Personal care and clinical care

Consumers and the community expect the safe, effective and quality delivery of personal and clinical care. The Standard applies to all services delivering personal and clinical care specified in the Quality of Care Principles 2014. Personal and clinical care and services can include:

• supervising or helping with bathing, showering, personal hygiene and dressing 
• providing personal mobility aids and communication assistance for consumers with impaired hearing, sight or speech
• nursing services, such as catheter care and wound management
• services aimed at getting back or improving a consumer’s independence or daily living activities
• specialised therapy services, such as support for consumers living with cognitive impairment. 

Most aged care organisations deliver good outcomes for consumers. However, consumers don’t always receive care from organisations in a safe and effective way. Harmful events that organisations could have prevented continue to happen in aged care service delivery. This Standard highlights several key areas where organisations need to do more and be proactive in their preparations to minimise the risk of an outbreak and ensure they keep consumers safe and that they receive the best possible care and services. 



The guidance in this Standard is not clinical guidance. It doesn’t include instructions or ‘how to’ information on the different aspects of care. Organisations need to develop and implement an approach that makes sure they are providing safe and effective personal and clinical care to consumers. This approach needs to be in line with best practice evidence and meet the consumer’s needs, goals and preferences. The organisation is expected to then have policies and procedures that support the workforce to deliver care and treatment in line with this approach. This includes, for residential aged care services, a dedicated clinical staff member responsible to support the design, implementation and continuous improvement of infection prevention and control policies, procedures and practices.

Standard 3 links to:

Standard 1 – All aspects of personal and clinical care need to treat consumers with dignity and respect and support them to make choices. It’s also important that personal and clinical are delivered in a way that is culturally safe.

Standard 2 – Assessment and the development of a care and services plan that reflects the consumer’s needs, goals and preferences supports the delivery of tailored personal and clinical care. The consumer’s advance care and end of life care wishes can be delivered if these are planned.

Standard 7 – Workforce interactions with consumers need to be kind, caring and respectful of each consumer’s identity, culture and diversity. In particular, the workforce needs to have the competency, qualifications and knowledge to deliver safe and effective personal and clinical care and promote consumers’ health, well-being and cultural safety.

Standard 8 – The organisation’s governing body is accountable for the delivery of safe and quality care. Including the effectiveness of clinical governance and risk management systems and practices, to manage high-impact and high-prevalence risks associated with the care of consumers.

Requirement (3) (a)

Each consumer gets safe and effective personal care, clinical care, or both personal care and clinical care, that:

i) is best practice; and

ii) is tailored to their needs; and

iii) optimises their health and well-being

Intent of this requirement

This requirement sets out the expectation that organisations do everything they can to provide safe and effective personal and clinical care. This means organisations make sure that the personal and clinical care they provide is:

(i) best practice

Organisations are expected to refer to relevant national guidance about how to deliver safe and effective care and to implement this in their services. It’s understood that there isn’t always strong evidence for all aspects of clinical and personal care. However, where there is evidence, services should use this to provide best practice care. This provides the best possible basis for decisions about the type of care provided to meet consumers’ identified needs, as well as the way the organisation provides that care.

(ii) tailored to their needs

Organisations are expected to make sure that personal and clinical care is tailored and based on an assessment of a consumer’s needs, goals and preferences. This means working with the consumer making any reasonable changes to tailor care and providing support to help consumer’s understand and make informed decisions about their options. This includes how much they want to manage these options themselves. There may be times when an organisation can’t meet a consumer’s needs and preferences. In these cases, the organisation should explain this to the consumer and discuss how it will affect them so that the consumer can understand the reasons and look at other options. This is to help the consumer make an informed decision about their care and services.

(iii) optimising the consumer’s health and well-being

Safe and effective personal or clinical care improves the consumer’s well-being, including:

• physical and mental state
• spiritual and emotional life (feelings, thoughts, beliefs, attitudes)
• social life (relationships, attitudes, cultural values and the influences of those around them, such as family and community).

Reflective questions

• What systems does the organisation have to identify and apply up-to-date guidance on best practice for delivering personal or clinical care? How do the organisation’s policies, procedures, and care models reflect this?
• How does the organisation monitor whether they tailor and deliver personal and clinical care in line with the consumer’s needs, goals and preferences?
• How does the organisation make sure that they have sufficient numbers and the right mix of workforce members, with the right skills, to meet consumers’ personal and clinical care needs?
• How does the organisation ask for feedback from consumers and their representatives, about how the personal and clinical care delivered meets their needs and optimises their health and well-being? How can the service show that they acted in response to any negative feedback?
• How does the organisation provide or help consumers to access other providers, organisations or individuals to improve their health and well-being? (Such as allied health and other therapies.)
• Does the organisation monitor how effective their care practices are in meeting this requirement? How is the delivery of personal and clinical care reviewed and improved in response to any deficits?
• How does the organisation develop the competency and knowledge of the workforce to provide personal and clinical care that is tailored to the consumer and reflects best practice?
• What processes are in place to provide personal and clinical care in line with the Charter of Aged Care Rights? This includes practices that make sure consumers have information and support to make decisions about their care.

Examples of actions and evidence

Consumers

• Consumers say they are confident they are getting care that is safe and right for them.
• Consumers say they are getting care that reflects their individual needs and situation.
• Consumers say the personal or clinical care received supports their health and well-being.

Workforce and others

• Management of the organisation can describe how they deliver personal and clinical care in line with the service’s practices and policies for safe and effective care.
• Management of the organisation can describe how they deliver personal and clinical care in line with the consumer’s needs, goals and preferences.
• The workforce can give examples of how the organisation tailored personal or clinical care to optimise the consumer’s health and well-being.
• The workforce can describe how they set up and monitor that the personal and clinical care they provide is best practice and where they go to get information or advice on best practice.
• The workforce can describe how the organisation supports them to deliver personal and clinical care that is best practice and meets the needs of each consumer. They can also describe what they would do if they weren’t able to deliver best practice care or saw others delivering care that wasn’t best practice.
• The workforce can describe the communication processes the organisation uses to provide updates on new or revised practices for safe and effective care.

Organisation

• Policies, procedures and assessment tools show that best practice guides the personal and clinical care that the workforce provides.
• Evidence that the organisation’s approach to providing personal and clinical care meets the needs of diverse consumers. This includes Aboriginal and Torres Strait Islander consumers.
• Evidence that the organisation has reviewed or audited service delivery records to make sure they are in line with best practice guidelines and the needs, goals and preferences of consumers.
• Records reflect how the organisation makes decisions about best practice guidelines for personal and clinical care and ways to meet best practice approaches.
• Evidence of how the organisation keeps improving its performance against this requirement. This includes how it changes its policies, procedures and practices based on best practice evidence.
• Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.

Intent of this requirement

To meet this requirement, organisations need to do all they can to manage risks related to the personal and clinical care of each consumer. This means following best practice guidance and applying measures to make sure the risk is as low as possible whilst supporting a consumer’s independence and self-determination to make their own choices, including to take some risks in life.  

Effective management of risks is underpinned by clinical governance systems for safety and quality. This includes reviewing how personal and clinical care is delivered to apply new practices and responding appropriately and promptly to a consumer’s changing needs.  

For high-impact or high-prevalent risks related to the personal and clinical care of each consumer, organisations are expected to use risk assessments to find ways to reduce these risks. They should do these assessments in consultation with the consumer. This can involve the organisation’s service environment, equipment, workforce training, systems, processes or practices that affect any aspect of how they deliver personal and clinical care to consumers.

Organisations are expected to manage risks related to the care of each consumer in line with the consumer’s care and services plan. This is so that the organisation supports them to safely maintain their best possible level of independence and function. For example, if there is a risk that a consumer may fall, the care and services plan would include what assistance or mobility aid the organisation will provide to help the consumer to move about safely.

The organisation is expected to educate and support its workforce to minimise risks to consumers. Members of the workforce providing personal and clinical care to consumers also need to have the right qualifications, knowledge and experience to deliver care safely. To develop strategies to minimise the affect and number of risks for consumers, organisations can use advice from allied health practitioners and others.  

Organisations need to deliver personal or clinical care and manage risk in a way that balances the consumer’s rights and preferences with their safety and the safety of others. This includes managing challenging behaviours in ways that involve the consumers, and respects their rights, dignity and independence. This means organisations can manage risk and provide personal and clinical care in the least restrictive way and least restrictive service environment, while keeping consumers, the workforce and others safe. 

Dementia affects many consumers receiving care and services.There are some gaps between what generally happens now and what is best practice care for consumers living with dementia. Although antipsychotic medicines may be appropriate for adults with severe mental health issues or long-term mental illness, there is concern that these medicines are being prescribed inappropriately in people aged 65 years and over for their sedative effects – that is, as a form of chemical restraint for people with psychological and behavioural symptoms of dementia or delirium.

Understanding and applying best practice in care and services for consumers living with dementia is vital to delivering safe and effective care and services that meet the consumer’s needs, goals and preferences. Consumers living with dementia are also at higher risk of harm from the points listed below. 

While organisations need to manage all risks related to the personal and clinical care for each consumer, 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. This includes:

Managing hydration and nutrition

This is important for a consumer’s quality of life. It helps to minimise the risk of infections, pressure injuries, anaemia, hypotension, confusion and impaired cognition, decreased wound healing and fractures. 

Managing risks of choking

Swallowing difficulties are common among consumers. If a service doesn’t manage swallowing problems, it can lead to death from choking. 

Managing medications safely

Consumers can have multiple medical conditions and use several drugs together. This means that they are at high risk of medication mistakes. These mistakes can result in hospital visits that could have been avoided, illness and death. This risk can be minimised through effective policies and procedures that support safe use of medicines.

Managing pain

 If pain isn’t managed, it can make consumers confused, they can have interrupted sleep, not get the nutrition they need, be less mobile, feel depressed and isolated and take longer to get better.

Preventing and managing pressure injuries

When consumers can’t move around on their own, they can get pressure injuries. Factors such as poor nutrition, poor skin health and lack of oxygen to tissues can also cause pressure injuries. 

Minimising restrictive practices

These interventions have high potential for harm and are practices that organisations can avoid with positive changes in how they assess, plan and deliver personal and clinical care for consumers. If an organisation uses restrictive practices such as physical or chemical restraint, these are expected to be consistent with best practice and used as a last resort, for as short a time as possible and comply with relevant legislation. 

Managing delirium

This is a common and serious problem for consumers that isn’t well understood. Not recognising the signs of delirium can prevent organisations from providing quality personal and clinical care, and impact the consumer’s well-being.

Managing hearing loss

Hearing loss is a common condition in consumers. There is a clear link between hearing assistance and improving a consumer’s quality of life. This includes less social isolation, stress and frustration, as well as reducing the risk of consumers developing medical conditions, such as depression.

These examples are not all the risks that an organisation may need to manage for consumers. However, there are some of the common risks that organisations need to identify and manage. If organisations appropriately manage risks, a consumer’s care and services should be safe and effective and improve their health and well-being.

Reflective questions

• How does the organisation tell the workforce about relevant legislation and best practice standards for managing high-impact or high-prevalence risks when caring for consumers? What processes are in place to make sure that evidence-based documents and tools for managing high-impact or high-prevalence risks are up-to-date and in line with best practice?
  
   
• How does the organisation make sure that the workforce is following best practice guidelines and tools to prevent and manage high-impact or high-prevalence risks? 

• What assessment tools or processes does the organisation use to monitor and respond to high-impact or high-prevalence risks to consumers? How are consumer care and services plans and risks communicated to members of the workforce who deliver personal and clinical care? 

• What systems are in place to gain access to relevant health professionals’ assessments that can help prevent and manage high-impact or high-prevalence risks for consumers?

• What information and support does the organisation provide to consumers about preventing and managing high-impact and high-prevalence risks related to their personal and clinical care? 

• How does the organisation evaluate and review how they manage of high-impact or high-prevalence risks in the personal and clinical care the deliver for consumers? 

Examples of actions and evidence

Consumers 

• Consumers say their care is safe and right for them.

• Consumers say members of the workforce explain risks to their well-being and they get to have input into the steps to reduce the risks.

Workforce and others 

• Members of the workforce can describe how they identify, assess and manage high-impact or high-prevalence risks to the safety, health and well-being of each consumer when delivering personal or clinical care.

• The workforce can describe how they get information or advice on best practice to manage high-impact or high-prevalence risks.

• The workforce can describe how the organisation supports them to identify and manage the high-impact or high-prevalence risks to the safety, health and well-being for each consumer.

• Workforce orientation, training or other records that show how the organisation supported the workforce to understand their roles and responsibilities to prevent and reduce harm from high-impact or high-prevalence risksand meet this requirement.

Organisation  

• Policies and procedures describe how the organisation manages high-impact or high-prevalence risks to the safety, health or well-being of consumers.

• The organisation uses best practice guidelines, decision-making tools and protocols to manage high-impact or high-prevalent risks to consumers.

• Documented risk assessments and care and services plans for each consumer and evidence that the organisation delivers personal and clinical care in line with these assessments and care and services plans. 

• Records of relevant allied health input to preventing and managing high-impact or high-prevalence risks for consumers.

• Records of ‘near-misses’ and incidents and actions taken to address risks are documented. 

• Communications that show that the organisation updates the workforce on new or changed practices to assess and manage high-impact or high-prevalence risks to consumers’ safety, health and well-being.

• Evidence of continuous improvement, including how the organisation reviews its policies, procedures and practices based on evidence. As well as how it learns from what’s not working.

• Evidence of monitoring and reporting of performance against this requirement.

Intent of this requirement

This requirement focuses on how personal and clinical care is delivered at the end of a consumer’s life. Organisations are expected to recognise the needs, goals and preferences of consumers who are nearing the end of their life. Communication with the consumer and a care and services plan that reflects to their needs, goals and preferences will support this requirement.  

An understanding that dying and death are part of each consumer’s human experience, not just a biological or medical event, needs to underpin all end of life care. Organisations that take the right approach will deliver care that is culturally safe, provide it in the most suitable setting, and deliver it in a timely manner. 

To maximise the consumer’s comfort and maintain their dignity at end of life organisations need access to an appropriately skilled and qualified workforce. There needs to be a timely response if a consumer is in physical, psychosocial or spiritual distress to ensure suffering is prevented or relieved and their dignity is maintained at their end of life. How an organisation does this will depend on the setting, the needs of consumers and what specialist resources and members of the workforce they have available. It will also need to be in line with relevant national practice guidelines and state and territory programs. 

Involving a consumer’s representative in their end of life care decisions must be in line with a consumer’s wishes. Where a consumer lacks the capacity to make decisions they may have a court or tribunal-appointed guardian to make decisions on their behalf. When this is the case an organisation needs to manage this according to relevant law and best practice guidance.

Reflective questions

• How are the consumer’s needs, goals and preferences for their end of life care reflected in their care and services plan, including the situation, environment and place where they wish to die?
  
   
• What processes are in place to support conversations with the consumer, and others the consumer wants involved, about their cultural, spiritual and physical needs?
  
   
• How does the organisation make sure that they promptly recognise when the consumer is moving to the terminal phase of life? And how do they communicate this to the consumer, others the consumer wants involved and relevant health professionals? 
  
   
• How does the organisation work with others outside the service (such as palliative care specialists) to improve the consumer’s end of life care?
  
   
• How does the organisation evaluate and review end of life services to make sure they are effective and meet the needs and preferences of consumers?

Examples of actions and evidence

Consumers  

• Consumers say they feel confident that when they need end of life care, the organisation will support them: 
  • to be as free from pain as possible
  • to have those important to them with them
  • to die in line with their social, cultural and religious and spiritual preferences.
    
     
• Consumer representatives say they feel positive about their experience with the organisation and the workforce at the time of the consumer’s death. 

Workforce and others 

• Relevant members of the workforce say they feel well prepared and supported to have conversations with consumers about end of life care.

• Relevant members of the workforce can describe how they support consumers at the end of their lives. This includes being as free from pain as possible, having those important to them with them, and dying in line with their social, cultural and religious and spiritual preferences.

• Evidence that the workforce, through their education and experience, recognise end of life signs and can review a consumer’s needs, goals and preferences in line with their wishes. 

• Members of the workforce are respectful and can describe how they have supported a range of consumers to make end of life choices. This includes situations where the consumer’s wishes have been different to what the workforce member or organisation believes. 

• The workforce can describe how they support consumers to direct their own end of life care where possible.

• Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.

Organisation

• Care and services plans reflect changes in care and services, in line with the consumer’s end of life care needs, goals and preferences. This includes advance care planning when this has occurred.

• Examples of the use of tools and resources for supported decision-making with consumers, representatives and others they want to involve in decisions about their end of life care.

• Policies and procedures for end of life care document how to recognise when consumers are at the end of life and what supervision and support is provided to members of the workforce providing end of life care.

• Examples of activities the organisation has implemented to balance end of life care with consumer goals and best practice and how these activities have been evaluated.

• Evidence of how the organisation monitors and reports its performance against this requirement.

Intent of this requirement

This requirement explains how organisations are expected to respond to deterioration or change in a consumer’s mental health, cognitive or physical function, capacity or condition.  

A consumer may experience health conditions or impairments that restrict their capacity or abilities. How these restrictions affect the consumer’s day to day activities or function also depends on the consumer’s personal circumstances and environment. The right care and services can support the consumer’s day to day function, their activity and participation in the community. However, the balance can change quickly due to changes in the consumer’s circumstances, environment or health status.  It is important that organisations pick up these changes because:

• if the consumer’s loss of function is temporary, it can be improved or reversed with the right care and services 
  
   
• a higher level of ongoing care and services may be needed to meet the consumer’s needs 
  
   
• further health complications for the consumer can be avoided by intervening early.

However there is evidence that warning signs of a consumer’s changing or deteriorating function, capacity or condition is not always recognised or acted upon on promptly or in the right way. Changes may be mental, cognitive or physical in nature. Identifying changes or deterioration early can improve outcomes and mean that consumers need less intervention in the future. 

Organisations are expected to have systems and processes, relative to the services they deliver, that support the workforce to recognise, and respond to a consumer whose function, capacity or health condition changes or deteriorates. This includes ways for the workforce, consumers, and others to identify and escalate concerns so that the organisation can assess the situation and take action.

Reflective questions

• What systems and policies are in place in the organisation to recognise and respond to changes or deterioration in the health or function of a consumer? 
  
   
• How is the workforce supported to recognise and respond to a sudden or unexpected deterioration of a consumer’s mental health, cognitive or physical condition, function or capacity? For example, how do members of the workforce recognise signs and symptoms of deterioration and what to do?
  
   
• Are there any gaps or delays in identifying, communicating and responding to deterioration between providers, organisations or individuals providing care and services? How can consumers, the workforce and others who review systems and processes, improve early recognition and response to deterioration or loss in a consumer’s health or function?
  
   
• How does the organisation provide information to consumers and representatives on recognising changes or deterioration in health or function? This includes how important recognising it can be. And how does the organisation support consumers and representatives to understand how they can raise concerns about possible changes or deterioration? 

Examples of actions and evidence

Consumers 

• Consumers say they are confident that members of the workforce providing their care and services know them and would pick up a change in their condition, health or abilities. They also say the members of the workforce providing their care and services would know what to do about a change in their condition, health or any loss of abilities.
  
   
• Consumers and representatives say that they understand how to raise concerns about any deterioration in condition, health or ability which occurs.
  
   
• Consumers and their representatives say that the organisation responded well to a change or deterioration in condition, health or ability when they needed to.

Workforce and others 

• The workforce can describe the different situations where a change in a consumer’s condition, health or abilities should be identified and what response they should take. 
  
   
• The workforce can describe how they should communicate information about a consumer’s condition, health or abilities deteriorating, who should be involved and what actions they should take.
  
   
• The workforce can describe how they identify signs of deterioration. They can also describe their understanding of their role and the organisation’s processes for communicating and escalating any concerns.
  
   
• Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.

Organisation

• Evidence that the workforce who deliver care and services, document routine observations in line with the care and services plan and relevant policy and procedures. They also respond to triggers to escalate care when a consumer deteriorates.
  
   
• Consumer records show critical information about a change in a consumer’s condition, health or abilities provided by members of the workforce, the consumer or their representative is acted on by the organisation.
  
   
• Roles, responsibilities and accountabilities for members of the workforce for recognising and responding to a consumer’s deterioration are documented.
  
   
• Policy and procedures document the organisation’s processes for responding to deterioration or change in a consumer’s condition, health or abilities, relevant to the services they provide. This includes how to communicate appropriately and involve consumers, their representatives and others including carers and families. 
  
   
• Examples of documents about recognising and responding to deterioration. This can include advance care plans, documented needs, goals and preferences and documented discussions with consumers their representatives and others.
  
   
• Evidence of improvements adopted after incident reports, investigations or feedback. This can include records from an incident management system about incidents or ‘near misses’ where the service didn’t recognise a consumer’s deterioration.
  
   
• Evidence of how the organisation monitors and reports its performance against this requirement.

Intent of this requirement

This requirement focuses on the communication processes that organisations are expected to have, so that their workforce has information about delivering safe and effective personal and clinical care and understanding the consumer’s condition, needs, goals and preferences. The information the workforce has access to should help them provide and coordinate care that respects the consumer’s choices. Good information management systems mean the consumer doesn’t have to keep repeating their story. 

If organisations transfer important information about a consumer’s care within and between organisations that are responsible for the consumer’s care and services, they can improve outcomes for the consumer. If the consumer’s condition, needs, goals and preferences are known to those involved in the consumer’s care it will: 

• improve the safety, effectiveness and consistency of care and reduce the risk of harm
  
   
• improve the consumer’s experience of care and deliver care which reflects their choices.

There are many different situations where this requirement applies. Including how an organisation communicates information about a consumer’s condition, needs, goals and preferences:  

• if their regular member of the workforce changes
  
   
• when members of the workforce change between work shifts 
  
   
• when a consumer is transferred to hospital for specialist treatment
  
   
• when the consumer’s condition, needs, goals or preferences have changed. 

How information is communicated can vary, but the method needs to be efficient and fit the situation. Organisations need to collect and share consumer’s personal information in a way that complies with relevant privacy legislation. The organisation is also expected to find ways to include consumers, their representatives and others the consumer wants involved, in communication processes. 

Reflective questions

• What communication systems does the organisation use to make information easily available to relevant agency staff, substitute general practitioners, paramedics and others? This is vital for anyone who needs to provide personal or clinical care without already knowing the consumer.
  
   
• When two or more organisations share care, or where there are integrated services, what arrangements does the organisation have to share relevant information promptly? How do they plan and deliver care? How does handover occur?
  
   
• What tools and supports does the organisation provide for the workforce to understand and communicate consumer-centred information? This should provide a complete picture of a consumer’s care needs and preferences.  
  
   
• How does the organisation support the workforce to see that part of their job is to work together to improve day-to-day care and be clear on instructions on how to best support consumers? 
  
   
• What systems does the organisation have in place to include consumers, representatives and others they want to include, in communications about their care? 

Examples of actions and evidence

Consumers 

• Consumers say they are fully informed and able to consent to information being shared with others about them.
  
   
• Consumers say their personal or clinical care is consistent. They have continuity of care and don’t have to repeat their story or their preferences to multiple people.
  
   
• Consumers say the organisation coordinates their personal or clinical care well. They benefit from different organisations working together and sharing information about them.
  
   
• Consumers say they have quality personal or clinical care because the workforce and relevant others have correct and up-to-date information. This includes replacement workforce members and those from different organisations.
  
   
• Consumer representatives say that the organisation has processes to support continuity of care. It also has processes to communicate important information about a consumer’s care and how it delivers it.

Workforce and others 

• The workforce can describe how the organisation tells them about a consumer’s condition, needs, goals and preferences as it relates to their own roles, duties and responsibilities. The workforce can also describe how they share this information.
  
   
• Relevant members of the workforce show a clear understanding of information sharing and different types of consent.
  
   
• Relevant members of the workforce can describe how accurate, up-to-date and relevant information is shared with others as consumers move between care settings, such as between home and hospital.
  
   
• The workforce can describe the different situations where they shared care documents or communicated information about the consumer’s condition, needs and preferences and how they complied with relevant privacy obligations.
  
   
• Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.

Organisation

• Evidence of an effective system to manage information that keeps suitable controls over privacy and is in line with relevant legislation.
  
   
• Evidence that the organisation is actively communicating with others, internally and externally, to make sure that care and services are delivered without any disruptions.
  
   
• Evidence that the organisation monitors how the workforce manages information in relation to information gaps, pending and missing information and that follow up occurs.
  
   
• Records reflect how the organisation asks for consent to release or share information using methods suitable for each consumer and in accordance with Privacy legislation.
  
   
• Evidence that relevant members of the workforce have access to consumer records.
  
   
• Consumer care and service plans show evidence of updates, reviews and communication alerts. This includes information from multiple sources, updates from reassessments and their results.
  
   
• Policies and procedures that show how the organisation communicates important information about a consumer when they share the responsibility for their care with other providers, or have transferred a consumer to another organisation.

Intent of this requirement

Organisations that provide care and services are expected to consult with the consumer and make appropriate referrals to other individuals, organisations or providers  that can provide a care and services that meets the consumer’s needs. This is to make sure that the care and services meet the consumer’s needs, goals and preferences and improves their health and well-being.

After finding out what a consumer’s needs, goals and preferences are for independence, health and well-being, an organisation may decide that specialist providers will be better able to give the consumer the particular care they need. Specialist services can include allied health, hearing, dental, medical or psychiatric services or other specialised therapy services.

Having an active network of other individuals, organisations or providers, they can refer or collaborate with, means the organisation can meet the diverse needs of consumers. It is expected that organisations do this in line with the Quality of Care Principles, 2014. 

Organisations will need to meet obligations relating to privacy of information when co-ordinating care with other providers, organisations or individuals.

Reflective questions

• How has the organisation identified individuals, organisations or providers that can deliver care, services and supports to better meet consumer choices?
  
   
• When more than one organisation is responsible for a consumer’s, is it clear to everyone who is responsible for providing personal or clinical care at any point in time?
  
   
• If their condition deteriorates, what services may the consumer need that can’t be safely managed within the organisation? What systems does the organisation have to make timely referrals, if this is in line with the consumer’s preferences?
  
   
• What are the organisation’s barriers to timely referrals and does it actively work to remove these barriers?

Examples of actions and evidence

Consumers 

• Consumers say that where the organisation has been unable to provide suitable care they have helped organise someone else to provide it.
  
   
• Consumers say the organisation has referred them to the appropriate providers, organisations or individuals to meet their changing personal or clinical care needs.
  
   
• Consumers believe referrals happen promptly when their personal or clinical needs change.
  
   
• Consumers say they are satisfied with the care delivered by those they’ve been referred to. They also say the care from the other individuals, organisations or providers are delivered in a culturally safe way.

Workforce and others

• The workforce can identify other individuals, organisations or providers they can make referrals to and any referral criteria that applies.
  
   
• The workforce can describe how they refer consumers to other individuals, organisations or providers and how they collaborate to meet the diverse needs of consumers.
  
   
• The workforce can describe how the consumer is actively involved in decisions and about referrals and how consent is obtained.
  
   
• Workforce orientation, training or other records that show how the organisation supports the workforce to meet this requirement.

Organisation 

• The organisation’s strategic and operational planning describes activities that maintain a network of individuals, organisations or providers they can refer consumers to.
  
   
• Evidence that the organisation has links with other individuals, organisations or providers to make sure consumers can access a range of care and services, for example memorandums of understanding.
  
   
• Policy documents for referrals to other individuals, organisations or providers that include arrangements for services that the organisation doesn’t provide. This includes contacts, roles and responsibilities of the workforce when making referrals, and involving consumers and their representatives. 
  
   
• Consumers’ care and services plans show that the organisation collaborates with other individuals, organisations or providers to support the diverse needs of consumers.
  
   
• Records that show the organisation regularly reviews the individuals, organisations or providers they refer consumers to, to make sure their services remain safe and effective and quality care and services are being delivered.
  
   
• Consumer records show the organisation makes timely referrals to health practitioners, specialised allied health, or other services, to meet the care needs of consumers.
  
   
• Evidence of referral processes, outcomes for consumers, and projects that show quality improvement.

Requirement (3) (g)

Minimisation of infection-related risks through implementing:

a. standard and transmission-based precautions to prevent and control infection; and

b. practices to promote appropriate antibiotic prescribing and use to support optimal care and reduce the risk of increasing resistance to antibiotics.

Intent of this requirement

Organisations are expected to minimise infection-related risks in two ways.

Infection control

Organisations are expected to assess the risk of, and take steps to prevent, detect and control the spread and severity of infections. To minimise the risk of transmission, severe illness, hospitalisation or even death, precautionary infection control measures should be prioritised, including standard and transmission-based precautions and facilitating timely access to relevant vaccinations including for COVID-19.

Organisations providing residential aged care need to offer the workforce influenza vaccinations and keep records of these vaccinations. They also need to promote the benefits of influenza and coronavirus (COVID-19) vaccinations to both residents and staff. Residential care services, home care services and flexible care services providing transition care and short-term restorative care, need to keep records and report on workforce and consumer coronavirus (COVID-19) vaccinations. This information should inform infection prevention and control planning.

If community transmission starts to occur in your area, you must increase your vigilance and escalate your response, particularly around infection prevention and control.

It’s expected that organisations develop and implement an effective infection prevention and control program that is in line with current national guidelines, recommendations or advice. This may include information from the Infection Control Expert Group, the Communicable Disease Network Australia (CDNA), the Australian Health Protection Principal Committee (AHPPC), Australian Technical Advisory Group on Immunisation (ATAGI) and the Chief Medical Officer. 



Infection prevention and control programs will vary in scope and complexity depending on the nature of the care and services the organisation provides. Organisations must demonstrate infection prevention and control expertise, such as appointment of infection prevention control (IPC) lead(s), meeting (ongoing) training requirements around infection prevention and control, which should be available to all staff. Processes for routinely screening staff and visitors on entry to a residential care facility are important where there is any risk of infectious disease being introduced to the facility. 



Residential aged care services are required to appoint at least one clinical staff member as infection prevention and control IPC lead(s). This ensures that these organisations are prepared to prevent and respond to infectious diseases, including coronavirus (COVID-19) and influenza. The IPC lead(s) must be a designated member of the nursing staff who has completed an identified IPC course.

Antibiotic resistance

Ideal use of antibiotics means treating consumers ‘with the right antibiotic to treat their confirmed condition, the right dose, by the right route at the right time and for the right duration based on accurate assessment and timely review’. 



Using antimicrobials incorrectly, including antibiotics, can cause antimicrobial resistant (AMR) infections. AMR infections affect consumers’ safety and well-being because treatments are more complex and longer and can cause more disease and deaths. AMR infections not only affect the individual consumer, but can also spread and affect other people. Good use of antimicrobials makes sure they continue to be effective. This is key to providing safe and effective care to consumers. It also reduces the growth in resistant organisms. 



Organisations providing care and services need to help to minimise the development and spread of antimicrobial resistance in line with the national guidelines.

Reflective questions

• What systems and processes has the organisation implemented to prevent and control infection and to support appropriate use of antimicrobials? 
  
   
• How does the organisation know whether hand washing practices are effective and in line with national hand hygiene guidelines?
  
   
• What are the influenza and COVID-19 immunisation rates for consumers and the workforce in residential services? How does this information inform infection prevention and control planning? 
  
   
• What is the organisation’s plan for managing an infectious outbreak including for coronavirus (COVID 19)? Are there systems in place for managing consumers with known infections? Are there processes for communicating protocols where the care takes place and between the workforce or providers, organisations or individuals where care and services are shared? 
  
   
• How does the organisation apply risk management principles to implement systems for a clean environment and equipment? 
  
   
• How does the organisation promote infection control and appropriate antibiotic prescribing practices to the workforce, consumers and others to enhance effectiveness? 
  
   
• Are there agreed processes for access to other providers, organisations or individuals, such as general practitioners, nurse practitioners or public health units and community pharmacies for timely prescriptions in the event of an outbreak?
  
   
• Who in the organisation provides advice and oversight as part of ongoing, day-to-day operations of infection prevention and control? 
  
   
• How does the organisation demonstrate that it uses and references national accepted guidelines for infection prevention and control, including those provided during the coronavirus (COVID-19) pandemic? 
  
   
• Can the organisation’s infection control processes be quickly escalated in line with the current situation?
  
   
• Does the organisation communicate regularly with staff regarding expectations around cohorting, physical distancing, staying home when unwell and the importance of infection prevention and control? 

Examples of actions and evidence

Consumers 

• Consumers are confident in the organisation’s ability to manage an infectious outbreak.
  
   
• Consumers and their representatives have been given information on how to minimise the spread of infections, such as hand washing.
  
   
• Consumers’ and representatives’ observations of members of the workforce confirm that they practice good hand hygiene and help consumers to do the same.

Workforce and others  

• Staff say the organisation has told them about the benefits of the influenza vaccination and offered them an influenza vaccination each year. 
• The workforce can describe the practical steps they take to reduce the risk of increasing resistance to antibiotics. 
• The organisation’s management describe how it supports members of the workforce to understand and promote appropriate prescribing of antibiotics. 
• Records show that the organisation educates relevant members of the workforce in antimicrobial resistance and strategies to reduce the risk of increasing resistance to antibiotics. 
• Records show that the organisation has appointed an IPC lead(s) that must be engaged onsite and dedicated to a facility. 
• Records show that the IPC lead(s)have completed at least the minimum requirements of the Department's coronavirus COVID-19 focused and specified training modules.
• Records show that policies and procedure are contemporary and refer to best practice guidance, including those specific for outbreak prevention and management, that staff are aware of these policies and procedures, and supports and services have been planned and practised for a potential outbreak.
• Workforce orientation and training or other records that show how the organisation supports the workforce to follow the organisation’s infection prevention and control program and how to meet this requirement.

Organisation 

• Evidence of a documented infection prevention and control program.
• Records evidencing workforce influenza immunisation program, up-to-date records of staff flu vaccinations, and evidence of methods to promote the benefits of vaccination to staff.
• An outbreak management plan, such as for COVID-19, gastroenteritis or influenza, that explains how the organisation will prepare for, identify and manage any outbreaks.
• Evidence of how the organisation will educate the workforce on outbreak management and their roles and responsibilities. 
• Evidence of IPC training delivered to all staff when they begin employment at the facility and ongoing training annually or more frequently as required.
• Care and services plans that identify consumer infections and any transmission based precautions implemented by the workforce. Relevant details of how a consumer’s infectious status is clearly and sensitively communicated if care is shared. 
• A current list of infectious diseases that the organisation needs to tell government authorities about. Contacts at relevant state or territory government departments that can help prepare for, identify and manage any outbreaks are documented and readily available to relevant members of the workforce. 
• Evidence of antimicrobial stewardship policy and processes to support appropriate administration of antibiotics. 
• Evidence of care strategies used to minimise the need for antibiotics (such as measures to reduce the risk of urinary tract infections or treat minor skin infections). 
• Policy documents that detail infection prevention and control procedures that include risk assessment and risk management strategies, and instructions for the workforce. 
• Data that is used to monitor infections and resolution rates and the effectiveness of the infection prevention and control program. 
• Action plans for improvement based on the risk assessment of the organisation’s infection prevention and control systems

• Aged Care Act 1997 (Cth), User Rights Amendment (Charter of Aged Care Rights) Principles 2019
• Privacy Act 1988 (Cth), Schedule 1, Australian Privacy Principles
• Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019
• State and Territory work health and safety legislation
• State and Territory mental health, guardianship and administration, enduring power of attorney and medical directive/advance care planning legislation
• Aged Care Legislation Amendment (Quality Indicator Program) Principles 2019