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*.