What does this Standard mean for workers*?

Standard 3 describes how providers and workers* must engage with older people to make sure quality care* and services are delivered, regardless of care type.

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

Regardless of your role, you should:

• Deliver care which meets each older person’s care and services plan*. You are responsible for making sure you understand how to deliver care which meets the older person’s needs, goals and preferences* as recorded in their care and services plan*. You should be supported by the provider to manage risks associated with the older person’s care. Care plans may be available as physical documents or through your organisation’s information management system*. Different information may be available to you, depending on the care and services you are delivering and the older person’s preferences. Where you find inaccurate or incomplete information, you should escalate this to the appropriate person within your organisation.
• Deliver care and services in a way which is culturally safe*, trauma aware and healing informed*. See Standard 1 key concepts.
• Optimise each older person’s quality of life* by supporting reablement* and helping maintain function. Reablement* and maintaining physical and cognitive function can be an important goal for older people and is often central to their quality of life*. It’s important you partner with the older person to understand what quality of life* looks like for them. Supporting an older person to meet their goals may involve:
  • making suggestions through your organisation’s systems* for referrals to other health professionals*
  • using equipment, aids, devices and other products.
• Empower* older people to take supported risks, make choices about their care and optimise their quality of life*. Older people have the right to make decisions that affect their lives and to have those decisions respected, even if there is some risk to themselves. You must respect the autonomy of older people when delivering their care and services. When an older person makes a choice which involves risk, you should support them, while also making sure the older person understands the risks. You should work with the older person to put strategies in place to mitigate risks (with the older person’s agreement). This is sometimes referred to as dignity of risk*. Your organisation may have policies* to support dignity of risk* and the need to document discussions and outcomes in a care and services plan*.
• Recognise and respond to deterioration*. Deterioration* refers to physiological, psychological or cognitive changes which may indicate a significant worsening of the older person’s health, condition or wellbeing*. Your organisation must make sure you are trained to identify signs of deterioration* and respond appropriately. If you identify deterioration*, it is important to escalate this within your organisation so the older person’s needs can be reassessed, and their care plan reviewed.

• Effectively communicate about an older person’s care within your organisation and with others involved in their care*. There may be a range of people involved in an older person’s care, including:

  • other workers* 
  • health professionals*
  • other service providers 
  • substitute decision-makers*
  • volunteers 
  • supporters
  • family 
  • carers*.

  You should communicate critical information* about an older person’s care to others involved in their care*, with the older person’s consent. If part of your role, you should also coordinate their care and services. Your organisation should have a system* you can use to record notes, observations, progress and other updates to make sure relevant information is communicated and shared in a timely* way.

Tips for workers*

Workers* responsible for assessment and planning

As part of doing an assessment, make sure you:

• have the appropriate skills, qualifications and training to complete the assessment
• use appropriate and validated assessment tools* to assess the needs, conditions and abilities of older people. This includes using tailored tools or providing additional support for people with specific needs or with diverse backgrounds (for example, people with cognitive impairment* or dementia*, Aboriginal and/or Torres Strait Islander persons, and people from culturally and linguistically diverse backgrounds).

As part of assessing and planning care and services for the older person, make sure you:

• build trust with older people and make sure they feel safe to talk about their identity 
• support older people to communicate their needs, goals and preferences*, including where they may have challenges communicating or need support to make decisions (see Standard 1)
• partner with older people, the people important to them, and others involved in their care* in planning and reviewing their care and services
• talk to older people about their care options and any associated risks
• respect the independence of older people in directing their care and services, and what is important to them (linked to Standard 1)
• offer older people the option to take part in advance care planning* (see Outcome 3.1 of the Provider Guidance)

As part of developing and maintaining care and services plans*, make sure you:

• offer older people a copy or summary of their care and services plan* and give this to them when they want it
• keep information detailed, accurate and current so you can deliver care that meets each older person’s needs, goals and preferences* 
• can access and understand care and services plans* and use them to guide your delivery of care and services to the older person
• review care and services plans* regularly* so they continue to meet the older person’s needs, goals and preferences* when things change.

Where the older person is receiving clinical care* services, also see Standard 5.

Where care is provided in a residential environment, also see Standard 6 and Standard 7.

Key concepts

Care and services plans*

Care and services plans* should focus on the older person, as highlighted in Standard 1. They should help make sure the older person’s choices, needs and circumstances are respected. These plans should support the older person to stay involved in decisions about their care and services.

A care and services plan* is a document (or set of documents) that describes the care and services an older person is receiving. This includes information about an older person’s needs, goals and preferences*, risks relevant to the delivery of care and strategies for managing these, and how and when services are delivered. Care plans should be the ‘source of truth’ about an older person’s care needs and should direct how to deliver care and services. Care plans are dynamic documents and should be reviewed and updated as an older person’s needs and circumstances change.

Supporting older people living with dementia*

Your organisation should have systems* and strategies for supporting people living with dementia* to live well. It’s important to understand there are many different types of dementia* and it can impact people in very different ways. While dementia* can impact an older person’s capacity to make decisions, it is important you support them to live their life in a way that is meaningful to them.

You can improve the way you support an older person living with dementia* by getting to know them. This includes recognising and identifying:

• how their dementia* impacts them
• their strengths and skills and how they are best encouraged to use these regularly*
• when there is a change in their strengths and skills that require a reassessment of their care and services plan*
• the things they enjoy.

This helps to support their quality of life* and engagement in day-to-day activities as their condition progresses.

Providing person-centred*, culturally safe*, trauma aware and healing informed care* is particularly important for people living with dementia* (see Standard 1). Getting to know an older person’s supporters, carers* and families and recognising them as key partners in their care is also helpful.

Dignity of risk*

Dignity of risk* supports an older person’s independence and right to make their own choices, even if those choices involve some risk. If an older person’s choices are possibly harmful to them, you are expected to help them understand the risk and how it could be managed to help them live the way they choose (linked to Standard 1).

For example, some older people may choose to continue smoking cigarettes despite the risk of harm identified to them, such as risk of:

• breathing difficulties
• delays to wound healing 
• burns to clothing or skin.

You should help each older person understand how these risks could harm their health and wellbeing* and identify ways of managing the risk. For example, to reduce the risk of burns to clothing or skin, the older person may agree to wear a protective smoking apron.

Older people can choose to accept these risks and management strategies so they can live the life they want, and you must respect their decision. Where an older person’s decision-making capacity is impaired, you will need to use the principles of supported decision-making* to help older people make informed decisions. This includes involving the older person’s supporters, family, carers* and loved ones they want engaged in their care to help with their decision-making. Use substitute decision-makers* only after all options to support an older person to make decisions are exhausted. Where substitute decision-makers* are involved, work with them to find a solution that best supports the older person’s wellbeing* and independence. Make sure you follow your organisation’s policies* and procedures* in relation to informed consent* and dignity of risk* processes*. This may include guidance on documentation and use of risk assessments.

Supporting older people to make informed choices is a key part of maintaining their quality of life*.