Clinical care | Aged Care Quality and Safety Commission

Disclaimer: This information remains in draft and will be finalised after the Aged Care Rules come into force. This information is a guide only and is not prescriptive or exhaustive.

Please check back as the Commission are regularly making changes.

Last updated - Version 0.3

This document was updated on 09 April 2025. Learn what has changed.

I receive person-centred, evidence-based, safe, effective, and coordinated clinical care services by health professionals and competent aged care workers that meets my changing clinical needs and is in line with my goals and preferences.

- Expectation statement for older people

Intent of Standard 5

The Clinical Care Standard describes the responsibilities of providers to deliver safe and quality clinical care services to older people. The governing body has overall responsibility to ensure a clinical governance framework is implemented and to monitor its effectiveness in supporting aged care workers to deliver quality clinical care services. Providers operationalise the clinical governance framework and report on its performance.

Many older people who require clinical care services have multiple chronic co-morbidities and complex care needs. These people may be experiencing sickness, frailty, disability, cognitive impairment or be nearing the end of their life. Access to a range of health professionals is crucial to address these complex needs. Quality clinical care services can optimise an older person’s quality of life, reablement and maintenance of function. Improved health and wellbeing supports continued participation in activities that are enjoyable and give life meaning.

At all times, clinical care services provided should be person-centred, inclusive, safe, effective and coordinated. It should be planned and delivered in partnership with the older person, involving their supporters and others in line with the older person’s needs and preferences. Delivering safe, quality clinical care services requires a multidisciplinary approach with a skilled workforce with clear accountabilities that are supported to deliver contemporary, evidence-based care. Allied health professionals have distinct roles in reablement and maintenance of an older person’s functional capabilities.

Effective implementation of Standard 5 is reliant on the systems and processes from Standards 1–7. Standard 5 does not seek to replicate the base expectation of understanding the person in Standard 1 or the base planning, assessment and delivery expectation of Standard 3. For example, implementation of processes for advance care planning in action 3.1.6 is critical to quality clinical care, including at the end of life (action 5.7.2). These systems and processes establish a baseline expectation which supports the delivery of person-centred and safe clinical care services, ensuring that risks of harm to older people from clinical care services are minimised and support continuous quality improvement.

Updates to guidance

An updated version of the strengthened Standards was published by the Department of Health, Disability and Ageing on 18 February 2025. Please see here for more information Strengthened Aged Care Quality Standards – February 2025 | Australian Government Department of Health, Disability and Ageing.

The Commission is currently updating our guidance content to reflect these changes. Please ensure you check back regularly.

What are the outcomes you need to achieve?

This standard contains the following outcomes

Outcome 5.1: Clinical governance

Governing body
Routinely collected information
Standard national terminology
Clinical governance
Conformant software
Scope of practice
Roles and responsibilities
Clinical information system
External health professionals ( for Outcome 5.1)
Healthcare Identifiers
Interoperability
My Health Record
Coordination of care

Outcome 5.2: Preventing and controlling infections in delivering clinical care services

Antimicrobial resistance (AMR)
Antimicrobial stewardship
Aseptic technique
Infection Prevention and Control (IPC) Lead
Infection control
Infection prevention
Invasive devices

Outcome 5.3: Safe and quality use of medicines

Medication administration
Medication management system
Quality use of medicines (QUM)
Medication review
Polypharmacy
Medicine side-effect
Medicine related adverse event
Psychotropics medicines

Outcome 5.4: Comprehensive care

Comprehensive care
Comprehensive clinical assessment
Reablement
Reassessment
Telehealth
Introduction, Situation, Background, Assessment, Recommendation (ISBAR) framework
Multidisciplinary care
Goals of care
Deterioration

Outcome 5.5: Safety of clinical care services

Sensory impairment
Eating and drinking with acknowledged risk (EDAR)
Incontinence
Incontinence associated dermatits
Falls
Functional decline
Mental health
Mental illness
Psychological safety
Wellbeing
Oral health
Oral hygiene
Preventative
Pain management
Pain-related communication barriers

Outcome 5.6: Cognitive impairment

Cognitive impairment
Behaviour Support Plan
Changes in behaviour
Restrictive practices

Outcome 5.7: Palliative care and end-of-life care

Anticipatory Medicines
End-of-life
Recognizing End-of-life
Advance care planning
End-of-life planning conversations
Bereavement support
Last days of life
Spiritual care

Key tasks

Governing body

Information for governing bodies*

This guidance should be read in conjunction with Quality Standard 2 which relates directly to the governing body*.

The governing body* plays an important role in aged care and services. They’re responsible for an organisation delivering quality care* and services (Outcomes 2.2 and 2.3).

The governing body* needs to:

supervise provider activities
lead a culture of safety, inclusion and quality
help identify and address issues.

It is important the governing body* puts in place processes* to check the organisation’s strategies for delivering tailored care and services meet each older person’s needs, goals and preferences*. This includes monitoring the organisation’s performance, such as by reviewing reports on:

how they’re delivering clinical care and services
how they’re managing complaints*, feedback* and incidents* (Outcomes 2.5 and 2.6)
the quality of care and services workers* are delivering. For example, through quality assurance or system* reviews (Outcome 2.8).

Make sure the organisation has a culture of safety, inclusion and quality by monitoring and investigating areas you find in the organisation’s reports you can improve. Identify opportunities and make recommendations to your organisation to improve its culture of safety, including quality care*. Provide feedback* and support to the provider.

You also need to monitor the performance of any associated providers*.

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*. This means being open about what has gone wrong. Share this information with older people, their supporters and others they may want to involve, such as family and carers*
have strategies to reduce the risk of things going wrong again.

The provider guidance for Outcome 2.3 has more information on open disclosure*.

Effectiveness of this Standard is reliant on the systems and processes from Standards 1-7.

Standard 2 provides detailed information for governing bodies*.

Key tasks:

Outcome 5.1 is closely linked with Standard 2. The governing body* sets and leads the governance* structure and processes*, culture and direction of the organisation. It communicates the organisation’s priorities for improving the quality of clinical care* services to workers* and older people. Good clinical governance* also links to all other outcomes in Standard 5.

The governing body* should put in place and maintain systems* to communicate the organisation’s priorities and strategic directions for safe and quality clinical care* services to older people and workers*.

As a governing body*, you need to (Outcome 5.1):

approve a clinical governance* framework. Publish it and include it in strategic plans and the overall governance* systems* of the organisation.
manage the clinical governance* framework. Include systems* that reflect the size and how complex the organisation is to:
- set priorities for achieving person-centred*, safe, coordinated and effective clinical care* services
- define roles and responsibilities* for delivering and coordinating clinical care* services
- work with older people, their supporters, family, carers* and workers* to design care and services
- keep records, analyse and report on internal and external clinical safety and quality data. This should include feedback* from older people and others involved in their care*
- make sure the organisation uses contemporary, evidence-based practice*
- identify and manage clinical risk
- assess and keep improving clinical care* service quality by collecting data on key focus areas for the provider. This could include older people’s level of satisfaction in how the provider supports their care goals.
monitor, review and improve clinical care safety and quality.

Governing bodies* must monitor how effective the organisation’s clinical governance* systems* are. You need to oversee the provider’s service by assessing regular reporting on care and services from provider management, such as:

reviewing services’ clinical performance and outcomes and using these to check how they’re performing, and find ways to improve the quality of care*
monitoring how providers respond to complaints*, feedback* and incidents*, including if people receiving care and their supporters are happy with the open disclosure* processes*
reviewing organisational self-assessment tools to collect information on clinical governance* arrangements and find any gaps in the clinical governance* framework that you need to address
using data and reporting to identify what the organisation’s key priorities are to improve the clinical care* services they’re providing
making sure the governing body* includes members that have the skills and knowledge to manage, monitor and improve the safety and quality of clinical care* services
making sure governing body* members understand what their role and responsibilities* are for monitoring, reviewing and improving person-centred*, safe, coordinated and effective clinical care* services
reviewing the governance* structure, role descriptions and contracts for:
- the board and associated committees
- management
- health professionals*
- other workers*.

This is important as it makes sure that each person’s responsibility for safe and quality care* is clear for workers* at all levels.

Governing body* members need to be trained in clinical governance* so that you can carry out your role and supervise management’s role. Organisations may choose to develop a skills matrix or framework. This should list the ‘must have’ skills, knowledge and behaviours governing body* members, and the governing body* as a whole, need to have.

Standard 2 provides detailed information for governing bodies*.

You can find more resources about the role of the governing body* and governance* in the Quality Standards Resource Centre.

The Commission developed the Governing for Reform in Aged Care Program to support the key recommendations of the Royal Commission into Aged Care Quality and Safety. The Program supports governing body* members, leaders and emerging leaders to strengthen corporate and clinical governance* capabilities and enact critical reform.

Workers

What does this Standard mean for workers*?

Standard 5 sets out requirements for the delivery of safe and quality clinical care* services, whether provided in an older person’s home or in a residential environment.

Older people tell us that having quality relationships with workers* is one of the most important aspects of their aged care experience. These relationships are central to the delivery of high quality, person-centred care*.

Regardless of your role, you should:

Understand your role and scope of practice* in delivering clinical care* services. To deliver safe and quality clinical care* services, it’s important you understand your role in the organisation and the activities you can and cannot perform. This includes how your role crosses over with the roles of others in your organisation. Your organisation will have a clinical governance* framework that sets out the governance*, roles and responsibilities* across the organisation for delivering safe and quality clinical care* services.
Participate in continuous professional development and maintain competencies relevant to your role. Your organisation will have systems* in place to make sure you are appropriately trained, educated and supported to care for older people. It’s important you take part in training and regular reviews to continuously improve your clinical care* skills and knowledge. If you need more training, help, or would like to further develop your skills, you should talk to your manager. They should provide the support you need to deliver quality care*.
Deliver safe and quality clinical care* services that are evidence-based* and person-centred*. Older people can expect to receive comprehensive*, safe and quality clinical care* services. It should be based on the latest evidence and tailored to the older person’s specific needs, goals and preferences*. You may need to refer to and collaborate with other health professionals* and specialist services to organise comprehensive assessments and management strategies for the older person. This is an important part of multidisciplinary care*. Depending on your role, you may help monitor and review the effectiveness of management strategies.
Deliver clinical care* services that meets each older person’s care and services plan*. You are responsible for making sure you understand how to deliver clinical care* services that meets the older person’s needs, goals and preferences*. You should manage any risks associated with the older person’s clinical care* services. Care and services plans* should guide how you provide clinical care* services. Care and services plans* may be available as physical documents or through your organisation’s electronic care management system*. It’s important care and services plans* are regularly* reviewed for effectiveness, including when an older person’s clinical needs and circumstances change.
Deliver clinical care* services in a way that is culturally safe*, trauma aware and healing informed* – See Standard 1.

You should support older people to take risks and make choices about their clinical care* in line with their wishes. Older people have the right to make decisions that affect their lives and to have those decisions respected, even if there is some risk to themselves. This is called dignity of risk*.

You also need to respect older people’s right to autonomy when delivering clinical care*. This includes when older people make a choice about their care that involves of clinical risk, provided the older person is fully informed regarding the risk.

For example, an older person who is at risk of pressure injury* may decide they do not want to follow a recommended plan of movement and pressure relieving devices. You have a responsibility to:
- partner with the older person to understand the reasons behind their choice. For example, is the cushion uncomfortable or is moving painful?
- work with the older person to explore alternatives and make sure they fully understand the risks related to their decision. For example, a case conference where health professionals*, the older person and their supporters are present is a reasonable way to achieve this
If the older person decides not to follow the pressure relieving recommendations, you should document this decision, and the decision-making support that has been provided, and regularly* review the decision with the older person. This supports the older person in their right to make informed decisions.
Recognise and respond to deterioration*. Deterioration* refers to physiological, psychological or cognitive changes that may indicate a significant worsening of the older person’s health, condition or wellbeing*. This includes when an older person approaches end-of-life* and palliative care*. Your organisation must make sure you are trained to monitor the older person to identify signs of deterioration* and respond appropriately. If you identify deterioration*, it is important to escalate this so the older person’s needs and preferences can be reassessed, and their care and services plan* reviewed. For example, for workers involved in medication management*, this would include:
- monitoring the effects of medicines* on the older person, especially if they take high-risk medicines*
- escalating and reporting any medicine-related adverse events* or medicine side-effects* in a timely* and appropriate way, if an older person deteriorates following medication administration*
- making sure a medication review* is conducted following deterioration*, and any changes or recommendations that come from the review are documented in the older person’s care and services plan* and medication chart.
Effectively communicate about an older person’s clinical care* services. There may be a range of people involved in an older person’s clinical care* services, including:
- other workers*
- health professionals*
- other service providers*
- volunteers
- supporters
- family
- carers*.
You should communicate critical information* about an older person’s clinical care* services to others involved in their care*, with the older person’s consent. Your organisation should have a system* you can use to record clinical information and make sure relevant information is communicated to those who need it in a timely* way.