Quality, safety and inclusion culture to support individuals | Aged Care Quality and Safety Commission

Legislation
Guidance

Outcome statement

The governing body must lead a culture of quality, safety and inclusion that supports individuals accessing quality funded aged care services by focussing on continuous improvement, embracing diversity and prioritising the safety, health and wellbeing of individuals.

Actions

2.2.1

The governing body leads a positive culture of quality funded aged care services and continuous improvement and demonstrates that this culture exists within the organisation.

2.2.2

In strategic and business planning, the governing body:

a) prioritises the physical and psychological safety, health and wellbeing of individuals

b) ensures that funded aged care services are accessible to, and appropriate for, individuals with specific needs and diverse backgrounds, Aboriginal or Torres Strait Islander persons and individuals living with dementia

c) adheres to legislative requirements, and active consideration is given to organisational and operational risks, and the wider organisational environment.

Why is this Outcome important?

Outcome 2.2b explains providers’ obligations to make sure their governing body leads a culture of quality, safety and inclusion that focuses on continuous improvement, embracing diversity and supporting older people’s safety, health and wellbeing.

The governing body must monitor the aged care services you provide through regular reviews. They must actively consider legislative requirements and the wider organisational and operational risks and needs. This helps you to deliver safe and quality care and services. It includes evaluating:

how effective your aged care services are
the safety and wellbeing of older people.

It is important to make sure your strategic and business planning addresses the needs of older people. By reviewing relevant quality and safety data and prioritising the physical and psychological safety, health and wellbeing of older people, the governing body can encourage a culture of quality, safety and inclusion. This includes making sure older people with specific needs and diverse backgrounds can receive aged care services that are accessible, appropriate, inclusive and meet their needs. This includes:

people with specific needs
people who identify as Aboriginal and Torres Strait Islander
people from culturally and linguistically diverse backgrounds
people living with dementia.

This supports you to deliver person-centred care and helps the governing body to lead a positive culture of quality care and services that are accessible and appropriate.

You need to give focus to:

strategic and business planning
addressing the needs of older people with specific needs and diverse backgrounds, including:
- Aboriginal and Torres Strait Islander persons
- people from culturally and linguistically diverse backgrounds
- people living with dementia.

All providers delivering aged care services in a residential care home, home or community setting are expected to regularly report to their governing body and work together to support older people receiving quality care and services.

However, the way providers delivering aged care services in a home or community setting work with their governing body to assess performance and drive continuous improvement may differ from aged care services delivered in a residential care home. This is because organisational governance can be more complex in home or community settings. For example, where organisations:

sub-contract some or all of the services delivered
have a high proportion of workers that are sub-contractors

A lack of direct oversight where services are subcontracted means that providers and their governing body may be less able to identify deficiencies in the care they deliver to older people and continuously improve their practice.

To lead a positive culture of quality care and services, governing bodies of organisations delivering aged care services in a home or community setting may embed a culture of self-assurance where the provider can independently and continually assess their performance. This helps make sure older people receive quality care and services that:

support them to live safely and independently in their homes for as long as possible
are accessible and appropriate for their specific needs and diverse backgrounds, in the context of their home environment.

Key Tasks

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).

Outcome service context

The processes of reporting significant matters or situations may differ between providers delivering aged care services in a residential care home, home or community setting. The guidance for Outcome 2.5 has more information on reporting and managing incidents.

Further resources about this outcome can be found on the Commission's Quality Standards Resource Centre.

Outcome 2.2b: Quality, safety and inclusion culture to support individuals