can cause harm to workers, such as new home environments or traumatic events.

Use risk assessments to understand:

• workers’ physical and psychological risks
• how to manage these risks on a case-by-case basis (Outcome 2.4).

Make sure you:

• put in place processes to identify and support workers in distress. For example, if they’re experiencing fatigue, bullying or harassment (Outcome 2.2a).
• complete regular checks to identify any new risks in the service environment (Outcome 4.1b). For example, risks of slips and trips. Make sure you manage these risks well.
• provide workers with guidance and training on how to respond to traumatic and emergency events and any other hazardous situations. Make sure training helps workers to manage their own health and the health of people receiving care. Make sure training meets the needs of workers (Outcome 2.9).
• match training needs to the type of service. For example, training in aged care services delivered in a home or community setting could include how to do manual tasks safely when assisting with personal care, cooking or cleaning. Make sure workers know their responsibilities to identify and report any concerns they have to the provider. The guidance for Outcomes 2.4 and 2.5 has more information on managing risks and incidents in aged care services delivered in a home or community setting.
• put in place incentives for workers to promote a safe working environment. For example, recognise quality and safe work that meets the needs of older people and workers. This can also help to make sure workers are satisfied in their role and receive the support they need. This can help minimise stuff turnover.
• put in place Key Performance Indicators (KPIs) for health and safety. Include these KPIs in strategic business planning (Outcome 2.1) and performance reporting (Outcome 2.3).

Document these strategies. Include your key initiatives for making sure you meet your workers’ health and safety needs. How you document these strategies should be based on how complex the organisation is and its context. For example, some organisations can build these processes into risk management systems (Outcome 2.4) and workforce planning processes (Outcome 2.8). More complex organisations may need to build this into strategic business planning (Outcome 2.1).
 

Monitor how well the workforce strategy is working.

Regularly review your workforce strategy to make sure it works well. Look for ways to improve the workforce strategy.

To check if your workforce strategy is working well, you can review:

• older people’s aged care service documents (Outcome 3.1)
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

Assess your workers’:

• qualifications, skills and competencies
• performance. You can do this through quality assurance and system reviews (Outcome 2.9).

This needs to be a key part of how you evaluate quality and care outcomes (Outcome 2.3).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their supporters and others they may want to involve, such as family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance on Outcome 2.3 has more information on monitoring the quality system.
 

Monitor that the workforce is healthy and safe.

Regularly review your workforce strategies to promote a healthy and safe workforce. Look for ways to improve your strategies.

To check if your workforce is healthy and safe, you can:

• ask workers if they feel supported to be healthy and safe. This includes any resources or processes they can use to support their health and safety.
• analyse risk (Outcome 2.4), incidents (Outcome 2.5), feedback and complaints (Outcome 2.6a and 2.6b) data to see if any issues are recurring. If this is the case, take action in a timely manner to reduce or prevent these issues from happening in the future.
• complete assessments or checks to make sure workers are delivering aged care services that are safe for older people, themselves and their co-workers (Outcome 2.3). If assessments identify any issues or concerns, take action in a timely manner to address these. For example:
  • the quality system may need to be modified
  • workers may need extra training so they understand how to perform their role safely.

Report your findings to the governing body (Outcome 2.3).
 

Put in place a human resources management system.

Put in place a pre-employment validation process. This checks that the information job applicants give you about their qualifications, skills and experience are accurate. Include:

• background checks
• processes to verify education and qualifications
• processes to confirm employment history
• reference checks
• competency assessments.

This helps make sure that potential workers have the right skills and experience to deliver safe and quality care and services (Outcome 2.2). It can also confirm if your organisation’s training system can update the person’s skills if needed.

Store this information in line with your information management system (Outcome 2.7). Make sure you store all the information from applicants accurately. That means documents you receive from applicants matches their profile.
 

Put in place strategies to roster workers for quality and safe aged care services.

Rostering needs to be informed by the organisation’s workforce strategy (Outcome 2.8).

When rostering, make sure you:

• consider the skills, number and mix of workers you need to deliver safe and quality care and services. Make sure enough workers are available when older people need more support. For example, during mornings, bedtime and mealtimes. This could also include when responding to high risk or complex situations. For example, when an older person shows signs of deterioration or changed behaviours (Outcome 5.4).
• assign an appropriate number and mix of workers to specific shifts and tasks. Base this on workers’ skills, qualifications and competencies.
• consider worker continuity. This supports a person’s continuity of care (Outcome 3.4). Use direct employment where possible and try to minimise the use of contractors such as agency workers. You can also try to offer shifts to workers who are directly employed first. If you need contractors, aim to roster the same contractors for the older person, unless the older person has asked not to. Complete competency checks for contractors in line with your policies and procedures. Properly induct and monitor the contractor.

Make sure rostering supports the delivery of quality and safe aged care services at all times. Aged care services need to be centred on the needs and preferences of older people (Outcome 3.2). Where possible, include the older person’s input when choosing their worker.

Provide workers with adequate and appropriate supervision, escalation, support and resources. This includes guidance and training on how to deliver quality and safe care.

Monitor and report Quality Indicator data about the turnover of your workers and the reasons for their departure.
 

Put in place a training system.

Develop your training system in consultation with workers and older people. This can include:

• regularly analysing training needs. List the skills needed for each role and what training can build these skills. Make sure training is based on contemporary, evidence-based practice. Make sure training also meets the organisation’s scope of services and the diversity of older people. It’s important to conduct training to fill any competency gaps identified during:
  • hiring activities (Outcome 2.8)
  • broader performance monitoring (Outcome 2.3)
  • assessment of the organisation’s quality and safety culture (Outcome 2.2a and 2.2b).
• putting in place training strategies and a ‘training matrix’ (or equivalent) which lists:
  • all worker role types. For example, care worker, chef, cleaner and administration roles.
  • the training needed for each role type, to help workers perform that role. This will help you determine what training you consider mandatory for your workforce.
• delivering training in line with any identified training needs. This may include training on how workers can:
  • deliver person-centred, rights-based care
  • provide culturally safe, trauma aware and healing informed care
  • care for people living with dementia
  • provide palliative and end-of-life care
  • respond to medical emergencies
  • meet the requirements of the Code of Conduct for Aged Care
  • meet the requirements of the Serious Incident Response Scheme (SIRS)
  • meet the requirements of the Quality Standards
  • meet other requirements relevant to their role. For example, an understanding of Infection Prevention and Control, relevant to their role. This includes training for Infection Prevention and Control Leads. This also includes specific training for people who have a formal role in an emergency, such as fire wardens and first aiders (Outcome 2.10).
• reviewing workers’ skills and understanding. After training, include processes to check that workers’ have the right skills and capabilities for their role. This can include competency evaluations and quality assurance. This can also include tracking who has completed training. Make sure that workers can provide quality and safe care for each older person.

Make sure training strategies consider the diversity of your workforce (Outcome 2.8). For example, provide workers with the support they need to take part in and complete training. Training and resources should be accessible for workers with English as a second language and be culturally sensitive. 
 
Keep training records for all workers, including contractors. This includes records that show they have completed training and the competency they need to perform their role. Record this information in line with the organisation’s information management system (Outcome 2.7). You can put in place a system to track workers' licenses and registrations that alerts you when they are about to expire. Make sure workers and others understand the policies and procedures relevant to their role (Outcome 2.7).

Make sure the training system is relevant for and accessible to contractors and employees.
 

Put in place strategies to regularly assess, monitor and review the performance of workers.

Make sure workers are providing quality and safe aged care services. Strategies to monitor workers’ performance can include:

• developing and monitoring performance measures. The performance measures of a worker will depend on their role and responsibilities. For example, positive feedback from older people for carers and hiring targets for administrative workers.
• completing regular performance reviews to an agreed schedule. Consider all monitored performance measures and feedback. Workers should have the opportunity to clarify or provide reasons for any feedback that does not meet their expectations. Make sure performance reviews:
  • fairly assess workers based on feedback provided by older people, other workers, supervisors and people they work with (Outcome 2.6a and 2.6b)
  • provide workers with support in areas identified for improvement in the training needs analysis. This is part of the training system.
  • encourage workers to deliver quality and safe aged care services (Outcome 2.3)
  • consider outcomes from the training system.
• having processes to assess all performance review outcomes. This can help to work out where you can make improvements. Recognise workers with positive outcomes. Develop improvement plans with workers who need to improve. Do this in partnership with the worker. Make sure improvement plans show how the worker can provide quality care and services (Outcome 2.3). Store information about worker performance using your information management system. This will make sure it’s accurate, secure and accessible (Outcome 2.7).
   

Monitor how well your strategies to roster workers for quality and safe aged care services are working.

To check if the workforce resource needs of the organisation are being met:

• talk with workers, older people, their supporters, families and carers
• review older people's aged care service documents (Outcome 3.1)
• review complaints, feedback and incident information (Outcomes 2.6a, 2.6b and 2.5)
• make sure skilled workers are available to deliver safe and quality care and services.

If you find any issues or ways you can improve your rostering address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their supporters and others they may want to involve, such as family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.
 

Monitor how well you use your training system.

Regularly review your training system to make sure it works well. Look for ways to improve the system.

To check if workers have the capabilities and access to appropriate supervision, escalation, support and resources they need to perform their role, you can review:

• older people’s aged care service documents (Outcome 3.1)
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5)
• worker performance and how they’re using the training system. You can do this through quality assurance and system reviews. (Outcome 2.9).
• training records to make sure workers have completed training as needed and in a timely manner
• policies and procedures.

Also, talk with:

• workers to see if they feel supported to:
  • complete their training
  • perform their role well and safely.
• older people, their supporters and others they may want to involve, such as families and carers, about the care and services they receive (Outcome 2.1).

These conversations can help you with continuous improvement actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their supporters and others they may want to involve (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place emergency and disaster management plans.

Develop emergency and disaster management plans. This helps to reduce risks to the health, safety, and wellbeing of older people and workers.

Make sure emergency and disaster management plans:

• are based on an emergency and disaster risk assessment. This assessment identifies different emergency and disaster situations that can happen when delivering aged care services. These can include environmental events or disasters, such as floods, heatwaves, fires and damage to infrastructure. This can also include medical emergencies. The risk assessment also helps assess how you and your workers need to respond to manage these situations. Make sure you do the emergency and disaster risk assessment as part of the organisation’s broader risk assessment (Outcome 2.4).
• are based on the service context. Use the emergency risk assessment to decide if you need an emergency and disaster management plan specific to the service. This depends on the context of the organisation. Sometimes a high-level plan can be enough.
• include strategies for communication and management planning during an emergency
• are developed in consultation with older people, their supporters, family, carers, workers, visitors and other response services. This makes sure the processes meet older people’s needs (Outcomes 2.1 and 1.1). Make sure strategies are included in a person’s care and services plans if needed. For example, where an older person has a disability or culturally diverse needs that may need to be considered during an emergency.
• are shared with older people and their supporters in a variety of ways. This can be by displaying the plans on noticeboards or email alerts (Outcomes 2.2b and 3.3). Make sure this information is shared in a way the older person understands (Outcome 1.3). Consider each older person’s language and communication needs and preferences (Outcome 1.1).
• tested on a periodic basis. For example, once a year. Use a variety of different emergency scenarios in your emergency drill schedule. If you find any issues through these tests, review and update the emergency plans. Issues can include workers not being sure what to do. Drills need to be done with workers, older people, their supporters, families and carers, visitors and other response partners (Outcome 2.1). These can be desktop drills. This will help to reduce disruption to older people. These drills can also include scenarios like power and internet outages.
• are evaluated and updated. After a drill, or if a real emergency happens, assess the responses and emergency plan to check if they worked well. Make changes if needed.
• include processes to respond quickly to outbreaks of infectious diseases. You need to do this even if the disease is only suspected (Outcome 4.2). You can develop an outbreak management plan.

Note: Response partners can include:

• government agencies
• the state emergency service
• other service providers
• community organisations
• local health services
• local public health units.
   

Make sure your workers have the time, support and resources to use emergency and disaster management plans.

Put in place a workforce strategy (Outcome 2.8) that considers:

• transitions of care (Outcome 3.4)
• continuity of care (Outcome 3.4)
• assessing workers’ abilities during the hiring process (Outcome 2.8)
• additional worker or workforce supports that may be needed during an emergency (Outcome 2.9)
• providing workers with guidance and training on their roles and responsibilities in an emergency or disaster.

Guidance and training needs to be in line with:

• the organisation’s policies and procedures
• workers’ roles and responsibilities.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and human resource management. 
 

Monitor how well your emergency and disaster management plans are working.

To make sure emergency and disaster management plans are working well, you can:

• talk with workers, older people, their supporters, families and carers
• assess emergency and disaster drill records.

You can also review:

• complaints and feedback (Outcome 2.6a and 2.6b)
• risk and incident information (Outcomes 2.4 and 2.5)
• policies and procedures.

Review your emergency plans and update them if needed. This will help to make sure your emergency plans stay current and effective. For example, review your plan:

• if you move or renovate
• if the number of older people in your care changes significantly
• if your workforce changes significantly
• after you do an emergency management drill
• after an emergency.

If you find any issues or ways you can improve, address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their supporters and others they may want to involve, such as family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place a system for assessment and planning.

Assessment and planning is an important part of delivering quality care and services. In your system for assessment and planning, make sure you prioritise:

• the older person’s quality of life
• their reablement
• maintaining their physical, mental and cognitive functions.

Making these areas a priority will support you to:

• deliver quality care and services
• create care and services plans that meet the needs, goals and preferences of older people.

Make sure your system includes processes to:

• partner with the older person about who they want involved in their assessment and planning. Use your organisation’s system to identify and guide workers about how to involve the older person and others (such as supporters, family or carers) who the older person chooses to involve in assessment and planning (Outcome 1.3). If the older person lacks the capacity to make decisions, the provider has the responsibility to know and record:
  • who the substitute decision-maker is
  • the types of decisions they are authorised to make on behalf of the person.
• talk with the older person and other people the older person would like involved in their aged care services (Outcome 2.1). This will help workers to understand each older person’s goals of care. It will also help support their quality of life and reablement and to maintain their function. Make sure these discussions are in line with culturally and psychologically safe care principles. This will help to plan and deliver care that is culturally safe, trauma aware and healing informed (Outcome 3.2).
• document the older person’s needs, goals and preferences (Outcome 1.1) in their care and services plan. This includes their:
  • culture, diversity and religious beliefs
  • connection to Country and community. For example, for older people who identify as Aboriginal and/or Torres Strait Islander or live in regional and remote settings.
  • individual background and life experiences
  • language and communication needs and preferences
  • gender identity and sexual orientation
  • decision to share this information, who to share this information with, and their preferences to talk or not talk about their experiences.
• consider risks to the older person’s health, safety and wellbeing. Also include how you and workers can support the older person to manage these risks (Outcome 2.4) and how you will communicate critical information about these risks to workers, supporters and others involved in the older person’s care. This helps you demonstrate preventative care. Do this in partnership with the older person.
• provide the resources and support each older person's needs when delivering aged care services. Make sure this information informs the supports that older people need to perform their activities of daily living. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on how you can support older people with activities of daily living. For older people receiving aged care services in a home setting, this could also involve identifying if referrals to other care services or providers may be needed.
• share information (Outcome 2.1). Workers need to inform older people that their own care and services plans are available and accessible to them. Use your information management (Outcome 2.7) and communication systems (Outcome 3.3) to do this.
• involve appropriate registered health practitioners and allied health professionals, and support services where you need to. For example, you may need to involve:
  • a mental health professional if the person has psychological deterioration
  • dementia support specialists if the person has cognitive deterioration
  • a dietitian to provide nutrition care in response to identified weight loss (Outcome 5.5).
• make sure care and service plans are accessible and available to workers as well as older people. Workers need to access, refer to and understand care and service plans to guide how they deliver aged care services.
• enable reporting your Quality Indicator data about the quality of care.

Create care and services plans that:

• are individualised and person-centred. Care and service plans need to show the older person’s unique needs, goals and preferences (Outcomes 3.2 and 3.3). This will make sure aged care services are delivered safely and in line with the older person’s needs and preferences. When making care and services plans, consider each older person’s:
  • culture, diversity and religious beliefs
  • individual background and life experiences
  • language and communication needs and preferences
  • gender identity and sexual orientation (Outcome 1.1).
• are comprehensive (Outcome 5.4). Consider each older person’s:
  • individual needs and preferences (Outcome 1.1)
  • goals of care in collaboration with their supporters, registered health practitioners, allied health professionals and others they want to involve in their care (Outcome 5.4)
  • choices so that you can support them in optimising their quality of life, reablement and maintenance of function
  • clinical needs and risks. For example, individual nutrition, hydration and dining needs and preferences (Outcome 6.2).

• consider which registered health practitioners, allied health professionals and services are needed to meet the older person’s clinical needs, with their informed consent. For example, a person may need

  • medical
  • rehabilitation
  • allied health
  • oral health
  • specialist nursing
  • dementia support services. 

  This will help make sure older people receive coordinated, multidisciplinary care (Outcome 5.4)

• are available to older people and people they want involved in their aged care services. This may include the older person’s supporters, family and carers if requested by the older person. You need to share this information in a way each older person understands (Outcome 1.3). This should consider each older person's language and communication needs and preferences (Outcome 1.1). For example, if an older person has a cognitive impairment, workers should support them to understand the information. This needs to be based on each older person’s needs to support their understanding.
• are clear and accessible.

Care and services plans need to be up-to-date and informed by assessments. Review the plans regularly, including:

• if there are changes in the older person’s circumstances. This can include a change to:
  • their needs, goals or preferences (Outcome 1.1). For example, if an older person’s dietary preferences change.
  • their mental health, cognitive or physical function, capacity or condition. This includes if their function, capacity or condition deteriorates, improves or changes (Outcome 5.4). For example, if an older person’s mobility decreases after a fall.
  • their ability to perform activities of daily living. For example, if an older person is no longer able to walk without help.
  • the care that family or carers can provide to the older person
  • the care responsibilities of the people providing aged care services to the older person. This means, if any services or registered health practitioners or allied health professionals involved in the older person’s care and services change. For example, when an older person’s GP retires and they organise a new one, make sure you review and update the person’s care and services plan.
• after an incident (Outcome 2.5). After an incident, document any changes to the care and services plan that are needed.
• if the care and services plan is not reflecting the needs, goals and preferences of the older person. Older people, their supporters, family, carers or others may raise issues through feedback or complaints (Outcome 2.6). Workers may raise issues through established escalation pathways using the information management (Outcome 2.7) and communication systems (Outcome 3.3).
• if risks associated with the delivery of aged care services are identified (Outcome 2.4). Document the risks, any strategies to prevent or reduce risk in the future and how you plan to monitor and assess these strategies. For example, if an older person is identified as being at risk of choking or have difficulties swallowing (Outcomes 5.4 and 5.5), make sure assessments are undertaken to evaluate the risk and documented, and update their care and services plan. Recommendations and strategies to mitigate risk should be individualised to each older person in line with their assessed needs. The care and services plan should also outline when the older person needs to be reassessed and who should do this.
• at transitions of care. For example, when an older person is discharged from hospital or changes from aged care services delivered in a home or community setting to aged care services delivered in a residential care home. The guidance for Outcome 3.4 has more information on coordinating transitions. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on how you can support older people during transitions.
   

Put in place processes for advance care planning.

These processes need to:

• provide information to older people about how they can plan for their future health care if they are not able to make their own decisions
• provide opportunities for the older person to talk about their future medical treatment and care needs, if they choose to. This may include their needs, goals and preferences for their future health care, and their beliefs, cultural and religious practices and traditions (Outcome 1.1).
• support the older person to complete and review advance care planning documents, if they choose to. This may include recording their choices in the required document (or documents). The process of recording choices for advance care planning varies between states and territories. It is important to understand and confirm the relevant state or territory information and forms needed for advance care planning. Workers and registered health practitioners and allied health professionals also need to understand these.
• support the older person to have choices and exercise dignity of risk (Outcomes 1.2 and 1.3). For example, an older person may make the informed decision to not have active treatment for specific illnesses in the future.
• support the older person to nominate and involve a substitute decision-maker for health and care decisions, if and when they choose. Make sure policies and processes for substitute decision-making are in line with your state or territory legislation. The guidance for Outcome 1.3 has more information on supported decision making and the role of substitute decision-makers.
• record occasions where an older person was provided with information about advance care planning, offered an opportunity to discuss advance care planning, or had a conversation about advance care planning
• include systems for storing, managing, using and sharing advance care planning documents securely (including appointments of a substitute decision-maker) with relevant people if needed, including at transitions of care. This makes sure they can be easily accessed and regularly reviewed, while maintaining privacy. Use your information management system (Outcome 2.7) and communication system (Outcome 3.3) to do this. Informed consent should be obtained from the older person to share their information and advance care planning documents (Outcome 1.3).
• explain to older people that, with their consent, their advance care planning documents can be uploaded to My Health Record.
• be integrated with your systems and easily accessible for quality clinical care (Outcome 5.1) where relevant.
   

Make sure workers who provide aged care services have the time, support, resources and skills to plan for and deliver care and services tailored to each older person’s needs and preferences.

Provide workers with guidance and training on how to plan for and deliver tailored aged care services for each older person (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers who deliver aged care services understand how to:

• undertake assessments
• develop care and services plans
• use this information to plan and deliver aged care services tailored to the older person’s needs, goals and preferences (Outcome 3.2).

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure workers can assess and understand care and services plans when they need them. Care and services plans need to be stored in line with your information management system (Outcome 2.7). 
 

Monitor how well your processes for assessment and planning are working.

To check if your assessment and planning processes work well, you can review:

• older people’s aged care services documents (Outcome 3.1). For example, care and services plans, progress notes and advance care planning documents. Check that each older person’s care and services plans include their current needs, goals, and preferences.
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

To check how well you are supporting advance care planning in everyday practice, you can undertake advance care planning reviews and assess how you:

• receive, store and manage advance care planning documents
• review, follow and share advance care planning documents with registered health practitioners and allied health professionals
• manage and share advance care planning documents to make sure relevant registered health practitioners and allied health professionals and services have access when needed, such as during transitions of care.

Look for situations where:     

• incidents have happened where the wrong service or care has been provided
• a care and services plan was not reviewed and updated after a change in circumstances
• an older person’s needs, goals or preferences were not documented in their care and services plan or advance care planning documents.

Also, talk with older people, their supporters, families and carers about the aged care services they receive (Outcome 2.1). For example, ask them if they were involved in the assessment and planning process of their aged care services. Ask them if their needs, goals and preferences have been understood and considered in their care and services plan and advance care planning. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Put in place strategies for providing quality and safe aged care services.

These strategies need to explain how you will deliver care and services plans. Make sure these strategies describe how aged care services will:

• meet the needs, goals, and preferences of older people (Outcome 1.1)
• be based on contemporary, evidence-based practices (Outcome 2.3)
• be culturally safe and appropriate for people with specific needs and diverse backgrounds (Outcome 1.1). For example, if an older person has specific cultural dietary or food preferences, you should document this in their care and services plan. For providers delivering aged care services in a residential care home, the guidance for Outcomes 6.2 and 6.3 has more information on how you can support older people’s needs and preferences on food, nutrition and the dining experience. You can also support cultural safety by:
  • providing older people with a culturally safe and sensitive environment
  • providing opportunities for older people to take part in cultural activities that are meaningful to them, if they wish to do so. This includes supporting them to exercise dignity of risk (Outcome 1.3). For example, when an Aboriginal and/or Torres Strait Islander older person wishes to attend cultural activities or ceremonial responsibilities on Country or Island home.
• be trauma aware and healing informed (Outcome 1.1). Make sure you understand and respond to the impacts of trauma and situations that may be triggering of trauma responses. Aged care services also need to consider the older person’s psychological needs and past experiences. For example, an older person who has experienced war may be particularly sensitive to loud or unexpected noises. Care leavers may also have difficulty interacting with workers, registered health practitioners and allied health professionals based on their past experiences or trauma. Provide older people with a safe and healing environment in line with trauma aware and healing informed care. For example, make sure the environment or interactions with workers do not resemble an institution.

You can support trauma aware and healing informed care by:

• providing a safe and supportive environment where older people:
  • feel accepted and valued (Outcomes 1.1 and 1.2). For example, approaching and responding to older people with empathy and positivity.
  • can speak up without reprisal (Outcome 2.6b). For example, older people can ask for help which will not lead to criticism. This includes encouraging and providing older people with help to complete surveys and give feedback and complaints anonymously if they wish.
• respecting the older person’s autonomy and dignity (Outcomes 1.1 and 1.2). For example, asking for the older person’s permission before attending any care tasks or touching their belongings.
• making sure older people don’t experience discrimination, abuse and neglect when receiving aged care services (Outcome 1.2). Abuse comes in many forms and includes sexual assault and coercion. Older people are particularly at risk of financial abuse as a form of coercive control.
• offering older people choices for how you deliver their aged care services (Outcome 1.3). This includes recognising the older person’s choice to exercise dignity of risk and decline specific aged care services.
• working in predictable and transparent ways. You can do this by working in partnership with the older person, their supporters and others involved in their care and services (Outcome 2.1).
• practising open disclosure and communicating with older people, their supporters and others they may want to involve, such as family and carers when things go wrong (Outcome 2.3)
• supporting the older person to select their workers (Outcome 3.2). This can include supporting the older person to choose workers based on their gender and the language they speak (Outcome 1.1). For example, for males from an Aboriginal and/or Torres Strait Island background, this may include organising a male worker of their choice to attend personal care or treatment (Outcome 1.2).
• minimising the use of restrictive practices (Outcome 3.2)
• recognising signs of distress or situations where the older person’s psychological safety is at risk (Outcome 5.5)
• having strong safety protocols.

Also, make sure these strategies describe how your aged care services will:

• optimise older people’s quality of life, reablement and help maintain their function. This will support the older person to be as independent as possible. For example, make sure it’s clear how you will:
  • make appropriate and timely referrals to registered health practitioners and allied health professionals (Outcome 3.4) when you identify risk. This includes professionals from a range of different disciplines. For older people using home services, this also includes referrals to My Aged Care for them to be reassessed. For example, accessing a physiotherapist in the community for physical reablement after a fall. Use your organisation’s communication system to manage referrals (Outcome 3.3). This will help you to deliver quality, multidisciplinary care (Outcome 5.4)
  • support older people to make informed decisions about the care they receive (Outcome 1.3), including how and when it is delivered. For example, you can organise a case conference with the older person and the people they want involved in their care with any additional support they need. This can help the older person to feel confident and supported to participate in the discussion.  
  • support older people to understand the information you give them. This includes how you give older people access to extra supports to help them to understand the information. This can include advocates, interpreting services to support discussions about aged care services and translation of written information into the older person’s preferred language. This could also include speech pathologists to support communication or use communication aids for those with a communication impairment.
  • support older people to exercise dignity of risk (Outcome 1.3). For example, if an older person has a history of falls but still wants to go for a daily walk to the shops on their own, you should support them to do this. This includes talking with the older person about the risks and consequences involved. The older person needs to be able to understand how the risks or consequences may affect them (Outcome 5.5).
  • support older people to take part in activities of daily living. This includes supporting them to maintain social connections with friends, family, volunteers, pets and the community (Outcome 1.1). For example, for older people living in a residential care home, provide them with opportunities to take part in activities that are meaningful to them. This may include gardening, music and trips in the community (Outcome 7.1). For older people receiving care in the home, provide strategies that support them to take part in social activities with friends, family and the community where possible. This should be informed by each older person’s needs, goals and preferences.
• maximise worker continuity. For example, having the same care workers regularly supporting an older person where possible, safe and preferred. This will support the provision of continuity of care (Outcome 3.4).
• provide reasonable opportunities for the older person to choose their workers, where possible. For example, you can support older people to choose workers based on their gender and the language they speak (Outcome 1.1). 

Put in place a system to provide care for people living with dementia.

Make sure this system supports safe and quality care and services for people living with dementia.

It’s important your system includes processes:

• to recognise early signs of dementia. The strategies you use for this should be informed by contemporary, evidence-based practices (Outcomes 2.3, 5.4 and 5.6)
• for workers to assess the strengths and skills of people living with dementia. Make sure you encourage older people to use and maintain their strengths and skills (Outcome 1.1). You can collaborate with registered practitioners, allied health professionals, allied health assistants and others involved in the older person's care to support their activities of daily living and quality of life and to maintain physical, mental and cognitive functions. For example, encourage and provide opportunities for people with dementia that are meaningful and in line with their preferences, such as rinsing their own dishes after a meal. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on how you can support older people with activities of daily living.
• to partner with the older person, their supporters and others they may want to involve, such as family, carers, and health professionals. You need to involve these people when planning and delivering aged care services to the older person (Outcome 2.1).

Put in place processes to make sure care and services plans for people living with dementia meet their individual behaviour support needs (such as mood, memory, thinking and behaviour), as well as their individual needs, goals and preferences. You need to tailor care and behaviour support strategies to the older person’s individual needs and preferences following best practice behaviour support. This should also be recorded in their behaviour support plan as part of their care and services plan (Outcomes 3.1 and 5.6). You need to identify, assess and record any changes in their individual care and behaviour support needs. For example, if a person living with dementia:

• experiences changed behaviour. This can include:
  • agitation. For example, when an older person calls out distressed, doesn’t recognise their surroundings and wants to leave.
  • changes in their perception of time.
• Is no longer assessed as needing the use of restrictive practices as part of their care to manage risks of harm, after they have settled into a new home or environment
• has behaviour support strategies that are no longer effective. 

Put in place strategies to minimise the inappropriate use of restrictive practices.

To prevent harm to the older person, or other people, make sure restrictive practices are:

• only used as a last resort. This means, you need to try tailored and individualised alternative strategies to every extent possible first. Document the use of these strategies in the older person’s behaviour support plan as part of their care and services plan (Outcomes 3.1 and 5.6). This includes evaluating the effectiveness of these strategies and considering the likely impact of the use of restrictive practices on the older person.
• used in the least restrictive form and for the shortest time necessary. This means, there is effective assessment, monitoring and review processes to make sure the least restrictive option is used.

Also, make sure restrictive practices are:

• only used if the older person or their restrictive practices substitute decision-maker provides informed consent to the use of the restrictive practice and how it will be used. If the older person lacks the capacity to give their informed consent, this needs to be obtained from their restrictive practices substitute decision-maker. Make sure you document a description of the consultation about the use of the restrictive practice and the giving of valid informed consent. The guidance material for Outcome 1.3 has more information on informed consent.
• monitored, reviewed and evaluated regularly or if there is a change in the older person’s circumstances. Check if there are any appropriate alternative strategies, even if it has been agreed that restrictive practices can be used. This also includes evaluating the use of these strategies with the aim to reduce and eliminate the need for a restrictive practice.
• documented in the older person’s behaviour support plan as part of their care and services plan if used or assessed as necessary. This will guide the safe and appropriate use of restrictive practices. This includes:
  • any alternative strategies that have been considered and used prior to the use of restrictive practices (Outcomes 3.1 and 5.6)
  • the documented success and failure of these attempted strategies to inform the older person’s care
  • the changed behaviours relevant to the need for the use of the restrictive practice
  • how the restrictive practice will be used. This includes its duration, frequency and intended outcome.
  • how the restrictive practice will be monitored and reviewed.

Where restrictive practices have been assessed as necessary, make sure they are used in line with relevant legislation and the older person’s assessed needs.
 

Put in place strategies to support workers to deliver quality and safe care and services.

You need to develop these strategies to meet the requirements of your risk management system (Outcome 2.4).

These strategies need to support workers to:

• recognise risks or concerns about an older person’s health, safety and wellbeing
• identify deterioration, changes to an older person’s physical, mental and cognitive functions, or changes in their ability to perform activities of daily living. This includes changes to an older person’s circumstances, needs, goals and preferences (Outcome 1.1). For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on identifying, monitoring and recording older people’s function in relation to activities of daily living.
• respond to and escalate risks. Have escalation procedures to make sure workers know who they can contact if they need support. For example, how to call for assistance and who to escalate concerns to after an older person has a fall.

Even if you don't deliver clinical care, you need to be aware of the clinical care that has been delivered to the older person so you can support workers to identify risks. For example, if an older person has a wound dressing, you, as the provider, will need to understand how you will deliver showering services. This includes how your workers:

• engage with the wound while showering the older person in line with registered health practitioner and allied health professional instructions and advice
• identify signs of wound deterioration (such as pus) so clinical issues can be appropriately escalated and in a timely way.

Also, make sure your strategies support workers to:

• make appropriate referrals and confirm these have been made in a timely manner such as referrals to registered health practitioner and allied health professionals. For example, when workers notice deterioration, changes to an older person’s physical, mental and cognitive functions, or changes in their ability to perform activities of daily living.
• make sure older people have access to multidisciplinary care. This involves input from a variety of registered health practitioners and allied health professionals. Make sure processes are in place to support workers to communicate with each other effectively (Outcome 3.3).
  • For regional and remote providers, limited resourcing may affect timely access to multidisciplinary care. These providers should consider strategies to make sure older people are appropriately referred to registered health practitioners and allied health professionals.
• maintain and support the older person’s mental health, cognitive or physical function. Make sure you arrange a medical review if you notice deterioration in any of these areas (Outcome 5.4).
• share information with older people when they’re delivering aged care services based on their language and communication needs and preferences. This can include both verbal and non-verbal communication.
• support older people to use equipment, aids, devices and products safely and effectively. The guidance for Outcomes 4.1a and 4.1b has more information on managing equipment at home and in the service environment.
• involve older people in choosing workers who provide their care.

Make sure your strategies support workers to provide care to people living with dementia. This includes:

• providing care that is informed by contemporary, evidence-based practices (Outcome 2.3)
• understanding the way different older people want information to be shared with them. Do this by identifying each older person’s language and communication needs and preferences (Outcome 1.3).
• recognising and responding to changed behaviours in people living with dementia. This includes making sure workers have access to behaviour-specific training (Outcome 2.9).

Also, make sure your strategies support workers to minimise the use of restrictive practices. This includes:

• understanding how to minimise the inappropriate use of restrictive practices
• clearly and consistently documenting the use of restrictive practices and how they were monitored
• confirming restrictive practices were used as a last resort to prevent harm to the older person or other people
• documenting the alternative strategies that have been considered or used prior to the use of restrictive practices. 
   

Make sure workers who deliver aged care services have the time, support, resources and skills to perform their role.

Provide workers with guidance and training on how to deliver quality aged care services, relevant to their role (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to deliver aged care services that:

• are culturally safe, trauma aware and healing informed
• meet the older person’s needs, goals and preferences
• optimise the older person’s quality of life, reablement and maintenance of function
• recognise and respond to risks, concerns, changes and deterioration of an older person
• support people living with dementia. This includes older people experiencing changed behaviours.
• minimise the use of inappropriate use of restrictive practices. Where restrictive practices are assessed as necessary, make sure they are used in line with the older person’s assessed needs.
• include the provision of person-centred behaviour support and best practice alternatives before the consideration or use of a restrictive practice
• enable effective verbal and non-verbal communication with older people. This includes people living with dementia, or older people who have difficulty communicating and changed communication needs.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training. 
 

Make sure that you deliver aged care services safely and meet older people’s needs and preferences.

Regularly review how you deliver aged care services across a sample of older people and workers. You can use information from these reviews to check whether you’re delivering aged care services as planned. This can include:

• completing experience surveys with people receiving care
• observing how workers are delivering care
• analysing incident, feedback and complaints information (Outcomes 2.5, 2.6a and 2.6b)
• reviewing clinical and care documents
• talking with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them if they feel they’re receiving safe and quality care and services that meet their needs, goals and preferences. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Use this information to find out if:

• workers understand how to:
  • make timely referrals to registered health practitioners and allied health professionals
  • care for people living with dementia. This needs to be in line with contemporary, evidence-based practices.
  • minimise the use of inappropriate restrictive practices
  • involve older people in selection of workers who provide their care
  • share information with older people when delivering aged care services
  • support the older person to use equipment, aids, devices and products safely and effectively.
• the older person’s records are comprehensive and have enough detail to determine what decisions were made, why they were made and who made them. You need to include this information in aged care service documents such as progress notes or care and service plans.
• Workers are delivering care in line with the older person’s care and services plan.

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place a communication system.

This system should include processes that make sure:

• the older person and those involved in their care are provided with critical information relevant to the delivery of their aged care services. This can include their supporters, family, carers, workers and registered health practitioners and allied health professionals. Information needs to be shared in a timely manner. This will help make sure older people receive the aged care services they need. Critical information can include:
  • information in a person’s care and services plan when they start receiving aged care services (Outcome 3.1)
  • risks and control strategies (Outcome 2.4)
  • incidents that can affect an older person (Outcome 2.5)
  • clinical information. For example, comprehensive care needs, changes or deterioration that can affect an older person (Outcome 5.4).
  • transitions of care (Outcome 3.4).
• you correctly store older people’s records, such as care and services plans, in your information management system (Outcome 2.7). Make sure you can identify these records, so the right records are matched to the right person. For example, you could use the older person’s Healthcare Identifiers.
• you correctly identify and match older people to their aged care services. You can do this using the older person’s full name, date of birth and their Healthcare Identifiers. For example, make sure you follow these processes in situations where you are:
  • delivering aged care services to an older person. For example, before administering medication or referring an older person to a registered health practitioner or allied health professional.
  • generating clinical handover, transfer or discharge information. This can also include information about an older person’s agreement, fees and invoices (Outcome 1.4).
• there are ways to escalate concerns about the older person. Older people, their supporters, families, carers, registered health practitioners, allied health professionals and others involved in their care need to be able to escalate concerns. Contact details for those involved in the care and services of the older person should be kept up to date and easily accessible. This information needs to be stored using your information management system (Outcome 2.7).
• workers can communicate and share information with older people safely and effectively. They should base this on each older person’s language and communication needs and preferences.

If you provide residential aged care services, your communication system needs to have processes to prepare and provide care statements to older people.

If you provide home aged care services, make sure you have processes to communicate clinical information to older people, supporters and other service providers.

Make sure workers are supported to communicate for safety and quality.

You can support workers by developing communication guides, training and strategies that are part of your organisation’s clinical governance framework (Outcomes 2.9 and 5.1). It may be helpful to develop a list of common scenarios and how workers can share information in each situation.

Make sure workers use the communication system:

• when the older person starts receiving aged care services
• when the older person’s needs, goals and preferences change. You should regularly partner with the older person and those involved in their aged care services (Outcome 2.1).
• when risks to the older person have been found (Outcome 2.4)
• when there is a change of circumstance, deterioration, or after an incident has occurred (Outcome 2.5)
• during handover or transitions of care. For example, during a transfer to hospital (Outcome 3.4). For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on how you support older people during transitions.
• to correctly identify and match older people to their aged care services.

When workers use the processes and systems in place to communicate for safety and quality, encourage workers to consider:

• what information they need to share
• how quickly they need to escalate information
• who should be involved
• how they can best share this information. For example, it may be better to make a phone call, send an email or have a conversation in person. Make sure these communications are documented in the information management system. Workers should consider each older person’s language and communication needs and preferences (Outcome 1.1) and share information in a way that they understand (Outcome 1.3). This can include:
  • using strategies such as simple language, large text and images as recommended by allied health professionals (where relevant)
  • language services like interpreters and translators
  • routinely checking that the older person and those involved in their care have understood the information correctly.

You should record information that has been shared in progress notes or other documents in line with your information management system (Outcome 2.7).

Monitor that workers communicate for safety and quality.

To check if your communication system is effective, you can review:

• older people’s aged care and services (Outcome 3.1) such as care and service plans and progress notes.
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

Look for situations where:

• older people didn’t know or understand something
• critical information was not shared.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them if they know and understand information about their care and services, including critical information. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality and communication systems (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Put in place strategies to coordinate transitions.

Put in place strategies for planned and unplanned transitions in situations where an older person:

• is transitioning to and from hospital
• moves between other care services or stays in the community
• is receiving home support and is transitioning between short-term and ongoing service pathways.

Make sure:

• those involved in an older person’s aged care and services have been identified. This includes:

  • supporters
  • family members
  • carers
  • health and registered providers
  • workers
  • other registered health practitioners and allied health professionals. 

  These people need to be involved in planning activities if the older person wants or needs them to (Outcome 2.1). For example, you should inform supporters and others they wish to involve, when an older person transfers to and from hospital or between service providers. This makes sure they understand any relevant changes to aged care services.

• the transition is planned and coordinated. You need to document the transition process needs to be documented in line with the information management system (Outcome 2.7). You need to communicate the transition process to the older person and those involved in their care and services. Do this using your communication system (Outcome 3.3). This supports continuity of aged care services for the older person.

Make sure workers have the time, support, resources and skills to coordinate aged care services.

Provide workers with guidance and training on how to coordinate aged care services (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• identify who is involved in the older person’s care
• talk with older people, their supporters and others they want to involve, such as families and carers, about transitions and coordinating aged care services
• use your organisation’s communication system and information management system to plan for and support transitions and coordinating aged care services.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training. 

Monitor that workers are partnering with older people and others involved in their aged care services.

To check if workers are partnering with older people and other providers well, you can review:

• how well workers are following your systems (Outcome 2.9)
• older people’s aged care services (Outcome 3.1) such as care and service plans and progress notes
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

Look for situations where:

• aged care services have not been planned and coordinated effectively
• the older person, their supporters, family, carers and others involved in their care have not been included during transitions of care.

Also, talk with older people, their supporters, families and carers about the aged care services they receive (Outcome 2.1). Ask them if their provider and workers partner with them, their supporters and others involved in their care during transitions of care. Ask them if they feel their aged care services are effectively planed and coordinated. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.
 

Put in place strategies that make sure the aged care services you deliver in an older person’s home are safe and meet their needs (Outcome 3.2).

These strategies need to cover all situations where you deliver aged care services in a person’s home. This helps make sure the environment is safe for the older person and workers.

When delivering care and services in a person’s home, use the organisation’s:

• risk management system (Outcome 2.4). Do this to identify, assess, document, manage and review any environmental risks that may affect the safety of the older person and workers. This includes risks to do with any equipment or aids you use in the delivery of aged care services. This also includes broader environmental risks such as overheating. Your risk management system should consider potential risks that fall outside the scope of older person’s care delivery. This can be done by conducting safety assessments and discussing options to mitigate any identified risks in consultation with the older person, as part of your service delivery obligations. For example, environmental risks such as cluttering, the presence of pets, poor lighting or unsafe flooring in the home that could lead to falls, particularly if the older person is at risk of falls. Where the older person receives aged care services from different providers, put in place systems that enable workers to share information with each other to help identify risks.
• communication system (Outcome 3.3). If you find any risks, discuss these and how you can manage them with the older person (Outcome 2.1). You also need to include other people, such as workers, supporters, family and carers in these discussions, with the older person’s consent. Keep in mind that not all risks can be eliminated or mitigated, and older people have the right to dignity of risk and choice during these discussions. Dignity of risk is the right of the older person to live the life they choose, even if their choices involve some risk.
• information management system to share information and communicate risks between providers, where the older person is receiving aged care services from different providers.

When the older person first starts receiving care, you may need to do an equipment and aid assessment. This assessment is to make sure the equipment and aids you give to the older person, or that they already have, meets their assessed needs. This includes you finding and providing the equipment, aids, devices and products they need. You need to complete an equipment and aid assessment even if you’re not providing equipment to the older person to assess that the older person’s care needs are met.

Put in place strategies that make sure the equipment and aids you provide to older people are suitable, safe, clean and meet their needs.

Make sure that any equipment and aids you provide:

• meet each older person’s needs and preferences (Outcome 1.1). Make sure this is based on the older person’s care and services plan as part of the assessment and planning process (Outcome 3.1). Some older people need a clinical assessment to identify what assistive equipment, aids and devices they need (Outcome 5.4). For example, an occupational therapist can assess the person to identify suitable mobility aids or transfer equipment, if they have difficulty moving around.
• are safe, clean and well-maintained for the older person to use and are used in the way they were designed and for their intended purpose. This includes equipment owned by providers and older people.

Also, put in place strategies to manage equipment. This can include:

• an inventory management system to record information about the equipment, such as where it is, what condition it’s in and who’s responsible for maintaining it. You can also use this system to record technical specifications of the equipment. This will help you to share and communicate information about the equipment and how it’s used. If you have many items to keep track of, an inventory management system can also help you track regular cleaning and maintenance needs.
• a maintenance plan that tracks when your equipment is scheduled for maintenance and repair works. This makes sure equipment is safe for ongoing use by the older person and workers. It needs to be clear whose responsibility it is to maintain equipment and aids. This can be documented in your agreements (Outcome 1.4).
• documented processes to make sure you clean equipment regularly. For example, before you give it to an older person and when it’s returned to you. This makes sure that equipment is cleaned and checked. Regular cleaning is important because dust, dirt or other materials can build up when equipment is used or has been stored. The process you use to clean equipment should also be in line with infection prevention and control practices (Outcome 4.2). For example, make sure equipment is cleaned straight away if it’s visibly dirty or soiled. You may need to increase how often you clean for high touch surfaces and during infectious disease outbreaks. These processes will help reduce the risk of surface contamination and transmission of infectious diseases (Outcome 4.2). It also needs to be clear whose responsibility it is to clean equipment and aids. You can record this in agreements (Outcome 1.4) or care and services plans (Outcome 3.1). Make sure equipment is cleaned with the right products, cleaning method, tools and following the manufacturer’s instructions and safety advice.
• processes to confirm that equipment associated providers and older people supply and own are safe and clean. This can include processes to ask for maintenance schedules and photos of equipment before it’s used, including equipment from the goods, equipment and assistive technology (GEAT) provider or procured through the assistive technology and home modifications scheme (AT-HM).

Make sure workers who provide aged care services in a home have the time, support and resources to manage risk.

Provide workers with guidance and training on how to assess, respond to and manage risks in a person’s home (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• identify and manage risks using the risk management system (Outcome 2.4)
• use the communication and information management systems to share critical information about identified risks (Outcomes 2.7 and 3.3)
• refuse to carry out an activity or provide aged care services if they feel unsafe or threatened
• remove themselves from an unsafe or threatening situation and raise concerns if they need
• record incidents and near misses using the incident management system (Outcome 2.5).

The guidance for Outcome 2.4 has more information on risk management.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.
 

Make sure workers have the time, support and resources to check that equipment is safe, clean, well-maintained and meets the older person’s needs.

Provide workers with instructions, guidance and training on how to check, maintain and clean equipment used in an older person’s home (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• their roles and responsibilities.

Make sure workers understand how to:

• maintain and clean equipment following the manufacturer’s instructions and safety advice and in line with your organisation’s maintenance plan
• use the right cleaning products and method
• check that equipment and aids meet the older person’s needs and preferences
• use equipment safely, including in the way it was designed and for its intended purpose. Support older people to use equipment and aids safely.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training. 

Monitor how well workers deliver aged care services in an older person’s home to make sure it’s safe and meets their needs.

To check if you’re managing risks in the home and the equipment you’re using well, you can review:

• older people’s aged care service documents (Outcome 3.1). For example, care and services plans and progress notes.
• feedback and complaints (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

Look for situations where:

• older people haven’t been involved in deciding how you’ll manage risks in their environment
• environmental risks haven’t been managed well
• equipment or aids have been reported as unsafe, unclean, not functional or not suitable for the older person’s needs.

Also, talk with older people, their supporters, families and carers about the safety, condition and comfort of their home when they’re receiving aged care services (Outcome 2.1). For example, ask them if their environment, equipment and aids are clean, safe, fit-for-purpose and meet their needs. Ask them if they feel their provider involves them when managing any environmental risks in their home. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). Assess if workers are using your risk management, communication and information management systems to help identify and communicate risks. You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure. This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Put in place strategies to maintain a safe, clean and comfortable service environment.

Use your risk management system (Outcome 2.4) when you put in place these strategies. This will help you to find, assess, document, manage and review any environmental risks that may affect the safety of the older person and workers. This includes risks related to the equipment or aids you use or provide to older people in the delivery of aged care services.

Make sure strategies include:

• a cleaning process:
  • that makes sure the service environment is clean, safe and comfortable. This can include buildings, access points, parking areas, gardens and the service environment’s general appearance and homeliness. Have a cleaning schedule that includes how often you recommend cleaning, as well as procedures and the responsibilities of all workers. Providers must store cleaning products safely.
  • that is in line with infection prevention and control practices (Outcome 4.2). Make sure you clean the service environment and equipment straight away if it’s visibly dirty or soiled. You may also need to increase how often you clean high touch surfaces and during infectious disease outbreaks. These processes will help reduce the risk of surface contamination and transmission of infectious diseases.
• a cleaning and maintenance process for equipment in the service environment. This makes sure that equipment is cleaned and checked regularly. Make sure equipment is cleaned and maintained using the right products, cleaning method, tools and following the manufacturer’s instructions and safety advice.

Make sure the design and maintenance of the service environment is fit-for-purpose and supports older people to do the things they want to do (Outcome 7.1). Do this in partnership with older people (Outcome 2.1) to make sure the environment meets their needs, goals and preferences (Outcome 1.1). Also, consider feedback from older people, their supporters, families and carers (Outcome 2.6b). When designing and maintaining the service environment, consider spaces that:

• are welcoming, comfortable and provide older people with a sense of belonging
• have areas and equipment that keep older people safe while also:
  • promoting movement, engagement and inclusion among older people
  • enabling older people to move about indoors and outdoors
  • supporting older people to exercise choice in their level of interaction (Outcome 3.2).  
• are culturally safe. For example, this includes the design of a culturally inclusive environment that:
  • meets the needs of the community you mostly deliver services in. For example, you may work with Aboriginal and/or Torres Strait Islander older people, their families and the wider community to design a service environment that encourages cultural safety, respect and being inclusive of local cultures.
  • enables the increased presence of an older person’s loved ones such as family, friends and carers to be with them more often during end-of-life care and allows them to stay overnight if needed to follow cultural practices.
  • supports an older person to pray or practise other spiritual rituals
  • supports older people to host visitors.
• enable dementia-friendly design principles
• supports older people to retain personal possessions if they so wish
• provides older people privacy when they want it.

For regional and remote providers, limited resources and higher costs may affect access to best practice design principles and design options. These providers should consider strategies to make sure their service environment:

• is safe
• is well maintained
• is fit-for-purpose
• meets older peoples' needs and preferences
• allows older people to do the things they want to do.

Make sure strategies consider if the service environment is suitable for each older person. Consider the service environment during the assessment and planning process (Outcome 3.1), and in partnership with the older person, to make sure it meets their needs, goals and preferences (Outcome 2.1). For example, look for ways to:

• make the service environment accessible, by considering the needs of each older person (Outcome 1.1). This includes older people living with disability. For example, installing entrance ramps or elevators in areas older people with mobility challenges may have difficulty accessing.
• identify and minimise risk. When you identify risks in the service environment, make sure you follow the risk management system (Outcome 2.4) to address them. Do this in partnership with older people (Outcome 2.1) to understand how you can support their needs and preferences (Outcome 2.1) while also removing and reducing risk where possible. Consider the older person’s right to exercise dignity of risk if they choose to (Outcome 1.3) and their right to make decisions about their personal possessions. Make sure the controls you have to minimise risks:
  • are unobtrusive. This means you should minimise safety risks in a way that is least restrictive on an older person’s freedom. For example, placing a fence around a secure area that is designed to blend into the landscape, or hidden using plants. Where it’s in the interests of an older person’s safety, it’s appropriate to risk assess the controls (Outcome 2.4).
  • optimise useful stimulation. For example, by using visual cues such as appropriate contrast to highlight key features, direct visual access to spaces, and text and image in signs. This also includes reducing unnecessary clutter and background noise.
  • provide older people with space to engage and interact with others in a way that suits them. This includes supporting older people who choose not to interact with others. For example, you could set up a communal area that encourages social interaction or facilitate a quiet space for older people who wish to be alone.
  • make the service environment easy to navigate. For example, by placing objects older people commonly use in clear sight, clear signage on the bathroom door and motion sensor activated lights in hallways.
• maintain and design the service environment to improve older people’s quality of life, reablement and maintenance of function (Outcome 3.2).

Older people should also have the choice to bring personal items to the residential care home (Outcome 1.3). For example, valuables, furniture or pictures. This can support the older person’s daily living, including their quality of life, and help them to take part in meaningful and engaging activities (Outcome 7.1). Make sure you put in place processes to identify, manage and minimise risks related to personal items using the risk management system (Outcome 2.4). This can include providing older people with enough secure storage for their belongings.

Put in place strategies that make sure the equipment used in the aged care services you deliver are suitable, safe and clean and meet the needs of older people.

These strategies can include:

• an inventory management system. This system is to record a list of your equipment. It includes details such as where they are and what condition they’re in. It can also include their technical specifications. This may help improve information sharing, communication and use of your equipment.
• a maintenance plan. This plan is to track the schedules for maintenance and repairs of your equipment used inside and outside the service environment. This will help you to make sure equipment is maintained and safe for the older person and workers to use.
• a cleaning plan. This plan makes sure that your equipment is cleaned and checked regularly. Regular cleaning is important because dust, dirt or other materials can build up when equipment is used or has been stored. It needs to be clear whose responsibility it is to clean and maintain equipment and aids.

Make sure equipment that older people share is checked and cleaned between each use. This will help reduce the risk of infection and outbreaks of infectious disease as a result of contaminated equipment and surfaces (Outcome 4.2).

Make sure any equipment you use in the service environment meets each older person’s needs and preferences and is used in the way it was designed and for its intended purpose. (Outcome 1.1). Make sure this is based on the older person’s care and services plan as part of the assessment and planning process (Outcome 3.1). Some older people need a clinical assessment to identify what assistive equipment, aids and devices they need (Outcome 5.4). For example, an appropriately qualified health professional can complete an assessment to identify suitable mobility aids or transfer equipment if the older person has difficulty moving around.

Also, make sure there is enough equipment available to meet each older person’s needs.

For regional and remote providers, limited resources may affect timely access to equipment, registered health practitioners and allied health professionals. These providers should have strategies to make sure equipment is safe, clean, well-maintained and meets the needs and preferences of each older person.

Make sure your workers have the time, support and resources to keep a safe, clean, comfortable and welcoming service environment.

Provide workers with guidance and training on how to maintain a safe, clean, comfortable and welcoming service environment. This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• maintain a safe, clean, comfortable and welcoming service environment that is fit-for-purpose and meets the needs and preferences of the older person
• use equipment safely and support older people to use equipment and aids safely
• use the risk management system to identify and manage environmental risks in the service environment.

Assess if workers are following your quality system (Outcome 2.9). Do this through quality assurance and system checks.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure the workers who use or manage equipment have the time, support and resources to maintain and clean equipment.

Provide workers with instructions, guidance and training on how to maintain, use and clean equipment used in the service environment (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• maintain, use and clean equipment following the manufacturer’s instructions and safety advice and in line with your organisation’s plans
• use the right cleaning products and method in line with your organisation’s cleaning plan
• do a risk assessment when equipment is faulty, damaged or causing risk of harm to people using it
• check that equipment and aids meet the older person’s needs and preferences and are used in the way it was designed and for its intended purpose. This includes knowing processes for how to escalate and refer to appropriately qualified registered health practitioners and allied health professionals (Outcomes 3.2 and 5.4) who can recommend suitable equipment and aids.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training. 

Monitor how well workers are maintaining a safe, clean and comfortable service environment.

To check if you’re maintaining a safe, clean and comfortable service environment, you can review:

• the older person’s aged care service documents (Outcome 3.1). For example, care and service plans and progress notes.
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

Look for situations where:

• you haven’t involved older people in deciding how you’ll manage risks in their service environment
• you haven’t managed environmental risks or incidents well
• people have reported not feeling safe, welcome or comfortable at the service.

Also, talk with older people, their supporters, families and carers about the safety, condition and comfort of the service environment (Outcome 2.1). For example, ask them if their environment is safe, fit-for-purpose and meets their needs. Ask them if they feel that their provider involves them when they manage any environmental risks in the service environment. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system checks. For workers caring for older people in a residential care home, you can do this as part of the monitoring process in Outcome 7.1.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Monitor how well workers are using and managing equipment.

To check if workers are using and managing equipment well, you can review:

• older people’s aged care service documents. For example, care and services plans and progress notes (Outcome 3.1).
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5)
• reports from your inventory management system and maintenance request records.

Look for situations where equipment or aids have been reported as:

• unsafe
• unclean
• not functional
• not suitable for the older person’s needs.

Also, talk with older people, their supporters, families and carers about the safety, condition and comfort of the equipment and aids they use (Outcome 2.1). For example, ask them if their equipment and aids are clean, safe, fit-for-purpose and meet their needs. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews. For workers caring for older people in a residential care home, you can do this as part of the monitoring process in Outcome 7.1.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Put in place a system for infection prevention and control.

Make sure this system reduces the spread of diseases and infections. This system should be used together with processes to prepare for, prevent and control infections in clinical care services (Outcome 5.2).

Make sure your infection prevention and control system includes processes to:

• appoint an Infection Prevention and Control Lead for residential care homes. This role acts as the main point of contact for all infection issues. This role also oversees the infection prevention and control system and processes to prepare for outbreaks. The Infection Prevention and Control Lead needs to be a nurse who has completed, or is in the process of completing, the required specialist infection prevention and control training. Consider how to best assign an Infection Prevention and Control Lead during workforce planning (Outcome 2.8). For providers delivering aged care services in a home or community setting, look for ways to appoint a worker or team to oversee your infection prevention and control system.
  • for regional and remote providers, limited resources and increased workforce challenges may affect access to appropriately qualified and trained Infection Prevention and Control Leads. These providers should consider strategies to make sure their infection and prevention control system is overseen.
• put in place infection control strategies that are appropriate for the older person’s home or service environment (Outcomes 4.1a and 4.1b). This includes standard and transmission-based controls. For example:
  • cleaning practices
  • hand hygiene practices
  • respiratory hygiene
  • cough etiquette
  • waste management and disposal.
• check infection prevention controls and processes to prepare for outbreaks are in line with contemporary, evidence-based practice (Outcome 5.2)
• put in place policies and procedures to prepare for, prevent and control infections. This includes developing and maintaining outbreak management plans.
• manage infections and infectious disease outbreaks (Outcome 2.10). This includes both suspected and confirmed infectious diseases such as COVID-19, influenza, gastroenteritis or novel viruses. This means you need to act promptly when people are sick, even if you’re not sure if it’s an infectious disease.
• collect and analyse data on immunisation and infection rates. This is to inform risk assessment and the ways you can improve your infection prevention and control system (Outcome 2.4).
• share information about infection risks with older people, their supporters, families, carers, visitors and workers by using the communication system (Outcome 3.3)
• prioritise the rights, safety, health and wellbeing of older people (Outcome 3.2). You need to include older people in deciding how to manage the risk of infection (Outcome 1.3).
• meet public health notification needs, where relevant.

For residential care homes, undertake risk-based vaccine-preventable diseases screening and immunisation for older people and workers. This includes disease screening and immunisation requirements for visitors. This makes sure visitors or workers don’t expose older people to infectious diseases.

Make sure you give older people current, accurate and timely information about vaccines from relevant registered health practitioners and allied health professionals. Make sure you provide this information in a way older people can understand by considering their language and communication needs and preferences (Outcome 1.1). This information can include benefits, risks and costs (where applicable) of vaccinations. The older person can then make an informed decision and provide informed consent if they have agreed to be vaccinated (Outcome 1.3).

Home care settings have unique infection risks. Older people are likely to have multiple workers and providers delivering aged care services in their home. Workers may also be moving between multiple home settings. This can increase the risk of infection between workers and older people. Put in place strategies to make sure workers are minimising or preventing the spread of infection. For example, support older people to maintain a clean and safe environment (Outcome 4.1a), perform hand hygiene and use personal protective equipment (PPE) appropriately.

The guidance for Outcome 5.2 has more information on infection prevention and control in clinical care services.

Put in place a system to manage the supply and use of personal protective equipment (PPE).

Put in place a system to make sure PPE is suitable, available and has instructions on how to use it safely. In particular, where you are using PPE as a mitigative control to reduce disease and infection, as part of the risk assessment system (Outcome 2.4). Make sure PPE is available for workers, older people, visitors and other care partners in your service, and you put in place strategies to make sure PPE is used correctly.

You need to develop, maintain and manage a PPE inventory to make sure there’s enough PPE stock. The inventory manages:

• what PPE you need. For example, gloves, gowns, face shields/glasses and masks.
• where to store PPE. Make sure you store PPE correctly, in a dedicated and accessible area.
• when you need to replace PPE.

This inventory can be integrated with your processes for managing equipment (Outcomes 4.1a and 4.2b).
 

Make sure workers have the time, support and resources to manage infections and use PPE.

Provide workers with guidance and training on correct infection prevention and control practices, including use of PPE (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers and other care partners in your service understand how to:

• use and apply the infection prevention and control system
• identify when to use standard and transmission-based precautions and apply this to the appropriate setting
• use and maintain PPE correctly. This applies to all people who need PPE, as well as to visitors and other care partners in your service.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training. 

Monitor that workers follow the system for infection prevention and control.

To check if your system for managing risks of infection is working, you can review:

• older people’s aged care service documents. For example, care and services plans and progress notes (Outcome 3.1).
• complaints and feedback (Outcome 2.6a and 2.6b)
• infection rates and trends
• incident information (Outcome 2.5).

Look for situations where:

• infections have been transmitted between workers, carers, older people or their families
• your organisation hasn’t responded to outbreaks of infectious diseases or viruses in a timely manner
• you haven’t shared information on infection risks well with older people, their supporters, family, carers or workers
• suitable PPE wasn’t available, used when needed or it wasn’t used correctly.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the infection prevention and control processes (Outcome 2.1). For example, ask them if they feel their provider and workers follow appropriate infection prevention and control precautions when delivering aged care services. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews. This can be done as part of the monitoring process in Outcome 5.2.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance material for Outcome 2.3 has more information on monitoring the quality system.

Outcome 5.1.1

• The decisions a governing body make are informed by high-quality and accurate data and reporting from provider management. This includes the decisions they make about:
  • priorities for care
  • areas that can be improved
  • the strategic direction of the organisation
  • resources.

Put in place systems that drive safety and quality improvement.

The provider has systems to monitor and evaluate the clinical care the service provides. This includes systems that use the results from monitoring and evaluation activities to improve funded aged care services.

Put in place processes that make sure the governing body has the information it needs to set priorities, strategic directions and monitor clinical outcomes and processes.

• Put in place a schedule for reporting to the governing body on the quality of the care you’re providing (Outcome 2.3).
• Use data you collect on how the service is performing to report to the governing body. This data should include:
  • feedback from older people receiving care, their supporters, families, carers, workers and other stakeholders, including information from complaints and other types of feedback
  • clinical incidents and other clinical measures or outcomes
  • clinical trends and reporting from other similar services
  • how effective the clinical governance system is in supporting quality care and managing clinical risk
  • data collected for mandatory Quality Indicators (QI)
  • data from routine data collection, including when someone starts receiving care from your service
  • risks and incidents including serious, non-reportable and near misses, as well as how they were managed and resolved
  • hospital transfers and the reasons for transfer.
• Make sure reports for the governing body are clear and use accurate data and quality analysis.
• Make sure you have involved workers, registered health practitioners, allied health professionals and older people receiving care in developing the goals for the service. You also need to share these goals with them.

Outcome 5.1.2: Put in place processes and systems in the clinical governance framework.

A clinical governance framework describes the systems an organisation uses to support workers, registered health practitioners, allied health professionals and committees to understand and perform their roles. It also explains their responsibilities and accountabilities for providing person-centred, safe, coordinated and effective care.

• Put in place the endorsed clinical governance framework by:
  • communicating a statement from the governing body about the organisation’s culture, priorities and commitment to providing quality clinical care services to all older people, workers, registered health practitioners and allied health professionals
  • outlining the roles, responsibilities and organisational structure for safely delivering quality clinical care services in the provider’s system
  • using measures of success in clinical governance and safe and quality clinical care services and reporting on these measures
  • putting in place processes for reviewing the clinical governance framework
  • making sure plans, policies and procedures are accessible and used by workers, registered health practitioners and allied health professionals. This includes documents and systems that support the clinical governance framework and achieving safe, quality clinical care services.
  • putting in place processes for workers to help them monitor, evaluate and improve clinical care services. This can include using risk management systems
  • clearly describing roles and responsibilities for clinical governance and safe, quality clinical care services in position descriptions. This makes sure that everyone working in the service understands, including contracted registered health practitioners and allied health professionals.
• Consider the resources you need to provide care based on contemporary, evidence-based practice, including training and development for workers.
• Make sure updates or changes to practice and assessment tools are identified and assessed against current legislation, guidelines and evidence.

Monitor, review and improve clinical care services.

• The decisions a governing body makes are informed by high-quality and accurate data and reporting from provider management. This includes the decisions they make about:
  • priorities for care
  • areas that can be improved
  • the strategic direction of the organisation
  • resources.
• Use internal and external data you’ve collected about the service, to report to the governing body. This includes data on:
  • how effective clinical processes are in supporting quality clinical care services
  • care outcomes and performance
  • feedback from older people, others involved in their care and workers, including complaints
  • clinical incidents and issues and other clinical indicators
  • the diversity or people who use their service including things like cultural background or disability (Outcome 1.1).
• Present data about the service in a way that is clear and useful to the governing body, managers, workers and older people.
• Consider how you use the clinical governance framework in practice and how you review it to make sure you’re providing quality care that is person-centred, safe, coordinated and effective.
• Use information and reporting from the monitoring you do (explained above) to review and improve clinical care services.
• Consider how you can measure success. Measures could include:
  • comparing complaints data to show how you’ve improved
  • positive feedback from older people
  • evidence workers know your key policies and procedures for safe, quality clinical care services and are seen following them
  • feedback from workers show they’re satisfied in their job
  • positive feedback from visitors to the service
  • improvement in data reported through the National Mandatory Aged Care Quality Indicator program.

Outcome 5.1.3

Put in place systems for employing, contracting and managing workers providing clinical care services.

• Make sure these systems follow the processes outlined in Outcome 2.9.
• Verify and record credentials, qualifications, training and registrations.
• Make sure management and workers understand the scope of practice for clinical care workers and contractors.
• Put in place processes to make sure that contracted and visiting registered health practitioners and allied health professionals have appropriate qualifications and experience to provide clinical care services.

Put in place processes for managing workers providing clinical care services.

• Make sure position descriptions and recruitment processes clearly state the clinical skills, experience, knowledge and qualifications each role needs.
• Make sure there are processes for:
  • describing and monitoring the scope of clinical practice
  • providing clinical education and training
  • monitoring and managing performance
  • managing registered health practitioner and allied health professional registration where required
  • ensuring workers, registered health practitioners and allied health professionals are aware and using the provider’s safety and quality systems and processes
  • delegating work to support quality care, within workers’ scope of practice.
• Clearly describe roles and responsibilities for clinical governance and safe, quality clinical care services and make sure everyone working in the service understands them.
• Make sure that roles and responsibilities for clinical governance and safe, quality clinical care services are:
  • included in position descriptions
  • the terms of reference for committees
  • described in policy and process documents.

Monitor, review and improve clinical care services.

• Regularly review the organisational structure, position descriptions and contracts to make sure that roles and responsibilities for safe, quality clinical care services are clearly explained at all levels of the organisation.
• Make sure a committee or specific person has the delegated responsibility for overseeing registered health practitioner and allied health professional registration and scope of practice.
• Ask older people for feedback on the care they receive from workers.
• Make sure there are processes to address concerns workers raise about what is expected in their role.
• The provider should ensure sufficient and appropriately qualified workers are available to provide the right care. The service culture should support clinical workers to report if they are not able to meet care needs safely. These workers must always work within their professional scope of practice.
• Review processes for monitoring, training and verifying competency and ensuring it aligns with evidence based practice (Outcome 2.9).

Outcome 5.1.4

Coordinated care makes sure older people have access to the clinical care services that are right for them at the right time and in the right place.

Put in place processes for agreement between health professionals and the provider.

• The provider is responsible for facilitating access to care for older people when the provider can’t meet their clinical care needs.
• These responsibilities could include:
  • working with visiting registered health practitioners and allied health professionals or practitioners to develop clear policies for procedures and practices for clinical care services
  • preparing private spaces for visits if the older person prefers
  • working with the older person to get ready for appointments and understand what has been recommended for their care and their care and services plans
  • supporting older people to access virtual care such as telehealth
  • providing registered health practitioners and allied health professionals access to clinical information systems to make sure clinical information (like assessments, medicines lists, charts and notes) are:
    • available
    • reviewed and updated
    • securely stored in the provider’s system
  • making sure workers make any needed changes after registered health practitioners and allied health professional reviews, including to medicines
  • making sure the registered health practitioner or allied health professional can access the older person’s home (if this is the provider’s responsibility) or the residential aged care home at the time of their appointment
  • making sure the clinical workers and external registered health practitioners and allied health professionals can access information about the services and level of care that the provider provides and how to refer to specialists when needed.
• Workers need to be informed and are responsible for keeping informed about any changes to an older person’s care needs after treatment or assessment by health professionals, as appropriate, and with consent of the older person or their supporter
• An agreement between health professionals and a provider could include:
  • what the older person expects and what their goals of care are
  • a list of responsibilities for clinical care services
  • what behaviours and responsibilities are expected of both groups when providing clinical care
  • the processes for providing care that is included in the provider’s clinical governance framework or the processes the provider and the registered health practitioner and allied health professional have agreed to
  • protocols for how clinical information is used including access, consent, sharing and editing
  • a timeframe to review the agreement
  • Processes for updating care and services plans and reporting feedback and incidents.

Monitor, respond and improve clinical care services.

• Ask for feedback from the older person to check that they’re satisfied with their care. Use this to improve care.
• Provide care in line with the agreed processes.
• Review agreements regularly between registered health practitioners and allied health professionals and providers to make sure they’re fit for purpose and support them to provide high-quality clinical care services.
• Review treatment and care plans regularly to make sure they are in line with contemporary, evidence-based practice.

Outcome 5.1.5

These key tasks can help all services work towards an integrated clinical information system. Consider how these can work in your service.

Use processes in Outcome 2.7 to make sure information is secure and accurate and you use it with consent. ‘Working towards’, means if you don’t yet have a clinical information system, the provider has:

• looked at available systems
• considered what they need the system to do
• developed a detailed plan to put in place a suitable system.

An effective clinical information system can support an older person’s clinical safety. It can improve communication and continuity and coordination of care between settings, registered health practitioners, allied health professionals and providers.

Using standard national terminology means that information included in an organisation’s clinical information system are interoperable with other clinical information systems. For example, the information can work with primary health provider systems and can be used for de-identified data analysis.

It also means that clinical information in an organisation’s system can be understood and used by other registered health practitioners and allied health professionals accessing this information. Using health identifiers makes sure the right information is connected with the correct older person. It also identifies the health professional or organisation that documented or reviewed the information in the system. Not all older people have, or have access to, My Health Record. Find out if older people have My Health Record and document this information into your systems.

Put in place a system to safely use clinical information.

• Include clinical information in care and service plans. Use it to plan for care and when a person transitions between care settings and also for delivery of care and support of the older person.
• Consider how outcomes of assessment from more than one registered health practitioner and allied health professional can be included in the providers clinical information system to help plan care.
• Consider how you’ve structured and organised the information you collected. Consider how you can use it securely, with the older person’s consent and in line with legislation.
• Manage clinical information using a digital clinical information system that uses conformant software and meets digital health standards.
• Consider how you can add data into systems once and use it multiple times for different purposes. For example, work towards systems that are integrated. This:
  • reduces mistakes
  • makes it easier for registered health practitioners and allied health professionals to know where to find the most up-to-date information
  • makes sure data can be used for analysis and reporting.
• Providers should consider what data they collect and why they collect it to make sure they’re collecting data for the appropriate reasons.

Put in place processes to manage clinical information.

• To safely manage clinical information, providers put in place processes for:
  • transferring information from existing systems into new systems. This helps mitigate the risk of incomplete, missing, unavailable or incorrect information in new systems.
  • medication management. The guidance for Outcome 5.3 has more information on documenting and managing medicines.
  • external registered health practitioners and allied health professionals to access the clinical information system when needed and with consent. This allows them to document outcomes of assessment and other relevant information. Also, consider how health professionals can access your clinical information system when offsite or during telehealth or virtual appointments.
  • health professionals such as registered nurses, entering clinical information in the clinical information system and using health identifiers
  • workers to access the information they need for their role with the consent of the older person or their supporter
  • registered health practitioners and allied health professionals to have access to clinical information in line with the older person’s wishes and relevant legislation
  • older people to access and review their care and services plans, if they ask to (Outcome 1.3). This should include considering displaying the plans onscreen or printing them.
  • using the healthcare provider directory when sending secure messages, referrals, discharge summaries and test results.
• Regularly review advance care plans in the provider’s clinical information system with the older person if that is their preference.
• Consider how you can support the older person to access and understand advance care planning documents.
• The provider has processes and the responsibility to:
  • ask for consent and record the outcome for sharing and accessing clinical information
  • assign and communicate roles and responsibilities for documenting and using clinical information.
• Eligible workers have health professional identifiers and use these and the older person’s individual health identifier when accessing or adding information in an older person’s My Health Record or other health record systems. Using healthcare identifiers supports interoperability (exchange of information) with nationally agreed health records and other clinical information system, such as primary health provider systems.
• Develop and put in place a security and access policy to make sure workers keep older people’s clinical information safe.

Monitor, review and improve processes for clinical information accuracy and use.

• Assess your software systems to understand how you manage and share clinical information currently.
• Identify gaps and areas where you can improve. For example, duplicating the same or similar information or manual entries that don’t use standard terminology or following the provider’s processes for recording clinical information.
• If you don’t have a system, you can use the Australian Digital Health Agency’s register of conformity to find suitable systems that meet the service’s needs.
• Use the resources on the Digital Health Agency’s website to make sure relevant clinical information is integrated with other systems using suitable software. If the provider doesn’t have a clinical information system, they need to develop a plan to find a suitable software system.
• Review processes and access requirements when you identify issues with the accuracy or security of information.
• Make sure workers, registered health practitioners and allied health professionals understand procedures for managing offline clinical information.

Outcome 5.2.1

While medical practitioners are responsible for prescribing antimicrobials (such as antibiotics), there are many other antimicrobial stewardship (AMS) strategies that aged care providers need to put into practice. The AMS Self-Assessment Tool and User Guide supports providers to monitor and understand their progress towards creating a comprehensive AMS program. Chapter 16 of the Antimicrobial Stewardship Book – Antimicrobial stewardship in community and residential aged care and the Antimicrobial Stewardship Clinical Care Standard have recommendations of contemporary, evidence-based practice.

Put in place a system for AMS.

Document the parts of your AMS system, including:

• policies and procedures to promote using antimicrobials appropriately
• roles and responsibilities for AMS in your organisation, including leadership responsibilities
• processes for regular clinical reviews of the appropriate duration of antimicrobials use, as well as specialist referrals, including microbiological testing where needed
• processes outlining how the service accesses AMS expertise, if needed. For example, through a referral or by asking for advice from a suitably qualified registered health practitioner or allied health professional, such as a pharmacist credentialed to conduct medication reviews. For example, a clear process for collection and arranging laboratory testing of a wound swab.
• AMS education and training for workers, registered health practitioners and allied health professionals you employ or contract, suitable to their role
• Processes for monitoring and reporting the effectiveness of the AMS system
• quality improvement processes for antimicrobial issues.

Put in place processes for effective AMS.

Make sure workers and health professionals:

• understand what they need to do to promote using antimicrobials appropriately and reducing antimicrobial resistance. This includes their role in preventing infection through:
  • hydration and diet
  • maintaining skin integrity
  • following appropriate hygiene and IPC practices such as hand hygiene.
• have the training and qualifications they need to perform their role
• understand how to monitor older people who have been prescribed antimicrobials for effectiveness, side effects and adverse events
• understand how to recognise and escalate if they find antimicrobials are being used inappropriately, including following appropriate processes for raising concerns with prescribers
• have access to relevant clinical guidelines, such as Therapeutic Guidelines: Antibiotics, the Australian Medicines Handbook and other locally endorsed guidelines.

AMS activities can also include giving the older person information and an opportunity to discuss the risks and benefits of antimicrobials. This can help them make informed decisions with their prescriber.

Monitor, review and improve AMS processes.

In proportion to the service’s level of involvement in supplying, administering and monitoring antimicrobials, consider how to:

• monitor the frequency, duration and the clinical reasons for using antimicrobials for the older people using the service
• analyse trends for using antimicrobials. This may include working with local pharmacies to gather data.
• regularly monitor infections and the use of antimicrobials. For aged care services delivered in a residential care home, this may include taking part in the Aged Care National Antimicrobial Prescribing Survey (AC-NAPS).
• analyse the data you collect through this monitoring and report it to relevant stakeholders. This includes your governing body, prescribers and to older people receiving care and their families. This can help you improve the effectiveness of your AMS systems and processes

Some of the key tasks in Action 5.3.6 on monitoring and evaluating medication management systems can also be helpful when monitoring antimicrobial use and trends in adverse medicine related events and side effects.

Outcome 5.2.2

Put in place an IPC system.

Document the parts of your IPC system, including:

• policies and procedures that guide:
  • IPC practices relevant to the clinical care services you provide
  • identifying people with suspected or confirmed infections and notifying and escalating to local public health units and health and medical practitioners if relevant in a timely way.
• roles and responsibilities for IPC, including senior leadership responsibilities and who holds the IPC Lead role (where relevant)
• clinical procedures that need aseptic technique and protocols for using aseptic technique and clean procedures
• invasive devices and protocols for their insertion, monitoring, maintenance and removal
• training systems to support workers, registered health practitioners and allied health professionals to meet their IPC responsibilities, including education for care workers to reduce the risk of contracting or spreading infection.

Make sure the IPC system is in line with:

• endorsed national and state or territory guidelines, legislation and regulations
• contemporary, evidence-based practice in line with the Aged Care Infection Prevention and Control (IPC) Guide, a resource of the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Put in place IPC processes for clinical care services.

Make sure processes support a risk-based approach to IPC for the service context. The processes should consider:

• the risk of infection in the environment that you deliver care
• types of services offered
• workers’, registered health practitioners and allied health professionals’ scope of practice.

Make sure you support workers, registered health practitioners and allied health professionals to meet their IPC roles and responsibilities, including:

• easy access to your IPC policies, procedures and protocols
• adequate training and time for workers responsible for IPC, such as the IPC Lead, to carry out their IPC activities
• adequate training and education for those who perform aseptic procedures and manage invasive medical devices
• appropriate equipment to perform aseptic procedures and safely manage invasive medical devices
• making sure that workers can recognise the signs and symptoms of infection
• a system to recognise and respond to older people with signs of infection and escalate concerns. This may include escalation process, and workers roles in responding to infection.
• processes to prevent, identify and manage urinary tract infections.

Monitor, review and improve IPC processes and outcomes.

As relevant to the service’s context and level of involvement in clinical procedures and using invasive devices, consider how to:

• monitor compliance with processes and protocols for aseptic technique and managing invasive devices, such as urinary catheters
• assess and monitor risks of infection and how effective your strategies to mitigate risk are
• use the data you collect from monitoring to identify opportunities where you can reduce the exposure and transmission of infections during clinical care services.

Outcome 5.3.1

Put in place a medication management system.

All providers whose workers are involved in any part of medication management must have systems and processes that supports safe use of medicines in a way that meets state or territory law and regulations. Where the provider employs or contracts nurses, the provider must support them to meet the legal requirements of their registration and professional standards. The e-Therapeutic guidelines and AMH Aged Care Companion can support workers and registered health practitioners.

When developing and reviewing your medication management policies and procedures, check the Department of Health, Disability and Ageing’s Guiding Principles for Medication Management in residential care homes, home or community settings, or for transitions of care, as relevant to the service context.

A medication management system sets robust clinical governance for all medicines-related activities. A medication management system includes:

• a governance mechanism for managing and monitoring the medication management system. For providers that administer medication, this should be through an expert multidisciplinary group. In aged care services delivered in a residential care home, this group is called a Medication Advisory Committee (MAC).
• policies and procedures for any medication management activities workers do, including:
  • discussing the risks and benefits with the older person
  • Prescribing by appropriate registered health practitioners
  • procuring
  • dispensing
  • storing
  • administering
  • packaging
  • supplying
  • monitoring the effects of medicines and escalate and report relevant adverse events or side effects
  • assisting people to self-administer medicines.
• policies on how medicines are used and how to escalate a review for registered health practitioners and trained workers administering medicines
• standardised documentation and communication templates and protocols to make sure that you have a current and accurate record of all medicines. This list should be available to the older person and those involved in their care.
• an adverse event and incident monitoring and reporting system and processes
• clear definitions of worker roles and responsibilities for managing medicines. This needs to be in line with national and state or territory legislation, regulations and professional standards. These need to state:
  • who can administer or assist with medications in which situations
  • what competencies, qualifications and training they need
  • protocols for supervising and delegating medicine management
  • protocols for reporting medicine management concerns and escalating.

Put in place processes for documentation and information access to make sure:

• there is a standard format in your information system to document:
  • information about a person’s medicines
  • clinical reasons for their use

  • a record of their use.

    Make sure this information is documented in the provider’s information system, using the National Residential Medication Chart or similar.

• there are standard protocols to support timely communication about medicines between the older person, workers, registered health practitioners, allied health professionals and others involved in their care. This is particularly important at transitions of care.
• all changes to a person’s medicines are documented in the provider’s information system in a timely way. This includes when the changes are recommended by an external registered health practitioner or allied health professional such as the person’s GP.

Processes for safe medication assistance should make sure that:

• workers understand what medication assistance tasks support self administration, such as prompting or assisting the person to open packaging. Medication assistance doesn’t include measuring, dispensing, or administering a dose of medicine to a person or making any decisions about medicine use.
• workers have the relevant training in medication assistance, are appropriately supervised and understand:
  • how to document the assistance they provided
  • how and where to escalate any concerns or observations about a person’s medicine use
  • what to do if an older person or carer tells them they are concerned about a medicine-related issue or the older person is acutely unwell.

Processes for safe medication administration should make sure:

• the difference between medication assistance and medication administration is clear. Medication administration (giving a dose of a medicine to a person) is a complex and high-risk task that is strictly regulated under law.
• relevant registered health practitioners understand their scope of practice, roles and responsibilities for medication administration under legislation, regulations and professional standards. The provider supports them to follow these, including through clear delegation and supervision protocols for making decisions.
• registered health practitioners carry out administration in line with their scope of practice, usually registered nurses or enrolled nurses with relevant training and supervision
• depending on state or territory law and regulations, in some situations, an appropriately trained and competent delegate, such as a care worker, can perform some medication administration tasks. This must be under the supervision of a registered health practitioner.
• the older person’s swallowing capacity and tolerance to different drugs are assessed and reviewed when needed. Recommendations should be documented and followed (Outcome 5.5).
• there is timely and continuous access to prescribed medicines, especially:
  • at transitions of care
  • when urgent clinical needs arise
  • where there are changes to prescribed medicines.

In residential services, emergency stocks (‘imprest’) of a limited range of medicines approved by the Medication Advisory Committee and in line with state or territory legislation, should be used for these purposes. Support for remote access for prescribing also helps make sure there is timely and continuous access.

Processes for person-centred medication management should make sure that:

• an older person who is assessed as competent and willing should be supported to administer their own medicines
• older people, their supporters and others they wish to involve are supported to take part in making informed decisions about their medicines when they want this. Any decisions about medicines need to be shared with the prescriber. Providers can support these decisions by:
  • giving older people an up-to-date, comprehensive and accurate medicines list
  • giving older people information about both non-pharmacological and pharmacological treatment options, where this is an option
  • giving older people information about the risks and benefits of medicines so they can give informed consent, and to support adherence to medicine treatment plans
  • involving the older person, their supporters and others they wish to involve in regular medication reviews

Outcome 5.3.2

Put in place processes for regular and as needed medication reviews.

In the medication management system described in Action 5.3.1, the regular review of each older person’s medicines by a qualified registered health practitioner is a key strategy for making sure medicines are used safely. Registered health practitioners include medical practitioners, nurse practitioners and pharmacists. In practice, ongoing reviews of a person’s medicines routinely happen as part of usual clinical practice. For example, during an appointment with a GP.

During hospital admissions, medications are often changed. Transitions of care, such as hospital discharge, are important causes for urgent medication review.

Comprehensive medication reviews by a credentialed pharmacist can also help to identify opportunities to:

• provide more optimal therapies
• identify side effects and interactions
• encourage adherence
• make sure medication is optimally administered
• deprescribe and reduce risk of harm from inappropriate polypharmacy.

Certain medicines can increase the risk of clinical incidents such as falls, and a medication review should be considered as part of a comprehensive assessment after incidents. Medication reviews should include identifying any medicines or remedies used by the older person that aren’t prescribed, such as over the counter medicines or supplements.

The following key tasks outline reasonable practice in medication reviews for providers with services that involve medication management:

• Put in place processes to support regular (at least once a year) medication review for each older person. If the registered health practitioner completing this review isn’t employed by or contracted to the provider, the provider needs to have processes to tell the registered health practitioner when there needs to be a review. This should include making sure any changes or recommendations that come from the review are documented in the person’s care and services plan and medication chart.
• Put in place processes to monitor, document and communicate the effects and side effects of prescribed medicines to the prescriber.
• Support workers and registered health practitioners to identify causes for medication review.
• Put in place processes to encourage the use of standardised processes for medication reviews. These should include:
  • documentation of available information about current (existing and newly prescribed) medicines
  • the history of medicine-related orders including oral and parenteral (ways other than oral), multiple and single dose medicines.
• Reviews should consider things like:
  • Is there a documented reason or evidence base for using the medicine?
  • Does the older person still need the medicine?
  • Is the medicine still working?
  • What risks are associated with the medicine and what monitoring is needed?
  • What risks are associated with stopping a medicine where polypharmacy is identified?
• Consider the need for modification of administered medicines if an older person is acutely unwell or their health condition has changed. This may include acute exacerbations of chronic conditions.

Outcome 5.3.3

Documenting and communicating each older person’s allergies and previous reactions to medicines is an important part of the safe and quality use of medicines. This should be recorded in the medication management system described in Action 5.3.1.

Put in place processes to document allergies and adverse reactions.

• Put in place a process to make sure workers, registered health practitioners and allied health professionals involved in the older person’s care document known medicine allergies and any adverse medicines-related event. These will often be reported by the older person themselves. Also, make sure this information is kept up to date.
• Make sure information about medicine allergies and adverse reactions is available to all registered health practitioners who prescribe, dispense or administer medicines.
• Make sure workers know how to observe and document the older person’s reactions to any medicines. This includes new allergies or side effects. Also, make sure they know how to escalate concerns to relevant registered health practitioners.

Outcome 5.3.4

As part of your medication management system (Action 5.3.1), you need to set up clear policies, procedures and processes for using high-risk medicines, in line with state or territory legislation.

High risk medicines include:

• opioids
• anticoagulants
• insulin
• psychotropic medicines, such as antipsychotics, antidepressants and anti-anxiety medicines.

These pose a higher risk to older people if used in error. They can be associated with:

• adverse drug events
• hospitalisation
• poor health-related quality of life
• death.

Put in place processes for safely using high-risk medicines.

• Put in place processes to identify, document, monitor, review and (deprescribe where appropriate) the high-risk medicines prescribed to older people in your service.
• Put in place processes to support safely using high-risk medicines for each older person prescribed them, including:
  • outlining clear roles and responsibilities for handling and storing high-risk medicines, in line with legislation
  • putting in place effective channels for communication and information sharing between those involved in the older person’s care, to monitor those taking high-risk medicines. This includes external registered health practitioners or allied health professionals such as GPs and pharmacists.
  • documenting risk of harm and necessary mitigation strategies. This helps make sure the medicine is used appropriately and the benefit for the person outweighs the risk.
  • consider planning regular medication reviews by a credentialed pharmacist to monitor how effective medications are, their adverse effects and interactions with other medications and comorbid conditions. A comorbid condition is more than one medical condition happening at the same time. This also needs to include identifying any opportunities to reduce the dose or deprescribe (Action 5.3.2).
  • supporting and facilitating the use of non-pharmacological strategies as a first line approach when appropriate. For example, when responding to changed behaviours as outlined in the Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard.

Outcome 5.3.5

Adverse medicines-related events are the unintended and sometimes harmful outcome of using a medicine, vaccine or medical device. Providers should respond to these adverse events following their incident management system (Outcome 2.5).

• Providers should also report any adverse medicines-related events to the Therapeutic Goods Administration. The Therapeutic Goods Administration regulates and investigates the safety, efficacy and supply of medicines. It has a national database of medicines-related adverse events.

Put in place processes for reporting to the Therapeutic Goods Administration.

• Put in place reporting processes for all new adverse medicines-related events. Train workers and health professionals to use them. Make sure that workers and registered health practitioners know what an adverse medicines-related event is, and what their roles and responsibilities are. Depending on organisational policy, this may mean reporting to a manager or supervisor who reports issues to the Therapeutic Goods Administration.

Outcome 5.3.6

Action 5.3.6 relates to monitoring, evaluating and improving the medication management systems and processes described in Actions 5.3.1 to 5.3.5.

Put in place systems to monitor and evaluate safe and quality use of medicines.

• Develop policies, procedures and guidelines for the systematic monitoring and evaluation of medication management processes and outcomes. Make sure these are endorsed by the organisation’s medicines governance group. For example, the Medication Advisory Committee in residential aged care.

Put in place processes to monitor, review and improve medication management.

• Consider how to monitor for updates to relevant legislation and guidelines, put in place changes and evaluate your organisation’s compliance.
• Consider how to assess if your medication management system is successful in incorporating safe and quality use of medicines in the everyday care of older people.
• Consider how to monitor if your medication review processes are being performed regularly and when clinically indicated. Also, if your organisation communicates and acts on recommendations. This may include:
  • reviewing how regularly routine medication reviews happen for each older person
  • reviewing records to assess how often outcomes of reviews and plans of action are documented
  • reviewing records to assess how often follow-up actions are taken after medication reviews.
• Strategies for monitoring and measuring how effective your processes are may include:
  • reviewing how you comply with the documentation you need to do at the start of care and at transitions of care
  • asking older people and their supporters if they feel informed and involved as much as they want to be in decisions about their medicines. This includes in medication reviews.
• Strategies for assessing the safe and appropriate use of medicines may include:
  • monitoring trends in the rate, type and effect of medicines-related adverse events (such as those related to falls and those leading to hospital admission)
  • analysing incident reports and reviewing clinical records to identify unreported or under-reported medicines safety issues
  • collecting and reporting data against quality use of medicines indicators, which can include but may not be limited to those in the National Mandatory Quality Indicator Program.
• Based on the outcomes of your monitoring, identify and put in place quality improvement strategies for medication management. Report the outcomes of your quality improvements to:
  • the governing body
  • workers
  • older people
  • other relevant organisations depending on the service context.

Outcome 5.4.1

Put in place systems for partnering with the older person, their supporters and others in assessment and planning.

• Comprehensive clinical care systems are designed to make sure clinical care assessment and planning prioritises the needs, goals and preferences of the older person. You need to have systems that support person-centred care (Outcome 1.1) and assessment and planning (Outcome 3.1). You also need to put in place systems and processes to:
  • support older people to partner in all aspects of their care and decision-making
  • identify the older person’s preferences for involving supporters, family and carers in their care
  • support workers, registered health practitioners and allied health professionals to understand their roles and responsibilities for partnering with older people. This includes supporting older people to understand the outcomes of assessment and the role of registered health practitioners and allied health professionals in their care. This helps to inform their choices and preferences for care and services (Outcome 3.1).
  • review ongoing and end-of-life documents (this may include an advance care planning document if in place or being considered) with the older person, their supporters and others to make sure they’re complete and current (Outcome 3.1). This should be done if and when the older person chooses.

Put in place processes for partnering with the older person, their supporters and others in assessment and planning.

• Partner with older people to set goals of care through discussions about:
  • what is important to them
  • their needs and values
  • their goals for their health and wellbeing.

These discussions need to be in line with the older person’s preferences. These should also include the older person’s supporters and others they choose to involve in their care. If an older person lacks the capacity to make decisions, include their substitute decision-maker.

• Document and include goals of care in clinical assessment and the care and services plan. Regularly assess and evaluate progress towards achieving the person’s goals of care.
• Support older people to access and understand information about their clinical care services, in line with their needs and preferences (Outcome 3.1)
• Provide workers with access to training on:
  • the principles of person-centred care
  • supported decision-making
  • informed consent
  • processes to communicate with older people in line with their preferences.

Monitor, review and improve systems for partnering with older people.

• Analyse feedback from older people and others involved in their care about the quality and experience of partnership in setting goals and decision-making.
• Review clinical records to make sure goals of care are included in clinical assessments and care and services plans.
• Collect information about older people’s experiences, reviews of documentation or other reporting and monitoring activities. Use this information to improve the safety and quality of systems and processes for partnering with older people. Report the results of the work you do to improve quality to the governing body, older people and workers.

Outcome 5.4.2

Put in place processes for comprehensive clinical assessment.

• You need to have robust systems for person-centred care (Outcome 1.1), assessment and planning and reablement (Outcome 3.1). Put in place evidenced-based clinical assessment processes that:
  • identify and address how complex the older person's clinical conditions, issues and risks are. The older person’s care and services plan needs to include strategies to prevent, mitigate and escalate:
    • acute conditions
    • exacerbations of chronic conditions
    • clinical risks of harm.
  • provide opportunities for older people to maintain or regain function or skills to optimise their independence and quality of life.
• Make sure that reassessment includes evaluating whether funded aged care services are effective and optimise the older person's quality of life, while respecting their choices and dignity of risk.
• Facilitate access to the older person’s preferred GP, nurse practitioner and other appropriate registered health practitioners and allied health professionals for clinical assessment and to support continuity of care. Use telehealth where appropriate for the older person, if the provider can support a telehealth appointment.
• Make sure registered health practitioners and allied health professionals have the knowledge, training and skills to:
  • complete a comprehensive clinical assessment
  • document the outcomes of the clinical assessment and any identified risks in the care and services plan
  • communicate these outcomes to those involved in the older person’s care (Outcome 3.4).
• Make sure there are processes for workers to use assessment outcomes to inform planning for continuity of care, including at transitions of care.
• Make sure appropriate assessment is completed by a qualified registered health practitioner or allied health professional.
  • Which includes supporting older people who have difficulty communicating.

Monitor, review and improve assessment and care planning.

• Analyse clinical data and feedback about comprehensive clinical assessment such as:
  • assessment quality and frequency
  • whether the older person’s preferred GP and relevant health professionals were involved
  • how assessments are included in care planning.
• Based on the outcomes of your monitoring, identify and put in place quality improvement strategies for comprehensive clinical assessment.
• Evaluate and report on the outcomes of your quality improvement activities to the governing body, workers, older people and other relevant organisations.

Outcome 5.4.3

Put in place processes for referring to and facilitating access to registered health practitioners or allied health professionals.

Develop robust systems for person-centred care (Outcome 1.1) and the assessment, planning and delivery of care (Outcomes 3.1 and 3.2), including processes for referring to and facilitating access to registered health practitioners and allied health professionals.

• Develop referral pathways that facilitate access to a range of registered health practitioners and allied health professionals and health services. These may include:
  • GPs and other primary health care professionals
  • nurse practitioners
  • registered nurses
  • pharmacists
  • specialist doctors such as a geriatrician or neurologist
  • allied health professionals (who have distinct roles to support reablement and maintain function).
• Make sure referral pathways include ways to access:
  • geriatricians and other specialist doctors
  • dentists and oral health practitioners
  • specialist nursing services
  • clinical advisory services
  • dementia support services
  • multidisciplinary specialist teams, such as a palliative care team.
• Identify and access services that provide emergency and out-of hours clinical care services such as medical and dental services when needed.
• Support the older person’s preferences about referral to registered health practitioners and allied health professionals and services. Identify and document their current relationships with registered health practitioners and allied health professionals and private health insurance status (if they have this) to support choice and continuity of care.
• Make sure workers, registered health practitioners and allied health professionals have the knowledge and skill to identify when older people need access to specific registered health practitioners and allied health professionals. This is based on assessments completed:
  • at the start of care
  • during scheduled clinical reviews
  • in response to change or deterioration in the older person’s condition or function
  • when the older person’s needs can’t be met by the provider’s workforce.
• Based on the older person’s clinical needs and preferences, facilitate access to relevant registered health practitioners and allied health professionals and specialist services when needed.
• Have robust processes to define the roles, responsibilities and accountability for registered health practitioners and allied health professionals involved in the older person’s clinical care services (Outcome 5.1). Document the details of the older person’s preferred registered health professional who is responsible for overall care (such as the GP or nurse practitioner). Make sure up-to-date contact details are available in the provider’s system.
• Make sure workers, registered health practitioners and allied health professionals use standardised clinical communication tools such as ISBAR to support communication with registered health practitioners and allied health professionals and use standard national terminology (Outcomes 3.4 and Outcome 5.1).

Monitor, review and improve processes for referring and facilitating access to registered health practitioners and allied health professionals.

• Collect, analyse and report data on referrals to registered health practitioners and allied health professionals and health services, including barriers to access and waiting times.
• Support effective partnerships with registered health practitioners and allied health professionals and services to address any barriers to access.

Outcome 5.4.4

Put in place processes to deliver multidisciplinary care.

• Have robust processes for delivering person-centred, holistic and comprehensive care in partnership with the older person. This care needs to address the older person’s goals of care, needs and preferences (Outcome 1.1 and 3.2). Carers, family and supporters are involved in line with the older person’s wishes.
• Develop robust processes in Action 5.4.3 and Outcome 5.1 to collaborate with the multidisciplinary team to:
  • define roles and responsibilities of members of the multidisciplinary team
  • review clinical needs and goals of care with the multidisciplinary team
  • share relevant clinical information with the multidisciplinary team, with the older person’s consent
  • support workers to develop skills in effective multidisciplinary teamwork and communication.
• Have robust processes for access to after-hours and urgent clinical care services when you identify clinical deterioration and need to escalate. This needs to be in line with the older person’s goals of care.
• Consider how your service supports virtual care arrangements.
• Have robust communication processes and protocols for notifying relevant people about clinical incidents or changes, including:
  • GPs and other registered health practitioners and allied health professionals
  • substitute decision-makers
  • the older person’s supporters, family and carers.

Examples include notification of a fall, transition of care, changes in clinical condition and incidents.

• Make sure effective communication is supported by documenting and sharing care and services plans and clinical information where appropriate.

Monitor, review and improve processes for multidisciplinary care.

• Consider strategies for monitoring and measuring the effectiveness of your processes to deliver comprehensive care.
• Identify areas of improvement when communicating and working with a multidisciplinary team.
• Make sure the monitoring and measuring of the delivery of comprehensive care includes:
  • reviews of care and service plans
  • assessment outcomes
  • timely access to registered health practitioners and allied health professionals that is in line with the older person’s needs and preferences.
• Consider incidents and indicator data to identify areas of improvement for delivering comprehensive care, such as the processes for access to after hours and urgent care.

Outcome 5.4.5

Put in place processes for clinical monitoring and reassessment.

• Develop robust systems for person-centred care (Outcome 1.1) and care planning and delivery (Outcomes 3.2 and 3.3). Do this by putting in place processes to support timely monitoring and reassessment of clinical conditions, including:
  • recognising and responding to signs and symptoms of clinical deterioration in an older person’s behaviour, cognition, mental, physical or oral health, and at transitions of care
  • developing and using escalation pathways for older people’s care
  • providing ways for older people, supporters, substitute decisions-makers, carers and family to escalate concerns about changes or deterioration in an older person’s condition
  • reviewing and evaluating the effectiveness of comprehensive care regularly. You also need to review when someone is transitioning between care, experiences clinical deterioration or changes in needs. This is done in partnership with the older person, a multidisciplinary team, the older person’s supporters and others they wish to involve such as carers and family.
• Train and support workers and health professionals to identify, monitor and respond to changes or clinical deterioration This should be in line with their scope of practice.

Monitor, review and improve processes for clinical monitoring and reassessment.

• Review feedback about how timely and appropriately workers, registered health professionals and allied health practitioners respond to change or deterioration.
• Review and analyse clinical assessment, monitoring and documentation of the older person’s clinical condition to identify areas for improvement.
• Use outcomes from this review to improve how you respond to clinical deterioration.

Outcome 5.5.1

Identifying, monitoring and managing clinical risks should be carried out in line with the principles of care planning, clinical governance and comprehensive care (Outcomes 3.1, 5.1 and 5.4). This is so older people can access registered health practitioners and allied health professionals who have the appropriate skills with a scope of practice to manage and treat their clinical care needs.

• Meeting clinical care needs includes providing older people with the information they need to make decisions about their care and making sure the person’s goals and preferences guide decisions. This includes supporting dignity of risk (Outcome 1.3).
• Registered health practitioners and allied health professionals referenced in these key tasks may include:
  • GPs and other primary health care professionals
  • geriatricians and other specialist doctors
  • nurse practitioners and specialist nurses
  • registered nurses
  • enrolled nurses
  • pharmacists
  • allied health professionals
  • oral health practitioners
  • multidisciplinary specialist teams, such as palliative care teams.
• Providers should partner with older people and make sure they have access to, and understand, the information they need to make decisions about their care so they can give informed consent.
• Consider how you can support older people to maintain function through understanding what skills and supports allied health professionals can offer to the older person.

Put in place systems to promote clinical safety, particularly for identified high impact and high prevalence areas of risk.

• Using contemporary evidence and input from qualified registered health practitioners and allied health professionals, have robust systems that include processes to:
  • identify, monitor and respond to clinical risks
  • escalate care
  • support older people to take part in activities that reduce clinical risk, optimise reablement and maintenance of function.
• Define workers’ roles and responsibilities for delivering clinical care services. Document outcomes of assessment and clinical care needs.

Put in place processes for clinical safety

Have robust processes to support appropriately skilled and qualified workers to:

• identify clinical care needs:
  • at the start of care
  • regularly during scheduled clinical reviews
  • when there is a change or deterioration in an older person’s health.
• use validated assessments and refer to a qualified registered health practitioner or allied health professional as agreed with the older person.
• document outcomes of assessment and the treatment options as agreed with the older person in the clinical information system
• monitor outcomes of assessment and care, working with appropriate registered health practitioners and allied health professionals, to prevent and identify deterioration
• respond to changes in an older person’s health using evidence-based approaches
• manage high impact and high prevalence risks using multidisciplinary team approaches for delivering holistic clinical care services
• make sure registered health practitioners and allied health professionals have the skills and competencies to manage and respond to the clinical care needs of older people. This includes identified areas of risk outlined in Actions 5.5.2 to 5.5.10 and other high prevalence areas of risk such as diabetes, enteral feeding, catheters and management of other invasive devices.
• consider how to transition older people appropriately and safely from your service to a health service. This includes sharing the necessary clinical information to care for the older person in a timely way.

Monitor and review the effect of clinical safety risks and improve the safety of clinical care services.

• If you identify inappropriate clinical actions, review the effectiveness of clinical decision making, processes for escalation and treatments. Use this information to improve care.
• Providers should use clinical data to monitor clinical safety in their service.

Outcome 5.5.2
Choking and swallowing

Follow the principles of care planning and comprehensive care as described in Outcomes 3.1 and 5.4. It’s important that an older person’s eating, drinking or swallowing difficulties are identified, assessed and safely managed by an appropriate registered health practitioner or allied health professional in a timely way. This needs to be in line the person’s needs and preferences. This may mitigate the risk of choking and other adverse outcomes.

Put in place processes to support safe eating, drinking and swallowing.

• Make sure the processes you develop to support safe eating, drinking and swallowing:
  • are evidence-based
  • have input from, and regular review by, qualified health professionals such as speech pathologists and dietitians.
• Support and train workers to understand their roles and responsibilities for eating, drinking and swallowing difficulties. This includes:
  • identifying risks to older people when providing food, fluids, oral care and medicines
  • responding to choking incidents in an emergency
  • making sure food and fluids are provided safely, and that supervision and assistance is provided when needed. Also, making sure workers understand best practice for preparing and providing texture modified food and thickened fluids in line with frameworks used.
  • accessing and using documented information about the older person’s safe eating, drinking and swallowing strategies, needs and preferences
  • using the incident management system to record, investigate, manage, and respond to choking and swallowing incidents
  • escalating care to supervisors and qualified registered health practitioners and allied health professionals when needed.
• Put in place processes so you can partner with the older person and their supporters to make informed decisions and to agree on strategies for managing risks around eating, drinking and swallowing. This must include getting the older person’s consent and making sure they have enough information to make decisions and give informed consent on the planned approaches for eating and drinking.
• Registered health practitioners and allied health professionals such as trained registered nurses or GPs can screen at the start of care and on a regular basis for eating, drinking or swallowing difficulties using a validated assessment tool. This may include recommending a simpler textured food, however should not include modifying or thickening fluids. They can manage risks in line with the service’s policy and as supported by a speech pathologist until a full speech pathologist assessment is completed in a timely way.
• Make sure eating, drinking and swallowing assessments are completed by a speech pathologist when risks are identified.
• Make sure the outcomes of the speech pathology assessment are documented in a report, with recommended management strategies, to reduce risks during:
  • eating
  • drinking
  • swallowing. For oral medicines, speech pathologists should refer to the prescriber and pharmacist for appropriate substitutions or alternative routes of medication provision. This should be documented in the older person’s care and services plan and medication plan.
  • oral care.
• Make sure relevant registered health practitioners and allied health professionals know about the outcome of assessments, such as the need for a nutrition and hydration review due to changes in clinical care needs.
• If the older person makes an informed decision to eat and drink food and fluids that they choose rather than what has been recommended by registered health practitioners and allied health professionals, make sure appropriate guidance is in place such as an eating and drinking with acknowledged risk (EDAR) management plan.
• Document the individualised risk mitigation strategies agreed on with the older person in all documentation where information relating to eating and drinking is recorded.
• Make sure necessary care changes are put in place when recommended by a qualified registered health practitioner or allied health professional including texture-modified foods and thickened fluids. These must be agreed on with the older person.

Monitor, review and improve processes to support safe eating, drinking and swallowing.

• Regularly review formal policies for safe eating, drinking and swallowing.
• Regularly review feedback to make sure you understand if the older person is satisfied with the level of input they have had into strategies to manage risk, including making decisions about their food, drink and dining experiences.
• Make sure documented incidents and outcomes of care are used to inform processes that support safe eating, drinking and swallowing and contribute to continuous improvement plans.

Outcome 5.5.3
Continence

Good continence care is very important to the health, quality of life and wellbeing of older people. Bladder and bowel problems are common in older people, particularly those with complex clinical needs. Providers need to make sure continence care meets older people’s needs and preferences, protects their dignity, and optimises their functional capability.

Put in place processes for continence care.

• Put in place processes to make sure continence care is person-centred, evidence-based and clinically informed, through assessment.
• Provide person-centred care by partnering with the older person to find out their choice, values, goals and preferences for continence care (Outcomes 1.1 and 5.4). Providers also need to document this information. Involve carers as partners in care planning, in line with the older person’s preferences.
• Support the older person to maintain and improve their mobility and function. This includes improving the physical environment to help maintain continence and independence.
• Identify if the older person needs a comprehensive, evidence-based continence assessment. This is to identify risks and treat issues that can cause or contribute to incontinence and bladder or bowel dysfunction.
• Providers need to support the use of tools for assessment and monitoring of bowel and bladder symptoms. Use the assessment to inform continence planning, care and evaluation.
• Assessment includes review of current medicines by a qualified registered health practitioner or health professional when bowel or bladder symptoms are identified, such as urinary incontinence, nocturia, constipation and overactive bladder.
• Consider different approaches when incontinence or other bladder or bowel problems are identified. Lifestyle interventions may be considered as a first line therapy.
• Facilitate access to relevant registered health practitioners and allied health professionals to support continence care when needed (Outcome 5.4). This may include assessment by a continence nurse.
• Make sure a suitably qualified registered health practitioner or allied health professional assesses the need for dietary changes to manage incontinence or other bladder or bowel symptoms such as constipation. Registered health practitioners and allied health professionals can include a continence nurse, GP or dietitian.
• Make sure strategies are in place to support both older people and workers to prevent, identify and manage urinary tract infections.
• Identify, assess, monitor and evaluate decline in skin integrity and IAD. This includes putting in place a skincare program for preventing and managing incontinence associated dermatitis (IAD) when needed.
• Prevent, identify and manage constipation with regular assessment and evidence-based tools. This may include assessment by a continence nurse, GP or dietitian.
• Make sure the use of continence aids and products meet the older person’s clinical needs and preferences.
• Make sure workers, registered health practitioners and allied health professionals have the required knowledge and skills to meet continence care needs. Make sure workers understand and communicate changes in an older person’s continence needs, or signs of IAD, and put in place strategies to reduce risk.

Monitor, review and improve processes for continence care.

• Review incidents and feedback from the older person, supporters, family, carers and workers about continence care and if toileting assistance is:
  • timely
  • meets the older person’s needs
  • in line with their preferences.
• Consider how workers deliver continence care to support the older person’s dignity, comfort, functional capacities and mobility.
• Regularly monitor the older person to make sure that adequate continence products are available and provided.

Outcome 5.5.4
Falls and mobility

Falls are a major cause of harm to older people. Many falls can be prevented by a combination of interventions tailored to the risks and needs of each older person. Falls prevention interventions:

• are planned and delivered in line with the older person’s goals and preferences
• respect an older person’s dignity of risk.

Working with multidisciplinary teams, older people, supporters, family and carers is important for falls prevention.

Put in place processes to minimise falls and fall-related harm.

• Put in place person-centred, evidence-based and best practice guidelines for falls prevention in residential services, community and home settings. These need to be in line with the type of services provided and the context where care is delivered.
• After an older person falls, undertake a post fall assessment, monitor and escalate for review by an appropriate registered health practitioner or allied health professional. This can include medication reviews. Update the care and services plan with assessment outcomes (Outcome 3.1).
• Facilitate access to registered health practitioners and allied health professionals when needed, after talking with the older person. This can include GPs, nurse practitioners, registered nurses, pharmacists and allied health professionals such as:
  • physiotherapists
  • occupational therapists
  • exercise physiologists
  • dietitians

  • podiatrists.

    They can carry out assessments, treatment, ongoing evaluation and monitoring of falls prevention approaches.

• Make sure workers, registered health practitioners and allied health professionals are given training in falls prevention and decline in an older person’s mobility or function (Outcomes 3.1 and 3.2).

Monitor, review and improve processes to reduce falls and harm from falls

• Use the incident management system to analyse data on falls and harm from falls to review processes and outcomes of care.
• Monitor the timeliness of access to registered health practitioners and allied health professionals, equipment and devices. Also, address access barriers.
• Consider feedback from older people, workers and others about falls prevention strategies, including any dignity of risk considerations.

Outcome 5.5.5
Nutrition and hydration

Preventing and responding to malnutrition and dehydration in a timely way is important as these conditions carry high risk of rapid clinical deterioration.

Put in place processes for maintaining nutrition and hydration.

• Make sure policies, procedures and processes are in line with contemporary, evidence-based practice guidelines and are developed in consultation with a dietitian. This is to identify, prevent and manage malnutrition and dehydration.
• Make sure workers, registered health practitioners and allied health professionals talk with the older person about their needs and preferences for preventing and managing malnutrition and dehydration. This includes cultural safety considerations, especially for older people who come from diverse backgrounds and have lived experience of trauma (Outcome 1.1). Document these in their care and services plan.
• Include prevention of malnutrition and dehydration in the delivery of aged care services, including (as relevant to the service):
  • making sure appropriate and varied foods and fluids with adequate nutrients are available that provide the opportunity to meet nutrition and hydration needs
  • considering the impact of chronic conditions
  • considering and minimising the impact of medicines on risk for malnutrition or dehydration, including unplanned weight loss or gain, changes to appetite and bowel changes
  • facilitating access to dietitians, speech pathologists, pharmacists, GPs, occupational therapists, other allied health and specialists when clinically indicated.
• Define workers’ roles and responsibilities to prevent malnutrition and dehydration and escalate concerns early. Identify tools and document processes for workers to monitor nutrition and hydration. These workers must be qualified and working within their scope of practice or role description.
• Put in place processes to identify dehydration and malnutrition early. Then, assess and manage these conditions. This includes:
  • screening, using a tool validated in aged care, to regularly assess nutrition and hydration and document findings. This includes rescreening in line with contemporary, evidence-based practice.
  • monitor and document the fluid intake and output of older people assessed as being at risk of or experiencing dehydration. The factors that put an older person at a higher risk of dehydration can include advanced cognitive impairment, for example, living with dementia (Outcome 5.6), medications (such as diuretics, laxatives), limited oral intake and acute illness. Use the information you gather to recognise and respond to inadequate fluid intake and dehydration risk in a timely manner.
  • monitor and document the hydration and nutrition status of older people who are identified to be at risk of or experiencing malnutrition. Use the information you gather to recognise and respond to inadequate intake and malnutrition risk in a timely manner.
  • think about and include the older person’s needs and preferences when monitoring their hydration and nutrition.
  • clinically assessing, reviewing and managing concerns regularly and as clinically indicated in line with contemporary, evidenced based practice. This needs to be done by a multidisciplinary team of qualified registered health practitioners and allied health professionals, including a dietitian.
  • referring for specialist clinical assessment and advice where needed
  • involving registered health practitioners and allied health professionals to decide if a nutrition or hydration intervention is effective
  • put in place recommended management strategies from registered health practitioners and allied health professionals' assessments, and documenting these in the care and services plan. Strategies may include therapeutic diets (such as high energy, high protein diet), texture-modified foods and thickened fluids. These must be in line with the older person’s preferences.
  • consider how the care, mealtime environment and access to assistive devices (as recommended by a qualified registered health practitioner or allied health professional) can optimise the older person’s independence, function and quality of life.

Monitor, review and improve processes for nutrition and hydration.

• Make sure the older person is satisfied with the strategies to manage risk. You can find this out by involving the older person in decision making and incorporating feedback.
• Have a dietitian review the documented outcomes of care (including weight and malnutrition screening) and reported incidents. Use these to support continuous improvement plans, including ongoing staff education.
• Monitor older people with chronic conditions or recent changes to medicines that may increase the risk of malnutrition or dehydration.
• Consider referral or access to registered health practitioners and allied health professionals, in line with the older person’s preferences, when chronic health conditions or lifestyle choices affect or are affected by nutrition and hydration.
• Analyse data collected and use these findings to improve care. This can include data on:
  • incidents
  • unplanned changes in weight
  • use of relevant registered health practitioners and allied health professionals
  • hospital transfers.

Outcome 5.5.6
Mental health

Mental health is a state of overall wellbeing that can be supported or improved for all older people. Changes to mental health and wellbeing is not an inevitable part of ageing.

When there are changes in the mental health of an older person, it’s important that you recognise these early and respond quickly.

Put in place processes to optimise mental health and respond to mental illness.

Put in place processes to make sure each older person is supported to maintain or improve their sense of mental health and wellbeing. This means processes which:

• encourage positive mental health for all older people in working practices
• use evidence-based strategies to promote mental wellbeing, such as:
  • serving and encouraging the eating and drinking of nutritious foods and drinks
  • encouraging and organising physical activity and sleep hygiene. Sleep hygiene is the healthy habits, behaviours and environment older people can use to help them get a good night's sleep.
  • creating settings and supports that allow social connection and reduce loneliness and social isolation
  • encouraging activities that are meaningful for people like hobbies or community groups
  • encouraging sense of coping with stress.
• define workers’ roles and responsibilities for older people’s mental health and wellbeing
• create a psychologically, physically and sexually safe setting for older people in supportive and non-restrictive ways.

Put in place processes to support recognising and responding to deterioration in mental health, to:

• prioritise working with each older person, their supporters, family and carers, to the extent the older person wants, to learn from their experience and knowledge about their own mental health. This can include knowledge about what change, or deterioration looks like for them, and strategies that have helped them maintain their mental health or cope with stress in the past.
• make sure this knowledge and experience is included in both assessing mental health needs at the start of care and planning a response to any deterioration
• identify signs of deteriorating mental health in a timely way
• escalate worker observations and concerns to qualified registered health practitioners and allied health professionals
• make sure workers are supportive and give person-centred responses to older people who are distressed or who have symptoms of mental illness (including thoughts of harm or suicide)
• make sure referral pathways are available to workers to escalate care
• make sure workers refer the person quickly if they identify deteriorating mental health. Consider locally available options, which may include referral to:
  • allied health professionals specialising in mental health
  • assessment by a GP or nurse practitioner for access to an older person’s mental health team, a psychogeriatrician, psychologist or psychiatrist.
• monitor and document:
  • changes in mental health
  • interventions and strategies used to respond to changes
  • observations of how effective interventions and strategies are.
• record in the care and services plan:
  • the outcomes of any assessments
  • recommended interventions and support strategies
  • responsibilities for implementing the recommended interventions and support strategies and reviewing progress.

Monitor, review and improve processes to optimise mental health and respond to mental illness.

• Consider how to monitor the safety and quality of the organisation’s processes to optimise mental health and respond to mental illness. Monitoring methods could include:
  • themes from incident reports related to mental health and trends in incident numbers and types
  • feedback from workers about their knowledge of and confidence in promoting mental health and responding supportively to mental illness
  • feedback from older people, their families and other supporters.
• Consider how to use the information you collect during monitoring to identify areas for quality improvement.
• Report the results of quality improvement efforts to the governing body, older people and workers.

Outcome 5.5.7
Oral health

Oral health is important for overall health, wellbeing and quality of life. In older people, poor oral health is related to:

• malnutrition
• swallowing difficulties
• pneumonia
• frailty
• systemic inflammation
• diabetes
• cardiovascular disease
• bone and joint health
• depression
• delirium
• dementia, including Alzheimer’s disease
• cancer.

Oral pain may affect an older person’s ability to eat, drink, swallow, speak and sleep. It may also affect their mood and behaviour. Older people living with cognitive impairment may find it difficult to report their own pain and discomfort. Oral health interventions:

• are person-centred
• are planned and delivered in line with the older person’s goals and preferences
• respect the older person’s dignity of risk.

Put in place processes to support the older person to maintain their oral health.

• Put in place person-centred processes (Outcome 1.1) that support the older person’s independence and functional capabilities with oral health care.
• In line with individually assessed care requirements, encourage and assist older people with:
  • natural teeth, to brush their teeth, gums and tongue
  • dentures, to brush and clean dentures.

The frequency of assistance, cleaning method and products used will vary based on individual needs and preferences, as well as recommendations by a dentist or oral health practitioner.

• Facilitate access to and use oral health products, aids and equipment.

Put in place processes to support oral health assessment and management.

• Facilitate access to oral health assessment by a dentist or oral health practitioner regularly, including on commencement of care, to identify pre-existing oral health concerns and strategies to prevent and manage issues.
• Complete an assessment of the older person’s mouth and oral cavity using a validated oral health assessment tool. This is done by a trained registered health practitioner or allied health professional, such as a registered nurse, on commencement of care, regularly and when changes or deterioration are identified.
• Dentists or oral health practitioners provide regular review and reassessment when you identify change or deterioration (Outcome 5.4). Providers should refer older people to dentists or oral health practitioners, including public dental services, in a timely way. Recognise and respond to changes in an older person’s oral health or ability to manage it themselves due to physical frailty or cognitive impairment. Escalate oral health concerns to oral and dental health practitioners.
• Facilitate access for review to other registered health practitioners and allied health professionals such as doctors, pharmacists and speech pathologists as needed, such as when dry mouth is identified or when there is polypharmacy.
• Make sure workers are trained to:
  • deliver oral hygiene (including assisted brushing). This can include supporting older people with complex needs or changed behaviours to maintain their oral health.
  • identify poor oral health and its impacts on the older person
  • refer older people to a dentist or oral health practitioner for further intervention and follow-up in a timely way.
• Identify, prioritise and deliver regular and appropriate oral care to older people with higher oral health care needs. This may include older people:
  • living with cognitive impairment
  • who are at the end of their life
  • with eating, drinking and swallowing issues
  • with dry mouth (xerostomia)
  • with altered salivation (reduced or excessive)
  • who are nil by mouth (Outcomes 5.6 and 5.7).
• Consider the link between oral health and diet and encourage nutritious food and non-sugary foods and drinks, while supporting the older person’s choice (Outcome 1.3).
• Consider the impact medicines changes have on oral health.

Monitor, review and improve processes to maintain oral health and prevent decline.

• Analyse clinical records to identify where poor oral health may be affecting the overall health of the older person. Do this in collaboration with registered health practitioners and allied health professionals or oral health practitioners and use this to improve care.
• Review clinical records on the frequency of oral health assessments. Make sure that care and services plans include oral health and the outcomes of regular oral health assessments. Include the older person’s ability to manage their own oral health and required products, aids and equipment.
• Consider how to monitor oral health, hygiene and access to oral health products to make sure older people’s needs are met.
• Use feedback from older people and workers on oral health processes to improve the quality of oral health care.
• Review and improve processes for using validated oral health assessment tools.

Outcome 5.5.8
Pain

Effective pain management is a key contributor to quality of life for older people. However, pain is sometimes difficult to identify and can be missed, especially if an older person can’t communicate their pain verbally. This means that evidence-based assessments are important in safe and quality care for pain.

Contemporary, evidence-based practice to address pain includes both nonpharmacological and pharmacological approaches. In many cases, nonpharmacological strategies can be highly effective. Strategies can include:

• psychological
• educational
• physical activity and movement
• nutritional
• complementary approaches (see Pain Management Guide Toolkit for Aged Care).

Have processes to optimise pain management.

• Put in place processes that support identifying and managing pain in a timely way. These include:
  • regular assessment by suitably qualified registered health practitioners and allied health professionals using validated assessment tools. These include tools to assess older people:
    • who cannot verbally report pain
    • experiencing delirium, dementia, cognitive impairment or sensory impairment from health conditions such as diabetes and peripheral vascular disease.
  • evidence-based strategies for pain management, including non-pharmacological options, tailored to the needs and preferences of the older person
  • monitoring and review by a qualified registered health practitioner and allied health professional such as a GP, pain specialist or pain clinic for persistent uncontrolled pain.
• Put in place processes to support registered health practitioners and allied health professionals and workers to know their roles and responsibilities to identify, assess, manage and monitor pain. These include:
  • for workers, identifying possible pain (including where the older person can’t express the severity of pain, its location or where their behaviour has changed) and escalating observations and concerns
  • for registered health practitioners and allied health professionals, assessing, planning and providing pain relief (both non-pharmacological and pharmacological) in line with the type of pain experienced and the preferences of the older person. This includes the need to monitor and evaluate the benefit of interventions.
  • updating the care and services plan, putting in place any care changes needed and informing supporters and others as appropriate.

Monitor, review and improve processes to manage pain.

• Consider how to monitor the safety and quality of the organisation’s processes to improve pain management. Monitoring could include:
  • for aged care services delivered in a residential care home, analysis of trends in older people’s responses to Question 2 of the QOL-ACC quality of life tool (this is used for the Quality of Life indicator under the National Mandatory Quality Indicator Program). The question relates to the older person’s opinion on how often their pain is managed well.
  • themes from complaints reports and other feedback from older people, their supporters, families and carers
  • feedback from workers about their knowledge of and confidence in recognising pain, including older people who have challenges communicating their pain.
• Consider how to use the information collected during monitoring to identify areas for quality improvement. Tools from the Pain Management Guide Toolkit for Aged Care such as the Pain Management Audit Checklist and the Pain Action Plan can be helpful for aged care services delivered in a residential care home.
• Report the results of efforts to improve quality to the governing body, older people and workers.
• Monitor benefits and safety of pain management processes, including escalating care of pain to qualified registered health practitioners and allied health professionals.

Outcome 5.5.9
Pressure injury and wounds

Older people’s skin is vulnerable to deterioration and breaks from pressure or other injury. Strategies to prevent wounds include regularly inspecting skin and managing other related clinical risks such as those described in Actions 5.1.3 to 5.1.10.

Using processes as outlined in Outcome 1.3 and 2.1, put in place and plan processes to prevent and manage pressure injuries and wounds in older people.

Put in place processes for preventing and managing pressure injuries and wounds. 

These include:

• using validated assessment tools to identify and assess wounds and monitor healing
• having a registered nurse or other qualified registered health practitioner and allied health professional assess the risk of pressure injuries, including but not limited to assessing:
  • the older person’s skin
  • mobility
  • existing pressure injuries or breaks in skin
  • the effect of conditions such as diabetes, incontinence and malnutrition
• personalised, evidence-based and risk-based pressure injury prevention plans.

Processes for delivery of care include:

• defining workers’ roles and responsibilities to manage skin integrity and breaks in skin integrity. Workers also need to document wound management plans to manage acute and chronic wounds, and regularly monitor wounds.
• referral pathways for escalating pressure injuries and wounds when needed
• maintaining the dignity and cultural safety of the older person when performing regular skin inspections
• referring the older person to qualified registered health practitioner and allied health professionals, to prevent wounds happening and to support wound healing
• considering nutrition assessment by a dietitian to support wound healing
• considering the benefits of maintaining or improving mobility and balance in reducing harm from pressure injuries and wounds.

Monitor, review and improve processes to prevent and manage pressure injuries and wounds.

• Consider regular reviews of processes used to monitor and respond to pressure injuries and wounds.
• Consider what effective, holistic and multidisciplinary pressure injury and wound prevention looks like in your service.
• Consider how to make sure clinical interventions follow an evidence-based pathway for wound care and that workers know what these are.
• Consider how aids and equipment, such as specialist mattresses may be accessed and used to reduce risk of pressure injuries.
• Consider the use of data, on managing and preventing pressure injuries and wounds, collected in the service, such as data on:
  • incidents
  • quality indicator data
  • hospital admissions
  • trends in data related to pressure injuries and wounds
  • feedback from older people.
• Analyse data collected to inform and develop plans for continuous improvement in relation to preventing and managing pressure injuries and wounds.

Outcome 5.5.10
Sensory impairment

Put in place processes to optimise support for people with sensory impairment.

• When putting in place and reviewing the organisation’s policies, protocols and procedures for optimal care of people with sensory impairment:
  • make sure they follow evidence-based guidelines for supporting people with vision or hearing loss and for people with balance disorders
  • support timely identification of sensory loss and development of personalised care strategies
  • define the roles and responsibilities of workers, registered health practitioners and allied health professionals in supporting an older person with sensory impairment. This may include making sure supports, such as glasses and hearing aids, are clean and functioning.
  • consider how the care setting, meal presentation and dining experience, and access to assistive devices can optimise the older person’s independence, function and quality of life. Assistive devices and aids can include hearing aids, walking aids and glasses.
  • document requirements for assistive devices in the clinical information system.
• Put in place processes to:
  • identify changes and decline in sensory function in a timely way
  • regularly monitor the older person’s hearing, vision and balance to identify changes in sensory function and to make sure aids and devices are appropriate
  • refer to specialist registered health practitioners and allied health professionals for management, including diagnosis, treatment and management of devices and aids
  • access assistive devices and aids and regularly monitor their use and how well they’re working
  • improve the care environment using strategies such as noise management, lighting, colour contrast, signage, textures and design.

Outcome 5.6.1

Put in place processes to identify and respond to complex needs.

• Put in place policies and procedures to make sure the older person’s rights to dignity, independence and choice are a part of processes to identify, monitor and provide care for cognitive impairment.
• Consider how policies, procedures and processes for the comprehensive funded aged care services delivered to people with cognitive impairment can support workers, registered health practitioners and allied health professionals to understand:
  • the range of possible physical, social, psychological and behaviour support needs associated with cognitive impairment
  • the importance of learning about the person to better identify and understand their needs, and preferences. This includes their history, personality, roles in life, values, beliefs, culture.
  • their roles and responsibilities for monitoring and mitigating clinical risks for the older person with cognitive impairment, including increasing risk of falls, pain, pressure injuries, oral deterioration, medication errors and delirium.
  • the range of potential contributing factors to cognitive and behaviour changes, including clinical, environmental and medication related factors. Consider that factors may be modifiable and require regular review to minimise impact.
• Put in place policies and procedures which explain how to identify signs of cognitive deterioration and what to do when these are identified. This includes:
  • putting in place best practice strategies for early recognition and response to acute delirium, such as those recommended in the Delirium Clinical Care Standard
  • identifying older people with symptoms of cognitive impairment, including recording information about a person’s specific diagnosis and considering referring them for specialist support services
  • identifying and addressing any clinical, psychosocial or environmental issues contributing to cognitive symptoms
  • escalating observations or concerns about cognitive change to relevant registered health practitioners and allied health professionals
  • screening and clinical assessment is completed in line with the older person’s needs and preferences. This is when cognitive impairment is first identified and when there is any change in cognitive status, including delirium.
  • identifying changing and related physical, social, psychological, communication and behaviour support needs associated with cognitive impairment. These can then be thoroughly assessed, monitored, supported and escalated as necessary.
  • assessing, managing and monitoring clinical risks including recent and repeated falls, pressure injuries, dehydration and medication changes or errors
  • documenting risks, needs and strategies to support cognitive impairment including changed behaviours in the care and services plan. This may include strategies for identifying and supporting unmet needs, mealtime support, memory support, safe movement, and managing and preventing falls.
  • identifying and addressing factors which can make cognitive or behaviour symptoms worse, as outlined in Action 5.6.3.
• Put in place processes for ongoing monitoring and response to:
  • changing clinical care needs which could include changes in behaviour, changes to medication
  • changing communication needs
  • changing daily care needs such as personal hygiene, dietary and hydration requirements.
  • need for additional care minutes from registered health practitioners and allied health professionals and workers.

Monitor, review and improve processes to identify and respond to complex needs.

• Consider how to monitor the safety and quality of the organisation’s processes to identify and respond to complex needs. Monitoring methods could include:
  • analysing trends in National Mandatory Quality Indicator Program data against indicators for clinical risks, such as hospital admissions, restrictive practices, falls and pressure injuries
  • analysing trends against relevant indicators from the Psychotropic Medicine in Cognitive Disability or Impairment Clinical Care Standard
  • themes from incident reports related to clinical risks such as falls, medication errors and pressure injuries
  • feedback from workers about their knowledge of and confidence in identifying and responding to complex needs
  • feedback from older people with cognitive impairment, their supporters and others about whether they feel that their full range of needs are understood and supported.
• Consider how to use the information collected during monitoring to identify areas for quality improvement.
• Consider how to measure if quality has improved.
• Report the results of quality improvement efforts to the governing body, older people and workers.

Outcome 5.6.2

Put in place processes to partner with older people with cognitive impairment.

Put in place policies and procedures that support collaboration, effective communication and shared decision-making between workers, registered health practitioners and allied health professionals and the older person, their supporters and others they may want to involve, such as family and carers (Outcome 3.2).

This can include:

• developing or identifying information on care for people with cognitive impairment that is easy to understand. Then, making this information available to the older person and their supporters (where required) in several formats.
• providing workers with access to training on how to identify individual communication needs, and on methods for communicating with the older person, their family and other supporters to understand:
  • the person
  • their preferences
  • interests
  • goals
  • preferred support strategies (as part of training activities specified in Action 2.9.6).
  • documenting the older person’s preferences and goals of care in their care and services plan and, when needed, in their behaviour support plan (Action 5.6.3).

Monitor, review and improve processes to partner with older people with cognitive impairment.

• Consider how to monitor the quality of the organisation’s partnerships with older people with cognitive impairment. Possible ways to achieve this include:
  • feedback from workers about their ability to partner with older people, their families and other supporters in a meaningful way
  • feedback from older people with cognitive impairment, their families and other supports:
    • whether they’re involved as much as they can or want to be in decisions about their care.
  • whether they feel their needs and preferences inform the strategies used to prevent and reduce the impact of distress from changed behaviours.
• Use the information to consider where there are opportunities for quality improvement in partnering with older people with cognitive impairment.
• To close the feedback loop, monitor the impact of any quality improvement activities and report these to the governing body, older people and workers. Closing the feedback loop is following up with the older people, their supporters, families and workers who have provided you with feedback.

Outcome 5.6.3

Put in place processes to prevent and support changed behaviours.

• Consider how to make sure that care is informed by assessment and understanding of any clinical, situational, psychosocial and environmental factors that may cause changed behaviours for an older person. Avoid assumptions that changes are caused by cognitive impairment.
• Identify and reduce stressors in the care environment and the day-to-day routines and processes that can increase the risk of acute behaviour changes happening.
• Put in place non-pharmacological strategies known to be effective and acceptable to the older person, as identified in Action 5.6.2, such as:
  • access to outdoor spaces
  • engagement in meaningful activities and interests, to reduce distress or harm, and changes in well-being from changed behaviours and to minimise use of restrictive practices (Outcome 3.2).
• Put in place assessment processes to respond to changed behaviours that include:
  • making sure the immediate safety of the older person and others is maintained
  • identifying factors that could cause changes, including needs that haven’t been met, environmental, malnutrition, dehydration, delirium, pain, eating or drinking, swallowing and medication changes
  • identifying each older person’s psychosocial and support needs
  • involving supporters, carers and family, or others who know the person (when relevant)
  • referring to behavioural support specialists/ services and allied health professionals when needed for aged care services delivered in a residential care home, home or community setting, as outlined in Action 7.2.3.
• Make sure person-centred, accessible and effective behaviour support plans are in place (in the care and services plan) and effectively implemented for the older person with changed behaviours.

Monitor, review and improve processes to prevent and manage changed behaviours.

• Consider how to monitor the safety and quality of the organisation’s processes to prevent and support changed behaviour. Monitoring methods could include:
  • analysing trends in Mandatory Quality Improvement Program data against indicators for restrictive practices and use of psychotropic medicines for residential services
  • analysing trends against relevant indicators from the Psychotropic Medicine in Cognitive Disability or Impairment Clinical Care Standard
  • considering themes from incident reports related to changed behaviours and trends in incident numbers and types
  • feedback from workers about their knowledge of and confidence in strategies to prevent and support changed behaviour
  • feedback from older people with cognitive impairment, their families and other supporters about whether they feel their needs and preferences inform the strategies used to prevent and reduce the impact of distress from changed behaviour. You should have processes to review and revise the behaviour support plan regularly or when there is a change in the older person’s circumstances.
• Consider how to use the information collected during monitoring to identify areas for quality improvement.
• Consider how to measure if quality has improved.
• Report the results of quality improvement efforts to the governing body, older people and workers.

Outcome 5.7.1

Put in place processes for recognising and preparing for palliative care and the end of life needs.

• Put in place person-centred, culturally safe processes (Standard 1) to recognise older people who are approaching the end of their life. As well as those who could benefit from palliative care. These processes can include:
  • supporting workers, registered health practitioners and allied health professionals to use risk prediction tools, trigger tools and questions
  • communicating with the older person, their supporters and others involved in the older person's care to identify signs they may be approaching the end of their life (Outcome 1.3)
  • identifying and managing acute deterioration that may be able to be reversed in line with the older person’s wishes.
  • involving the older person’s GP or nurse practitioner in discussions about diagnosis and prognosis as the older person approaches the end of their life.
• Facilitate access to registered health practitioners and allied health professionals to review medication to look at whether the older person’s medications should be de-prescribed or stopped. As well as looking at safe ways to administer medication. This is done is discussion with the older person and in line with their goals of care.
• Plan for anticipatory medicines and put in place processes for safe use and administration (when needed).
• Plan for and facilitate access to equipment, aids and devices. Make sure that workers, registered health practitioners and allied health professionals and carers are trained and confident using them.
• Make sure that workers have the knowledge and skills they need and can confidently recognise when an older person is approaching the end of their life. They also need to be able to perform their role within their scope of delivering clinical care services and where they deliver care.

Monitor, review and continuously improve how your organisation recognises palliative care and end-of-life.

• Collect and analyse data from evaluation, reviews and feedback. Use this to improve how you and your workers recognise and respond to care needs at the end-of-life.
• Look at feedback about the experiences of older people, supporters, substitute decision-makers, carers and family about how you and your workers supported them to prepare for end-of-life.

Outcome 5.7.2

Put in place processes for end-of-life planning.

• Build on the organisation’s systems and processes for:
  • person-centred care (Outcome 1.1)
  • dignity, choice, independence and quality of life (Outcomes 1.2 and 1.3)
  • assessment and planning (Outcome 3.1)
  • comprehensive care (Outcome 5.4).
• Put in place processes for end-of-life planning and making decisions that:
  • are culturally and psychologically safe, trauma aware and healing informed
  • support the older person to have ongoing end-of-life planning conversations with workers, registered health practitioners and allied health professionals and others. The planning and conversations should be in line with the older person’s preferences. For example, including supporters, carers and family in these conversations.
  • include reviewing advance care planning documents with the older person in line with their preferences.
• Workers, registered health practitioners and allied health professionals are trained and supported to have end-of-life conversations that are person-centred.
• End-of-life planning conversations should seek to find out what is important to the older person at the end of their life, including the place the older person would wish to be at the end of their life.
• Include the older person’s GP or nurse practitioner in discussions about diagnosis, prognosis and options for a coordinated planning and delivery of end-of-life care.
• Assist the older person to make their own decisions with supported decision making, when needed.
• Communicate with the person’s substitute decision-maker when an older person lacks capacity to take part in making decisions.
• Make sure policies and processes for advance care planning documents and substitute decision-making are in line with your state or territory legislation. Workers, registered health practitioners and allied health professionals also need to understand these.
• Store and manage advance care planning documents securely (including appointments of a substitute decision-maker). This makes sure they can be easily accessed and regularly reviewed, while maintaining privacy.
• Share current advance care planning documents when needed with the older person’s consent, particularly:
  • at transitions of care
  • with paramedics on transfer to hospital.
• Explain to older people that, with their consent, their advance care planning documents can be uploaded to My Health Record.

Monitor, review and improve processes to support older people at the end of life.

• Monitor how well your organisation is supporting advance care planning in everyday practice. This includes advance care planning reviews and assessment on:
  • how you receive, store and manage advance care planning documents
  • how you review, follow and share with health professionals’ advance care planning documents
  • how you manage and share advance care planning documents to ensure relevant health professionals and services have access when needed, such as during transitions of care.
• Analyse feedback from older people about the quality of end-of-life planning conversations.
• Consider how effective your processes are for supported decision-making when an older person’s capacity to make decisions about their own care is reduced.

Outcome 5.7.3