Draft Strengthened Quality Standards Guidance

Put in place strategies that support tailored care for each older person.

Partner with older people when developing and reviewing their care and service plan* (Outcome 3.1). Include in the plan how your care and services are going to be tailored and safe for the older person. This includes identifying, documenting and accommodating each older person’s:

• background
• gender identity, such as gender diverse or transgender
• sexual orientation
• culture and beliefs
• language and communication needs and preferences
• life experiences. It’s important to try and understand each older person's life experiences and how this can affect them. A life experience can be a single event at a particular time or a long period in an older person's life. Life experiences can include family, friends, career, meaningful activities and trauma.

Keep in mind an older person’s diversity* when considering daily activities like food preferences (Outcome 6.2) and community-based activities (Outcome 7.1). If the older person identifies as Aboriginal and Torres Strait Islander, you need to record this information with their consent (Outcome 2.7). If an older person has a diverse background, tailor their care and services plan* to make sure that their care and services are respectful and safe:

• spiritually
• socially
• emotionally
• culturally
• physically.

It’s important to make sure you respect older people’s privacy through this process* (Outcome 1.2).

Identify if the older person is vulnerable. For example, an older person may be more at risk if they:

• live on their own
• live in rural or remote areas without many service options
• are socially isolated or don’t have close relationships
• have few or no family or friends who ‘check in’ on them
• have cognitive impairment* and might have difficulty problem solving or advocating for themselves
• have difficulty communicating or expressing themselves
• are not very mobile
• show clinical frailty*
• are dependent on their carer* or only have one carer*.

Make sure their care and services plan* explains how you will address these circumstances and needs. Do this in partnership with the older person, their family, carers and others involved in their care and services with their permission.

Make sure older people receive quality care* and services based on their care and services plan*. This includes any clinical care*, palliative care* and end-of-life care* (Outcomes 3.2, 5.4 and 5.7).

Deliver care and services that:

• meet older people’s needs, goals and preferences*. For example, for older people living in a residential care home, make sure food, drinks and the dining experience* meet their needs and preferences (Outcomes 6.2, 6.3 and 6.4).
• improve people’s quality of life*
• help people to do what they want to do. For example, if an older person wants to go for a daily walk but is finding this difficult because of their health, look at how care and support can help them achieve their goals and move safely. This could include allocating a worker to assist or supervise the older person, providing mobility aids such as a four-wheel walker, or offering a wheelchair for part or all of the walk.
• help older people to get maintain and improve their physical, mental and cognitive function by encouraging them to use their skills and strengths. In some cases where older people have experienced a loss or reduced function, getting function back may not be possible. If this is the case, care and services should help them to maintain their current function. The guidance for Outcomes 3.1, 3.2 and 5.4 has more information on how you can support older people’s reablement* and maintenance of function.
• meet older people’s cultural needs and preferences, are culturally safe*, responsive and suitable for older people with diverse backgrounds (Outcome 3.2)
• are trauma aware and healing informed*. Make sure that workers understand different types of trauma and how this can affect older people. Older people may have past experiences of trauma that aren’t included in the care and services plan* or that the older person doesn’t want to share. The older person may show signs that they have past experiences of trauma. Workers should be aware of these signs and deliver trauma aware and healing informed care*. Make sure trauma aware and healing informed care* is part of your systems* and processes*.
• recognise the rights and autonomy of older people. This includes their right to intimacy, sexual and gender expression.
• are informed by contemporary, evidence-based practices*
• help older people to develop relationships and social connections. Older people who identify as Aboriginal and Torres Strait Islander may need extra support to stay connected with community, culture and Country. For residential care home providers, the guidance for Outcome 7.1 has more information on how you can help support older people with their daily living.
• match what you have agreed to with the older person during assessment and planning. They also need to be included in their care and services plan* (Outcome 3.1).

Partner with older people to deliver quality care* and services (Outcome 2.1). Make sure they:

• receive critical information* about their care and services (Outcome 3.3). Find out the older person’s language and how they need and prefer to be communicated with. Provide them with information in their language and that meets their communication needs and preferences. Include critical information* in care statements.
• receive planned and coordinated care* and services (Outcome 3.4). This includes where there are multiple health and aged care providers, family and carers* involved in delivering care and services, such as during transitions of care*. This may include hospital-in-the-home arrangements where an older person receives acute care in either their home or residential aged care environment. During transitions of care*, you are responsible for making sure there is effective communication processes, and the older person receives continuity of care. For residential care home providers, the guidance for Outcome 7.2 has more information on how you support older people with transitions.

There may be situations where an assessment of an older person’s care needs are beyond what you are required to deliver to them under your legislative obligations and registration conditions. You are at all times expected to partner with the older person and health care professionals to support them to access the care and services they need. You should be clear in your communication about what can and cannot be provided as part of your agreement to provide care in line with your legislative obligations.

Make sure workers have the time, support, resources and skills to plan for and deliver safe, quality and person-centred care*.

Provide your workers with guidance and training on how to deliver safe, quality and person-centred care* for each older person (Outcome 2.9). This needs to be in line with:

• the workers’ abilities and qualifications
• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• the workers’ roles and responsibilities*.

Make sure workers understand how to:

• create professional and trusting ongoing relationships with older people
• tailor care and services to each older person’s needs, goals and preferences*
• deliver care that is culturally safe*, trauma aware and healing informed*.

The guidance for Outcome 2.8 and Outcome 2.9 has more information on workforce planning and worker training.

Monitor how you plan for and deliver care and services to make sure older people’s needs, goals and preferences are at the centre all services and decisions you make*.

To check if you’re providing tailored care for each older person, you can review:

• each older person’s care and service documents. For example, care and services plan* s and progress notes (Outcome 3.1).
• complaint* s and feedback* you’ve received (Outcome 2.6)
• information about incidents* and near misses* in connection with the delivery of care and services (Outcome 2.5).

Look for situations where:

• older people have not felt safe, welcome, included or understood
• you haven’t met an older person’s communication needs and preferences
• you have delivered care and services in a way that isn’t culturally safe*, trauma aware or healing informed*
• you or your workers haven’t respected or recognised an older person’s rights or autonomy.

Also, talk with older people, their families and carers* about the care and services they receive. Ask them if there are any services that they’re not currently receiving that they would like to. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

If you find any issues or ways you can improve through your reviews and assessments, 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 what went wrong with older people, their family and carers*.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system* and open disclosure*.

Put in place a system* to recognise, respond to and stop abuse and discrimination from happening. This also applies to violence, racism, neglect and exploitation.

Integrate this system* with your systems* for:

• providing safe and quality care* and services (Outcome 2.3)
• managing incidents* (Outcome 2.5)
• managing feedback* and complaints* (Outcome 2.6)
• worker training (Outcome 2.9).

Be clear about how your organisation:

• uses systems* and processes* to stop abuse and discrimination from happening
• identifies cases of abuse, discrimination and neglect
• investigates and addresses these issues, to reduce the risk of them happening again
• monitors and evaluates how effective steps to respond to cases of neglect are
• encourages older people to provide feedback* and complaints* following your feedback* and complaints* management system* (Outcome 2.6).

Make sure workers follow the Code of Conduct for Aged Care. This will help your organisation and workers to:

• support an older person’s right to personal choice, dignity and respect
• promote kind, honest and respectful behaviour
• protect older people from harm.

Report any serious matters or situations where older people have been harmed or were at risk of harm by following the Serious Incident Response Scheme (SIRS) process.

Make sure workers get informed consent* from the older person or their substitute decision maker* when responding to situations that involve abuse or discrimination (Outcome 1.3).

Older people may experience complex family dynamics that workers may become aware of. If complex situations put the older person’s safety and wellbeing* at risk, they need to:

• escalate these concerns
• follow the organisation’s risk, incident and information management systems* (Outcomes 2.4, 2.5 and 2.7).

Put in place strategies that maintain the personal privacy of older people.

Make sure these strategies:

• meet the older person’s needs, goals and preferences* (Outcome 1.1)
• are part of the organisation’s information management system* and clinical information system* (Outcomes 2.7 and 5.1).

Have a process* for providing intimate personal care or treatment, such as help showering. During your assessment and planning (Outcome 3.1), work out when and how an older person receives intimate personal care or treatment. This needs to be:

• based on the older person’s needs and preferences
• done in private and in a sensitive way
• done in a trauma aware and healing informed* way (Outcomes 1.1 and 3.2)

Where an older person’s needs or preferences are different to the organisation’s usual approach, document this in the older person’s care and services plan* (Outcome 3.1). For example, if the older person prefers to shower only when a family member is there to help them and this isn’t on a regular day. Make sure you follow the older person’s care and services plan* when delivering care and services (Outcome 3.2). This will help to make sure their care is consistent.

Personal privacy also includes the older person’s personal space and the things they own.

Make sure workers have the time, support, resources and skills to treat older people with dignity, respect and privacy.

Give workers guidance and training on how to deliver care and services that respect older people’s dignity and privacy (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• treat older people with kindness, dignity and respect
• recognise and respect the relationship between older people, their family and carers*
• respect the privacy of older people. This includes their home and the things they own. It also includes their information and the things they discuss with you during care.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor how you plan for and deliver care and services to make sure older people are treated with dignity, respect and privacy.

To check if your organisation and workers are treating older people with dignity, respect and privacy, you can review:

• older people’s care and services (Outcome 3.1). For example, care and services plans* and progress notes.
• complaint*s and feedback* (Outcome 2.6)
• information about incidents* and near misses* (Outcome 2.5).

Look for situations where:

• older people haven’t been treated with kindness, dignity or respect
• the relationships between older people, their family, and carers* haven’t been recognised or respected
• the personal privacy of older people hasn’t been respected.

Also, talk with older people, their families and carers* about the care and services they receive (Outcome 2.1). Ask them how workers treat them and their family. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

If you find any issues or ways you can improve through your reviews and assessments, 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 what went wrong with older people, their family and carers*.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system* and open disclosure*.

Put in place a system* to provide information to older people.

Integrate this system* with your organisation’s:

• information management system* and clinical information system* (Outcomes 2.7 and 5.1)
• communication system* (Outcome 3.3)
• risk management system* (Outcome 2.4).

Make sure the system* for providing information to older people includes information about how you support them to make informed choices. This includes information about dignity of risk* and positive risk-taking. Risks are considered ‘positive’ if they encourage an older person’s independence and improve their quality of life*.

Make sure the information you give to older people is current and accurate. Make sure you share information in a timely* way with older people and others involved in their care and services, including:

• family
• carers*
• workers
• health professionals*.

You need to share information in a way that meets each older person’s language and communication needs and preferences (Outcome 1.1). This may include using:

• simple, plain language and avoiding medical jargon
• inclusive formats to give older people information if they have communication barriers*, such as using large text or images
• language services. For example, interpreters and translators for older people:
  • from culturally and linguistically diverse (CALD) backgrounds
  • from Aboriginal and Torres Strait Islander backgrounds
  • who are deaf, hard of hearing or deafblind.

Make sure older people understand the information you give them. Give them time to think about the information if they need it. This will help older people, their family and carers* to make informed decisions about their care and services.

Put in place a system* to get informed consent* from older people.

You need a system* that clearly explains:

• situations where you need to get informed consent*. You need to get informed consent* before an older person receives a clinical care* treatment, procedure or other intervention. This includes changes to their care and services. For example, when:
  • there are changes to fees and charges they have agreed to in the past (Outcome 1.4)
  • you need to collect use, store, or share older people’s information (Outcomes 2.7, 3.1, 3.3, 3.4 and 7.2)
  • you’re considering clinical interventions such as restrictive practices* or escalating an older person to medical or emergency services (Outcome 3.2).
• how to find out if an older person needs help to make decisions. This system* needs to explain how the older person can be supported if they need it. This includes access to advocates they want.
• how you support older people to make informed choices and take positive risks
• how you support older people with dignity of risk* (Outcomes 3.2 and 5.4). This includes risks that may be harmful to them, such as smoking.
• how you explain dignity of risk* and how it’s understood by the older person, their family and carers*.
• where older people haven’t given you informed consent* . You need to explain the steps workers should take to understand why and if the organisation can provide more support to help the older person make a decision. Depending on the conversation, document this in your information management system* (Outcome 2.7).

The guidance for Outcomes 3.2 and 5.4 has more information on dignity of risk* and decision-making.

The guidance for Outcomes 6.1 and 6.2 has more information on dignity of risk* for eating and drinking. This includes eating and drinking with acknowledged risk (EDAR)*.

Make sure that your systems* for planning and delivering care and services include the right people. This means making sure that you think about all people who the older person wants to be involved in the decision-making process.

When doing assessment and planning, including comprehensive care* planning and advance care planning* (Outcome 5.4), use the systems* for planning and delivering care and services to:

• find out if an older person needs support to make decisions. Document this information. Help the older person get the support they need to make, share and take part in decisions that affect their lives. If the older person wants an advocate to support them, help the older person find an advocate.
• identify which family and carers* the older person wants to be involved in making decisions. Make sure:
  • all relevant people are involved in future decisions
  • substitute decision-makers* are only asked to make health, medical and residential decisions for an older person if they lose their decision-making capacity
  • you keep records.
• find out the older person’s needs, goals and preferences*, so they can take positive risks. This supports the older person’s independence and quality of life*. Make sure that dignity of risk* is clearly shared with and understood by older people and those making decisions.
• monitor changes to the older person’s quality of life*. Take steps to manage and resolve any issues. Document this information in the older person’s care and services plan* and progress notes.

Older people in residential care homes need different processes for assessing, monitoring and supporting their quality of life* to people receiving home care. For residential care home providers, the guidance for Outcome 7.1 has more information on how you can support an older person’s independence and quality of life*.

Systems* for planning and delivering care and services need to be clear on what an organisation defines as a decision. This will depend on the type of care and services you deliver. This helps workers, older people, their family and carers* understand when to follow your process* for making decisions. For example, when the organisation or workers need to have formal conversations with older people or their substitute decision-maker* or both.

The guidance for Outcomes 3.1 and 5.4 has more information on assessment and planning.

Make sure workers have the time, support, resources and skills to help older people to make decisions about their care and services.

Give workers guidance and training on how to support older people to make decisions about their care and services (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• use the organisation’s systems* to share information with older people
• get informed consent* from the older person
• involve the right people in making decisions
• correctly document each of these steps.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor how you deliver care and services to make sure workers help older people to make decisions about their care and services.

Make sure your workers are following your:

• information management system* (Outcome 2.7)
• clinical information system* (Outcome 5.1)
• communication system* (Outcome 3.3).

To check if workers are helping older people to understand their dignity of risk* and make decisions, you can review:

• older people’s care and services (Outcome 3.1). For example, care and services plan* s and progress notes.
• complaints* and feedback* (Outcome 2.6)
• information about incidents* and near misses* (Outcome 2.5).

Look for situations where workers haven’t:

• supported the older person to make informed choices or decisions
• supported the older person with dignity of risk*
• provided information in a way the older person can view or understand.

Also, talk with older people, their families and carers* about the care and services they receive (Outcome 2.1). Ask them about how workers have supported them to make choices. Ask them if the information workers have given them has been in a way they can view and understand. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

If you find issues or ways you can improve through your reviews and assessments, 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 what went wrong with older people, their family and carers*.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality*.

Use your communication system* to help older people understand the agreements they are entering into, including the fees and charges for care and services (Outcome 3.3).

Give information about agreements to older people before they enter into any agreements. It can also be before they start receiving care, whichever happens first. For example, give them information about:

• any agreements they will have to sign before receiving care or services
• any situations where a change needs to be made to a current agreement
• the terms and conditions about their rights and responsibilities
• the care and services you will provide
• fees and other charges they need to pay.

Include information about fees and other charges in agreements and invoices.

This information should help the older person make an informed decision about whether to enter into an agreement (Outcome 1.3).

Give older people, their family and carers* time to understand the information you have given them (Outcome 1.3) before they enter into any agreements or start receiving care. In particular:

• make sure workers give older people enough time to consider their options when entering into a new agreement. They also need to do this when the organisation makes changes to the prices, fees and payments.
• give older people time and support to ask for external advice if needed.

Help the older person, their family and carers* understand the information you have given them (Outcome 1.3). Consider each older person’s language and communication needs and preferences (Outcome 1.1). For example, use plain language, large text, images, or have a conversation with them directly. Check to see if you need to use interpreters or translators.

Make sure workers check that the older person, their family or carers* understand the information they have given them.

The guidance for Outcome 3.3 has more information on using the communication system*.

Put in place a system* to manage prices, fees, invoices and payments.

This system* needs to include processes* to make sure that:

• the prices, fees and chargeable items specified in agreements and shown on invoices are accurate and transparent. This means invoices need to show the care and services given to the older person. For example, invoices need to be itemised so the older person knows exactly what you’re charging them for. Make sure charges follow the older person’s agreement.
• you give invoices to older people, or people responsible for paying them, in a timely* way
• you give invoices to older people in a format that they can understand clearly. Consider older people’s language and communication needs and preferences (Outcome 1.1). Make sure that if they need any other support to understand this information, that you document this in their assessment and planning (Outcome 3.1).
• you tell older people and those involved in their care when issues in invoices are found. Make sure you address these in a timely* way and where needed, give refunds to older people (Outcome 3.3).
• you investigate any issues. Resolve any system* issues to stop any overcharging or undercharging from happening again.

Do regular checks to make sure invoices are accurate and any issues with agreements can be found and resolved in a timely* way.

Give older people or people responsible for paying invoices ways to give feedback* or make complaints* if they have been given incorrect charges (Outcome 2.6). Don’t rely on older people to make complaints* about incorrect charges. Instead, have strong systems* in place to make sure billing is accurate at all times. These systems* should also allow you to monitor complaints* and record how you managed them.

Make sure that your system* for getting informed consent* from older people includes situations where fees and charges have changed (Outcome 1.3).

Use the system* for getting informed consent* when there are changes to:

• an older person’s care and services
• fees and charges they have agreed to in the past.

Get informed consent* from the older person before making any changes. This is so you can encourage them to choose freely and with dignity of risk* (Outcome 2.1). This makes sure that you record changes about the older person when making decisions about their care and services. This means you will be able to find records of care or financial changes that may affect the ability of older people or their family to pay the agreed fees.

The guidance for Outcome 1.3 has more information on informed consent* and decision-making.

Make sure workers have the time, support, resources and skills to use the systems* for agreements, invoicing and payments.

Give workers guidance and training on how to prepare invoices and agreements that are clear and easy for the older person to understand (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• give older people prices, fees and payments:
  • that are sufficient, accurate and transparent
  • in a timely* way
  • in a way they can view and understand.
• give older people enough time to think about their options before making decisions
• let older people know about any changes to fees and charges they have agreed to in the past
• get informed consent* from the older person before you make any changes to fees and charges.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor the use of your systems* for agreements, invoicing and payments and how well they work.

Check if your workers are following your systems* for agreements, invoicing and payments (Outcome 2.9).

To check if workers are supporting older people to understand their agreements, invoicing and payments, you can review:

• older people’s care and services (Outcome 3.1). For example, care and services plan* s and progress notes.
• complaints* and feedback* (Outcome 2.6)
• information about incidents* (Outcome 2.5).

Look for situations where older people have had issues with differences in their:

• agreements
• the care and services they receive
• fees.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if workers have given them information about their agreements and fees in a timely* way and in a way they can view and understand. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

If you find issues or ways you can improve though your reviews and assessments, 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 what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Partner with older people in the governance*, design, evaluation and improvement of quality care* and services.

Partner with a diverse range of older people to understand their needs and preferences. This includes older people who:

• use, or can use, the service
• identify as Aboriginal and Torres Strait Islander
• are culturally and linguistically diverse
• are living with dementia*
• are living with disability or mental illness
• are veterans or war widows
• are financially or socially disadvantaged
• are homeless or at risk of becoming homeless
• are parents and children who are separated by forced adoption or removal
• are adult survivors of institutional child sexual abuse
• are care leavers, including Forgotten Australians and former child migrants placed in out-of-home care
• are lesbian, gay, bisexual, trans, transgender, intersex or other sexual orientations or are gender diverse or bodily diverse
• are neurodivergent
• are deaf, deafblind, vision impaired or hard of hearing
• live in regional, remote or very remote areas
• are represented by the Consumers and Families Panel (Outcome 1.1).

You can do this by:

• talking with older people, their families and carers about their needs, goals and preferences*
• providing opportunities for older people to take part in your Consumer Advisory Body or other similar committees
• holding forums or feedback* sessions
• using surveys
• promoting the use of your complaints and feedback system.

Use the feedback from older people to:

• tailor information to older people’s needs and preferences (Outcome 3.3). Consider the language and communication needs and preferences of older people (Outcome 1.1).
• design and improve the quality and safety culture* and quality system* (Outcomes 2.2 and 2.3)
• design care and services to make sure they:
  • centre around the needs and preferences of older people (Outcomes 1.1 and 3.1)
  • are accessible, appropriate and culturally safe for people from diverse backgrounds, including Aboriginal and Torres Strait Islander peoples
  • meet all relevant cultural needs (Outcome 1.1)
  • meet the needs of older people living with dementia*, disability, mental illness* or cognitive impairment*.

You can also talk with relevant community organisations, advocacy services and spiritual and community leaders to support older people with diverse needs. For example, you can connect older people with local services and community groups that are relevant to them.

Support older people to take part in partnerships.

Put in place strategies to support workers to partner with older people. For example, strategies or supports that educate and guide your workers to:

• inform older people about how they can take part in partnerships
• encourage older people to contribute their ideas. For example, if they:
  • are less inclined to speak up
  • live with dementia*, mental illness* or disability
  • are affected by trauma.
• help older people contribute their ideas in a way they feel comfortable with. These can be:
  • one-to-one chats
  • anonymous feedback* boxes
  • other ways that suit them.

Monitor processes* for partnering with older people and how well they are working.

To check if you’re partnering with older people well, you can review:

• older people’s care and service documents (Outcome 3.1). For example, care and services plans* and progress notes. Make sure you include feedback* from the older person when you develop their care and services plan*.
• participation and feedback of older people involved in committees such as your Consumer Advisory Body
• the number and type of actions and improvements that you’ve made as a result of partnering with older people
• complaints and feedback* from older people (Outcome 2.6) about:
  • whether the partnering process* works for them
  • whether the partnering process* is improving quality care* and services
• incident* information (Outcome 2.5).

Also, talk with older people, their families and carers about the care and services they receive. For example, ask them:

• if they feel included in the governance*, design, evaluation and improvement of care and services
• if they feel that you and others listen to their feedback*
• if they have any suggestions to improve these processes*.

These conversations can help you with continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through system* reviews and quality assurance.

If you find any issues or ways you can improve through your reviews and quality assurance, you need to address them. If things go wrong, you need to:

• practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

You will know things are going well if older people say that they are confident that they feel:

• safe to speak up
• feel heard.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

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 for workers*. This information can come from:

• feedback* and complaints* from workers* (Outcome 2.6a)
• older people’s care and service documents (Outcome 3.1)
• results from evaluating workers’* performance and how well they’re using the quality system* (Outcome 2.9).

Review this information to encourage continuous improvement* in how you and your workers* deliver care and services in your day-to-day operations.

Make sure workers* follow the Code of Conduct for Aged Care. This will help your organisation and workers* to:

• promote a safe and inclusive environment
• protect older people from harm.

Talk with workers* to:

• leverage their expertise in delivering quality care and services to older people
• find out their needs for safety, health and wellbeing*. Prioritise and monitor the safety, health and wellbeing* of your workers*. Do this by following the governing body’s* strategic and business plan. For example, identify instances where you haven’t met workforce* health and safety needs. This can include one-off occurrences or organisation-wide issues. You may find this through feedback* and complaints* from workers (Outcome 2.6a). Report this to the governing body*.

The guidance for Outcome 2.8 has more information on supporting and maintaining a satisfied and psychologically safe* workforce*.

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 2.6a).
   

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 care and service documents (Outcome 3.1).

Review this information to encourage continuous improvement* in how older people receive care and 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 care and 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).

Put in place a quality system* that supports you to deliver safe and quality care* and services.

Make sure this system* supports safe and quality care* and services that centres around older people’s needs.

Put in place a quality system* that explains:

• who’s accountable and responsible for specific tasks
• ‘what good looks like’ for your organisation and range of services. This includes identifying key performance indicators (Outcome 2.8)
• how you will monitor performance in line with what the governing body* expects
• how you will monitor quality to make sure you achieve outcomes of the Quality Standards
• how you will report the results of monitoring activities in a way that supports you with continuous improvement* and practising open disclosure*. This includes how you will share this information with older people and your governing body*.

Where relevant, use your quality system* to make sure:

• you deliver safe and quality care* and services to older people. This means care that is person-centred*, culturally safe*, trauma aware and healing informed* (Outcome 1.1). Provide this in line with the organisational governance* and quality system* frameworks.
• you give older people current, accurate and timely* information about their care and services. Make sure this information is easy to understand and supports the older person to make informed decisions (Outcome 1.3).
• older people give informed consent* when you need it. For example, before a treatment, procedure or intervention (Outcome 1.3)
• prices, fees and payments are accurate and transparent for older people (Outcome 1.4)
• you support older people to take part in partnership* activities (Outcome 2.1)
• workers have the necessary skills, qualifications and competencies to perform their role (Outcome 2.9)
• your care and services assessment and planning processes* are working (Outcome 3.1 and Outcome 5.4)
• your processes* to coordinate care and services are working (Outcome 3.4)
• older people receive care and services in a physical environment that is safe and supports their needs (Outcomes 4.1 and 4.1b).

You should also use your quality system* to:

• recognise, stop and respond to discrimination, abuse and neglect (Outcome 1.2)
• manage organisational risk (Outcome 2.4)
• record, investigate, respond to and manage incidents and near misses that happen while delivering care and services (Outcome 2.5)
• receive, record, respond to and report on feedback* and complaints. Use this to support you with continuous improvement* (Outcome 2.6).
• analyse risks and their causes
• securely manage records (Outcome 2.7)
• put in place workforce* planning strategies (Outcome 2.8)
• care for older people living with dementia* (Outcome 3.2)
• communicate structured information about older people and their care and services (Outcome 3.3)
• prevent and control infection* (Outcomes 4.2 and 5.2)
• support the appropriate use of personal protective equipment (Outcome 4.2)
• put in place the clinical governance* framework to drive the safety and quality of care and services (Outcome 5.1)
• integrate clinical information into nationally agreed electronic health and aged care digital records (Outcome 5.1)
  • For regional and remote providers, limited access to internet and infrastructure may affect digital maturity. These providers should consider strategies to make sure they’re working towards putting in place a digital clinical information system* .
• support the safe and quality use of medicines (Outcome 5.3)
• monitor and continue to improve the food service (Outcome 6.1)
• have services and supports for daily living that improve the quality of life* of older people (Outcome 7.1)
• transition older people to and from hospital, other care services and stays in the community (Outcomes 7.2 and 3.4)
• measure against Quality Indicator data.

Use your quality system* to report quality performance information.

Report quality information to the governing body*. Also report this information to older people, their families and carers.

Make sure you write and distribute reports in line with the governing body*’s expectations and directions. This also includes monitoring the performance of any subcontracted providers.

Make sure reports clearly explain the results from performance monitoring, including where:

• things have gone well
• things have not gone well
• you will make changes to make sure similar situations don’t happen again.

When things go wrong, you need to practise open disclosure* (Outcome 2.3). This means you should:

• be open about what’s gone wrong
• acknowledge that something has gone wrong and the affect it has had on the older person receiving care
• apologise for what has gone wrong
• put in place strategies in partnership with older people to mitigate the risk of things going wrong again
• monitor and evaluate strategies to mitigate risk
• share this information with older people, their family and carers.

Use this information to develop strategies to stop things going wrong again. You should include processes* to investigate what has gone wrong in your organisation’s clinical governance* framework (Outcome 5.1).

Put in place strategies to help workers use the quality system*.

Put in place policies* and procedures* that support the use of your quality system* . Make sure these are:

• current and informed by the latest contemporary, evidence-based practices*
• regularly* reviewed
• clear and accessible for workers and relevant people.

Provide workers with guidance and training on how to use the quality system*. This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand:

• their role in the quality system*
• how to use the system* to tailor and improve care and services for older people.

The guidance for Outcomes 2.8 and 2.9 has more information about workforce* planning and human resource management.

Monitor how well you use your quality system*.

Regularly* review your quality system* to make sure it works well. Look for ways to improve the system*.

To check if your quality system* works well, you can review:

• older people’s care and service documents (Outcome 3.1). For example, care and services plan*s and progress notes. This makes sure care and services meet the needs and preferences of the older person.
• complaint*s and feedback* (Outcome 2.6)
• risk and incident* information (Outcomes 2.4 and 2.5)
• Quality Indicator data
• worker* performance and how well they’re using the quality system*. You can do this through quality assurance and system* reviews (Outcome 2.9).
• policies* and procedures*.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). For example, ask the older person if any issues they’ve raised have been recognised and addressed. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Analyse the service’s quality data to:

• identify organisation-wide issues that need resolving. To help with this, it’s useful to compare actual performance against expected practice. If actual performance falls short of planning targets, you may need to act. This may include asking for additional investment from the governing body*.
• identify and resolve any issues that aren’t organisation-wide. For example, if a particular worker* or older person needs more targeted support.

If you find any issues or ways you can improve your quality and safety culture*, you need to report them. This way, issues are addressed promptly. Report this information to the governing body* and the Quality Advisory Committee.

Put in place a risk management system*.

At a minimum, make sure your risk management system* has clear and documented processes* and roles and responsibilities* on:

• managing risks to:
  • older people
  • workers
  • your operations
  • business continuity
  • emergency and disaster management (Outcome 2.10)
  • emerging infectious diseases (Outcome 4.2)
  • your information management system* (Outcome 2.7) including data and digital records, such as cyber security risks.
• how to:
  • identify risks
  • assess risks
  • document risks
  • manage risks
  • review risks.
• the strategies to manage the risks you identify. Include how you:
  • prevent risks
  • control risks
  • minimise risks
  • eliminate risks.

Use your risk management system* to identify, manage and review risks.

Have clear processes* to:

• identify and escalate risks. Escalate new risks straight away as you identify them. You should use your broader performance monitoring to inform this (Outcome 2.3). In particular, reviews of feedback* and business data such as incidents and near misses. The risk management system* needs to encourage you to report and escalate issues. This makes sure you can deal with key risks promptly. This may mean you need to escalate certain risks to the governing body*. Risks found through this process* include any risks that can harm the organisation and its people. For example, risks to safety, older people, finances and reputation.
• assess risks. Once you identify risks, do a ‘risk assessment’ to check if there’s a chance of a negative outcome* and how severe that outcome would be. Document the risk assessment and use it to see if you can do an activity or take more actions to minimise the risk. You can also use a risk assessment to prioritise actions. In some cases, you may need a more detailed risk assessment. For example, an older person who is receiving home care services will need a risk assessment of their home environment when they start to have services in their home. You should also do this risk assessment regularly* to help identify possible risks to the older person or workers in the home (Outcome 4.1a).
• manage risks. Allocate actions and resources to minimise risks. Act to eliminate risks where possible. Use ways to control and minimise risks if you can’t eliminate them. Act to stop risks from happening again. This is particularly important if the risk is ‘high’. Actions may be related to key business goals, like workforce planning (Outcome 2.8). They could also relate to outcomes of the Quality Standards (Outcomes 5.4, 5.6 and 4.2). For example, using personal protective equipment to reduce the spread of an infection*.
• monitor risks. Gather and analyse data to make sure you continue to prevent or minimise risk as much as possible. Identify and address organisation-wide issues (Outcome 2.3).

Have at least one organisation-wide risk register and periodically review it for new and emerging risks and those already identified for any change in circumstances. If the organisation has multiple sites and locations, you may need a risk register for each one. You may also need to complete a separate assessment for high-risk activities.

Put in place strategies to help workers manage risk well.

Put in place policies* and procedures* that support you to use your risk management system* . Make sure these are:

• current and informed by the latest contemporary, evidence-based practices*
• regularly* reviewed
• clear and accessible for workers and relevant people.

Provide workers with guidance and training on how to use the risk management system* (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• workers’ roles and responsibilities*.

Make sure workers understand:

• their role in the risk management system*
• how to use the system* to manage risks when delivering care and services to older people. For example, how to report a risk.

The guidance for Outcomes 2.8 and 2.9 has more information about workforce* planning and human resource management.

Monitor how well you use the risk management system*.

Regularly* review your risk management system* to make sure it works well. Look for ways to improve the system*.

To check if your risk management system* works well, you can review:

• older people’s care and service documents (Outcome 3.1)
• complaints and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5)
• worker* performance and how well they’re using the risk management system*. You can do this through quality assurance and system* reviews (Outcome 2.9).
• policies* and procedures*.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if they feel their provider engages with them to identify, manage and review their risks. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance on Outcome 2.3 has more information on monitoring the quality system*.

Put in place an incident management* system*.

At a minimum, make sure your incident management* system* outlines:

• clear and documented processes*, roles and responsibilities* on how you:
  • acknowledge incidents*
  • record incidents
  • assess and investigate incidents
  • respond to incidents
  • manage incidents
  • resolve incidents
  • learn from incidents, to prevent or reduce future incidents from happening again.
• categories to define an incident*. Be clear about what an ‘incident*’ or ‘near miss*’ includes. This definition needs to be clear about what an incident is in the context of the organisation’s scope of services. Include situations that have, or could, cause harm to a person. The categories need to be in line with the Serious Incident Response Scheme (SIRS). They also need to include harm or possible harm to:
  • an older person
  • a member of their family
  • a worker*
  • another person providing care and services.

Incidents can be clinical or non-clinical. Incidents can also relate to worker* safety.

Use your incident management* system* to report and respond to incidents.

Have clear processes* to respond to each type of incident* that can happen when you deliver care and services. Outline who needs to be involved and the timeframe when you need to carry out key activities. Key activities can include reporting, investigations and sharing information.

Incidents that you need to report include near misses*, as well as incidents that:

• have happened
• are alleged or suspected, even if you can’t confirm the incident*.

Serious incidents must be reported following the Serious Incident Response Scheme (SIRS) process. These are incidents where older people have been harmed or were at risk of harm.

Have clear processes* to record and report different types of incidents. Include:

• who reports incidents
• how to document an incident* report
• what level of detail to put into an incident* report
• how to submit the incident* report
• how long you have to submit an incident* report.

After an incident*:

• be clear who is responsible for deciding on immediate actions to keep older people and workers safe
• review an older person’s care and services plan* if an incident involves them (Outcomes 3.1 and 5.4)
• investigate the cause of an incident*. Make sure incidents are investigated. This is to find and manage the underlying cause of an incident* and prevent it from happening again. Be open about the outcome* of the investigation. Share this with the older person, their families and carers if the older person chooses to.
• look for trends to find organisation-wide issues and ways to improve. Do this as part of your broader performance monitoring activities (Outcome 2.3). For example, an organisation wide issue could be:
  • aspects of care which aren’t delivered well. These may suggest that your organisation needs additional worker* training.
  • older people regularly* fall in a particular spot at the service delivery location and you need to redesign the area to be safer.
• use your incident management* system* to monitor and review the strategies you have to manage the cause of the incident and the risk of it happening again.

If you receive a complaint* after an incident* or near miss* , integrate this information with your feedback* and complaints* management system* (Outcome 2.6).

Have an incident* reporting form and incident* register. Record key information about each incident* that has happened.

Put in place strategies to help workers manage incidents well.

Put in place policies* and procedures* that support you to use your incident management* system*. Make sure these are:

• current and informed by the latest contemporary, evidence-based practices*
• regularly* reviewed
• clear and accessible for workers and relevant people.

Provide workers with guidance and training on how to use the incident management* system* (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• workers’ roles and responsibilities*.

Make sure workers understand:

• their role in the incident management* system*
• how to use the system* to manage incidents when delivering care and services to older people.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce* planning and human resource management.

Monitor how well you use the incident* management system*.

Regularly* review your incident* management system* to make sure it works well. Look for ways to improve the system*.

To check if your incident* management system works well, you can review:

• older people’s care and service documents (Outcome 3.1)
• complaint*s and feedback* (Outcome 2.6)
• information about incidents*
• worker* performance and how well they’re using the incident management* system*. You can do this through quality assurance and system* reviews (Outcome 2.9).
• policies* and procedures*.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if they feel their provider supports them to report incidents and involves them in finding ways to reduce incidents. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place an information management system* to manage records.

Put in place a system* for managing information, including the clinical information system* (Outcome 5.1), that:

• gives workers and others such as visiting health professionals, agency workers and contractors access to the right information at the right time
• enables older people to access the information they need to receive quality care* and services
• makes sure stored information is accurate and complete. This also applies to information that’s shared between services that provide support to the older person such as telehealth* services.
• makes sure that you get informed consent* (Outcome 1.3) to collect, use and store older people’s information. You also need informed consent* to disclose older people’s information with other people or organisations. This includes assessment information. If an older person withdraws their consent, record and communicate this.
• integrates information from different sources where needed, such as information from hospitals.
• manages cyber security risks (Outcome 2.4)
• has enough data storage for the records you need to keep.

The information management system*, including the clinical information system*, should be digital where possible. This will be specific to each provider*. There should always be ways to access critical information when digital systems are offline. For example, you can:

• put in place processes to make information available offline
• put in place processes to record clinical information on paper during internet or power outages.

Use your information management system* to record information.

Use the information management system* to make sure you securely manage any records at the service. Use the information management system* during processes*, systems* and strategies to do with:

• choice, independence and quality of life* (Outcome 1.3) and transparency and agreements (Outcome 1.4). Make sure information about the older person’s care, services, and agreements and care commencing (whichever comes first) is:
  • is current, accurate, timely* and easy to understand
  • supports the older person to make informed decisions
  • is accessible by workers
  • helps workers to partner with older people to make informed decisions based on accurate and timely* information.
• human resource management (Outcome 2.9). Store information from possible candidates and existing workers accurately against their profile.
• assessment and planning (Outcome 3.1). Each older person’s care and services plan* needs to include information about the risks associated with the delivery of care and services. It also needs to include how workers can support older people to manage these risks (Outcome 2.4). Make sure you securely store information from assessment and planning and risks and use it to inform the systems* for:
  • comprehensive care* (Outcome 5.4)
  • safe and quality use of medicines (Outcome 5.3) and antimicrobial stewardship* (Outcome 5.2)
  • clinical safety (Outcome 5.5)
  • infection prevention and control in the environment (Outcome 4.2) and when you deliver clinical care (Outcome 5.2)
  • palliative care* and end-of-life care* (Outcome 5.7)
  • food, drink and the dining experience* (Outcomes 6.1, 6.2 and 6.4).

Put in place a clinical information system*. This should be digital if possible. Use it to record and manage older people’s clinical information. For example, transitions of care (Outcome 3.4), assessment and planning (Outcome 3.1) and medication management* (Outcome 5.3). This will help you to deliver safe and quality care* and services. Where possible, the clinical information system* should also record Quality Indicator data. The guidance for Outcome 5.1 has more information on the clinical governance* framework.

Workers need to monitor and record each older person’s preferences, function and changes during activities of daily living*. For residential care providers, the guidance for Outcome 7.1 has more information on supporting older people with activities of daily living*.

During transitions of care*, make sure you give the family, carers, health professionals* or organisations that are involved the older person’s care timely*, current and accurate information about them. Make sure you provide this information with the older person’s informed consent*. The guidance for Outcome 3.4 has more information on coordinating care and services. For residential care home providers, the guidance for Outcome 7.2 has more information on transitions.

For home care providers, information about the older person’s care, such as nutritional needs or activities of daily living*, can be stored in the clinical sections of your database. This doesn’t need to be a dedicated clinical information system*. Make sure information about a person’s safe delivery of care and services is assessed and those involved in their care can access it. This includes contractors.

Put in place strategies to help workers to use the information management system* well.

Make sure all workers and others involved in a person’s care can access your information management system*. Make sure their access to your system* is appropriate to their role. This includes any system* workers or others, such as Commission Quality Auditors, use. This also includes any policies* and procedures*. Check with workers and others that they can access the information management system*. If they can’t, make sure you give them access.

Make sure policies* and procedures* support people to use your information management system*. Make sure these are:

• current and informed by the latest contemporary evidence-based practices*
• regularly* reviewed
• clear and accessible for workers and others involved in care and services.

Provide workers with guidance and training on how to use the information management system* (Outcome 2.9). This includes training to support digital skills if needed. This needs to be in line with:

• the organisation’s policies* and procedures*
• workers’ roles and responsibilities*.

Make sure workers understand:

• their role in the information management system*
• how to use the system* to safely manage information about older people and their care and services.
   

The guidance for Outcomes 2.8 and 2.9 has more information on workforce* planning and human resource management.

Monitor how well you use the information management system*.

Regularly* review your information management system* to make sure it works well. Look for ways to improve the system*. To check if you’re managing information well, you can review:

• older people’s care and service plans* (Outcome 3.1)
• complaints and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5)
• worker* performance and how well they’re using the information management system*. You can do this through quality assurance and system* reviews (Outcome 2.9).
• policies* and procedures*.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place a workforce* strategy.

To develop an effective workforce* strategy, make sure you understand and assess the needs of older people receiving care and the business. This will help you make sure there are enough workers and a good mix of qualified workers to provide safe and quality care* and services.

Make sure your workforce* strategy includes processes* to:

• identify the skills, qualifications and competencies your workers need to deliver safe and quality care* and services. Make sure these relate to what older people receiving care need and want. It’s important to understand older people’s clinical needs (Outcome 5.4). This includes the supports they need to eat and drink safely (Outcome 6.4). Workers’ skills and competencies must meet these needs.
• screen and hire suitably qualified and competent workers. Potential candidates should only be hired if you can confirm they can deliver quality and safe care and services. You can assess this through a pre-employment validation process* as part of your human resources management system* (Outcome 2.9). These can include background checks, processes* to confirm education, qualifications (relevant to their role) and employment history, reference checks, and competency and skill-based tests. Review any history of complaints*, incidents* or other feedback* relating to the worker to understand if there are any issues in their ability to deliver tailored care for each older person. If you find any issues through your reviews and assessments, assess if you can fill a candidate's gaps in skills with training (Outcome 2.9). However, these processes* do not apply to any workers listed on the Aged Care Banning Orders Register, as they must not be hired regardless of their competencies.
• identify the number and mix of skilled workers you need to provide the care and services that meets the older people’s needs (Outcome 2.8). To do this, consider:
  • the number of older people you’re caring for
  • the specific needs of the people under your care. This includes their clinical needs (Outcome 5.4). It also includes their emotional, spiritual, cultural and psychological needs (Outcome 1.1).
  • the number and mix of current workers along with the skills and services they can deliver.
• support diverse workers. For example, sexual and gender diverse, culturally and linguistically diverse, and Aboriginal and Torres Strait Islander workers.
• review rostering processes*. Make sure these processes* support flexible working for directly employed staff.

Make sure enough workers are available at times when older people need more support. For example, during mornings, bedtime and mealtimes. Also, try to maximise worker* continuity (Outcome 3.2). Follow processes to:

• meet the requirements of your 24/7 registered nurse and care minutes responsibilities. This is a legislative requirement for residential care providers.
• mitigate the risk and impact of workforce* shortages, absences or vacancies. Make sure:
  • you maintain relationships with aged care hiring agencies and labour hires
  • staffing needs are met on an ongoing basis. This is important when preparing for busy periods
  • consider the use of digital platforms to meet workforce needs.
• use direct employment where possible and minimise the use of contractors such as agency staff. This can help continuity of care. Only use contractors when staff who are directly employed are not available. If you need contractors, aim to roster the same contractors for the older person unless the older person has asked not to. Complete competency checks in line with your policies* and procedures*. Properly induct and monitor the contractor (Outcome 2.9).

Document your workforce* strategy. Have key initiatives to make sure you meet workforce* needs. How you document this needs to be based on how complex the organisation is and its context. For example, some organisations can build these processes* into risk management systems* (Outcome 2.4) and rostering processes*. More complex organisations may need to build this into strategic business planning (Outcome 2.1).

Put in place strategies that promote a healthy and safe workforce*.

When developing these strategies, consider:

• feedback* mechanisms, such as worker surveys
• worker health and safety risks that you’ve identified through your risk management system* (Outcome 2.4).

To find these risks, analyse the incidents* recorded in your risk management system* (Outcomes 2.4 and 2.5). Make sure these strategies outline how you will support a healthy and safe workforce*. You can do this by completing risk assessments in situations that can cause harm to workers, such as new home environments or traumatic events.

Use risk assessments to understand:

• workers’ physical and psychological risks
• how to manage these risks on a case-by-case basis (Outcome 2.4).

Make sure you:

• put in place processes* to identify and support workers in distress. For example, if they’re experiencing fatigue, bullying or harassment (Outcome 2.2).
• complete regular checks to identify any new risks in the service environment* (Outcome 4.1b). For example, risks of slips and trips. Make sure you manage these risks well.
• provide workers with guidance and training on how to respond to traumatic and emergency events and any other hazardous situations. Make sure training helps workers to manage their own health and the health of people receiving care. Make sure training meets the needs of workers (Outcome 2.9).
• match training needs to the type of service. For example, training in home care could include how to do manual tasks safely when assisting with personal care, cooking or cleaning. Make sure workers know their responsibilities* to identify and report any concerns they have to the provider. The guidance for Outcomes 2.4 and 2.5 has more information on managing risks and incidents in home care.
• put in place incentives for workers to promote a safe working environment. For example, recognise quality and safe work that meets the needs of older people and workers. This can also help to make sure workers are satisfied in their role and receive the support they need. This can help minimise stuff turnover.
• put in place Key Performance Indicators (KPIs) for health and safety. Include these KPIs in strategic business planning (Outcome 2.1) and performance reporting (Outcome 2.3).

Document these strategies. Include your key initiatives for making sure you meet your workers’ health and safety needs. How you document these strategies should be based on how complex the organisation is and its context. For example, some organisations can build these processes* into risk management systems* (Outcome 2.4) and workforce* planning processes* (Outcome 2.8). More complex organisations may need to build this into strategic business planning (Outcome 2.1).

Monitor how well the workforce* strategy is working.

Regularly* review your workforce* strategy to make sure it works well. Look for ways to improve the workforce strategy.

To check if your workforce* strategy is working well, you can review:

• older people’s care and service documents (Outcome 3.1)
• complaint*s and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5).

Assess your workers’:

• qualifications, skills and competencies
• performance. You can do this through quality assurance and system* reviews (Outcome 2.9).

This needs to be a key part of how you evaluate quality and care outcomes (Outcome 2.3).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance on Outcome 2.3 has more information on monitoring the quality system*.

Monitor that the workforce* is healthy and safe.

Regularly* review your workforce strategies to promote a healthy and safe workforce*. Look for ways to improve your strategies.

To check if your workforce* is healthy and safe, you can:

• ask workers if they feel supported to be healthy and safe. This includes any resources or processes* they can use to support their health and safety.
• analyse risk (Outcome 2.4), incident* (Outcome 2.5) and feedback* and complaint* s (Outcome 2.6) data to see if any issues are recurring. If this is the case, take action in a timely* manner to reduce or prevent these issues from happening in the future.
• complete assessments or checks to make sure workers are delivering care and services that are safe for older people, themselves and their coworkers (Outcome 2.3). If assessments identify any issues or concerns, take action in a timely* manner to address these. For example:
  • the quality system* may need to be modified
  • workers may need extra training so they understand how to perform their role safely.

Report your findings to the governing body* (Outcome 2.3).

Put in place a human resources management system*.

Put in place a pre-employment validation process*. This checks that the information job applicants give you about their qualifications, skills and experience are accurate. Include:

• background checks
• processes* to verify education and qualifications
• processes* to confirm employment history
• reference checks
• competency assessments.

This helps make sure that potential workers have the right skills and experience to provide safe and quality care* and services (Outcome 2.2). It can also confirm if your organisation’s training system* can update the person’s skills if needed.

Store this information in line with your information management system* (Outcome 2.7). Make sure you store all the information from applicants accurately. That means documents you receive from applicants matches their profile.

Put in place strategies to roster workers for quality and safe care and services.

Rostering needs to be informed by the organisation’s workforce* strategy (Outcome 2.8).

When rostering, make sure you:

• consider the skills, number and mix of workers you need to deliver safe and quality care* and services. Make sure enough workers are available when older people need more support. For example, during mornings, bedtime and mealtimes. This could also include when responding to high risk or complex situations. For example, when an older person shows signs of deterioration* or changed behaviours* (Outcome 5.4).
• assign an appropriate number and mix of workers to specific shifts and tasks. Base this on workers’ skills, qualifications and competencies.
• consider worker* continuity. This supports a person’s continuity of care (Outcome 3.4). Use direct employment where possible and try to minimise the use of contractors such as agency staff. You can also try to offer shifts to staff who are directly employed first. If you need contractors, aim to roster the same contractors for the older person, unless the older person has asked not to. Complete competency checks for contractors in line with your policies* and procedures*. Properly induct and monitor the contractor.

Make sure rostering supports the delivery of quality and safe care and services at all times. Care and services need to be centred on the needs and preferences of older people (Outcome 3.2). Where possible, include the older person’s input when choosing their worker.

Provide workers with adequate and appropriate supervision, support and resources. This includes guidance and training on how to provide quality and safe care.

Monitor and report Quality Indicator data about the turnover of your workers and the reasons for their departure.

Put in place a training system*.

Develop your training system* in consultation with workers and older people. This can include:

• regularly* analysing training needs. List the skills needed for each role and what training can build these skills. Make sure training is based on contemporary, evidence-based practice*. Make sure training also meets the organisation’s scope of services and the diversity* of older people. It’s important to conduct training to fill any competency gaps identified during:
  • hiring activities (Outcome 2.8)
  • broader performance monitoring (Outcome 2.3)
  • assessment of the organisation’s quality and safety culture* (Outcome 2.2).
• putting in place training strategies and a ‘training matrix’ (or equivalent) which lists:
  • all worker* role types. For example, care worker*, chef, cleaner and administration roles.
  • the training needed for each role type, to help workers perform that role.
• delivering training in line with any identified training needs. This may include training on how workers can:
  • deliver person-centred*, rights-based care
  • provide culturally safe*, trauma aware and healing informed care*
  • care for people living with dementia*
  • provide palliative and end-of-life care*
  • respond to medical emergencies
  • meet the requirements of the Code of Conduct for Aged Care
  • meet the requirements of the Serious Incident Response Scheme (SIRS)
  • meet the requirements of the Quality Standards
  • meet other requirements relevant to their role. For example, an understanding of Infection Prevention and Control*, relevant to their role. This includes training for Infection Prevention and Control Leads*. This also includes specific training for people who have a formal role in an emergency, such as fire wardens and first aiders (Outcome 2.10).
• reviewing workers’ skills and understanding. After training, include processes* to check that workers’ have the right skills and capabilities for their role. This can include competency evaluations and quality assurance. This can also include tracking who has completed training.

Make sure that workers can provide quality and safe care for each older person. Make sure training strategies consider the diversity of your workforce* (Outcome 2.8). For example, provide workers with the support they need to take part in and complete training.

Keep training records for all workers, including contractors. This includes records that show they have completed training and the competency they need to perform their role. Record this information in line with the organisation’s information management system* (Outcome 2.7). You can put in place a system* to track workers' licenses and registrations that alerts you when they are about to expire. Make sure workers and others understand the policies* and procedures* relevant to their role (Outcome 2.7).

Make sure the training system* is relevant for and accessible to contractors and employees.

Put in place strategies to regularly* assess, monitor and review the performance of workers.

Make sure workers are providing quality and safe care and services. Strategies to monitor workers’ performance can include:

• developing and monitoring performance measures. The performance measures of a worker* will depend on their role and responsibilities*. For example, positive feedback* from older people for carers and hiring targets for administrative workers.
• completing regular performance reviews to an agreed schedule. Consider all monitored performance measures and feedback*. Workers should have the opportunity to clarify or provide reasons for any feedback* that does not meet their expectations. Make sure performance reviews:
  • fairly assess workers based on feedback* provided by older people, other workers, supervisors and people they work with (Outcome 2.6)
  • provide workers with support in areas identified for improvement in the training needs analysis. This is part of the training system*.
  • encourage workers to deliver quality and safe care and services (Outcome 2.3)
  • consider outcomes from the training system*.
• having processes* to assess all performance review outcomes. This can help to work out where you can make improvements. Recognise workers with positive outcomes. Develop improvement plans with workers who need to improve. Do this in partnership with the worker. Make sure improvement plans show how the worker* can provide quality care* and services (Outcome 2.3). Store information about worker* performance using your information management system*. This will make sure it’s accurate, secure and accessible (Outcome 2.7).

Monitor how well your strategies to roster workers for quality and safe care and services are working.

To check if the staff resource needs of the organisation are being met:

• talk with workers, older people, their families and carers
• review older people's care and service documents (Outcome 3.1)
• review complaints*, feedback* and incident* information (Outcomes 2.6 and 2.5)
• make sure skilled workers are available to deliver safe and quality care* and services.

If you find any issues or ways you can improve your rostering address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

Monitor how well you use your training system*.

Regularly* review your training system* to make sure it works well. Look for ways to improve the system*.

To check if workers have the capabilities, supervision, support and resources they need to perform their role, you can review:

• older people’s care and service documents (Outcome 3.1)
• complaints* and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5)
• worker* performance and how they’re using the training system*. You can do this through quality assurance and system* reviews. (Outcome 2.9).
• training records to make sure workers have completed training as needed and in a timely manner
• policies* and procedures*.

Also, talk with:

• workers to see if they feel supported to:
  • complete their training
  • perform their role well and safely.
• older people, their families and carers about the care and services they receive (Outcome 2.1).

These conversations can help you with continuous improvement* actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place emergency and disaster management plans.

Develop emergency and disaster management plans. This helps to reduce risks to the health, safety, and wellbeing* of older people and workers.

Make sure emergency and disaster management plans:

• are based on an emergency and disaster risk assessment. This assessment identifies emergency and disaster situations that can happen when delivering care and services. These can include environmental events or disasters, such as floods, heatwaves, fires, and damage to infrastructure. This can also include medical emergencies. The risk assessment also helps assess how you and your workers need to respond to manage these situations. Make sure you do the emergency and disaster risk assessment as part of the organisation’s broader risk assessment (Outcome 2.4).
  • in residential care, the emergency plan applies to all older people and workers. The plan describes how the organisation and workers will respond to an emergency or disaster and how you will manage risks. The plan also considers extra supports that each older person may need. You need to communicate these extra supports to workers so they can act appropriately in an emergency.
  • in home care, the emergency plan needs to address the older person and the home care environment. It may be helpful to complete risk assessments for home care in regional and remote communities with local services from the area. This may also help you find ways to share resources during an emergency. Local services can understand particular risks that others may not (Outcome 4.1a). For example, high kangaroo activity on a road may be a risk to the worker when travelling, or a road may be more likely to flood. There can also be higher risks for those who don’t have access to transport in areas at risk of bushfires, heatwaves or floods. Use your incident management* and risk management systems* in this process* to identify and manage these situations (Outcomes 2.4 and 2.5).
• are based on the service context. Use the emergency risk assessment to decide if you need an emergency and disaster management plan specific to the service. This depends on the context of the organisation. Sometimes a high-level plan can be enough. For example, in home care, a high-level plan can be enough if there is a broader risk assessment for each home setting (Outcome 4.1a). The broad risk assessment for each home setting needs to assess any particular challenges in emergency responses. For example, during heatwaves and in flood prone areas.
• include strategies for communication and management planning during an emergency
• are developed in consultation with older people, their family, carers, workers, visitors and other response services. This makes sure the processes meet older people’s needs (Outcomes 2.1 and 1.1). Make sure strategies are included in a person’s care and services plan*s if needed. For example, where an older person has a disability or culturally diverse needs that may need to be considered during an emergency.
• are shared with older people and their families in a variety of ways. This can be by displaying the plans on noticeboards or email alerts (Outcomes 2.2 and 3.3). Make sure this information is shared in a way the older person understands (Outcome 1.3). Consider each older person’s language and communication needs and preferences (Outcome 1.1).
• tested on a periodic basis. For example, once a year. Use a variety of different emergency scenarios in your emergency drill schedule. If you find any issues through these tests, review and update the emergency plans. Issues can include workers not being sure what to do. Drills need to be done with workers, older people, their families and carers, visitors and other response partners (Outcome 2.1). These can be desktop drills. This will help to reduce disruption to older people. These drills can also include scenarios like power and internet outages.
• are evaluated and updated. After a drill, or if a real emergency happens, assess the responses and emergency plan to check if they worked well. Make changes if needed.
• include processes to respond quickly to outbreaks of infectious diseases. You need to do this even if the disease is only suspected (Outcome 4.2). You can develop an outbreak management plan.

Note: Response partners can include:

• government agencies
• the state emergency service
• other service providers
• community organisations local health services
• local public health units.

Make sure your workers have the time, support and resources to use emergency and disaster management plans.

Put in place a workforce* strategy (Outcome 2.8) that considers:

• transitions of care* (Outcome 3.4)
• continuity of care (Outcome 3.4)
• assessing workers’ abilities during the hiring process* (Outcome 2.8)
• additional staff or workforce* supports that may be needed during an emergency (Outcome 2.9)
• providing workers with guidance and training on their roles and responsibilities* in an emergency or disaster.

Guidance and training needs to be in line with:

• the organisation’s policies* and procedures*
• workers’ roles and responsibilities*.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce* planning and human resource management.

Monitor how well your emergency and disaster management plans are working.

To make sure emergency and disaster management plans are working well, you can:

• talk with workers, older people, their families and carers
• assess emergency and disaster drill records.

You can also review:

• complaints* and feedback* (Outcome 2.6)
• risk and incident* information (Outcomes 2.4 and 2.5)
• policies* and procedures*.

Review your emergency plans and update them if needed. This will help to make sure your emergency plans stay current and effective. For example, review your plan:

• if you move or renovate
• if the number of older people in your care changes significantly
• if your workforce changes significantly
• after you do an emergency management drill
• after an emergency.

If you find any issues or ways you can improve, address them. If things go wrong, be open about it. Share what went wrong with workers, older people, their family and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place a system* for assessment and planning.

Assessment and planning is an important part of delivering quality care* and services. In your system* for assessment and planning, make sure you prioritise:

• the older person’s quality of life*
• their reablement*
• maintaining their physical, mental and cognitive functions.

Making these areas a priority will support you to:

• deliver quality care* and services
• create care and services plans* that meet the needs, goals and preferences* of older people.

Make sure your system* includes processes* to:

• partner with the older person about who they want involved in their assessment and planning. Use your organisation’s system* to identify and guide workers about how to involve the older person and others (such as family or carers) who the older person chooses to involve in assessment and planning (Outcome 1.3). If the older person lacks the capacity to make decisions, the provider has the responsibility to know and record:
  • who the substitute decision-maker* is
  • the types of decisions they are authorised to make on behalf of the person.
• talk with the older person and other people the older person would like involved in their care and services (Outcome 2.1). This will help workers to understand each older person’s goals of care*. It will also help support their quality of life* and reablement* and to maintain their function. Make sure these discussions are in line with culturally and psychologically safe* care principles. This will help to plan and deliver care that is culturally safe* , trauma aware and healing informed* (Outcome 3.2).
• document the older person’s needs, goals and preferences* (Outcome 1.1) in their care and services plan*. This includes their:
  • culture, diversity and religious beliefs
  • connection to Country and community. For example, for older people who identify as Aboriginal and Torres Strait Islander or live in regional and remote settings.
  • individual background and life experiences
  • language and communication needs and preferences
  • gender identity and sexual orientation
  • decision to share this information, who to share this information with, and their preferences to talk or not talk about their experiences.
• consider risks to the older person’s health, safety and wellbeing*. Also include how you will manage these risks (Outcome 2.4). Do this in partnership* with the older person.
• provide the resources and support each older person needs when delivering care and services. Make sure this information informs the supports what older people need to perform their activities of daily living*. For residential care providers, the guidance for Outcome 7.1 has more information on how you can support older people with activities of daily living*. For older people receiving care and services in a home setting, this could also involve identifying if referrals to other care services or providers may be needed.
• share information (Outcome 2.1). Workers need to inform older people that their own care and services plans* are available and accessible to them. Use your information management (Outcome 2.7) and communication systems* (Outcome 3.3) to do this.
• involve appropriate health professionals* and support services where you need to. For example, you may need to involve:
  • a mental health professional* if the person has psychological deterioration*
  • dementia* support specialists if the person has cognitive deterioration*
  • a dietician to provide nutrition care in response to identified weight loss (Outcome 5.5).
• make sure care and service plans* are accessible and available to workers as well as older people. Workers need to access, refer to and understand care and service plans* to guide how they deliver care and services.
• enable reporting your Quality Indicator data about the quality of care.

Create care and services plans* that:

• are individualised and person-centred*. Care and service plans* need to show the older person’s unique needs, goals and preferences* (Outcomes 3.2 and 3.3). This will make sure care and services are delivered safely and in line with the older person’s needs and preferences. When making care and services plans*, consider each older person’s:
  • culture, diversity and religious beliefs
  • individual background and life experiences
  • language and communication needs and preferences
  • gender identity and sexual orientation (Outcome 1.1).
• are comprehensive (Outcome 5.4). Consider each older person’s:
  • individual needs and preferences (Outcome 1.1)
  • goals of care* in collaboration with their family, carers, health professionals* and others they wish to involve in their care (Outcome 5.4)
  • choices so that you can support them in optimising their quality of life*, reablement* and maintenance of function
  • clinical needs and risks. For example, individual nutrition, hydration and dining needs and preferences (Outcome 6.2).
• consider which health professionals* and services are needed to meet the older person’s clinical needs, with their informed consent*. For example, a person may need:
  • medical
  • rehabilitation
  • allied health
  • oral health
  • specialist nursing

  • dementia* support services. 

    This will help make sure older people receive coordinated, multidisciplinary care* (Outcome 5.4).

• are available to older people and people they want involved in their care and services. This may include the older person’s family and carers if requested by the older person. You need to share this information in a way each older person understands (Outcome 1.3). This should consider each older person's language and communication needs and preferences (Outcome 1.1). For example, if an older person has a cognitive impairment*, workers should support them to understand the information. This needs to be based on each older person’s needs to support their understanding.
• are clear and accessible.

Care and services plans* need to be up-to-date and informed by assessments. Review the plans regularly*, including:

• if there are changes in the older person’s circumstances. This can include a change to:
  • their needs, goals or preferences (Outcome 1.1). For example, if an older person’s dietary preferences change.
  • their mental health*, cognitive or physical function, capacity or condition. This includes if their function, capacity or condition deteriorates*, improves or changes (Outcome 5.4). For example, if an older person’s mobility decreases after a fall.
  • their ability to perform activities of daily living*. For example, if an older person is no longer able to walk without help
  • the care that family or carers can provide to the older person
• the care responsibilities of the people providing care and services to the older person. This means, if any services or allied health* and health professionals* involved in the older person’s care and services change. For example, when an older person’s GP retires and they organise a new one, make sure you review and update the person’s care and services plan*.
• after an incident* (Outcome 2.5). After an incident*, document any changes to the care and services plan* that are needed.
• if the care and services plan* is not reflecting the needs, goals and preferences of the older person. Older people, their family, carers or others may raise issues through feedback* or complaints* (Outcome 2.6). Workers may raise issues through established escalation pathways using the information management* (Outcome 2.7) and communication systems* (Outcome 3.3).
• if risks are identified (Outcome 2.4). Document the risks, any strategies to prevent or reduce risk in the future and how you plan to monitor and assess these strategies. For example, if an older person is identified as being at risk of choking or have difficulties swallowing (Outcomes 5.4 and 5.5), make sure assessments are undertaken to evaluate the risk and documented, and update their care and services plan*. Recommendations and strategies to mitigate risk should be individualised to each older person in line with their assessed needs. The care and services plan* should also outline when the older person needs to be reassessed and who should do this.
• at transitions of care*. For example, when an older person is discharged from hospital or changes from home care to residential care services. The guidance for Outcome 3.4 has more information on coordinating transitions. For residential care providers, the guidance for Outcome 7.2 has more information on how you can support older people during transitions.

Put in place processes* for advance care planning*.

These processes* need to:

• support the older person to talk about their future medical treatment and care needs. Talk with the older person about their needs, goals and preferences*. This includes their beliefs, cultural and religious practices and traditions (Outcome 1.1)
• support the older person to complete and review advance care planning* documents, if they choose to
• support the older person to have choices and exercise dignity of risk* (Outcomes 1.2 and 1.3). For example, if an older person makes the informed decision to not use recommended pressure relieving devices or walking aids (as prescribed by a relevant health professional*).
• support the older person to nominate and involve a substitute decision-maker* for health and care decisions, if and when they choose. The guidance for Outcome 1.3 has more information on supported decision making* and the role of substitute decision-makers*.
• make sure you store, manage, use and share advance care planning* documents with relevant people if needed, including at transitions of care*. Use your information management system* (Outcome 2.7) and communication system* (Outcome 3.3) to do this. Informed consent* should be obtained from the older person to share their information and advance care plan (Outcome 1.3).
• be integrated with your systems* and easily accessible for quality clinical care* (Outcome 5.1) where relevant.

Make sure workers who provide care and services have the time, support, resources and skills to plan for and deliver care and services tailored to each older person’s needs and preferences.

Provide workers with guidance and training on how to plan for and deliver tailored care and services for each older person (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers who deliver care and services understand how to:

• undertake assessments
• develop care and services plans*
• use this information to plan and deliver care and services tailored to the older person’s needs, goals and preferences* (Outcome 3.2).

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure workers can assess and understand care and services plans* when they need them. Care and services plans* need to be stored in line with your information management system* (Outcome 2.7).

Monitor how well your processes* for assessment and planning are working.

To check if your assessment and planning processes* work well, you can review:

• older people’s care and services documents (Outcome 3.1). For example, care and services plans*, progress notes and advance care planning documents*. Check that each older person’s care and services plans* include their current needs, goals, and preferences*.
• complaints* and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5).

Look for situations where:

• incidents* have happened where the wrong service or care has been provided
• a care and services plan* was not reviewed and updated after a change in circumstances
• an older person’s needs, goals or preferences were not documented in their care and services plan* or advance care planning documents*.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). For example, ask them if they were involved in the assessment and planning process* of their care and services. Ask them if their needs, goals and preferences* have been understood and considered in their care and services plan* and advance care planning* . These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

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* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place strategies for providing quality and safe care and services.

These strategies need to explain how you will deliver care and services plans*. Make sure these strategies describe how care and services will:

• meet the needs, goals, and preferences* of older people (Outcome 1.1)
• be based on contemporary, evidence-based practices* (Outcome 2.3)
• be culturally safe* and appropriate for people with specific needs and diverse backgrounds (Outcome 1.1). For example, if an older person has specific cultural dietary or food preferences, you should document this in their care and services plan*. For residential care home providers, the guidance for Outcomes 6.2 and 6.3 has more information on how you can support older people’s needs and preferences on food, nutrition and the dining experience*. You can also support cultural safety by:
  • providing older people with a culturally safe* and sensitive environment
  • providing opportunities for older people to take part in cultural activities that are meaningful to them, if they wish to do so. This includes supporting them to exercise dignity of risk* (Outcome 1.3). For example, when an Aboriginal and Torres Strait Islander older person wishes to attend cultural activities or ceremonial responsibilities on Country.
• be trauma aware and healing informed* (Outcome 1.1). Make sure you understand and respond to the impacts of trauma and situations that may be triggering of trauma responses. Care and services also need to consider the older person’s psychological needs and past experiences. For example, an older person who has experienced war may be particularly sensitive to loud or unexpected noises. Care leavers may also have difficulty interacting with workers, allied health* and health professionals* based on their past experiences or trauma. Provide older people with a safe and healing environment in line with trauma aware and healing informed care*. For example, make sure the environment or interactions with workers do not resemble an institution.

You can support trauma aware and healing informed care* by:

• providing a safe and supportive environment where older people:
  • feel accepted and valued (Outcomes 1.1 and 1.2). For example, approaching and responding to older people with empathy and positivity.
  • can speak up without reprisal (Outcome 2.6). For example, older people can ask for help which will not lead to criticism. This includes encouraging and providing older people with help to complete surveys and give feedback* and complaints* anonymously if they wish.
• respecting the older person’s autonomy and dignity (Outcomes 1.1 and 1.2). For example, asking for the older person’s permission before attending any care tasks or touching their belongings.
• making sure older people don’t experience discrimination, abuse and neglect when receiving care and services (Outcome 1.2)
• offering older people choices for how you deliver their care and services (Outcome 1.3). This includes recognising the older person’s choice to exercise dignity of risk* and decline tasks they receive care and services.
• working in predictable and transparent ways. You can do this by working in partnership with the older person, their family, carers and others involved in their care and services (Outcome 2.1).
• practising open disclosure* and communicating with older people, their family and carers when things go wrong (Outcome 2.3)
• supporting the older person to select their workers (Outcome 3.2). This can include supporting the older person to choose workers based on their gender and the language they speak (Outcome 1.1). For example, for males from an Aboriginal and Torres Strait Island background, this may include organising a male worker of their choice to attend to personal care or treatment (Outcome 1.2).
• minimising the use of restrictive practices* (Outcome 3.2)
• recognising signs of distress or situations where the older person’s psychological safety* is at risk (Outcome 5.5)
• having strong safety protocols.

Also, make sure these strategies describe how your care and services will:

• optimise older people’s quality of life*, reablement* and help maintain their function. This will support the older person to be as independent as possible. For example, make sure it’s clear how you will:
  • make appropriate and timely* referrals to health professionals* (Outcome 3.4) when you identify risk. This includes professionals from a range of different disciplines. For older people using home care services, this also includes referrals to My Aged Care for them to be reassessed. For example, accessing a physiotherapist in the community for physical reablement after a fall. Use your organisation’s communication system* to manage referrals (Outcome 3.3). This will help you to deliver quality, multidisciplinary care* (Outcome 5.4)
  • support older people to make informed decisions about the care they receive (Outcome 1.3). For example, you can organise a case conference with the older person and the people they want involved in their care with any additional support they need. This can help the older person to feel confident and supported to participate in the discussion.
  • support older people to understand the information you give them. This includes how you give older people access to extra supports to help them to understand the information. This can include advocates, interpreting services to support discussions about care and services and translation of written information into the older person’s preferred language. In addition, this could also include speech pathologists to support communication or using communication aids for those with communication impairment.
  • support older people to exercise dignity of risk* (Outcome 1.3). For example, if an older person has a history of falls* but still wants to go for a daily walk to the shops on their own, you should support them to do this. This includes talking with the older person about the risks and consequences involved. The older person needs to be able to understand how the risks or consequences may affect them. (Outcome 5.5).
  • support older people to take part in activities of daily living*. This includes supporting them to maintain social connections with friends, family and the community (Outcome 1.1). For example, for older people living in a residential care home, provide them opportunities to take part in activities that are meaningful to them. This may include gardening, music and trips in the community (Outcome 7.1). For older people receiving care in the home, provide strategies that support them to take part in social activities with friends, family and the community where possible. This should be informed by each older person’s needs, goals and preferences*.
• maximise worker continuity. For example, having the same care workers regularly* supporting an older person where possible, safe and preferred. This will support the provision of continuity of care (Outcome 3.4).
• provide reasonable opportunities for the older person to choose their workers, where possible. For example, you can support older people to choose workers based on their gender and the language they speak (Outcome 1.1).

Put in place a system* to provide care for people living with dementia*.

Make sure this system* supports safe and quality care* and services for people living with dementia*.

It’s important your system includes processes*:

• to recognise early signs of dementia*. The strategies you use for this should be informed by contemporary, evidence-based practices* (Outcomes 2.3, 5.4 and 5.6)
• for workers to assess the strengths and skills of people living with dementia*. Make sure you encourage older people to use and maintain their strengths and skills (Outcome 1.1). You can collaborate with allied health* and other health professionals* to support older people’s activities of daily living* and quality of life* and to maintain physical, mental and cognitive functions. For example, encourage and provide opportunities for people with dementia that are meaningful and in line with their preferences, such as rinsing their own dishes after a meal. For residential care providers, the guidance for Outcome 7.1 has more information on how you can support older people with activities of daily living*.
• to partner with the older person, their family, carers and health professionals*. You need to involve these people when planning and delivering care and services to the older person (Outcome 2.1).

Put in place processes* to make sure care and services plans* for people living with dementia* meet their individual behaviour support needs (such as mood, memory, thinking and behaviour), as well as their individual needs, goals and preferences*. You need to tailor care and behaviour support strategies to the older person’s individual needs and preferences following best practice behaviour support. This should also be recorded in their behaviour support plan* as part of their care and services plan* (Outcomes 3.1 and 5.6). You need to identify, assess and record any changes in their individual care and behaviour support needs. For example, if a person living with dementia*:

• experiences changed behaviour*. This can include:
  • agitation. For example, when an older person calls out distressed, doesn’t recognise their surroundings and wants to leave.
  • changes in their perception of time.
• Is no longer assessed as needing the use of restrictive practices* as part of their care to manage risks of harm, after they have settled into a new home or environment
• has behaviour support strategies that are no longer effective.

Put in place strategies to minimise the inappropriate use of restrictive practices.

To prevent harm to the older person, or other people, make sure restrictive practices* are:

• only used as a last resort. This means, you need to try tailored and individualised alternative strategies to the extent possible first. Document the use of these strategies in the older person’s behaviour support plan* as part of their care and services plan* (Outcomes 3.1 and 5.6). This includes evaluating the effectiveness of these strategies and considering the likely impact of the use of restrictive practices* on the older person.
• used in the least restrictive form and for the shortest time necessary. This means, there is effective assessment, monitoring and review processes* to make sure the least restrictive option is used.

Also, make sure restrictive practices* are:

• only used if the older person or their restrictive practices* substitute decision-maker* provides informed consent* to the use of the restrictive practice and how it will be used. If the older person lacks the capacity to give their informed consent*, this needs to be obtained from their restrictive practices* substitute decision-maker*. Make sure you document a description of the consultation about the use of the restrictive practice and the giving of valid informed consent*. The guidance material for Outcome 1.3 has more information on informed consent*.
• monitored, reviewed and evaluated regularly* or if there is a change in the older person’s circumstances. Check if there are any appropriate alternative strategies, even if it has been agreed that restrictive practices* can be used. This also includes evaluating the use of these strategies with the aim to reduce and eliminate the need for a restrictive practice.
• documented in the older person’s behaviour support plan* as part of their care and services plan* if used or assessed as necessary. This will guide the safe and appropriate use of restrictive practices*. This includes:
  • any alternative strategies that have been considered and used prior to the use of restrictive practices* (Outcomes 3.1 and 5.6)
  • the documented success and failure of these attempted strategies to inform the older person’s care
  • the changed behaviours* relevant to the need for the use of the restrictive practice
  • how the restrictive practice will be used. This includes its duration, frequency and intended outcome.
  • how the restrictive practice will be monitored and reviewed.

Where restrictive practices* have been assessed as necessary, make sure they are used in line with relevant legislation and the older person’s assessed needs.

Put in place strategies to support workers to deliver quality and safe care and services.

You need to develop these strategies to meet the requirements of your risk management system* (Outcome 2.4).

These strategies need to support workers to:

• recognise risks or concerns about an older person’s health, safety and wellbeing*
• identify deterioration*, changes to an older person’s physical, mental and cognitive functions, or changes in their ability to perform activities of daily living*. This includes changes to an older person’s circumstances, needs, goals and preferences* (Outcome 1.1). For residential care providers, the guidance for Outcome 7.1 has more information on identifying, monitoring and recording older people’s function in relation to activities of daily living*. 
• respond to and escalate risks. Have escalation procedures* to make sure workers know who they can contact if they need support. For example, how to call for assistance and who to escalate concerns to after an older person has a fall*.

Even if you don't deliver clinical care*, you need to be aware of the clinical care* that has been delivered to the older person so you can support workers to identify risks. For example, if an older person has a wound dressing, you, as the provider, will need to understand how you will deliver showering services. This includes how your workers:

• engage with the wound while showering the older person in line with health professional* instructions and advice
• identify signs of wound deterioration* (such as pus) so clinical issues can be appropriately escalated and in a timely* way.

Also, make sure your strategies support workers to:

• make appropriate referrals and confirm these have been made in a timely* manner such as referrals to health professionals*. For example, when workers notice deterioration*, changes to an older person’s physical, mental and cognitive functions, or changes in their ability to perform activities of daily living*.
• make sure older people have access to multidisciplinary care*. This involves input from a variety of health professionals* . Make sure processes are in place to support workers to communicate with each other effectively (Outcome 3.3).
  • for regional and remote providers, limited resourcing may affect timely* access to multidisciplinary care*. These providers should consider strategies to make sure older people are appropriately referred to allied health* and health professionals*.
• maintain and support the older person’s mental health*, cognitive or physical function. Make sure you arrange a medical review if you notice deterioration* in any of these areas (Outcome 5.4).
• share information with older people when they’re delivering care and services based on their language and communication needs and preferences. This can include both verbal and non-verbal communication.
• support older people to use equipment, aids, devices and products safely and effectively. The guidance for Outcomes 4.1a and 4.1b has more information on managing equipment at home and in the service environment.
• involve older people in choosing workers who provide their care.

Make sure your strategies support workers to provide care to people living with dementia*. This includes:

• providing care that is informed by contemporary, evidence-based practices* (Outcome 2.3)
• understanding the way different older people want information to be shared with them. Do this by identifying each older person’s language and communication needs and preferences (Outcome 1.3).
• recognising and responding to changed behaviours* in people living with dementia*. This includes making sure workers have access to behaviour-specific training (Outcome 2.9).

Also, make sure your strategies support workers to minimise the use of restrictive practices*. This includes:

• understanding how to minimise the inappropriate use of restrictive practices*
• clearly and consistently documenting the use of restrictive practices* and how they were monitored
• confirming restrictive practices* were used as a last resort to prevent harm to the older person or other people
• documenting the alternative strategies that have been considered or used prior to the use of restrictive practices*.

Make sure workers who deliver care and services have the time, support, resources and skills to perform their role.

Provide workers with guidance and training on how to deliver quality care and services, relevant to their role (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to deliver care and services that:

• are culturally safe*, trauma aware and healing informed*
• meet the older person’s needs, goals and preferences*
• optimise the older person’s quality of life*, reablement* and maintenance of function
• recognise and respond to risks, concerns, changes and deterioration* of an older person
• support people living with dementia*. This includes older people experiencing changed behaviours*.
• minimise the use of inappropriate use of restrictive practices*. Where restrictive practices* are assessed as necessary, make sure they are used in line with the older person’s assessed needs.
• include the provision of person-centred behaviour support and best practice alternatives before the consideration or use of a restrictive practice
• enable effective verbal and non-verbal communication with older people. This includes people living with dementia*, or older people who have difficulty communicating and changed communication needs.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure that you deliver care and services safely and meet older people’s needs and preferences.

Regularly* review how you deliver care and services across a sample of older people and workers. You can use information from these reviews to check whether you’re delivering care and services as planned. This can include:

• completing experience surveys with people receiving care
• observing how workers are delivering care
• analysing incident*, feedback* and complaints* information (Outcomes 2.5 and 2.6)
• reviewing clinical and care documents
• talking with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if they feel they’re receiving safe and quality care and services that meet their needs, goals and preferences*. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Use this information to find out if:

• workers understand how to:
  • make timely* referrals to health professionals*
  • care for people living with dementia*. This needs to be in line with contemporary, evidence-based practices*.
  • minimise the use of inappropriate restrictive practices*
  • involve older people in selection of workers who provide their care
  • share information with older people when delivering care and services
  • support the older person to use equipment, aids, devices and products safely and effectively.
• the older person’s records are comprehensive and have enough detail to determine what decisions were made, why they were made and who made them. You need to include this information in care and service documents such as progress notes or care and service plans*.
• workers are delivering care in line with the older person’s care and services plan*.

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

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* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place a communication system*.

This system* should include processes* that make sure:

• the older person and those involved in their care are provided with critical information*. This can include their family, carers or others, workers and health professionals*. Information needs to be shared in a timely* manner. This will help make sure older people receive the care and services they need. Critical information* can include:
  • information in a person’s care and services plan* when they start receiving care and services (Outcome 3.1)
  • risks and control strategies (Outcome 2.4)
  • incidents* that can affect an older person (Outcome 2.5)
  • clinical information* . For example, comprehensive care* needs, changes or deterioration that can affect an older person (Outcome 5.4).
  • transitions of care* (Outcome 3.4).
• you correctly store older people’s records, such as care and services plans*, in your information management system* (Outcome 2.7). Make sure you can identify these records, so the right records are matched to the right person. For example, you could use the older person’s Healthcare Identifiers*.
• you correctly identify and match older people to their care and services. You can do this can using the older person’s full name, date of birth and their Healthcare Identifiers*. For example, make sure you follow these processes* in situations where you are:
  • delivering care and services to an older person. For example, before administering medication or referring an older person to an allied health* or health professional*.
  • generating clinical handover, transfer or discharge information. This can also include information about an older person’s agreement, fees and invoices (Outcome 1.4).
• there are ways to escalate concerns about the older person. Older people, their families, carers, and health professionals* involved in the older person’s care need to be able to escalate concerns. Contact details for those involved in the care and services of the older person should be kept up to date and easily accessible. This information needs to be stored using your information management system* (Outcome 2.7).
• workers can communicate and share information with older people safely and effectively. They should base this on each older person’s language and communication needs and preferences.

If you provide residential care and services, your communication system* needs to have processes* to prepare and provide care statements to older people.

If you provide home care and services, make sure you have processes to communicate clinical information* to older people, families and other service providers.

Make sure workers are supported to communicate for safety and quality.

You can support workers by developing communication guides, training and strategies that are part of your organisation’s clinical governance* framework (Outcomes 2.9 and 5.1). It may be helpful to develop a list of common scenarios and how workers can share information in each situation.

Make sure workers use the communication system*:

• when the older person starts receiving care and services
• when the older person’s needs, goals and preferences* change. You should regularly* partner with the older person and those involved in their care and services (Outcome 2.1).
• when risks have been found (Outcome 2.4)
• when there is a change of circumstance, deterioration*, or after an incident* has occurred (Outcome 2.5)
• during handover or transitions of care*. For example, during a transfer to hospital (Outcome 3.4). For residential care providers, the guidance for Outcome 7.2 has more information on how you support older people during transitions.
• to correctly identify and match older people to their care and services.

When workers use the processes* and systems* in place to communicate for safety and quality, encourage workers to consider:

• what information they need to share
• how quickly they need to escalate information
• who should be involved
• how they can best share this information. For example, it may be better to make a phone call, send an email or have a conversation in person. Make sure these communications are documented in the information management system*. Workers should consider each older person’s language and communication needs and preferences (Outcome 1.1) and share information in a way that they understand (Outcome 1.3). This can include:
  • using strategies such as simple language, large text and images as recommended by allied health* professionals (where relevant)
  • language services like interpreters and translators
  • routinely checking that the older person and those involved in their care have understood the information correctly.

You should record information that has been shared in progress notes or other documents in line with your information management system* (Outcome 2.7).

Monitor that workers communicate for safety and quality.

To check if your communication system* is effective, you can review:

• older people’s care and services (Outcome 3.1) such as care and service plans* and progress notes.
• complaints* and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5).

Look for situations where:

• older people didn’t know or understand something
• critical information* was not shared.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if they know and understand information about their care and services, including critical information*. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality and communication systems* (Outcome 2.9). You can do this through quality assurance and system* reviews.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place strategies to coordinate transitions.

Put in place strategies for planned and unplanned transitions in situations where an older person:

• is transitioning to and from hospital
• moves between other care services or stays in the community
• is receiving home support and is transitioning between short-term and ongoing service pathways.

Make sure:

• those involved in an older person’s care and services have been identified. This includes:
  • family members
  • carers
  • health and aged care providers
  • workers
  • other health professionals*. These people need to be involved in planning activities if the older person wants or needs them to (Outcome 2.1). For example, you should inform family members, carers and substitute decision-makers* when an older person transfers to and from hospital or between service providers. This makes sure they understand any relevant changes to care and services.
• the transition is planned and coordinated. The transition process* needs to be documented in line with the information management system* (Outcome 2.7). You need to communicate the transition process* to the older person and those involved in their care and services. Do this using your communication system* (Outcome 3.3). This supports continuity of care and services for the older person.

For residential care providers, the guidance for Outcome 7.2 has more information on managing transitions for older people.

Make sure workers have the time, support, resources and skills to coordinate care and services.

Provide workers with guidance and training on how to coordinate care and services (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• identify who is involved in the older person’s care
• talk with older people, their families and carers about transitions and coordinating care and services
• use your organisation’s communication system* and information management system* to plan for and support transitions and coordinating care and services.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor that workers are partnering with older people and others involved in their care and services.

To check if workers are partnering with older people and other providers well, you can review:

• how well workers are following your systems* (Outcome 2.9)
• older people’s care and services (Outcome 3.1) such as care and service plans* and progress notes
• complaints* and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5).

Look for situations where:

• care and services have not been planned and coordinated effectively
• the older person, their family, carers and others involved in their care have not been included during transitions of care*.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if their provider and workers partner with them, their family, carers and others involved in their care during transitions of care*. Ask them if they feel their care and services are effectively planned and coordinated. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

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* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place strategies that make sure the care and services you deliver in an older person’s home are safe and meet their needs (Outcome 3.2).

These strategies need to cover all situations where you deliver care and services at a person’s home. This helps make sure the environment is safe for the older person and workers.

When delivering care and services in a person’s home, use the organisation’s:

• risk management system* (Outcome 2.4). Do this to identify, assess, document, manage and review any environmental risks that may affect the safety of the older person and workers. This includes risks to do with any equipment or aids you use in the delivery of care and services. This also includes broader environmental risks such as overheating. Where the older person receives care and services from different providers, put in place systems* that enables workers to share information with each other to help identify risks.
• communication system* (Outcome 3.3). If you find any risks, discuss these and how you can manage them with the older person (Outcome 2.1). You also need to include other people, such as workers, family and carers in these discussions, with the older person’s consent. Keep in mind that not all risks can be eliminated or mitigated, and older people have the right to dignity of risk* and choice during these discussions. Dignity of risk* is the right of the older person to live the life they choose, even if their choices involve some risk. 
• information management system* to share information and communicate risks between providers, where the older person is receiving care and services from different providers.
• When the older person first starts receiving care, you may need to do an equipment and aid assessment. This assessment is to make sure the equipment and aids you give to the older person, or that they already have, meets their assessed needs. This includes you finding and providing the equipment, aids, devices and products they need. You need to complete an equipment and aid assessment even if you’re not providing equipment to the older person to assess that the older person’s care needs are met.

Put in place strategies that make sure the equipment and aids you provide to older people are suitable, safe, clean and meet their needs.

Make sure that any equipment and aids you provide:

• meet each older person’s needs and preferences (Outcome 1.1). Make sure this is based on the older person’s care and services plan* as part of the assessment and planning process (Outcome 3.1). Some older people need a clinical assessment to identify what assistive equipment, aids and devices they need (Outcome 5.4). For example, an occupational therapist can assess the person to identify suitable mobility aids or transfer equipment, if they have difficulty moving around.
• are safe, clean and well-maintained for the older person to use. This includes equipment owned by providers and older people.

Also, put in place strategies to manage equipment. This can include:

• an inventory management system* to record information about the equipment, such as where it is, what condition it’s in and who’s responsible for maintaining it. You can also use this system* to record technical specifications of the equipment. This will help you to share and communicate information about the equipment and how it’s used. If you have many items to keep track of, an inventory management system* can also help you track regular cleaning and maintenance needs.
• a maintenance plan that tracks when your equipment is scheduled for maintenance and repair works. This makes sure equipment is safe for ongoing use by the older person and workers. It needs to be clear whose responsibility it is to maintain equipment and aids. This can be documented in your agreements (Outcome 1.4).
• documented processes* to make sure you clean equipment regularly*. For example, before you give it to an older person and when it’s returned to you. This makes sure that equipment is cleaned and checked. Regular cleaning is important because dust, dirt or other materials can build up when equipment is used or has been stored. The process* you use to clean equipment should also be in line with infection prevention and control* practices (Outcome 4.2). For example, make sure equipment is cleaned straight away if it’s visibly dirty or soiled. You may need to increase how often you clean for high touch surfaces and during infectious disease outbreaks. These processes will help reduce the risk of surface contamination and transmission of infectious diseases (Outcome 4.2). It also needs to be clear whose responsibility it is to clean equipment and aids. You can record this in agreements (Outcome 1.4) or care and services plans* (Outcome 3.1). Make sure equipment is cleaned with the right products, cleaning method, tools and following the manufacturer’s instructions and safety advice.
• processes* to confirm that equipment contractors and older people supply and own and are safe and clean. This can include processes* to ask for maintenance schedules and photos of equipment before it’s used, including equipment from the goods, equipment and assistive technology (GEAT) provider* or procured through the assistive technology and home modifications scheme (AT-HM).

Make sure workers who provide care and services in a home have the time, support and resources to manage risk.

Provide workers with guidance and training on how to assess, respond to and manage risks in a person’s home (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• identify and manage risks using the risk management system* (Outcome 2.4)
• use the communication and information management system*s to share critical information about identified risks (Outcomes 2.7 and 3.3)
• refuse to carry out an activity or provide care and services if they feel unsafe or threatened
• remove themselves from an unsafe or threatening situation and raise concerns if they need
• record incident*s and near miss*es using the incident management system* (Outcome 2.5).

The guidance for Outcome 2.4 has more information on risk management.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure workers have the time, support and resources to check that equipment is safe, clean, well-maintained and meets the older person’s needs.

Provide workers with instructions, guidance and training on how to check, maintain and clean equipment used in an older person’s home (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• their roles and responsibilities*.

Make sure workers understand how to:

• maintain and clean equipment following the manufacturer’s instructions and safety advice and in line with your organisation’s maintenance plan
• use the right cleaning products and method
• check that equipment and aids meet the older person’s needs and preferences
• use equipment safely and support older people to use equipment and aids safely.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor how well workers deliver care and services in an older person’s home to make sure it’s safe and meets their needs.

To check if you’re managing risks in the home and the equipment you’re using well, you can review:

• older people’s care and service documents (Outcome 3.1). For example, care and services plans and progress notes.
• feedback* and complaints* (Outcome 2.6)
• incident* information (Outcome 2.5).

Look for situations where:

• older people haven’t been involved in deciding how you’ll manage risks in their environment
• environmental risks haven’t been managed well
• equipment or aids have been reported as unsafe, unclean, not functional or not suitable for the older person’s needs.

Also, talk with older people, their families and carers about the safety, condition and comfort of their home when they’re receiving care and services (Outcome 2.1). For example, ask them if their environment, equipment and aids are clean, safe, fit-for-purpose and meet their needs. Ask them if they feel their provider involves them when managing any environmental risks in their home. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). Assess if workers are using your risk management, communication and information management systems* to help identify and communicate risks. You can do this through quality assurance and system* reviews.

If you find any issues or ways you can improve through your reviews and assessments, 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 what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place strategies to maintain a safe, clean and comfortable service environment*.

Use your risk management system* (Outcome 2.4) when you put in place these strategies. This will help you to find, assess, document, manage and review any environmental risks that may affect the safety of the older person and workers. This includes risks related to the equipment or aids you use in the delivery of care and services.

Make sure strategies include:

• a cleaning process*:
  • that makes sure the service environment* is clean, safe and comfortable. This can include buildings, access points, parking areas, gardens and the service environment*’s general appearance and homeliness. Have a cleaning schedule that includes how often you recommend cleaning, as well as procedures* and the responsibilities of all workers. Providers must store cleaning products safely.
  • that is in line with infection prevention and control* practices (Outcome 4.2). Make sure you clean the service environment* and equipment straight away if it’s visibly dirty or soiled. You may also need to increase how often you clean high touch surfaces and during infectious disease outbreaks. These processes* will help reduce the risk of surface contamination and transmission of infectious diseases.
• a cleaning and maintenance process* for equipment in the service environment*. This makes sure that equipment is cleaned and checked regularly*. Make sure equipment is cleaned and maintained using the right products, cleaning method, tools and following the manufacturer’s instructions and safety advice.

Make sure the design and maintenance of the service environment* is fit-for-purpose and supports older people to do the things they want to do (Outcome 7.1). Do this in partnership with older people (Outcome 2.1) to make sure the environment meets their needs, goals and preferences* (Outcome 1.1). Also, consider feedback* from older people, their families and carers (Outcome 2.6). When designing and maintaining the service environment*, consider spaces that:

• are welcoming, comfortable and provide older people with a sense of belonging
• have areas and equipment that keep older people safe while also:
  • promoting movement, engagement and inclusion among older people
  • enabling older people to move about indoors and outdoors.
• are culturally safe*. For example, this includes the design of a culturally inclusive environment that:
  • meets the needs of the community you mostly deliver services in. For example, you may work with Aboriginal and Torres Strait Islander older people, their families and the wider community to design a service environment* that encourages cultural safety, respect and being inclusive of local cultures.
  • enables the increased presence of an older person’s loved ones such as family, friends and carers to be with them more often during end-of-life care* and allows them to stay overnight if needed to follow cultural practices.
  • supports an older person to pray or practise other spiritual rituals
  • allows older people to host visitors.
• enable dementia-friendly design principles
• allow older people privacy when they want it.

For regional and remote providers, limited resources and higher costs may affect access to best practice design principles and design options. These providers should consider strategies to make sure their service environment*:

• is safe
• is well maintained
• is fit-for-purpose
• meets older peoples' needs and preferences
• allows older people to do the things they want to do.

Make sure strategies consider if the service environment* is suitable for each older person. Consider the service environment* during the assessment and planning process (Outcome 3.1), and in partnership with the older person, to make sure it meets their needs, goals and preferences* (Outcome 2.1). For example, look for ways to:

• make the service environment* accessible, by considering the needs of each older person (Outcome 1.1). This includes older people living with disability. For example, installing entrance ramps or elevators in areas older people with mobility challenges may have difficulty accessing.
• identify and minimise risk. When you identify risks in the service environment*, make sure you follow the risk management system* (Outcome 2.4) to address them. Do this in partnership with older people (Outcome 2.1) to understand how you can support their needs and preferences (Outcome 2.1) while also removing and reducing risk where possible. Consider the older person’s right to exercise dignity of risk* if they choose to (Outcome 1.3). Make sure the controls you have to minimise risks:
  • are unobtrusive. This means you should minimise safety risks in a way that is least restrictive on an older person’s freedom. For example, placing a fence around a secure area that is designed to blend into the landscape, or hidden using plants. Where it’s in the interests of an older person’s safety, it’s appropriate to risk assess the controls (Outcome 2.4).
  • optimise useful stimulation. For example, by using visual cues such as appropriate contrast to highlight key features, direct visual access to spaces, and text and image in signs. This also includes reducing unnecessary clutter and background noise.
  • make the service environment* easy to navigate. For example, by placing objects older people commonly use in clear sight, clear signage on the bathroom door and motion sensor activated lights in hallways.
• maintain and design the service environment* to improve older people’s quality of life*, reablement* and maintenance of function (Outcome 3.2).

Older people should also have the choice to bring personal items to the residential care home (Outcome 1.3). For example, valuables, furniture or pictures. This can support the older person’s daily living, including their quality of life*, and help them to take part in meaningful and engaging activities (Outcome 7.1). Make sure you put in place processes* to identify, manage and minimise risks related to personal items using the risk management system* (Outcome 2.4). This can include providing older people with enough secure storage for their belongings.

Put in place strategies that make sure the equipment used in the care and services you deliver are suitable, safe and clean and meet the needs of older people.

These strategies can include:

• an inventory management system*. This system* is to record a list of your equipment. It includes details such as where they are and what condition they’re in. It can also include their technical specifications. This may help improve information sharing, communication and use of your equipment.
• a maintenance plan. This plan is to track the schedules for maintenance and repairs of your equipment used inside and outside the service environment*. This will help you to make sure equipment is maintained and safe for the older person and workers to use.
• a cleaning plan. This plan makes sure that your equipment is cleaned and checked regularly. Regular cleaning is important because dust, dirt or other materials can build up when equipment is used or has been stored. It needs to be clear whose responsibility it is to clean and maintain equipment and aids.

Make sure equipment that older people share is checked and cleaned between each use. This will help reduce the risk of infection and outbreaks of infectious disease as a result of contaminated equipment and surfaces (Outcome 4.2).

Make sure any equipment you use in the service environment* meets each older person’s needs and preferences (Outcome 1.1). Make sure this is based on the older person’s care and services plan* as part of the assessment and planning process* (Outcome 3.1). Some older people need a clinical assessment to identify what assistive equipment, aids and devices they need (Outcome 5.4). For example, an appropriately qualified health professional can complete an assessment to identify suitable mobility aids or transfer equipment if the older person has difficulty moving around.

Also, make sure there is enough equipment available to meet each older person’s needs.

For regional and remote providers, limited resources may affect timely* access to equipment, allied health* and health professionals*. These providers should have strategies to make sure equipment is safe, clean, well-maintained and meets the needs and preferences of each older person.

Make sure your workers have the time, support and resources to keep a safe, clean, comfortable and welcoming service environment*.

Provide workers with guidance and training on how to maintain a safe, clean, comfortable and welcoming service environment*. This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• maintain a safe, clean, comfortable and welcoming service environment* that is fit-for purpose and meets the needs and preferences of the older person
• use equipment safely and support older people to use equipment and aids safely
• use the risk management system* to identify and manage environmental risks in the service environment*.

Assess if workers are following your quality system* (Outcome 2.9). Do this through quality assurance and system* checks.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure the workers who use or manage equipment have the time, support and resources to maintain and clean equipment.

Provide workers with instructions, guidance and training on how to maintain and clean equipment used in the service environment* (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers understand how to:

• maintain and clean equipment following the manufacturer’s instructions and safety advice and in line with your organisation’s plans
• use the right cleaning products and method in line with your organisation’s cleaning plan
• do a risk assessment when equipment is faulty, damaged or causing risk of harm to people using it
• check that equipment and aids meet the older person’s needs and preferences. This includes knowing processes* for how to escalate and refer to appropriately qualified health professionals (Outcomes 3.2 and 5.4) who can recommend suitable equipment and aids.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor how well workers are maintaining a safe, clean and comfortable service environment*.

To check if you’re maintaining a safe, clean and comfortable service environment*, you can review:

• the older person’s care and service documents (Outcome 3.1). For example, care and service plans and progress notes.
• complaints* and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5).

Look for situations where:

• you haven’t involved older people in deciding how you’ll manage risks in their service environment*
• you haven’t managed environmental risks or incidents well
• people have reported not feeling safe, welcome or comfortable at the service.

Also, talk with older people, their families and carers about the safety, condition and comfort of the service environment* (Outcome 2.1). For example, ask them if their environment is safe, fit for-purpose and meets their needs. Ask them if they feel that their provider involves them when they manage any environmental risks in the service environment*. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* checks. For workers caring for older people in a residential care home, you can do this as part of the monitoring process* in Outcome 7.1.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Monitor how well workers are using and managing equipment.

To check if workers are using and managing equipment well, you can review:

• older people’s care and service documents. For example, care and services plans and progress notes (Outcome 3.1).
• complaints* and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5)
• reports from your inventory management system* and maintenance request records.

Look for situations where equipment or aids have been reported as:

• unsafe
• unclean
• not functional
• not suitable for the older person’s needs.

Also, talk with older people, their families and carers about the safety, condition and comfort of the equipment and aids they use (Outcome 2.1). For example, ask them if their equipment and aids are clean, safe, fit-for-purpose and meet their needs. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews. For workers caring for older people in a residential care home, you can do this as part of the monitoring process* in Outcome 7.1.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.

Put in place a system* for infection prevention and control*.

Make sure this system* reduces the spread of diseases and infections. This system* should be used together with processes* to prepare for, prevent and control infections in clinical care (Outcome 5.2).

Make sure your infection prevention and control* system* includes processes* to:

• appoint an Infection Prevention and Control Lead* for residential care homes. This role acts as the main point of contact for all infection issues. This role also oversees the infection prevention and control* system* and processes* to prepare for outbreaks. The Infection Prevention and Control Lead* needs to be a nurse who has completed, or is in the process of completing, the required specialist infection prevention and control* training. Consider how to best assign an Infection Prevention and Control Lead* during workforce* planning (Outcome 2.8). For home care providers, look for ways to appoint a worker or team to oversee your infection prevention and control* system*.
  • for regional and remote providers, limited resources and increased workforce challenges may affect access to appropriately qualified and trained Infection Prevention and Control Leads* . These providers should consider strategies to make sure their infection and prevention control* system* is overseen.
• put in place infection control strategies that are appropriate for the older person’s home or service environment* (Outcomes 4.1a and 4.1b). This includes standard and transmission-based controls. For example:
  • cleaning practices
  • hand hygiene practices
  • respiratory hygiene
  • cough etiquette
  • waste management and disposal.
• check infection* prevention controls and processes* to prepare for outbreaks are in line with contemporary, evidence-based practice* (Outcome 5.2)
• put in place policies* and procedures* to prepare for, prevent and control infections. This includes developing and maintaining outbreak management plans.
• manage infections and infectious disease outbreaks (Outcome 2.10). This includes both suspected and confirmed infectious diseases such as COVID-19, influenza, gastroenteritis or novel viruses. This means you need to act promptly when people are sick, even if you’re not sure if it’s an infectious disease.
• collect and analyse data on immunisation and infection* rates. This is to inform risk assessment and the ways you can improve your infection prevention and control* system* (Outcome 2.4).
• share information about infection* risks with older people, their families, carers, visitors and workers by using the communication system* (Outcome 3.3)
• prioritise the rights, safety, health and wellbeing of older people (Outcome 3.2). You need to include older people in deciding how to manage the risk of infection* (Outcome 1.3).
• meet public health notification needs, where relevant.

For residential care homes, undertake risk-based vaccine-preventable diseases screening and immunisation for older people and workers. This includes disease screening and immunisation requirements for visitors. This makes sure visitors or workers don’t expose older people to infectious diseases.

Make sure you give older people current, accurate and timely* information about vaccines from relevant health professionals*. Make sure you provide this information in a way older people can understand by considering their language and communication needs and preferences (Outcome 1.1). This information can include benefits, risks and costs (where applicable) of vaccinations. The older person can then make an informed decision and provide informed consent* if they have agreed to be vaccinated (Outcome 1.3).

Home care settings have unique infection risks. Older people are likely to have multiple workers and providers delivering care and services in their home. Workers may also be moving between multiple home settings. This can increase the risk of infection* between workers and older people. Put in place strategies to make sure workers are minimising or preventing the spread of infection*. For example, support older people to maintain a clean and safe environment (Outcome 4.1a), perform hand hygiene and use personal protective equipment (PPE) appropriately.

The guidance for Outcome 5.2 has more information on infection prevention and control* in clinical care*.

Put in place a system* to manage the supply and use of personal protective equipment (PPE).

Put in place a system* to make sure PPE is suitable, available and has instructions on how to use it safely. In particular, where you are using PPE as a mitigative control to reduce disease and infection, as part of the risk assessment system* (Outcome 2.4). Make sure PPE is available for workers, older people, visitors and other care partners in your service, and you put in place strategies to make sure PPE is used correctly.

You need to develop, maintain and manage a PPE inventory to make sure there’s enough PPE stock. The inventory manages:

• what PPE you need. For example, gloves, gowns, face shields/glasses and masks.
• where to store PPE. Make sure you store PPE correctly, in a dedicated and accessible area.
• when you need to replace PPE.

This inventory can be integrated with your processes* for managing equipment (Outcomes 4.1a and 4.2b).

Make sure workers have the time, support and resources to manage infections and use PPE.

Provide workers with guidance and training on correct infection prevention and control* practices, including use of PPE (Outcome 2.9). This needs to be in line with:

• the organisation’s policies* and procedures*
• contemporary, evidence-based practice*
• workers’ roles and responsibilities*.

Make sure workers and other care partners in your service understand how to:

• use and apply the infection prevention and control* system*
• identify when to use standard and transmission-based precautions and apply this to the appropriate setting
• use and maintain PPE correctly. This applies to all people who need PPE, as well as to visitors and other care partners in your service.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Monitor that workers follow the system* for infection prevention and control*.

To check if your system* for managing risks of infection* is working, you can review:

• older people’s care and service documents. For example, care and services plans and progress notes (Outcome 3.1).
• complaints* and feedback* (Outcome 2.6)
• infection rates and trends
• incident* information (Outcome 2.5).

Look for situations where:

• infections have been transmitted between workers, carers, older people or their families
• your organisation hasn’t responded to outbreaks of infectious diseases or viruses in a timely* manner
• you haven’t shared information on infection* risks well with older people, their family, carers or workers
• suitable PPE wasn’t available, used when needed or it wasn’t used correctly.

Also, talk with older people, their families and carers about the infection prevention and control* processes (Outcome 2.1). For example, ask them if they feel their provider and workers follow appropriate infection prevention and control precautions when delivering care and services. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews. This can be done as part of the monitoring process* in Outcome 5.2.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:

• practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance material for Outcome 2.3 has more information on monitoring the quality system*.