Standard 8 - Requirement (3) (d)

Intent of this requirement

Organisations are expected to have systems and processes that help them identify and assess risks to the health, safety and well-being of consumers. If risks are found, organisations are expected to find ways to reduce or remove the risks in a timeframe that matches the level of risk and how it’s affecting consumers.

It’s expected that the organisation’s risk management system identifies and evaluates incidents and ‘near misses’ (both clinical incidents and incidents in delivering care and services). It’s also expected that the organisation uses this information to improve its performance and how it delivers quality care and services.

Organisations are expected to escalate risks to the health, safety and well-being of their consumers within the organisation or to a relevant external service or organisation. It’s also expected that organisations continue to monitor risks to consumers and others and take action if a risk has increased.

In particular effective risk management systems and practices are required in the following areas:

a.      Managing high-impact or high-prevalence risks associated with the care of consumers
While organisations need to manage all risks related to care and services, some risks are more common and have a higher impact on the health and well-being of consumers. Preventable harm from these risks continues to happen in aged care. Sound governance systems are required to support the delivery of care under Standard 3. Personal and Clinical Care.

b.      Identifying and responding to abuse and neglect of consumer
All Australians have rights, which do not diminish with age, to live dignified, self-determined lives, free from exploitation, violence and abuse. The organisation is expected to have systems to provide appropriate protections and safeguards around the delivery of care and services, to respond effectively to incidents of abuse, to report this according to the law, and to raise awareness in the organisation to lower the risk of elder abuse.

c.       Supporting consumers to live the best life they can
Organisations are expected to have systems and processes to reduce the possibility of risks and the impact they have on consumers however, this should be in consultation with consumers to support them to live the best life they can. These systems underpin outcomes under Standard 1 and delivery of care and services under Standard 3 and Standard 4.

Reflective questions

• Does the organisation have systems for identifying, minimising and managing risks to the safety and well-being of consumers? What are the systems to manage high-impact, high-prevalence risks and how are these systems reviewed to keep improving outcomes for consumers?
   
• How does the organisation make information about current procedures and guidance for managing risks available to consumers, representatives the workforce and others?
   
• Does the workforce know what harm, abuse and neglect looks like? How does the organisation support its workforce to understand their roles and responsibilities for preventing and reporting abuse?
   
• Does the organisation have strategies to make sure that responses to allegations of harm use the principles of natural justice? Does the organisation support all parties during an investigation?
   
• How does the organisation support the workforce to use a problem-solving approach to respect a consumer’s wishes to act independently, but also to identify and reduce risks so they can support their independence as safely as possible?

Examples of actions and evidence

Consumers

• Consumers say organisational decisions on how to reduce possible or real risks are made with them and they feel their opinions are heard. 
   
• Consumers say the organisation responds promptly to charges or concerns about harm, abuse and neglect.
   
• Consumers feel comfortable with how the organisation balances risks and quality of life. They feel they are living the best life they can.

Workforce and others

• The workforce can describe how they try to reduce common and high-impact or high-prevalent risks to health and well-being. They can also describe how the way they do this supports consumers’ dignity and quality of life.
   
• The workforce can describe what their responsibilities are in investigating and recording any charge or instance of harm, abuse or neglect and where to go for advice if they need it.
   
• The workforce describe how the systems and processes for safely delivering clinical care are reliable. They also say they have the chance to take part in designing, monitoring and evaluating these systems.
   
• The workforce can demonstrate their knowledge of the organisation’s legislative reporting requirements of harm, abuse or neglect as it relates to their role and responsibilities.
   
• The workforce can describe the organisation’s reporting systems for ‘near misses’ and incidents. They can also describe the processes for managing risks related to their role in the organisation.
   
• Evidence that the organisation’s training around safeguarding is delivered in a way that is relevant to different roles. The workforce can describe how they are able to recognise different types of abuse or neglect and the ways they can report concerns.
   
• The workforce can give examples of respecting consumers’ wishes and how they have identified and reduced risks to support their independence as safely as possible.

Organisation

• Records show the organisation has trained the workforce that any control, restraint or restrictive practice is only used when absolutely necessary, and any use of restraint is in line with up-to-date national guidance and best practice, and as a last resort.
   
• Records show the organisation reports notifiable incidents appropriately.
   
• Records show the organisation continually monitors risks to consumers and takes appropriate action if a risk has increased.
   
• Evidence that the organisation uses effective investigation as soon as it’s aware of any allegation or evidence of harm, abuse or neglect. Evidence shows that the organisation also refers the case to the correct body in line with legislation.
   
• Evidence that the organisation monitors systems that can identify possible abuse such as reports of incidents and complaints. Evidence shows that the organisation also takes steps to stop the abuse and reports it as required by law.
   
• Evidence of ways in which the organisation has strengthened systems for prevention of abuse and neglect. This can include asking for specialist advice or support.
   
• Evidence and examples of how the organisation shows, monitors and reports how it performs against this standard. Examples of continuous improvement against this requirement.

Back to Standard 8. Organisational governance.

Back to new Aged Care Quality Standards.