Intent of this requirement
This requirement is about making sure that assessment and planning are effective. These processes will support organisations to deliver safe and effective care and services.
Relevant risks to a consumer’s safety, health and well-being need to be assessed and included in planning a consumer’s care. This supports consumers to get the best possible care and services and makes sure their safety, health and well-being aren't compromised.
To assess, plan and deliver care and services that are safe and effective, members of the workforce need to have the relevant skills, qualifications and knowledge to assess individual consumers’ needs and to understand their needs, goals and preferences.
When two or more organisations share the care and services for a consumer, or where there are integrated care and services, there need to be arrangements in place to share and combine relevant information. This includes information about any risks to the consumer’s safety, health and well-being. Organisations will need to comply with obligations relating to privacy of information when coordinating care with other organisations, individuals and service providers.
- What assessment and planning processes enable consumers, their representatives, the workforce and others, to work together in developing a safe and effective care and services plan?
- How does the organisation use information from other sources, such as government assessment services, when developing assessment and planning methods?
- Do the workforce use validated risk assessment and planning tools? Do they ask for input from relevant, qualified practitioners about assessing and managing specific and common risks for older people? This may include diseases or conditions such as incontinence, hearing loss and cognitive impairment.
- How does the organisation know and measure whether assessment and planning processes are resulting in safe and effective care and services? How does the organisation monitor how effective the care and services plan is in meeting the consumer’s goals?
Examples of actions and evidence
- Consumers say their care is well planned to meet all their needs.
- Consumers say they feel safe and confident because members of the workforce took the time to listen and understand how to support their health and well-being.
- Where it applies, consumers can give examples of how their care and services plan includes input from relevant practitioners to work out the help they need for day-to-day living activities.
- Consumers describe how the workforce took a problem-solving approach to managing or minimising risk or meeting their needs, goals and preferences where a solution wasn’t obvious.
Workforce and others
- The workforce can describe the assessment and care planning processes and how they inform how care and services are delivered.
- The workforce can describe how they assess risk, and how they work together with consumers to minimise risk.
- The workforce can describe how they can access appropriately skilled individuals or service providers to contribute to assessing and planning safe and effective care. (For example, input into planning for emotional health and well-being, clinical and personal care, continence management, dietary requirements, eating aids and assistance, mobility aids and assistance, and hearing, visual or communication assistance).
- The workforce can describe how consumers, and others who contribute more broadly to care and services (such as medical professionals), work together to deliver a tailored care and services plan, and monitor and review the plan as needed.
- Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.
- Evidence that shows members of the workforce are clear on who is accountable within the organisation for assessing, planning and reviewing the care and services needs of consumers.
- Records that show how members of the workforce consider risk with the consumer during assessment and planning to make sure care and services are safe and effective.
- Evidence of how the organisation makes sure workforce assessment and planning skills match the type and complexity of the consumer’s needs, such as specialised clinical skills or particular cultural skills.
- Evidence that when validated assessment tools are available (including risk assessments), they are used the workforce in assessment and planning for consumers’ care and services.
- Evidence of guidance for relevant members of the workforce on undertaking assessment and planning in a culturally safe way, tailored to the needs of each consumer.
- Evidence of how assessment and planning processes (and documents) inform safe and effective care and services, including where care and services are shared with other organisations.
- Evidence of the organisation monitoring assessment and planning tools and processes to make sure they are effective and are identifying and addressing the needs of consumers.
- Records that show how the organisation monitors, reports and continuously improves assessment and planning of care and services.