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 the behaviour of workers* is the most important factor in their aged care experience.

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 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  
  • family  
  • carers.  

You should communicate important information about an older person’s care to those who need it, 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 care planning

• As part of doing an assessment, make sure:

  • you have the appropriate skills, qualifications and training to complete the assessment
  • you 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 Torres Strait Islander peoples, and people from culturally and linguistically diverse backgrounds).

  As part of care planning, 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 plans, make sure you:

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

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

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

Key tasks: 

Care and service plans*

Care and service plans* should focus on the 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 person to stay involved in decisions about their care and services.

A care and service plan* is a document (or set of documents) that describes the care and services a person is receiving. This includes information about a 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 a 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 a 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.  

You can improve the way you support a person living with dementia* by getting to know them, including:

• how their dementia* impacts them
• their strengths
• the things they enjoy.  

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 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).  

Some older people may choose to consume food and drink that have been identified as a risk to them, for example:

• certain ingredients (such as sugar, salt or fat)  
• serving size, texture or consistency
• fast food  
• food cooked by family  
• food that could be difficult to swallow or lead to choking*.  

Older people can choose to accept these risks so they can enjoy their meal, and you must respect their decision. Where an older person lacks capacity to make an informed decision, you will need to use the principles of supported decision-making* and work with their substitute decision maker* to find a solution that 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*.  

Supporting older people to make informed choices about all aspects of their food, drink and the dining experience* is a key part of maintaining their quality of life*.