Quality Standards Guidance Resource Sep22

Guidance
and Resources
for Providers to support
the Aged Care Quality
Standards
Copyright Attribution
Aged Care Quality and Safety Commission Material obtained from this guide is to be attributed
(Commission) encourages the dissemination to the Commission as:
and exchange of information. All material presented ©Aged Care Quality and Safety Commission 2018.
within this guide and on our website is provided CITE: Aged Care Quality and Safety Commission 2018,
under a Creative Commons Attribution 3.0 Australia, Guidance and Resources for Providers to support
with the exception of: the Aged Care Quality Standards.
• the Commission’s logo, and content supplied Guidance and Resources for Providers to support
by third parties. the Aged Care Quality Standards is accurate
as of publication in September 2022. For the latest version
and updates, please refer to our website.
Aged Care Quality and Safety Commission

The details of the relevant license conditions agedcarequality.gov.au
are available on the Creative Commons website,
as is the full legal code for the CC BY 3.0 AU license.
Published September 2022
1800 951 822

agedcarequality.gov.au
Contents
Introduction 2
About the Aged Care Quality Standards
Standard 1 5
Consumer dignity and choice
Standard 2 29
Ongoing assessment and planning with consumers
Standard 3 53
Personal care and clinical care
Standard 4 87
Services and supports for daily living
Standard 5 117
Organisation’s service environment
Standard 6 131
Feedback and complaints
Standard 7 147
Human resources
Standard 8 167
Organisational governance
Glossary 191
Introduction
Servi
are ces
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Pe clin liv po
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Org environ
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anis
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Ongoing assessm
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Human re ources
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Organisations providing Commonwealth The Quality Standards are made

subsidised aged care services are required up of eight individual Standards:
to comply with the Aged Care Quality 1. Consumer dignity and choice
Standards (Quality Standards) from 1 July
2. O
ngoing assessment and planning
2019. Organisations will be assessed and
with consumers
must be able to provide evidence of their
compliance with and performance against 3. Personal care and clinical care
the Quality Standards. 4. Services and supports for daily living
The Quality Standards focus on outcomes 5. Organisation’s service environment
for consumers and reflect the level of care
6. Feedback and complaints
and services the community can expect from
organisations that provide Commonwealth 7. Human resources
subsidised aged care services. 8. Organisational governance.
2 agedcarequality.gov.au
Introduction
Each of the Standards is expressed in relation to best practice provision of aged

in three ways: care services. Further, compliance with
• a statement of outcome for the consumer the Quality Standards in accordance with
• a statement of expectation this Guidance material does not relieve
for the organisation organisations of their obligation to comply
• organisational requirements with all relevant laws of the jurisdiction
to demonstrate that the Standard in which they operate. Organisations are also
has been met. expected to take account of other recognised
Compliance with the Quality Standards guidance that might be specific to the
is mandatory from 1 July 2019. Organisations services they deliver. This includes guidance
are required to demonstrate performance produced by the Department of Health,
on an ongoing basis to meet Australian and other relevant authorities.
Government requirements. The Australian Using the Guidance material
Government may take action when providers
This Guidance material has been
do not comply. This includes under aged care
written for organisations that provide
legislation or through the funding agreement
Commonwealth subsidised aged care
with the organisation.
services. It is designed to support
The Quality Standards provide a framework organisations and their workforce to:
of core requirements for quality and safety.
• understand the Quality Standards and
Some Standards will apply differently
what is expected when the Standards
to organisations, depending on the types
are assessed
of care and services they provide. Many
organisations will go beyond these core • reflect on everyday practice and areas
requirements to provide a higher quality for improvement
of care and services for consumers. • know when they are being achieved
• undertake ongoing performance reviews
About this Guidance material against the Quality Standards.
This Guidance material is intended to assist In relation to each of the Standards,
organisations to implement and maintain this Guidance material provides:
their compliance with the Quality Standards.
• some background information about
It describes the intent of the Standards
each Standard
and expectations of performance, along
with supporting information, and examples • the intent of each Standard and
of evidence of compliance. This also how it supports the consumer outcome
provides an indication of the matters • key resources relevant to each Standard
that Aged Care Quality Assessors (quality • legislation relevant to each Standard.
assessors) consider in assessing compliance. This Guidance material also provides
This Guidance material is not a legal (described as part of each Standard):
document and does not form part of the • the intent of the requirement and how
Quality Standards. It guides compliance it supports the consumer outcome
with the Quality Standards but does not
• reflective questions on everyday practice
purport to provide comprehensive guidance
agedcarequality.gov.au 3
Introduction
• examples of the types of evidence that For each of the requirements, quality
an organisation may use to demonstrate assessors expect the organisation and
that it is meeting the requirements their workforce to demonstrate that they:
• case studies. • understand the requirement
The organisation is responsible for meeting • apply the requirement, and this is clear
the Quality Standards and deciding how in the way they provide care and services
to do this. They are expected to show how • monitor how they are applying the
their approach enables them to meet the requirement and the outcomes they achieve
requirements of the Quality Standards. Aged • review outcomes and adjust practices
care organisations vary in size and structure based on these reviews to keep improving.
and will have different ways of meeting the
Quality assessors are proportionate in how
Quality Standards. This Guidance material
the Quality Standards are applied to different
doesn’t cover all possible strategies or
types of services. Quality assessors consider
sources of evidence that could be used by
the size and type of services and the
an organisation. Examples of strategies
relevance of the requirement to the service
and evidence that are not listed can also
provided. The strategies used to achieve
be used to demonstrate performance.
the outcomes will vary in complexity, scope
Each organisation should interpret the
and scale, based on the type of organisation,
Guidance material considering its own
the consumer profile, and the risk to the
service delivery model.
safety, health and well-being of consumers.
Importantly the Guidance material is not
The Aged Care Quality and Safety
prescriptive, nor is it clinical guidance.
Commission will consider this Guidance
It doesn’t include instructions or ‘how
so that the intent of the Standard is applied
to’ information on the different aspects
consistently when deciding whether
of care. Organisations are expected to take
an organisation meets the requirements
account of other recognised guidance
of the Quality Standards.
that might be specific to the services
they deliver. This includes guidance Subcontracted services will not be separately
produced by the Department of Health, assessed against the Quality Standards.
and relevant authorities. The organisation that receives funding
directly from the Australian Government
Aged Care Quality and Safety is expected to ensure its workforce (including
Commission assessment subcontractors) meets its responsibilities.
of performance This is because ultimately the funded
The structure of the Quality Standards allows organisation will be held responsible for the
quality assessors’ processes for assessment delivery of safe and quality care and services
and monitoring to focus on consumer in accordance with the Quality Standards.
outcomes and consider evidence of the
consumer’s experience and the systems and
processes that the organisation has in place
to support the provision of safe and quality
care and services.
Standard 1 |
Standard 1 |
Consumer outcome Requirements

1 (1) I am treated with dignity 1 (3) The organisation demonstrates
the following:
and respect, and can 1 (3) (a) Each consumer is treated
maintain my identity. with dignity and respect,
with their identity, culture
I can make informed and diversity valued.
choices about my care 1 (3) (b) Care and services are
and services, and live culturally safe.
1 (3) (c) Each consumer is supported
the life I choose. to exercise choice and
independence, including to:
(i) make decisions about their
Organisation statement own care and the way care
and services are delivered;
1 (2) The organisation: and
1 (2) (a) has a culture of (ii) make decisions about when
inclusion and respect family, friends, carers or
others should be involved
for consumers; and in their care; and
1 (2) (b) supports consumers (iii) communicate their decisions;
and
to exercise choice and (iv) make connections with
independence; and others and maintain
relationships of choice,
1 (2) (c) respects consumers’ including intimate
privacy. relationships.
1 (3) (d) Each consumer is supported
to take risks to enable them
to live the best life they can.
1 (3) (e) Information provided to each
consumer is current, accurate
and timely, and communicated
in a way that is clear, easy
to understand and enables
them to exercise choice.
1 (3) (f) Each consumer’s privacy
is respected and personal
information kept confidential.
Standard |
Standard 1 |
1
Purpose and scope Identity, culture and diversity

of the Standard All aged care organisations are expected
to deliver care and services that are inclusive
Standard 1 is a foundation Standard
and do not discriminate. Care and services
that reflects seven important concepts.
are expected to be responsive, inclusive
These concepts recognise the importance
and sensitive to culturally and linguistically
of a consumer’s sense of self. They also
diverse consumers. They are also expected
highlight the importance of the consumer
to be responsive, inclusive and sensitive
being able to act independently, make
to consumers who are lesbian, gay, bisexual,
their own choices and take part in their
transgender and intersex. They are also
community. These are all important
expected to be responsive, inclusive and
in fostering social inclusion, health
sensitive to consumers who are Aboriginal
and well-being.
and Torres Strait Islander.
Dignity and respect The consumer defines their own identity and
Being treated with dignity and respect this should be respected and not questioned.
is essential to quality of life. It includes Respecting the identity, culture and diversity
actions to recognise consumer’s strengths of a consumer, means understanding their
and empower them to be independent. needs and preferences. Organisations
It means communicating respectfully and are expected to provide care and services
recognising and respecting a consumer’s that reflect a consumer’s social, cultural,
individuality in all aspects of care and language, religious, spiritual, psychological
services. Dignified and respectful care and and medical needs.
services will help consumers to live their
lives the way they choose, including social Cultural safety
and intimate relationships. The consumer defines what cultural safety is.
It’s their experience of the care and services
they are given and how able they feel to raise
concerns. The key features of cultural safety
are; understanding a consumer’s culture,
acknowledging differences, and being
actively aware and respectful of these
differences in planning and delivering care
and services.
Standard 1 |
Choice In all cases, it’s expected that organisations

The consumer’s right to make informed manage consumer choices in line with the
choices, to understand their options, and Aged Care Charter of Rights, their agreement
to be as independent as they want, all with the consumer and other responsibilities
affect quality of life. The organisation needs under the Aged Care Act 1997, as well as
to provide genuine options that support their obligations under competition and
choice. The workforce needs to involve, consumer law.
listen to and respect the consumer’s views Dignity of risk
and communicate with the consumer about Dignity of risk is about the right of consumers
their choices. to make their own decisions about their care
Consumers who need support to make and services, as well as their right to take
decisions are expected to be provided with risks. Organisations need to take a balanced
access to the support they need to make, approach to managing risk and respecting
communicate and take part in decisions that consumer rights. If a consumer makes a
affect their lives. When a representative is choice that is possibly harmful to them,
appointed to make decisions for a consumer, then the organisation is expected to help
it’s expected that an organisation manages the consumer understand the risk and how
this according to relevant law and best it could be managed. Together, they should
practice guidance. look for solutions that are tailored to help
Providing choice also includes care and the consumer to live the way they choose.
services that the organisation might not Organisations have other responsibilities
provide itself, that it could help the consumer for the health and safety of the workforce
to access. These services could be from other and others in the service environment. In
specialist providers or individuals, or they meeting these obligations the organisation
could be services from other organisations is expected to show how they involve the
that are better placed to support the consumer and look for solutions that have
consumer’s needs. the least restriction on the consumer’s
The location or environment may limit choices and independence.
access to particular care and services. There
may also be situations where consumers
won’t be able to have unlimited choice, such
as if their choice negatively affects other
people. In these situations, it’s expected that
the organisation will take reasonable steps
to find alternatives that can help meet the
consumer’s needs and preferences.
Standard |
Standard 1 |
1
Information
Giving consumers timely information in a Assessment against
form and language that they understand this Standard
is vital to their ability to make an informed For each of the requirements,
choice and make sure they can get the organisations need to demonstrate
most out of their care and services. The that they:
needs and abilities of each consumer will
• understand the requirement
affect the kind of information and how
it’s communicated. Organisations are • apply the requirement, and this
expected to address barriers to effectively is clear in the way they provide care
communicating information, taking into and services
account health status, cognitive or sensory • monitor how they are applying
ability, and language. the requirement and the outcomes
they achieve
Personal privacy
A key part of treating a consumer with dignity • review outcomes and adjust their
and respect is making sure their privacy is practices based on these reviews
respected. The organisation needs to make to keep improving.
sure the behaviour and interactions of the
workforce and others don’t compromise
consumer privacy. Organisations are also
expected to respect each consumer’s right
to privacy in how they collect, use and
communicate the consumer’s personal
information and manage this according to
relevant law and best practice guidance.
Standard 1 |
Linked Standards Resources and references

Standard 1 supports all of the other Quality • Aged Care Sector Committee Sub-Group
Standards and is essential to providing (2017). Aged Care Diversity Framework 1
consumer-centred care. • Aged Care Sector Committee Sub-Group
(2019). Aged Care Diversity Framework
Relevant legislation
action plans 2
•A ged Care Act 1997 (Cth), User Rights
• Australian Health Ministers’ Advisory
Amendment (Charter of Aged Care Rights)
Council (2016). Cultural Respect Framework
Principles 2019
for Aboriginal and Torres Strait Island
• Aged Care Act 1997 (section 11.3) Health 2016-2026 3
Meaning of people with special needs
• Centre for Cultural Diversity in Ageing,
• Privacy Act 1988 (Cth), Schedule 1, Inclusive Service Standards 4
Australian Privacy Principles
• Cognitive Decline Partnership Centre (2018).
Supported decision-making in aged care:
A policy development guideline for aged
care providers in Australia. (2nd edition) 5
• La Trobe University (2013).
Sexuality Assessment Tool (SexAT)
for residential aged care facilities 6
• La Trobe University (2016). The Rainbow
Tick Guide to LGBTI Inclusive Practice 7
1 https://agedcare.health.gov.au/support-services/people-from-diverse-backgrounds/aged-care-diversity-framework
2 https://agedcare.health.gov.au/support-services/people-from-diverse-backgrounds/aged-care-diversity-framework-action-plans
3 http://healthbulletin.org.au/articles/cultural-respect-framework-2016-2026-for-aboriginal-and-torres-strait-islander-health/
4 http://www.culturaldiversity.com.au/service-providers/inclusive-services-standard
5 http://sydney.edu.au/medicine/cdpc/documents/resources/SDM-Policy-Guidelines.pdf
6 https://www.latrobe.edu.au/__data/assets/pdf_file/0008/746711/DCRC-Sexuality-Assessment-Tool-SexAT.pdf
7 https://www.latrobe.edu.au/arcshs/health-and-wellbeing/lgbti-ageing-and-aged-care/resources-reports-and-training
Standard |
Standard 1
Requirement (3)(a) 1
Each consumer is treated

with dignity and respect,
with their identity, culture
and diversity valued.
Standard 1 | Requirement (3)(a)
Intent of this requirement Reflective questions

People are all shaped by personal
characteristics, experiences, values and How does the workforce support the
beliefs. Aged care consumers have the rights of consumers in line with the Charter
same diversity of characteristics and life of Aged Care Rights?
experiences as the rest of the community.
Each consumer has social, cultural, language, How would a consumer know that the
religious, spiritual, psychological and medical organisation is inclusive and would support
needs that affect the care, services and them to express their culture, diversity
supports they need. and identity if they wanted?
No two consumers’ lived experiences are
Does the organisation collaborate with
the same. What is respectful or dignified for
others or look for expert advice to support
one consumer might not be for another. This
it respond to a consumers’ diverse needs?
means organisations need to take the time
to listen to and understand each consumer’s
How does the organisation support
personal experience. They need to work with
the workforce to understand how their
consumers in an inclusive and respectful
own culture, personal attitudes, values
way, using a consumer-focused approach.
and beliefs affect the way they deliver
It’s important for an organisation to address care and services?
diversity, whether or not a consumer has told
them about their unique life experiences or Are there ways for consumers to report
characteristics. Using strategies to support disrespectful care or discrimination in
the organisation’s commitment to diversity how their care and services are delivered?
helps consumers to feel confident sharing What processes does the organisation
their identity and helps the workforce to see have for handling consumer-to-consumer
them as a whole person. discrimination while maintaining the dignity
of all involved?
Standard |
1
Examples of actions and evidence Organisation

Consumers • Strategic documents, policies and
•C
onsumers say they are treated with procedures have an inclusive, consumer-
dignity and respect at all times. centred approach to delivering care and
•C
onsumers say they feel accepted and services. They explain the organisation’s
valued whatever their needs, ability, commitment to diversity.
gender, age, religion, spirituality, mental • A diversity action plan, or similar document,
health status, ethnicity, background shows that the workforce has put strategies
or sexual orientation. in place for inclusive care and service
•C
onsumers say they are treated fairly and delivery and these are followed.
don’t experience discrimination. • Records show how consumers are involved
in defining dignity and respect, and ways
Workforce and others
they believe dignity and respect can
• T he workforce can describe what treating
be maintained.
consumers with dignity and respect means
in practice and what they would do if • Evidence that the organisation tells
they thought a consumer’s dignity wasn’t consumers about their rights, including
being upheld. their right to have their dignity maintained,
be treated with respect and how it supports
• T he workforce can describe how they
the identity, culture and diversity
respect and promote cultural awareness
of consumers when delivering care
in their everyday practice.
and services.
• T he workforce show how they recognise,
promote and value diversity, including
differences in culture, beliefs, relationships
and sexuality.
•W orkforce orientation, training or other
records that show how the organisation
supported the workforce to meet
this requirement.
Standard 1
Requirement (3)(b)
Care and services

are culturally safe.
Standard |
Standard 1 | Requirement (3)(b)
1

Delivering culturally safe care and services
is about recognising, respecting and How does the organisation consider family
supporting the unique cultural identities and community connections, and support
of consumers by meeting their needs and cultural customs, beliefs, needs and
expectations and recognising their rights. practices when planning care and services?
An understanding of a consumer’s cultural
How does the management of the
identity can lead to better care and service
organisation communicate to the
outcomes for consumers. What is culturally
workforce about culturally safe service
safe for one consumer can be different to
practices in relation to the unique needs
what is culturally safe for another consumer.
of their consumers?
This can be true even among people who
identify as being from the same group.
Is the organisation’s commitment
Delivering care and services that are to cultural safety clear to consumers,
culturally safe, means working with the potential consumers and the workforce?
consumer, and any other people they want
to involve, so that their cultural preferences How has the organisation embedded
and needs can be understood. It goes further safe and inclusive practices in how
than just respecting diversity. It means that it delivers care and services and within
organisations know what to do to make each its service environment?
consumer feel respected, valued and safe.
Achieving culturally safe care and Do forms, surveys and information use
services means that an organisation must inclusive and gender-neutral language?
demonstrate its inclusive care and support
for cultural diversity for each consumer Do forms, surveys and information
throughout the Quality Standards. provide options that allow people
to share their identity and their health
and support needs?
Examples of action and evidence Workforce and others

• The workforce can describe how they adapt
Consumers
the way care and services are offered so
• Consumers say members of the workforce
they are culturally safe for each consumer.
delivering care and services understand
their needs and preferences and know what • The workforce can describe how they
to do to make sure they feel respected, address misconceptions, bias, stereotypes
valued and safe. and other barriers to delivering culturally
safe care and services.
• Consumers can give examples of ways
that members of the workforce have • Management of the organisation shows
delivered care so that they feel comfortable a clear understanding of events and
and safe (for example, respecting their preferences that may affect what is
ethnicity, spirituality, culture, sexuality culturally safe for people with special
and relationship status). needs, as identified in the Aged Care Act.
• Consumers say the workforce make all • Workforce orientation, training or other
their visitors feel welcome. Consumers feel records that show how the organisation
that people who are significant in their life supported the workforce to deliver
are also comfortable displaying affection culturally safe care and services and
and support in front of the workforce to meet this requirement.
and others. Organisation
• Consumers say they have been asked to • Evidence that strategic documents,
share their experiences of care and services, policies and procedures have
and they have given feedback on whether an inclusive, consumer-centred approach
the organisation has met their expectations to organisational practices and care and
of cultural safety. service delivery.
• Evidence that the organisation is proactive
rather than responsive to cultural safety
issues and supports the workforce to work
in cross-cultural settings in a positive way.
• Management of the organisation has
asked for and considered the opinions
of consumers and their representatives
when reviewing how they can improve the
cultural safety of care and services.
• Records show that the organisation has
delivered care and services in a way that
reflects what culturally safe care means
for individual consumers. For example,
demonstrate the steps taken to meet the
consumer’s preference for the gender of the
care worker to deliver the care or service.
Standard |
Standard 1
Requirement (3)(c) 1
Each consumer is supported

to exercise choice and
independence, including to:
(i) make decisions about
their own care and the
way care and services
are delivered; and
(ii) make decisions about
when family, friends,
carers or others should
be involved in their care;
and
(iii) communicate their
decisions; and
(iv) make connections with
others and maintain
relationships of choice,
including intimate
relationships.
Standard 1 | Requirement (3)(c)

This requirement recognises that making
decisions about life, and having those How does the organisation support each
decisions respected, is an essential right consumer to make decisions about the
of each consumer. This principle means way they live and understand the care
as much as possible that decisions are made and service options available to them?
by consumers themselves.
How does the organisation make sure
A consumer may choose to involve others
the workforce doesn’t limit a consumer’s
as representatives in making their decision.
choices because they have made a
For example, the consumer may choose
judgement about the wisdom of that choice
to have a relative, partner, friend as a
or what the outcome will be?
representative involved in decisions about
their care. Where a consumer lacks the
How does the organisation support the
capacity to make decisions they may have
workforce to manage issues of consent
a court or tribunal-appointed guardian
and work out a consumer’s ability to
to make decisions on their behalf.
make decisions?
Organisations are expected to recognise
the consumer’s social networks, and If a consumer wants to pursue an intimate
support each consumer to choose their or sexual relationship, how would the
social connections, including their close organisation support them to do this?
or intimate relationships. How would the consumer know the
Wherever consumer choice is mentioned organisation supports this?
in this document, it includes the need for
consumers to have options and information
to support their choice. There may also
be situations where consumers won’t be
able to have unlimited choice, such as if their
choice negatively affects other people.
In these situations, it’s expected that the
organisation will take reasonable steps
to find alternatives that can help meet the
consumer’s needs and preferences.
In all cases, it’s expected that organisations
manage consumer choices in line with
the Aged Care Charter of Rights, their
agreement with the consumer and other
responsibilities under the Aged Care Act
1997, as well as their obligations under
competition and consumer law.
Standard |
1

Consumers • Evidence of how the organisation manages
•C
onsumers say the organisation supports situations where the consumer’s decision
them to make and communicate decisions is different to what another person, such
affecting their health and well-being and as a family member, might think is in their
that they can change these decisions ‘best interest’.
at any time. • Evidence of how the organisation supports
•C
onsumers say they are recognised as an consumer choice and independence, and
expert in their own experiences, and their how agreements are reached if they aren’t
personal preferences, lifestyle and care and able to meet a consumer’s choice.
services choices are respected. • Records include details of consumer’s
•C
onsumers say they have as much control representatives and show the key decisions
over the planning and delivery of care that consumers have made about care
and services as they want to. and services.
•C
onsumers say the workforce respect • Evidence the information that the
their independence, including their right organisation provides to consumers
to intimacy and sexual expression. and their representatives, supports
their ability to understand the choices
Workforce and others available to them.
• T he workforce can describe how they
have achieved the level of skills or
knowledge they need to support consumers
to exercise choice.
• T he workforce can give examples of how
they help consumers make day-to-day
choices and help with access to any
support the consumer needs to make
or communicate decisions, such as
an interpreter.
• T he workforce can describe the problem-
solving steps they take to reach an outcome
for a consumer when they aren’t able
to meet the consumer’s choice or when
a consumer’s choice affects the rights
or well-being of others.
this requirement.
Standard 1
Requirement (3)(d)
Each consumer is supported

to take risks to enable them
to live the best life they can.
Standard |
Standard 1 | Requirement (3)(d)
1

All adults have an equal right to make
decisions about things that affect their lives How does the organisation plan, adopt
and to continue to make those decisions as and review ways to support consumer
they get older. Making decisions in everyday choice and decision-making, including
life involves risks. This requirement is about when it involves risk?
how the organisation respects a consumer’s
wishes and preferences relating to the risks What methods or strategies does
they choose to take. management of the organisation and
the workforce use to support consumers
Dignity of risk supports a consumer’s
to make choices, including when a choice
independence and self-determination
may include risks to the consumer?
to make their own choices, including to take
some risks in life. If consumer choices are
Do interactions between consumers
possibly harmful to them, organisations are
and the workforce show that they support
expected to help the consumer understand
consumers to make choices which
the risk and how it could be managed to help
involve risk?
them live the way they choose.
Do these interactions show that they
Organisations have other responsibilities respect the consumer’s decisions?
under law to manage risks to the health and
safety of the workforce and others in the How does the organisation review risks
service environment. In meeting these that they have identified?
obligations the organisation is expected How do they use risk mitigation to inform
to show how they involve consumers future risk management approaches
and look for solutions that are the least and problem solving to improve outcomes
restrictive of their choice and independence. for consumers?

the workforce to respect a consumer’s
decisions and choices, even when they feel
uncomfortable about the risk involved?

Consumers • Evidence of policies and procedures that
• Consumers say the workforce understand support the workforce to manage any
what is important to them and aren’t tension between consumers taking risks,
judgemental about choices they make. or refusing care or services, and their
professional or legal obligations.
• Consumers say they feel heard when they
tell members of the workforce what matters • Examples of problem-solving tools or
to them and what they want. decision support processes that combine
a consumer’s values, goals and preferences
• Consumers say they are supported to
with information about benefits and risks,
understand benefits and possible harm
to achieve consumer-centred solutions.
when they make decisions about taking
risks in day-to-day life and over the • If a consumer’s choices and preferences
long term. are restricted, there are policies and
procedures that make sure these
• Consumers say they are an active
restrictions are limited and tailored
partner in decisions that involve risk and
and proportionate to the risk.
problem-solving solutions to reduce risk
where possible.
• The workforce can describe how they use
problem-solving solutions to minimise risk
and tailor solutions to help the consumer
live the life they choose.
• The workforce can describe examples
of how the organisation has supported
consumers to have choice and control,
including when that choice involves risk.
• The workforce can describe how the
organisation takes reasonable care to
avoid risks without limiting the ability of
consumers to take responsibility for their
own decisions and choices.
• Workforce orientation, training or other
this requirement.
Standard |
Standard 1
Requirement (3)(e) 1
Information provided to
each consumer is current,
accurate and timely,
and communicated in
a way that is clear, easy
to understand and enables
them to exercise choice.
Standard 1 | Requirement (3)(e)

Timely and easily understood information
is vital for consumers to be able to make How does the organisation identify
informed choices. It’s expected that the communication needs of consumers?
organisations communicate clearly and
supply helpful resources about their care and How does the organisation communicate
services, including the care and services they information to consumers with low literacy
offer, commitments and obligations. levels, sensory or hearing impairments,
Each consumer’s needs and ability will affect language barriers or poor cognition?
the kind of information they need and the
What strategies and communication
way it needs to be communicated. Sensory
aids does the organisation use to adapt
impairments, such as vision or hearing loss,
communication to meet the diverse needs
are common in older people. This means it’s
of consumers?
vital to provide help or communication aids
to make sure sensory impairments do not
Do members of the workforce who provide
affect a consumer’s ability to exercise choice
information to consumers have knowledge
and be a partner in the care and services
and understanding of the care and services
choices they make.
on offer?
Providing information in an appropriate Can they answer any questions
format, through different channels and in consumers have?
languages consumers understand, will help
consumers get the most out of their care How does the organisation involve
and services. consumers in developing information-
based resources, for example, through
focus groups or consultations?
Standard |
1
Examples of actions and evidence Workforce and others

• The workforce can describe different ways
Consumers
information is communicated to make sure
•C
onsumers say they get the right
it’s easy to understand and accessible
information, at the right time and in a way
to diverse consumers.
they can understand.
• Management of the organisation can
•C
onsumers say they can access translation
describe how often they review the
services and communication tools when
information provided to consumers,
they need to and members of the workforce
so it’s current and relevant.
support them to use these.
• The workforce can describe how
•C
onsumers say they are involved
information is combined when multiple
in discussions or meetings and are
organisations provide care and services,
encouraged to ask questions.
so that each organisation has access to
•C
onsumers say they can make choices
current, accurate and timely information.
and get information about risks, possible
• The workforce can describe strategies
outcomes and options when making
to communicate information to consumers
decisions that can involve balancing risk
with poor cognition. They can also describe
and quality of life.
strategies to communicate information
to consumers who need visual aids
or hearing assistance.
supported the workforce to communicate
with diverse consumers and to meet
this requirement.
Organisation
• Evidence that each consumer or their
representative has all the information
they need to make informed choices
and decisions about all aspects of care
and services.
• Evidence of accurate, timely and
relevant recording and communication
of information.
• Evidence that the organisation provides
each consumer, or potential consumer, with
information in a way that meets their needs.
This allows them to make informed choices,
understand their rights and the services
available to them.
Standard 1
Requirement (3)(f)
Each consumer’s
privacy is respected
and personal information
kept confidential.
Standard |
Standard 1 | Requirement (3)(f)
1

A key aspect of dignity and respect
is making sure a consumer’s privacy Do day-to-day interactions between
is respected. The organisation needs consumers, the workforce and others
to make sure communication, behaviour show respect for consumer privacy
and interactions of the workforce and and confidentiality?
others don’t compromise a consumer’s
privacy. For example, if the workforce talk How does the organisation make sure
about the consumer to others not involved other consumers, families and visitors
in providing care and services without also respect each consumer’s privacy
consent or are careless about how they enter and confidentiality?
the consumer’s room or home, this can affect
Does the workforce know each consumer’s
the consumer’s dignity.
preferences for personal privacy, for
Organisations have access to a range
example, showering or entering their room
of personal information about a consumer.
(including when they are with visitors)?
This includes health information which
is regarded as one of the most sensitive What practical steps does the organisation
types of personal information. It is essential take to make sure consumer’s information is
that organisations respect a consumer’s kept confidential and only those who need
right to privacy, in how they collect, use and to know have access to the information?
communicate personal information.
The Privacy Act 1988 and the Aged Care Act What practical steps does the organisation
1997 both permit the disclosure and sharing take to ensure accurate health information
of health information if the information is safely transferred to those providing
is necessary to provide health services health care?
to individuals, for example, between aged
care services and hospital services.

Consumers • The workforce can describe how the
• Consumers say the organisation protects organisation maintains and shares records
the privacy and confidentiality of to protect privacy and confidentiality, in line
their information. with consumer preferences.
• Consumers are satisfied care and services, • Evidence that information is available
including personal care, are undertaken to relevant members of the workforce
in a way that respects their privacy. and others providing care in a timely
manner and is provided in a way that
• Consumers say the workforce and others
protects the confidentiality and integrity
consistently respect their privacy and
of the information.
confidentiality in how they communicate
and interact with them. • Processes or procedures support
the workforce to manage requests
• Consumers say the organisation respects
for information from others, such as
their personal space and privacy when their
family members or significant others,
friends, partners or significant others visit.
in a consistent, professional, sensitive
Workforce and others and appropriate way.
• Observed delivery of care and services
is respectful of consumer privacy.
• The workforce can describe how they
support consumers to communicate their
preferences for how they want their privacy
maintained (including their information,
their space, and how they are treated
or cared for).
• The workforce can give examples of how
they maintain the privacy of individuals
in the delivery of care and services, and
demonstrate their understanding that
consumers receiving personal care can
feel vulnerable.
• The workforce can show they clearly
understand the importance of
confidentiality and describe (relevant
to their role) how they collect, use and
communicate any personal information
to maintain privacy.
supported the workforce to respect
a consumer’s right to privacy and to meet
this requirement.
Standard 2 |
Standard 2
Ongoing assessment and
planning with consumers
Standard 2 |

I am a partner in
2 (1)
2 (3) The organisation demonstrates
the following:
ongoing assessment 2 (3) (a) Assessment and planning,
and planning that helps including consideration of risks
to the consumer’s health and well-
me get the care and being, informs the delivery of safe
services I need for my and effective care and services;
health and well-being. 2 (3) (b) Assessment and planning

identifies and addresses the
consumer’s current needs,
goals and preferences, including
Organisation statement advance care planning and
The
2 (2) organisation end of life planning if the
consumer wishes;
undertakes initial and 2 (3) (c) Assessment and planning:
ongoing assessment (i) is based on ongoing
and planning for care and partnership with the
consumer and others that the
services in partnership consumer wishes to involve
with the consumer. in assessment, planning and
review of the consumer’s care
Assessment and planning and services; and
has a focus on optimising (ii) includes other organisations,
and individuals and providers
health and well-being of other care and services,
in accordance with the that are involved in the care
of the consumer.
consumer’s needs, goals
2 (3) (d) The outcomes of assessment
and preferences. and planning are effectively
communicated to the consumer
and documented in a care and
services plan that is readily
available to the consumer,
and where care and services
are provided;
2 (3) (e) Care and services are reviewed
regularly for effectiveness, and
when circumstances change
or when incidents impact on
the needs, goals or preferences
of the consumer.
Standard 2 |
Standard |
Purpose and scope It’s expected that an appropriately skilled
of the Standard and qualified workforce undertakes
Standard 2 builds on the foundations
assessment and planning. Assessment and
planning undertaken should be in addition
²
of Standard 1 and includes requirements for
to and compliment any Aged Care
organisations to work in partnership with
Assessment Team or Regional Assessment
consumers. This Standard describes what
Service assessments.
organisations need to do to plan care and
services with consumers. The planned care Assessment and care planning is expected
and services should meet each consumer’s to provide access to advance care planning
needs, goals and preferences and including the completion of legally binding
optimise their health and well-being. While advance care directives, and end of life
a consumer might have some challenges planning if the consumer wants this.
with their health and abilities, they still have Organisations need to document the
goals they want to achieve, roles that have outcomes of assessments and discussions
meaning, and want to live as well as they can. with the consumer in a care and services
This means organisations need to listen plan and set an agreed review date. Care and
to what the consumer wants and look at what services plans may include advance care
they can do (their abilities). Organisations planning, advance care directives, and end
can then focus on planning care and of life planning documents. The plan should
services to ensure that consumers can be available to the consumer and to those
still get to where they need to go, do what providing care to the consumer. It also needs
they need to do and have opportunities for to be updated on an ongoing basis as the
participation and growth. The plan needs consumer’s needs, goals or preferences
to be regularly reviewed so that changes change, and after any transition
in a consumer’s health or abilities are picked between services.
up and care and services are identified and In line with Standard 1, it’s expected when
put in place to minimise the impact of any planning or making changes to care and
loss of ability, and to support consumers services plans, consumers are given options
to live their day-to-day lives with dignity. and helped to make informed decisions
The level of assessment and planning will about their options. This includes how much
depend on the level of care and services they want to be involved in managing these
the organisation is providing and the risks options themselves.
of delivering care and services for the
consumer. For example, an organisation
providing weekly cleaning services
to a consumer in their home, would
need less assessment and planning than
an organisation providing residential aged
care services.
Standard 2 |
Linked Standards
Assessment against Standard 2 links to:
this Standard
For each of the requirements, Standard 1
organisations need to demonstrate All aspect of assessment and care
that they: and services planning needs to
• understand the requirement treat consumers with dignity and respect
and support them to make choices. It’s also
• apply the requirement, and this
important that assessment and care planning
is clear in the way they provide care
occurs in a way that is culturally safe.
and services
• monitor how they are applying
the requirement and the outcomes Standard 3
they achieve Assessment and planning of the
• review outcomes and adjust their consumer’s needs, goals and
practices based on these reviews preferences supports the delivery of tailored
to keep improving. personal and clinical care. If care planning
includes advance and end of life care
planning this will be delivered in line with
consumers wishes.
Standard 4
Assessment and planning of
the consumer’s needs, goals and
preferences enables the delivery of safe
and effective services and supports.
Standard 7
Workforce interactions with
consumers need to be kind, caring
and respectful of each consumer’s identity,
culture and diversity. In particular the
workforce needs to have the competency,
qualifications and knowledge to develop
a care and services plan which meets the
consumer’s needs, goals and preferences.
Standard 8
The organisation’s governing body
is accountable for the delivery of
safe, effective and quality care and services
as assessed and planned.
Standard 2 |
Standard |
Relevant legislation Resources and references
• Aged Care Act 1997 (Cth), User Rights • Advance Care Planning Australia 1
Amendment (Charter of Aged Care Rights) • Cognitive Decline Partnership Centre (2018). ²
Principles 2019 Supported decision-making in aged care:
• Privacy Act 1988 (Cth), Schedule 1, A policy development guideline for aged
Australian Privacy Principles care providers in Australia. (2nd edition) 2
• State and Territory privacy and health • Council of the Ageing (2017).
records legislation Home Care Today Resources 3
• State and Territory work health and • End of Life Directions for Aged Care
safety legislation Resources 4
• State and Territory mental health, • Palliative Care Australia (2018). National
guardianship and administration, Palliative Care Standards (5th edition) 5
enduring power of attorney and medical • Palliative Care Australia (2017).
directive/advance care planning legislation Principles for Palliative and End-of-Life Care
in Residential Aged Care 6
• Victorian Government, Department
of Health, Participating with consumers
information sheets 7
• World Health Organisation (2017).
WHO Integrated care for older people:
guidelines on community-level
interventions to manage declines
in intrinsic capacity 8
1 https://www.advancecareplanning.org.au
2 http://sydney.edu.au/medicine/cdpc/documents/resources/SDM-Policy-Guidelines.pdf
3 https://www.cota.org.au/information/aged-care-for-providers/home-care-today-providers/
4 https://www.eldac.com.au/
5 http://palliativecare.org.au/standards
6 http://palliativecare.org.au/wp-content/uploads/dlm_uploads/2017/05/PCA018_Guiding-Principles-for-PC-Aged-Care_W03-002.pdf
7 https://www2.health.vic.gov.au/ageing-and-aged-care/residential-aged-care/safety-and-quality/participating-with-consumers
8 http://www.who.int/ageing/publications/guidelines-icope/en/
Standard 2
Requirement (3)(a)
Assessment and planning,

including consideration of
risks to the consumer’s health
and well-being, informs the
delivery of safe and effective
care and services.
Standard |
Intent of this requirement there are integrated care and services, there
This requirement is about making sure that need to be arrangements in place to share
assessment and planning are effective. and combine relevant information. This
includes information about any risks to the
²
These processes will support organisations
to deliver safe and effective care consumer’s safety, health and well-being.
and services.
Relevant risks to a consumer’s safety, Reflective questions
health and well-being need to be assessed,
discussed with the consumer, and included What assessment and planning processes
in planning a consumer’s care. This supports enable consumers, their representatives,
consumers to get the best possible care and the workforce and others, to work together
services and makes sure their safety, health in developing a safe and effective care
and well-being aren’t compromised. and services plan?
To assess, plan and deliver care and services
that are safe and effective, members How does the organisation use information
of the workforce need to have the relevant from other sources, such as government
skills, qualifications and knowledge assessment services, when developing
to assess individual consumers’ needs assessment and planning methods?
and to understand their needs, goals
and preferences. Do the workforce use validated risk
Where consumers have lost their decision assessment and planning tools?
making capacity and have an advance care Do they ask for input from relevant,
directive in place, health professionals qualified practitioners about assessing
have obligations to access and enact the and managing specific and common risks
advance care directive. It should be available for older people?
at the point of care and shared across This may include diseases or conditions
service providers. such as incontinence, hearing loss
or cognitive impairment, high-impact
Where a consumer has requested care
or high-prevalence risks, or the use
or services which may pose a risk to their
of restrictive practices.
safety, health or well-being, such as the
use of a physical restraint for comfort,
How does the organisation define advance
organisations are expected to discuss
care planning policy and ensure consumers
the risks and alternative solutions with
are using quality and complete statutory
the consumer, so the consumer can make
advance care directive forms?
an informed decision about their care and
How does the organisation know and
services. Arrangements to protect consumers
measure whether assessment and planning
require assessment, documentation in care
processes are resulting in safe and effective
and services plans, informed consent and
care and services?
regular monitoring and review, in line with
How does the organisation monitor how
best practice and legislation.
effective the care and services plan
When two or more organisations share the is in meeting the consumer’s goals?
care and services for a consumer, or where

Consumers • The workforce can describe advance care
• Consumers say their care is well planned planning and advance care directives.
to meet all their needs. • Evidence that advance care directive
• Consumers say they feel safe and confident documentation informs end-of-life care
because members of the workforce took and decisions.
the time to listen and understand how • The workforce can describe the assessment
to support their health and well-being. and care planning processes and how they
inform how care and services are delivered.
• Where it applies, consumers can give
examples of how their care and services • The workforce can describe how they
plan includes input from relevant assess risk, and how they work together
practitioners to work out the help they need with consumers to minimise risk.
for day-to-day living activities. • The workforce can describe how they can
• Where physical or chemical restraint access appropriately skilled individuals
is in use, consumers or their representatives or service providers to contribute to
say they have given informed consent, assessing and planning safe and effective
consistent with state and territory law. care. (For example, input into planning
• Consumers describe how the workforce for emotional health and well-being,
took a problem-solving approach clinical and personal care, continence
to managing or minimising risk or meeting management, dietary requirements,
their needs, goals and preferences where eating aids and assistance, mobility
a solution wasn’t obvious. aids and assistance, and hearing, visual
or communication assistance).
• The workforce can describe how consumers,
and others who contribute more broadly
to care and services (such as medical
professionals), work together to deliver
a tailored care and services plan, and
monitor and review the plan as needed.
this requirement.
Standard |
Organisation
• Evidence of how the organisation makes sure • Evidence of guidance for relevant members
the workforce has undertaken advance care
planning training and
of the workforce on undertaking assessment
and planning in a culturally safe way,
²
has policy to inform advance care directive tailored to the needs of each consumer.
documentation; ensuring documentation • Evidence of how assessment and planning
is accurate, up-to-date, complete, shared processes (and documents) inform safe
and stored with relevant healthcare and effective care and services, including
providers. where care and services are shared with
• Evidence that shows members of the other organisations.
workforce are clear on who is accountable • Evidence of the organisation monitoring
within the organisation for assessing, assessment and planning tools and
planning and reviewing the care and processes to make sure they are effective
services needs of consumers. and are identifying and addressing the
• Records that show how members of the needs of consumers.
workforce consider risk with the consumer • Records that show how the organisation
during assessment and planning to make monitors, reports and continuously
sure care and services are safe and effective. improves assessment and planning
• Evidence of how the organisation makes sure of care and services.
workforce assessment and planning skills
match the type and complexity of the
consumer’s needs, such as specialised
clinical skills or particular cultural skills.
• Evidence that when validated assessment
tools are available (including risk
assessments), they are used by the
workforce in assessment and planning for
consumers’ care and services.
Standard 2
Requirement (3)(b)
Assessment and planning

identifies and addresses
the consumer’s current
needs, goals and
preferences, including
advance care planning
and end of life planning
if the consumer wishes.
Standard |
Intent of this requirement As part of advance care planning, consumers
For this requirement, organisations are may wish to complete an advance care
expected to do everything they reasonably directive detailing their care preferences ²
can to plan care and services that centre on or appointment of a substitute decision-
the consumer’s needs and goals and reflect maker. Advance care directives are legally
their personal preferences. This means: binding documents, which can only
be completed by a competent consumer
• c onsidering the consumer’s condition and
who still has decision-making capacity.
functional abilities and identifying what
help they need to live as well as they can If a consumer is unable to document
an advance care directive due to lack
• l istening to and understanding what is
of decision making capacity, a medically
important to the consumer and working out
driven document outlining the plan of care
how their goals and preferences can be met
in relation to emergency treatment or severe
• t ailoring an approach to fit the consumer’s clinical deterioration can be useful (e.g. acute
cultural and personal preferences resuscitation plan, do not resuscitate
and how they want to have care and order). This document should be developed
services delivered. in consultation with the substitute decision-
If an organisation can’t meet a consumer’s maker of a consumer without decision
preferences for care and services, they will making capacity.
need to explain why, so the consumer can Where a consumer lacks the capacity to make
understand the reasons and look at other decisions providers will need to check if they
options. This allows the consumer to make have previously appointed a substitute
an informed decision about their care decision-maker (e.g. attorney, guardian).
and services. All states and territories have a default
Through this requirement, it’s expected decision-maker (e.g. partner, eldest child,
that advance care planning including or carer) with the exception of the Northern
completion of advance care directives, and Territory. If no substitute decision-maker
end of life planning happen in line with the can be identified, they will require a court
consumer’s preference. These conversations or tribunal appointed guardian to make
are often left too late. It can cause distress medical decisions.
for the consumer’s representatives, family
and carers and members of the workforce
when the consumer’s wishes are unknown.
The consequence may be that the consumer
does not have the end of life experience they
would have wanted.
Reflective questions
What systems and processes does the How does the organisation make sure
organisation use to support a consumer- they give consumers culturally safe and
centred assessment of the needs, goals supportive opportunities to talk about
and preferences of each consumer? dying so they can make their wishes known?
How is this done in a way that meets the
Does the organisation evaluate whether needs of a diverse range of consumers?
assessment processes are identifying
consumer needs, goals and preferences? How does the organisation monitor that
Are these documented in a care and a consumer’s assessment and care planning
services plan? includes the consumer’s social, cultural,
language, religious, spiritual, psychological
How does the organisation access a skilled and medical needs?
and qualified workforce to assess and plan
care and services, including advance care
planning and end of life care planning?
Standard |
Examples of actions and evidence information to consumers on end of life
Consumers planning or palliative care if the consumer
• Consumers have access to advance care wishes to include these in their care and
services plan.
²
planning and end-of-life planning.
• If a consumer chooses to complete • Workforce, orientation, training or other
an advance care directive, it is done while records that show how the organisation
they still have decision making capacity. supports the workforce to identify
•C onsumers say they have been listened consumer’s needs, goals and preferences
to and their care and services are planned through assessment and care planning and
around what is important to them, meet this requirement.
such as their intimate relationships, Organisation
spirituality and culture. • Evidence of strategies, policies and
•C onsumers are happy with their care and procedures that support a consumer-
services plan and feel it covers how they centred approach to assessment and
want their care and services delivered. planning for care and services.
•C onsumers say they didn’t feel judged • Policies and processes that describe how
or uncomfortable when talking about the assessment and care planning are to be
care and services they need and how they undertaken and the matters to be taken
want these delivered. into account, such as the consumer’s need
for communication assistance.
• The workforce can describe advance care • Records of appropriately skilled and
planning and understand the substitute qualified members of the workforce being
decision-maker should be consulted involved in the assessment of a consumer’s
in medical decisions including consent, needs, goals and preferences.
refusal and/or withdrawal of treatment. • Evidence that shows individual, tailored
• Advance care directive documentation care and services plans are documented
should be accurate, up-to-date, complete, for each consumer.
shared and stored with relevant care and • Policies and processes that provide
service providers. consumers with opportunities to have
• T he workforce involved in assessment and safe and supported conversations about
planning can describe how it’s undertaken death and dying, to make their end
to meet the consumer’s needs, goals of life and palliative care wishes known
and preferences. to the organisation.
• T he workforce can provide examples • Evidence that there is clear guidance
of inclusive care planning which is tailored for members of the workforce on decision-
to meet the particular cultural preferences making processes when a consumer’s
of consumers from diverse backgrounds. wishes and preferences are not known.
•M embers of the workforce know how This includes wishes that were documented
to access people with the relevant in the past, advance directives, and the role
knowledge or qualifications to provide of representatives.
Standard 2
Requirement (3)(c)
Assessment and planning:

(i) is based on ongoing
partnership with the
consumer and others
that the consumer wishes
to involve in assessment,
planning and review
of the consumer’s care
and services; and
(ii) includes other
organisations and
individuals and
providers of other care
and services, that are
involved in the care
of the consumer.
Standard |
Intent of this requirement Assessment and planning are also expected
For this requirement, it’s expected that to include other organisations, individuals
an organisation will carry out ongoing or service providers involved in caring
for consumers. This requires effective
²
assessment and planning with the consumer
their representatives and others who the communication with other service providers.
consumer wants to involve in assessment Consumers may also be receiving care and
and planning of their care and services. support from unpaid carers, such as family
Partnering involves ongoing sharing of and friends. These people may have been
information, asking for feedback from the supporting the consumer over a period
consumer, and supporting and encouraging of time, before they accessed care and
consumers to take part in assessing and services. Involving them in assessment
planning their own care and services. This and planning (if the consumer wishes) can
approach recognises that making decisions help the organisation to get to know the
about their own life, and having those consumer’s needs, goals and preferences
decisions respected, is an essential right and help continuity of care and services
of each consumer, improves their health for the consumer.
and well-being and shows the organisation Organisations will need to comply
values the consumer. with obligations relating to privacy
The consumer can decide to be involved of information when coordinating care
as much or as little as they want to be in with other organisations, individuals
the assessment and planning process. A or service providers.
consumer may choose to involve others as
representatives in making their decisions. For
example, the consumer may choose to have a
relative, partner, or friend as a representative
involved in decisions about their care. Where
a consumer lacks the capacity to make
decisions they may have a court or tribunal-
appointed guardian to make decisions on
their behalf.
Do the organisation’s policies guide the What systems does the organisation have
workforce in how to involve, listen to, and in place to identify other organisations,
respect the views of the consumer and individuals or service providers that
how to include them as much as possible are involved in the care of the consumer,
in planning their care and services? or should be involved in their care
(to be able to meet the needs, goals
Does the organisation guide the workforce and preferences of the consumer)?
on how to involve others (such as family or
other carers) in a consumer’s assessment How does the workforce involve the
and care planning if the consumer wants consumer’s medical practitioner and other
to assign some or all of, their care and preferred service providers, such as those
services planning to others? providing dental care, hearing aids
or glasses?
consumers who need help with How does the organisation bring together
communicating to take part in planning those involved in a consumer’s care
their care and services? (including other organisations, individuals
and specialist service providers)
How do the organisation’s practices to talk about and coordinate care and
encourage consumers to tell the service delivery and to make sure the
organisation when their needs, goals consumer’s care and services are seamless
and preferences have changed? and focused?
How does the organisation respond
when this happens? If an organisation can’t meet all of the
consumer’s expectations, how do they
communicate this to the consumer?
a consumer’s access to other
service providers?
Standard |
Examples of actions and evidence • Members of the workforce who share
Consumers information about consumers with
•C
onsumers say they are actively involved other organisations, individuals or
service providers describe how they
²
in the assessment, planning and review
of their care and services. They can describe meet obligations relating to privacy
their care and services plan and how of information when coordinating care.
it helps them to meet their goals. • Workforce orientation, training or other
•C
onsumer representatives (including carers) records that show how the organisation
say they are actively involved, with the supports the workforce to meet
consumer’s consent, in the assessment, this requirement.
planning and review of care and services. Organisation
•C
onsumer representatives (including • Evidence of consumer information and
carers) say the organisation makes it easy support to help consumers take part
for them to be involved in the assessment, in assessing and planning their care
planning and review of the consumer’s care and services.
and services. • Evidence that information and resources
•W
here a number of organisations provide are available in appropriate formats and
care and services, the consumer says language translations to help consumers
the organisation has helped them to partner in assessment and planning.
understand how they fit together. And they • Clear lines of workforce responsibility
know which organisation is responsible for for the assessment, planning and review
different aspects of their care and services, of care and services plans and what each
and who to contact in different situations. element involves.
•C
onsumers say their assessment and • Evidence the skills and qualifications of the
care planning is coordinated and they are workforce are appropriate for the type and
satisfied the right people are involved. complexity of the assessment and planning
Workforce and others of care and services being undertaken.
•M embers of the workforce can describe • Resources and tools that support
what it means to partner with consumers to shared decision-making for care and
assess, plan and review care and services. services planning.
• T he workforce and others delivering care • Care and services plans for consumers
and services describe how they work show integrated and coordinated
collaboratively. assessment and planning involving all
•M anagement can describe innovative and relevant organisations, individuals and
effective ways they have coordinated care service providers.
and services for consumers where the • Evidence of arrangements or agreements
organisation itself has been unable to meet with those outside the service involved
a consumer’s needs, goals or preferences. in planning care and services, to meet the
consumer’s needs, goals and preferences.
Standard 2
Requirement (3)(d)
The outcomes of assessment

and planning are effectively
communicated to the
consumer and documented
in a care and services plan
that is readily available to
the consumer, and where care
and services are provided.
Standard |
Intent of this requirement Relevant risks to a consumer’s safety, health
A care and services plan is expected and well-being need to be documented
to be documented and reflect the outcomes in the care and services plan to make sure ²
of assessment and planning for each their safety isn’t compromised. This includes
consumer. Accurate and up-to-date care and things such as allergies and other risks
services plans are important for delivering relating to the consumer’s needs.
safe and effective care and services, as well When two or more organisations, individuals
as positive outcomes for consumers. or service providers share a consumer’s care
A care and services plan, which includes and services, or where there are integrated
a person’s needs, goals and preferences, services, the care and services plan and
should be available to the consumer in a way outcomes from assessment and planning
they can understand. This may involve need to be shared. Information sharing
support to have information in an accessible needs to happen promptly and comply with
language and format, or to help consumers obligations relating to privacy of information.
understand the content. It may include
involving consumers in discussions, inviting
them to meet and encouraging them to ask
questions about their care and services plan.
This will help consumers understand and
have ownership of the care and services plan
as they are entitled to have.
The care and services plan can take different
forms. It can be a single document or several
documents that show an overview of the
care and services to be delivered. Care and
services plans may include advance care
planning, advance care directives, or end
of life planning documents. It should be
available to those providing care and
services to the consumer. This doesn’t
mean the care and services plan needs
to be available at all times and to all
members of the workforce, but the relevant
information must be available when and
where it is needed to support safe and
effective care and services.
How does the organisation communicate What systems are in place to make sure
assessment and planning information in relevant information for delivering
a way the consumer understands? a consumer’s care and services
is available where the care or service
When a consumer asks for a copy of their is actually delivered?
care and services plan, how promptly does
the organisation provide it? What processes are there to communicate
Is it in a format they understand? critical information in a care and
services plan to the workforce, including
When a consumer has trouble information alerts and risks?
understanding outcomes of assessment
and planning, how does the organisation Is the level of detail in the care and
support the consumer? services plans enough to enable the
Are interpreters available when explaining appropriate and correct delivery of care
the plan? and services to the consumer to optimise
How are the consumer’s consumer health and well-being?
representatives involved? For example, the consumer’s preferences
for personal hygiene, oral health care,
How does the organisation document taking medication, how to check a hearing
care and services plans? device is working properly and where
Are they in plain English? glasses are kept.
Standard |
• Policies and procedures explain the
Consumers
•C
onsumers say they know how to get a copy
organisation’s systems, so that outcomes
of assessment and planning are fully
²
of their care and services plan if they
documented and are available where care
want it. They say it will be in a format
and services are delivered.
they can understand and they will get
it in a timely manner. • Evidence that care and services plans are
accurate and reflect the outcomes of the
•C
onsumers say they have been supported
most up-to-date assessments and reviews
to understand their care and services plan
of consumer needs, goals or preferences.
and can describe how it meets their needs,
goals and preferences. • Evidence the consumer or their
representative is involved in developing and
•C
onsumers can describe the details of their
reviewing the care and services plan.
care and services plan and who will provide
the care and services. • Evidence of how the organisation monitors
the effectiveness of the care and services
•C
onsumers confirm they are involved if
plan and documents assessment and
changes are made to their care and services
planning process to improve outcomes
plan, and they understand the changes.
for consumers.
• T he workforce can describe processes for
documenting the outcomes of assessment
and planning in a care and services plan.
• T he workforce can describe how they access
the care and services plan and how they
use the information in it that is relevant
to their role to deliver safe and effective
care and services.
• T he workforce can describe how
changes to the care and services plan
are communicated and say they receive
updated information promptly.
• T he workforce say care and services plans
are current and contain enough detail
to deliver appropriate and correct care
and services for the consumer.
supports the workforce to document and
communicate the results of assessment
and planning and meet this requirement.
Standard 2
Requirement (3)(e)
Care and services are

reviewed regularly for
effectiveness, and when
circumstances change
or when incidents
impact on the needs,
goals or preferences
of the consumer.
Standard |
Through this requirement, organisations
are expected to regularly review the care How does the organisation respond
to adverse incidents and near misses?
²
and services they provide to consumers.
This is important to make sure that the: How does it learn from these events
to update the way care is planned
• c are and services plans are up-to-date
and delivered?
and meet the consumer’s current needs,
goals and preferences
What systems are in place to
• c are and services the organisation recognise and respond to changes
provides meet the consumer’s needs safely in a consumer’s condition?
and effectively What processes does the organisation then
• c are and services the organisation use to update care and services plans and
provides are updated to apply better make sure consumers are safe, and risks
practice when available. are minimised?
All care and services plans are expected
to include an agreed review date. How often How does the organisation identify when
a review is done depends on the needs a consumer wishes to change the care and
of each consumer and on the nature and services that are provided, or the way the
type of services the organisation is providing. care and services are provided?
However, in addition to the reviews that are
scheduled, a consumer’s care and services What processes does the organisation
plan should be reviewed when: use to include evidence of better practice
• t he consumer’s condition changes when reviewing how effective care and
(for example, physical or mental health) services are?
• s ituations change (for example,
if the organisation’s arrangements
for a service changes)
• incidents or accidents happen
(for example, if a consumer has fallen).

Consumers • Documented care and services plans that
• Consumers say the organisation regularly show the organisation conducts regular
communicates with them about their care reviews, including risk assessments.
and services, seeks feedback and makes • Evidence that members of the workforce
changes to meet their current needs, with relevant skills and qualifications review
goals and preferences. the plans regularly.
• Consumers say when something goes • Policies and procedures that describe the
wrong, or things change, the organisation need for regularly reviewing how effective
communicates with them about this and the care and services plan is, and whether
seeks their input to update their care and consumer outcomes are being achieved.
services plan to ensure safe and effective • Evidence of how the organisation
care and services can be delivered. monitors reports and keeps improving
Workforce and others outcomes for consumers through effective
• The workforce can describe when and assessment and planning.
how they reassess a consumer’s needs,
goals and preferences, how they involve
the consumer and how reassessment
information is used to update care and
services plans.
• The workforce can describe examples
of reviewing care and service practices due
to adverse incidents or near-miss events.
• The workforce can describe how these
reviews capture all aspects of a consumer’s
health and well-being, including emotional,
spiritual and psychological.
• The workforce can describe how regular
reviews of a consumer’s care and services
can identify ways to respect the dignity of
consumers, such as new dentures, hearing
aid maintenance or an assistive device
for eating.
this requirement.
Standard 3 |
Standard 3 |
Consumer outcome 3 (3) (b) Effective management of high-

I get personal care,
3 (1)
impact or high-prevalence
risks associated with the care
clinical care, or both of each consumer.
personal care and 3 (3) (c) The needs, goals and
preferences of consumers
clinical care, that is safe nearing the end of life are
and right for me. recognised and addressed, their
comfort maximised and their
dignity preserved.
Organisation statement 3 (3) (d) Deterioration or change
of a consumer’s mental
The
3 (2) organisation delivers health, cognitive or physical
safe and effective function, capacity or condition
is recognised and responded
personal care, clinical to in a timely manner.
care, or both personal 3 (3) (e) Information about the
consumer’s condition, needs
care and clinical care, and preferences is documented
in accordance with and communicated within the
organisation, and with others
the consumer’s needs, where responsibility for care
goals and preferences is shared.
to optimise health 3 (3) (f) Timely and appropriate
referrals to individuals, other
and well-being. organisations and providers
of other care and services.
3 (3) (g) Minimisation of infection-related
Requirements
risks through implementing:
the following: (i) standard and transmission-
based precautions to prevent
3 (3) (a) Each consumer gets safe and
and control infection; and
effective personal care, clinical
care, or both personal care and (ii) practices to promote
clinical care, that: appropriate antibiotic
prescribing and use
(i) Is best practice; and
to support optimal care and
(ii) tailored to their needs; and reduce the risk of increasing
(iii) optimises their health resistance to antibiotics.
and well-being.
Standard 3 |
Purpose and scope The guidance in this Standard is not clinical

of the Standard guidance. It doesn’t include instructions
or ‘how to’ information on the different
Consumers and the community expect
aspects of care. Organisations need
the safe, effective and quality delivery
to develop and implement an approach
of personal and clinical care. The Standard
that makes sure they are providing safe
applies to all services delivering personal
Standard |
and effective personal and clinical care
and clinical care specified in the Quality of
to consumers. This approach needs to be
Care Principles 2014. Personal and clinical
in line with best practice evidence and
care and services can include:
• supervising or helping with bathing,
meet the consumer’s needs, goals and
preferences. The organisation is expected
3
showering, personal hygiene and dressing to then have policies and procedures
• providing personal mobility aids and that support the workforce to deliver
communication assistance for consumers care and treatment in line with this
with impaired hearing, sight or speech approach. This includes, for residential
• nursing services, such as catheter care and aged care services, a dedicated clinical
wound management staff member responsible to support the
• services aimed at getting back or improving design, implementation and continuous
a consumer’s independence or daily improvement of infection prevention and
living activities control policies, procedures and practices.
• specialised therapy services, such
as support for consumers living with
cognitive impairment.
Most aged care organisations deliver Assessment against
good outcomes for consumers. However,
this Standard
consumers don’t always receive care
from organisations in a safe and effective For each of the requirements,
way. Harmful events that organisations organisations need to demonstrate
could have prevented continue to happen that they:
in aged care service delivery. This Standard • understand the requirement
highlights several key areas where • apply the requirement, and this
organisations need to do more and be is clear in the way they provide care
proactive in their preparations to minimise and services
the risk of an outbreak and ensure they keep • monitor how they are applying
consumers safe and that they receive the the requirement and the outcomes
best possible care and services. they achieve
• review outcomes and adjust their
practices based on these reviews
to keep improving.
Standard 3 |
Linked Standards Relevant legislation

Standard 3 links to: • Aged Care Act 1997 (Cth), User Rights
Standard 1 Principles 2019
All aspects of personal and clinical • Aged Care Legislation Amendment
care need to treat consumers (Quality Indicator Program) Principles 2019
with dignity and respect and support them • Privacy Act 1988 (Cth), Schedule 1,
to make choices. It’s also important that Australian Privacy Principles
personal and clinical are delivered in a way • Quality of Care Amendment (Minimising
that is culturally safe. the Use of Restraints) Principles 2019
• State and Territory work health
Standard 2 and safety legislation
Assessment and the development • State and Territory mental health,
of a care and services plan that guardianship and administration, enduring
reflects the consumer’s needs, goals and power of attorney and medical directive/
preferences supports the delivery of tailored advance care planning legislation
personal and clinical care. The consumer’s
advance care and end of life care wishes can
be delivered if these are planned.
Standard 7
culture and diversity. In particular, the
qualifications and knowledge to deliver safe
and effective personal and clinical care and
promote consumers’ health, well-being and
cultural safety.
Standard 8
is accountable for the delivery
of safe and quality care. Including the
effectiveness of clinical governance and
risk management systems and practices,
to manage high-impact and high-prevalence
risks associated with the care of consumers.
Standard 3 |
Resources and references • Australian Government, Department

• Alzheimer’s Australia (2014). The use of Health & Department of Agriculture
of restraints and psychotropic medications (2015). Responding to the threat
in people with dementia 1 of antimicrobial resistance: Australia’s first
• Aged Care Quality and Safety Commission, National Antimicrobial Resistance Strategy
Clinical Governance resources 2 2015–2019 7
Standard |
• Australian Commission on Safety and • Australian Wound Management Association
Quality in Health Care (2016). Antimicrobial (2012). Pan Pacific Clinical Practice Guideline
Stewardship Clinical Care Standard 3 for the Prevention and Management
• Australian Commission on Safety
of Pressure Injury 8 3
and Quality in Health Care (2016). • Deafness Forum Australia (2018). Good
Delirium Clinical Care Standard 4 Practice Guide, Reference Resources for
Aged Care Hearing Assistance Programs 9
and Quality in Health Care (2009). • Department of Health (2012). Decision-
Guidebook for Preventing Falls and Harm making tool: supporting a restraint-free
From Falls in Older People 5 environment in residential aged care 10
• Australian Commission of Safety and • Department of Health (2012). Guiding
Quality in Health Care (2015). National principles for medication management
consensus statement: essential elements in residential aged care facilities 11
for safe and high-quality end-of-life care 6
1 https://www.dementia.org.au/files/NATIONAL/documents/Alzheimers-Australia-Numbered-Publication-38.pdf
2 https://www.agedcarequality.gov.au/providers/quality-care-resources/clinical-governance
3 https://www.safetyandquality.gov.au/publications/antimicrobial-stewardship-clinical-care-standard/
4 https://www.safetyandquality.gov.au/publications/delirium-clinical-care-standard/
5 ttps://www.safetyandquality.gov.au/publications/guidebook-for-preventing-falls-and-harm-from-falls-in-older-people-
h
australian-residential-aged-care-facilities-2009/
6 ttps://www.safetyandquality.gov.au/wp-content/uploads/2015/05/National-Consensus-Statement-Essential-Elements-forsafe-
h
high-quality-end-of-life-care.pdf
7 https://www.amr.gov.au/resources/national-amr-strategy
8 https://www.woundsaustralia.com.au/Web/Resources/Publications/Publications.aspx
9 https://www.deafnessforum.org.au/resources/training-resources-in-hearing-assistance-in-aged-care-services-and-hospitals/
10 https://agedcare.health.gov.au/publications-articles/resources-learning-training/decision-making-tool-supporting-a-restraint-
free-environment
11 http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdf-resguide-cnt.htm
Standard 3 |
• Department of Health (2016). National Aged • National Diabetes Services Scheme and
Care Quality Indicator Program | Resource Diabetes Australia, Healthy eating – A guide
manual for residential aged care facilities 12 for older people living with diabetes 20
• Department of Health, National Framework • NSW Health (2015). Best Practice Food
for Action on Dementia 2015–2019 13 and Nutrition Manual for Aged Care
• Diabetes Australia, Diabetes management Facilities, (2nd edition) 21
in aged care – A practical handbook 14 • National Health and Medical Research
• Dying to talk, Aboriginal and Torres Strait Council (2010). Australian guidelines
Islander Discussion Starter 15 for the prevention and control of infection
• Guideline Adaptation Committee (2016). in healthcare 22
Clinical Practice Guidelines and Principles • The Australian Pain Society (2018).
of Care for People with Dementia 16 Pain in Residential Aged Care, Management
• End of Life Directions for Aged Care Strategies, (2nd edition) 23
Resources 17 • Victorian Government, Department
• Macular Disease Foundation Australia, of Health, Nutrition and swallowing 24
Aged care resources 18 • Victorian Government, Department
• National Ageing Research Institute, of Health (2014). Recognising and
Resources for Health Professionals, Responding to Clinical Deterioration 25
Falls and balance 19 • Victorian Government, Department of
Health, Residential aged care services –
Standardised care processes 26
12 ttps://agedcare.health.gov.au/ensuring-quality/quality-indicators/national-aged-care-quality-indicator-program-resource-
h
manual-for-residential-aged-care-facilities
13 ttps://agedcare.health.gov.au/ageing-and-aged-care-older-people-their-families-and-carers-dementia/national-framework-for-
h
action-on-dementia-2015-2019
14 https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/01ebfd4b-99b9-439e-8c19-126090cbb9c3.pdf
15 http://dyingtotalk.org.au/aboriginal-torres-strait-islander-discussion-starter/
16 http://sydney.edu.au/medicine/cdpc/resources/dementia-guidelines.php
17 https://www.eldac.com.au/
18 https://www.mdfoundation.com.au/content/aged-care-resources
19 https://www.nari.net.au/resources/health-professionals/falls-and-balance
20 http://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/1581db13-3932-40fe-a46b-fcd719c60bdf.pdf
21 https://www.cclhd.health.nsw.gov.au/wp-content/uploads/BestPracticeFoodandNutritionManualforAgedCareEdition2.1.pdf
22 https://www.nhmrc.gov.au/guidelines-publications/cd33
23 https://www.apsoc.org.au/publications
24 https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/nutrition-swallowing
25 https://www2.health.vic.gov.au/about/publications/policiesandguidelines/nsqhs-online-learning-st9-clinical-deterioration
26 ttps://www2.health.vic.gov.au/ageing-and-aged-care/residential-aged-care/safety-and-quality/improving-resident-care/
h
standardised-care-processes
Standard 3
Requirement (3)(a)
Standard |
3
Each consumer gets safe

and effective personal care,
clinical care, or both personal
care and clinical care, that:
(i) is best practice; and
(ii) is tailored to their needs;
and
(iii) optimises their health
and well-being.
Intent of this requirement (ii) tailored to their needs

This requirement sets out the expectation Organisations are expected to make
that organisations do everything they can sure that personal and clinical care
to provide safe and effective personal and is tailored and based on an assessment
clinical care. This means organisations make of a consumer’s needs, goals and
sure that the personal and clinical care they preferences. This means working with
provide is: the consumer, making any reasonable
(i) best practice changes to tailor care and providing
Organisations are expected to refer support to help consumer’s understand
to relevant national guidance about and make informed decisions about
how to deliver safe and effective care their options. This includes how much
and to implement this in their services. they want to manage these options
It’s understood that there isn’t always themselves. There may be times when
strong evidence for all aspects of an organisation can’t meet a consumer’s
clinical and personal care. However, needs and preferences. In these cases,
where there is evidence, services the organisation should explain this
should use this to provide best practice to the consumer and discuss how it will
care. This provides the best possible affect them so that the consumer
basis for decisions about the type can understand the reasons and look
of care provided to meet consumers’ at other options. This is to help the
identified needs, as well as the way consumer make an informed decision
the organisation provides that care. about their care and services.
(iii) optimising the consumer’s health
and well-being
Safe and effective personal or clinical
care improves the consumer’s
well-being, including:
— physical and mental state
— spiritual and emotional life (feelings,
thoughts, beliefs, attitudes)
— social life (relationships, attitudes,
cultural values and the influences
of those around them, such as family
and community).
What systems does the organisation have How does the organisation provide or help
to identify and apply up-to-date guidance consumers to access other providers,
on best practice for delivering personal organisations or individuals to improve
or clinical care? their health and well-being?
How do the organisation’s policies, (Such as allied health and other therapies.)
Standard |
procedures, and care models reflect this?
Does the organisation monitor how
How does the organisation monitor
whether they tailor and deliver personal
effective their care practices are in meeting
this requirement?
3
and clinical care in line with the consumer’s How is the delivery of personal and clinical
needs, goals and preferences? care reviewed and improved in response
to any deficits?
How does the organisation make sure that
they have sufficient numbers and the right How does the organisation develop
mix of workforce members, with the right the competency and knowledge of the
skills, to meet consumers’ personal and workforce to provide personal and clinical
clinical care needs? care that is tailored to the consumer
and reflects best practice?
How does the organisation ask for feedback
from consumers and their representatives, What processes are in place to provide
about how the personal and clinical care personal and clinical care in line with the
delivered meets their needs and optimises Charter of Aged Care Rights?
their health and well-being? This includes practices that make sure
How can the service show that they acted consumers have information and support
in response to any negative feedback? to make decisions about their care.

• Policies, procedures and assessment
Consumers
tools show that best practice guides
• Consumers say they are confident they are
the personal and clinical care that the
getting care that is safe and right for them.
workforce provides.
• Consumers say they are getting care that
• Evidence that the organisation’s approach
reflects their individual needs and situation.
to providing personal and clinical care
• Consumers say the personal or clinical
meets the needs of diverse consumers.
care received supports their health
This includes Aboriginal and Torres Strait
and well-being.
Islander consumers.
Workforce and others • Evidence that the organisation has reviewed
• Management of the organisation can or audited service delivery records to make
describe how they deliver personal and sure they are in line with best practice
clinical care in line with the service’s guidelines and the needs, goals and
practices and policies for safe and preferences of consumers.
effective care.
• Records reflect how the organisation makes
• Management of the organisation can decisions about best practice guidelines for
describe how they deliver personal and personal and clinical care and ways to meet
clinical care in line with the consumer’s best practice approaches.
needs, goals and preferences.
• Evidence of how the organisation keeps
• The workforce can give examples of how improving its performance against this
the organisation tailored personal or requirement. This includes how it changes
clinical care to optimise the consumer’s its policies, procedures and practices based
health and well-being. on best practice evidence.
• The workforce can describe how they set up • Workforce orientation, training or other
and monitor that the personal and clinical records that show how the organisation
care they provide is best practice and where supported the workforce to meet
they go to get information or advice on this requirement.
best practice.
organisation supports them to deliver
personal and clinical care that is best
practice and meets the needs of each
consumer. They can also describe what they
would do if they weren’t able to deliver best
practice care or saw others delivering care
that wasn’t best practice.
• The workforce can describe the
communication processes the organisation
uses to provide updates on new or revised
practices for safe and effective care.
Standard 3
Requirement (3)(b)
Standard |
3
Effective management
of high-impact or
high-prevalence risks
associated with the care
of each consumer.
Intent of this requirement The organisation is expected to educate

To meet this requirement, organisations and support its workforce to minimise risks
need to do all they can to manage risks to consumers. Members of the workforce
related to the personal and clinical care providing personal and clinical care
of each consumer. This means following to consumers also need to have the right
best practice guidance and applying qualifications, knowledge and experience
measures to make sure the risk is as low as to deliver care safely. To develop strategies
possible, whilst supporting a consumer’s to minimise the affect and number of risks
independence and self-determination for consumers, organisations can use advice
to make their own choices, including to take from allied health practitioners and others.
some risks in life. Organisations need to deliver personal
Effective management of risks or clinical care and manage risk in a way
is underpinned by clinical governance that balances the consumer’s rights and
systems for safety and quality. This includes preferences with their safety and the safety
reviewing how personal and clinical care of others. This includes managing challenging
is delivered to apply new practices and behaviours in ways that involve the
responding appropriately and promptly consumer and respects their rights, dignity
to a consumer’s changing needs. and independence. This means organisations
For high-impact or high-prevalent risks can manage risk and provide personal and
related to the personal and clinical care of clinical care in the least restrictive way and
each consumer, organisations are expected least restrictive service environment, while
to use risk assessments to find ways to keeping consumers, the workforce and
reduce these risks. They should do these others safe.
assessments in consultation with the Dementia affects many consumers receiving
consumer. This can involve the organisation’s care and services. There are some gaps
service environment, equipment, workforce between what generally happens now and
training, systems, processes or practices what is best practice care for consumers
that affect any aspect of how they deliver living with dementia. Although antipsychotic
personal and clinical care to consumers. medicines may be appropriate for adults
Organisations are expected to manage risks with severe mental health issues or long-
related to the care of each consumer in line term mental illness, there is concern that
with the consumer’s care and services plan. these medicines are being prescribed
This is so that the organisation supports inappropriately in people aged 65 years
them to safely maintain their best possible and over for their sedative effects – that
level of independence and function. is, as a form of chemical restraint for
For example, if there is a risk that a consumer people with psychological and behavioural
may fall, the care and services plan would symptoms of dementia or delirium.
include what assistance or mobility aid
the organisation will provide to help the
consumer to move about safely.
Understanding and applying best practice Preventing and managing pressure injuries
in care and services for consumers living When consumers can’t move around on their
with dementia is vital to delivering safe and own, they can get pressure injuries. Factors
effective care and services that meet the such as poor nutrition, poor skin health and
consumer’s needs, goals and preferences. lack of oxygen to tissues can also cause
Consumers living with dementia are also pressure injuries.
Standard |
at higher risk of harm from the points Minimising restrictive practices
listed below. These interventions have high potential for
While organisations need to manage all harm and are practices that organisations
risks related to the personal and clinical
care for each consumer, some risks are
can avoid with positive changes in how they 3
assess, plan and deliver personal and clinical
more common and have a higher impact care for consumers. If an organisation uses
on the health and well-being of consumers. restrictive practices such as physical or
Preventable harm from these risks continues chemical restraint, these are expected to be
to happen in aged care. This includes: consistent with best practice and used as
Managing hydration and nutrition a last resort, for as short a time as possible
This is important for a consumer’s quality of and comply with relevant legislation.
life. It helps to minimise the risk of infections, Managing delirium
pressure injuries, anaemia, hypotension, This is a common and serious problem
confusion and impaired cognition, decreased for consumers that isn’t well understood.
wound healing and fractures. Not recognising the signs of delirium can
Managing risks of choking prevent organisations from providing quality
Swallowing difficulties are common among personal and clinical care, and impact the
consumers. If a service doesn’t manage consumer’s well-being.
swallowing problems, it can lead to death Managing hearing loss
from choking. Hearing loss is a common condition in
Managing medications safely consumers. There is a clear link between
Consumers can have multiple medical hearing assistance and improving a
conditions and use several drugs together. consumer’s quality of life. This includes
This means that they are at high risk of less social isolation, stress and frustration,
medication mistakes. These mistakes can as well as reducing the risk of consumers
result in hospital visits that could have developing medical conditions, such
been avoided, illness and death. This risk as depression.
can be minimised through effective policies These examples are not all the risks that
and procedures that support safe use an organisation may need to manage for
of medicines. consumers. However, there are some of
Managing pain the common risks that organisations need
If pain isn’t managed, it can make consumers to identify and manage. If organisations
confused, they can have interrupted sleep, appropriately manage risks, a consumer’s
not get the nutrition they need, be less care and services should be safe
mobile, feel depressed and isolated and take and effective and improve their health
longer to get better. and well-being.
ow does the organisation tell the

H What systems are in place to gain
workforce about relevant legislation and access to relevant health professionals’
best practice standards for managing assessments that can help prevent and
high-impact or high-prevalence risks when manage high-impact or high-prevalence
caring for consumers? risks for consumers?
What processes are in place to make sure
that evidence-based documents and What information and support does the
tools for managing high-impact or high- organisation provide to consumers about
prevalence risks are up-to-date and in line preventing and managing high-impact
with best practice? and high-prevalence risks related to their
personal and clinical care?
How does the organisation make sure that
the workforce is following best practice How does the organisation evaluate and
guidelines and tools to prevent and manage review how they manage high-impact
high-impact or high-prevalence risks? or high-prevalence risks in the personal and
clinical care they deliver for consumers?
What assessment tools or processes
does the organisation use to monitor and
respond to high-impact or high-prevalence
risks to consumers?
How are consumer care and services plans
and risks communicated to members of
the workforce who deliver personal and
clinical care?

• Policies and procedures describe how
Consumers
the organisation manages high-impact or
• Consumers say their care is safe and right
high-prevalence risks to the safety, health
for them.
or well-being of consumers.
• The organisation uses best practice
explain risks to their well-being and they
Standard |
guidelines, decision-making tools
get to have input into the steps to reduce
and protocols to manage high-impact
the risks.
or high-prevalent risks to consumers.
• Members of the workforce can describe
• Documented risk assessments and care 3
and services plans for each consumer and
how they identify, assess and manage
evidence that the organisation delivers
high-impact or high-prevalence risks
personal and clinical care in line with these
to the safety, health and well-being of
assessments and care and services plans.
each consumer when delivering personal
• Records of relevant allied health input
or clinical care.
to preventing and managing high-impact
or high-prevalence risks for consumers.
get information or advice on best
• Records of ‘near-misses’ and incidents
practice to manage high-impact or high-
and actions taken to address risks
prevalence risks.
are documented.
• Communications that show that the
organisation supports them to identify and
organisation updates the workforce on new
manage the high-impact or high-prevalence
or changed practices to assess and manage
risks to the safety, health and well-being
high-impact or high-prevalence risks
for each consumer.
to consumers’ safety, health and well-being.
• Evidence of continuous improvement,
including how the organisation reviews its
supported the workforce to understand
policies, procedures and practices based
their roles and responsibilities to prevent
on evidence. As well as how it learns from
and reduce harm from high-impact or high-
what’s not working.
prevalence risks and meet this requirement.
• Evidence of monitoring and reporting
of performance against this requirement.
Standard 3
Requirement (3)(c)
The needs, goals and

preferences of consumers
nearing the end of life are
recognised and addressed,
their comfort maximised and
their dignity preserved.

This requirement focuses on how personal
and clinical care is delivered at the end How are the consumer’s needs, goals
of a consumer’s life. Organisations are and preferences for their end of life care
expected to recognise the needs, goals and reflected in their care and services plan,
preferences of consumers who are nearing including the situation, environment and
Standard |
the end of their life. Communication with the place where they wish to die?
consumer and a care and services plan that
reflects their needs, goals and preferences What processes are in place to support
will support this requirement. conversations with the consumer, and
others the consumer wants involved, about
3
An understanding that dying and death are
their cultural, spiritual and physical needs?
part of each consumer’s human experience,
not just a biological or medical event, needs
to underpin all end of life care. Organisations
that they promptly recognise when the
that take the right approach will deliver
consumer is moving to the terminal phase
care that is culturally safe, provide
of life?
it in the most suitable setting, and deliver
And how do they communicate this to the
it in a timely manner.
consumer, others the consumer wants
To maximise the consumer’s comfort involved and relevant health professionals?
and maintain their dignity at end of life
organisations need access to an appropriately How does the organisation work with others
skilled and qualified workforce. There needs outside the service (such as palliative care
to be a timely response if a consumer is in specialists) to improve the consumer’s end
physical, psychosocial or spiritual distress to of life care?
ensure suffering is prevented or relieved and
their dignity is maintained at their end of life. How does the organisation evaluate and
How an organisation does this will depend review end of life services to make sure
on the setting, the needs of consumers and they are effective and meet the needs
what specialist resources and members and preferences of consumers?
of the workforce they have available.
It will also need to be in line with relevant
national practice guidelines and state and
territory programs.
Involving a consumer’s representative
in their end of life care decisions must be
in line with a consumer’s wishes. Where
a consumer lacks the capacity to make
decisions they may have a court or tribunal-
appointed guardian to make decisions
on their behalf. When this is the case an
organisation needs to manage this according
to relevant law and best practice guidance.
Examples of actions and evidence • The workforce can describe how they
Consumers support consumers to direct their own end
• Consumers say they feel confident of life care where possible.
that when they need end of life care, • Workforce orientation, training or other
the organisation will support them: records that show how the organisation
— to be as free from pain as possible supported the workforce to meet
this requirement.
— to have those important to them
with them Organisation
—to die in line with their social, cultural and • Care and services plans reflect changes
religious and spiritual preferences. in care and services, in line with the
consumer’s end of life care needs, goals
• Consumer representatives say they feel
and preferences. This includes advance care
positive about their experience with the
planning when this has occurred.
organisation and the workforce at the time
of the consumer’s death. • Examples of the use of tools and resources
for supported decision-making with
Workforce and others consumers, representatives and others they
• Relevant members of the workforce say want to involve in decisions about their end
they feel well prepared and supported of life care.
to have conversations with consumers
• Policies and procedures for end of life
about end of life care.
care document how to recognise when
• Relevant members of the workforce can consumers are at the end of life and what
describe how they support consumers at supervision and support is provided
the end of their lives. This includes being to members of the workforce providing end
as free from pain as possible, having of life care.
those important to them with them, and
• Examples of activities the organisation has
dying in line with their social, cultural and
implemented to balance end of life care
religious and spiritual preferences.
with consumer goals and best practice and
• Evidence that the workforce, through their how these activities have been evaluated.
education and experience, recognise end
• Evidence of how the organisation
of life signs and can review a consumer’s
monitors and reports its performance
needs, goals and preferences in line with
against this requirement.
their wishes.
• Members of the workforce are respectful
and can describe how they have supported
a range of consumers to make end
of life choices. This includes situations
where the consumer’s wishes have been
different to what the workforce member
or organisation believes.
Standard 3
Requirement (3)(d)
Standard |
3
Deterioration or change of
a consumer’s mental health,
cognitive or physical function,
capacity or condition is
recognised and responded
to in a timely manner.
Intent of this requirement However there is evidence that warning signs

This requirement explains how organisations of a consumer’s changing or deteriorating
are expected to respond to deterioration function, capacity or condition is not always
or change in a consumer’s mental health, recognised or acted upon on promptly
cognitive or physical function, capacity or in the right way. Changes may be mental,
or condition. cognitive or physical in nature. Identifying
A consumer may experience health changes or deterioration early can improve
conditions or impairments that restrict their outcomes and mean that consumers need
capacity or abilities. How these restrictions less intervention in the future.
affect the consumer’s day to day activities Organisations are expected to have systems
or function also depends on the consumer’s and processes, relative to the services
personal circumstances and environment. they deliver, that support the workforce
The right care and services can support to recognise, and respond to a consumer
the consumer’s day to day function, their whose function, capacity or health condition
activity and participation in the community. changes or deteriorates. This includes ways
However, the balance can change quickly due for the workforce, consumers, and others
to changes in the consumer’s circumstances, to identify and escalate concerns so that the
environment or health status. It is organisation can assess the situation and
important that organisations pick up these take action.
changes because:
• if the consumer’s loss of function is
temporary, it can be improved or reversed
with the right care and services
• a higher level of ongoing care and
services may be needed to meet the
consumer’s needs
• further health complications for
the consumer can be avoided
by intervening early.
hat systems and policies are in place

W re there any gaps or delays in identifying,
A
in the organisation to recognise and communicating and responding
respond to changes or deterioration to deterioration between providers,
in the health or function of a consumer? organisations or individuals providing care
Standard |
and services?
ow is the workforce supported
H How can consumers, the workforce and
to recognise and respond to a others who review systems and processes,
sudden or unexpected deterioration
of a consumer’s mental health, cognitive
improve early recognition and response
to deterioration or loss in a consumer’s
3
or physical condition, function or capacity? health or function?
For example, how do members of the
workforce recognise signs and symptoms How does the organisation provide
of deterioration and what to do? information to consumers and
representatives on recognising changes
or deterioration in health or function?
This includes how important recognising
it can be. And how does the organisation
support consumers and representatives
to understand how they can raise concerns
about possible changes or deterioration?

Consumers • Evidence that the workforce who deliver
• Consumers say they are confident that care and services, document routine
members of the workforce providing their observations in line with the care
care and services know them and would and services plan and relevant policy
pick up a change in their condition, health and procedures. They also respond
or abilities. They also say the members to triggers to escalate care when
of the workforce providing their care and a consumer deteriorates.
services would know what to do about • Consumer records show critical information
a change in their condition, health or any about a change in a consumer’s
loss of abilities. condition, health or abilities provided
• Consumers and representatives say that by members of the workforce, the
they understand how to raise concerns consumer or their representative is acted
about any deterioration in condition, health on by the organisation.
or ability which occurs. • Roles, responsibilities and accountabilities
• Consumers and their representatives for members of the workforce for
say that the organisation responded well recognising and responding to a consumer’s
to a change or deterioration in condition, deterioration are documented.
health or ability when they needed to. • Policy and procedures document the
organisation’s processes for responding
to deterioration or change in a consumer’s
• The workforce can describe the different
condition, health or abilities, relevant to the
situations where a change in a consumer’s
services they provide. This includes how
condition, health or abilities should
to communicate appropriately and involve
be identified and what response they
consumers, their representatives and
should take.
others including carers and families.
• Examples of documents about recognising
should communicate information about
and responding to deterioration. This can
a consumer’s condition, health or abilities
include advance care plans, documented
deteriorating, who should be involved and
needs, goals and preferences and
what actions they should take.
documented discussions with consumers
• The workforce can describe how they their representatives and others.
identify signs of deterioration. They can
• Evidence of improvements adopted after
also describe their understanding of their
incident reports, investigations or feedback.
role and the organisation’s processes
This can include records from an incident
for communicating and escalating
management system about incidents
any concerns.
or ‘near misses’ where the service didn’t
• Workforce orientation, training or other recognise a consumer’s deterioration.
• Evidence of how the organisation monitors
and reports its performance against
this requirement.
this requirement.
Standard 3
Requirement (3)(e)
Standard |
3
Information about
the consumer’s condition,
needs and preferences
is documented and
communicated within
the organisation, and with
others where responsibility
for care is shared.
Intent of this requirement There are many different situations where

This requirement focuses on the this requirement applies. Including how an
communication processes that organisations organisation communicates information
are expected to have, so that their about a consumer’s condition, needs, goals
workforce has information about delivering and preferences:
safe and effective personal and clinical • if their regular member of the
care and understanding the consumer’s workforce changes
condition, needs, goals and preferences. • when members of the workforce change
The information the workforce has access between work shifts
to should help them provide and coordinate • when a consumer is transferred to hospital
care that respects the consumer’s choices. for specialist treatment
Good information management systems
• when the consumer’s condition, needs,
mean the consumer doesn’t have to keep
goals or preferences have changed.
repeating their story.
How information is communicated can vary,
If organisations transfer important
but the method needs to be efficient and fit
information about a consumer’s care
the situation. Organisations need to collect
within and between organisations that are
and share consumer’s personal information
responsible for the consumer’s care and
in a way that complies with relevant privacy
services, they can improve outcomes for
legislation. The organisation is also expected
the consumer. If the consumer’s condition,
to find ways to include consumers, their
needs, goals and preferences are known to
representatives and others the consumer
those involved in the consumer’s care it will:
wants involved, in communication processes.
• improve the safety, effectiveness and
consistency of care and reduce the risk
of harm
• improve the consumer’s experience
of care and deliver care which reflects
their choices.
What communication systems does the What tools and supports does the
organisation use to make information organisation provide for the workforce
easily available to relevant agency to understand and communicate
staff, substitute general practitioners, consumer-centred information?
Standard |
paramedics and others? This should provide a complete picture of
This is vital for anyone who needs a consumer’s care needs and preferences.
to provide personal or clinical care without
already knowing the consumer. ow does the organisation support the
H
workforce to see that part of their job
3
hen two or more organisations share
W is to work together to improve day-to-day
care,or where there are integrated care and be clear on instructions on how
services,what arrangements does to best support consumers?
the organisation have to share relevant
information promptly? What systems does the organisation
How do they plan and deliver care? have in place to include consumers,
How does handover occur? representatives and others they want
to include, in communications about
their care?
Examples of actions and evidence situations where they shared care

Consumers documents or communicated information
• Consumers say they are fully informed and about the consumer’s condition, needs and
able to consent to information being shared preferences and how they complied with
with others about them. relevant privacy obligations.
• Consumers say their personal or clinical • Workforce orientation, training or other
care is consistent. They have continuity records that show how the organisation
of care and don’t have to repeat their story supported the workforce to meet
or their preferences to multiple people. this requirement.
• Consumers say the organisation Organisation
coordinates their personal or clinical • Evidence of an effective system to
care well. They benefit from different manage information that keeps suitable
organisations working together and sharing controls over privacy and is in line with
information about them. relevant legislation.
• Consumers say they have quality personal • Evidence that the organisation is actively
or clinical care because the workforce and communicating with others, internally
relevant others have correct and up-to-date and externally, to make sure that care
information. This includes replacement and services are delivered without
workforce members and those from any disruptions.
different organisations. • Evidence that the organisation monitors
• Consumer representatives say that the how the workforce manages information
organisation has processes to support in relation to information gaps, pending
continuity of care. It also has processes to and missing information and that follow
communicate important information about up occurs.
a consumer’s care and how it delivers it. • Records reflect how the organisation asks
Workforce and others for consent to release or share information
• The workforce can describe how the using methods suitable for each consumer
organisation tells them about a consumer’s and in accordance with Privacy legislation.
condition, needs, goals and preferences • Evidence that relevant members of the
as it relates to their own roles, duties and workforce have access to consumer records.
responsibilities. The workforce can also • Consumer care and service plans show
describe how they share this information. evidence of updates, reviews and
• Relevant members of the workforce show communication alerts. This includes
a clear understanding of information information from multiple sources, updates
sharing and different types of consent. from reassessments and their results.
• Relevant members of the workforce can • Policies and procedures that show how
describe how accurate, up-to-date and the organisation communicates important
relevant information is shared with others information about a consumer when they
as consumers move between care settings, share the responsibility for their care
such as between home and hospital. with other providers, or have transferred
• The workforce can describe the different a consumer to another organisation.
Standard 3
Requirement (3)(f)
Standard |
3
Timely and appropriate

referrals to individuals,
other organisations
and providers of other
care and services.

Organisations that provide care and services
are expected to consult with the consumer How has the organisation identified
and make appropriate referrals to other individuals, organisations or providers that
individuals, organisations or providers that can deliver care, services and supports
can provide a care and services that meets to better meet consumer choices?
the consumer’s needs. This is to make
sure that the care and services meet the When more than one organisation
consumer’s needs, goals and preferences is responsible for a consumer’s,
and improves their health and well-being. is it clear to everyone who is responsible
for providing personal or clinical care at any
After finding out what a consumer’s needs,
point in time?
goals and preferences are for independence,
health and well-being, an organisation may
I f their condition deteriorates, what
decide that specialist providers will be better
services may the consumer need that can’t
able to give the consumer the particular care
be safely managed within the organisation?
they need. Specialist services can include
What systems does the organisation have
allied health, hearing, dental, medical or
to make timely referrals, if this is in line with
psychiatric services or other specialised
the consumer’s preference?
therapy services.
Having an active network of other What are the organisation’s barriers
individuals, organisations or providers, to timely referrals and does it actively work
they can refer or collaborate with, means to remove these barriers?
the organisation can meet the diverse
needs of consumers. It is expected that
organisations do this in line with the Quality
of Care Principles, 2014.
Organisations will need to meet obligations
relating to privacy of information when
co-ordinating care with other providers,
organisations or individuals.

• The organisation’s strategic and operational
Consumers
planning describes activities that maintain
• Consumers say that where the organisation
a network of individuals, organisations or
has been unable to provide suitable care
providers they can refer consumers to.
they have helped organise someone else
to provide it. • Evidence that the organisation has links
Standard |
with other individuals, organisations or
• Consumers say the organisation has
providers to make sure consumers can
referred them to the appropriate providers,
access a range of care and services, for
organisations or individuals to meet their
changing personal or clinical care needs.
example memorandums of understanding. 3
• Policy documents for referrals to other
• Consumers believe referrals happen
individuals, organisations or providers
promptly when their personal or clinical
that include arrangements for services
needs change.
that the organisation doesn’t provide.
• Consumers say they are satisfied with
This includes contacts, roles and
the care delivered by those they’ve been
responsibilities of the workforce when
referred to. They also say the care from the
making referrals, and involving consumers
other individuals, organisations or providers
and their representatives.
are delivered in a culturally safe way.
• Consumers’ care and services plans show
Workforce and others that the organisation collaborates with
• The workforce can identify other other individuals, organisations or providers
individuals, organisations or providers to support the diverse needs of consumers.
they can make referrals to and any referral
• Records that show the organisation
criteria that applies.
regularly reviews the individuals,
• The workforce can describe how they organisations or providers they refer
refer consumers to other individuals, consumers to, to make sure their services
organisations or providers and how they remain safe and effective and quality care
collaborate to meet the diverse needs and services are being delivered.
of consumers.
• Consumer records show the organisation
• The workforce can describe how the makes timely referrals to health
consumer is actively involved in decisions practitioners, specialised allied health,
and about referrals and how consent or other services, to meet the care needs
is obtained. of consumers.
• Workforce orientation, training or other • Evidence of referral processes, outcomes
records that show how the organisation for consumers, and projects that show
supports the workforce to meet quality improvement.
this requirement.
Standard 3
Requirement (3)(g)
Minimisation of infection-
related risks through
implementing:
(i) standard and
transmission-based
precautions to prevent
and control infection;
and
(ii) practices to promote
appropriate antibiotic
prescribing and use
to support optimal care
and reduce the risk of
increasing resistance
to antibiotics.
Standard 3 | Requirement (3)(g)
Intent of this requirement Control Expert Group, Communicable Disease

Organisations are expected to minimise Network Australia (CDNA), Australian Health
infection-related risks in two ways. Protection Principal Committee (AHPPC),
Australian Technical Advisory Group on
Infection control
Immunisation (ATAGI) and the Chief
Organisations are expected to assess the
Medical Officer.
risk of, and take steps to prevent, detect and
Standard |
control the spread and severity of infections. Infection prevention and control programs
To minimise the risk of transmission, severe will vary in scope and complexity depending
illness, hospitalisation or even death, on the nature of the care and services the
precautionary infection control measures organisation provides. Organisations must 3
should be prioritised, including standard demonstrate infection prevention and
and transmission-based precautions control expertise, such as appointment of
and facilitating timely access to relevant infection prevention control (IPC) lead(s),
vaccinations including for COVID-19. meeting (ongoing) training requirements
around infection prevention and control,
Organisations providing residential aged
which should be available to all staff.
care need to offer the workforce influenza
Processes for routinely screening staff and
vaccinations and keep records of these
visitors on entry to a residential care facility
vaccinations. They also need to promote
are important where there is any risk of
the benefits of influenza and coronavirus
infectious disease being introduced to
(COVID-19) vaccinations to both residents and
the facility.
staff. Residential care services, home care
services and flexible care services providing Residential aged care services are required
transition care and short-term restorative to appoint at least one clinical staff member
care need to keep records and report as infection prevention and control IPC
on workforce and consumer coronavirus lead(s). This ensures that these organisations
(COVID-19) vaccinations. This information are prepared to prevent and respond to
should inform infection prevention and infectious diseases, including coronavirus
control planning. (COVID-19) and influenza. The IPC lead(s) must
be a designated member of the nursing staff
If community transmission starts to occur in
who has completed an identified IPC course.
your area, you must increase your vigilance
and escalate your response, particularly Antibiotic resistance
around infection prevention and control. Ideal use of antibiotics means treating
It’s expected that organisations develop consumers ‘with the right antibiotic to treat
and implement an effective infection their confirmed condition, the right dose,
prevention and control program that is by the right route at the right time and for the
in line with current national guidelines, right duration based on accurate assessment
recommendations or advice. This may and timely review’. 22
include information from the Infection
22 https://www.safetyandquality.gov.au/wp-content/uploads/2014/11/Antimicrobial-Stewardship-Clinical-Care-Standard-web.pdf
Using antimicrobials incorrectly, including What is the organisation’s plan for

antibiotics, can cause antimicrobial resistant managing an infectious outbreak including
(AMR) infections. AMR infections affect for coronavirus (COVID 19)? Are there
consumers’ safety and well-being because systems in place for managing consumers
treatments are more complex and longer with known infections? Are there processes
and can cause more disease and deaths. for communicating protocols where the care
AMR infections not only affect the individual takes place and between the workforce
consumer, but can also spread and affect or providers, organisations or individuals
other people. Good use of antimicrobials where care and services are shared?
makes sure they continue to be effective.
This is key to providing safe and effective How does the organisation apply risk
care to consumers. It also reduces the management principles to implement
growth in resistant organisms. systems for a clean environment
Organisations providing care and services and equipment?
need to help to minimise the development
and spread of antimicrobial resistance in line How does the organisation promote
with the national guidelines. 23 infection control and appropriate
antibiotic prescribing practices to the
workforce, consumers and others
to enhance effectiveness?
Are there agreed processes for access
What systems and processes has the to other providers, organisations or
organisation implemented to prevent individuals, such as general practitioners,
and control infection and to support nurse practitioners or public health units
appropriate use of antimicrobials? and community pharmacies for timely
prescriptions in the event of an outbreak?
How does the organisation know whether
hand washing practices are effective and in Who in the organisation provides advice
line with national hand hygiene guidelines? and oversight as part of ongoing, day-to-
day operations of infection prevention
What are the influenza and COVID-19 and control?
immunisation rates for consumers and the
workforce in residential services? How How does the organisation demonstrate
does this information inform infection that it uses and references national
prevention and control planning? accepted guidelines for infection
prevention and control, including those
provided during the coronavirus (COVID-19)
pandemic?
Can the organisation’s infection control • Records show that the organisation
processes be quickly escalated in line with educates relevant members of the
the current situation? workforce in antimicrobial resistance and
strategies to reduce the risk of increasing
Does the organisation communicate resistance to antibiotics.
regularly with staff regarding expectations • Records show that the organisation
around cohorting, physical distancing,
Standard |
has appointed an IPC lead(s) that must
staying home when unwell and the be engaged onsite and dedicated
importance of infection prevention to a facility.
and control?
• Records show that the IPC lead(s) 3
have completed at least the minimum
requirements of the Department’s
coronavirus COVID-19 focused and specified
Examples of actions and evidence training modules.
• Records show that policies and procedures
Consumers
are contemporary and refer to best practice
• Consumers are confident in the
guidance, including those specific for
organisation’s ability to manage
outbreak prevention and management,
an infectious outbreak.
that staff are aware of these policies and
• Consumers and their representatives procedures, and supports and services
have been given information on how have been planned and practised for
to minimise the spread of infections, a potential outbreak.
such as hand washing.
• Workforce orientation and training or other
• Consumers’ and representatives’ records that show how the organisation
observations of members of the supports the workforce to follow the
workforce confirm that they practice organisation’s infection prevention
good hand hygiene and help consumers and control program and how to meet
to do the same. this requirement.
• Staff say the organisation has told them
about the benefits of the influenza
vaccination and offered them an influenza
vaccination each year.
• The workforce can describe the practical
steps they take to reduce the risk
of increasing resistance to antibiotics.
• The organisation’s management describe
how it supports members of the workforce
to understand and promote appropriate
prescribing of antibiotics.
Organisation • Evidence of antimicrobial stewardship

• Evidence of a documented infection policy and processes to support
prevention and control program. appropriate administration of antibiotics.
• Records evidencing workforce influenza • Evidence of care strategies used to minimise
immunisation program, up-to-date records the need for antibiotics (such as measures
of staff flu vaccinations, and evidence to reduce the risk of urinary tract infections
of methods to promote the benefits or treat minor skin infections).
of vaccination to staff. • Policy documents that detail infection
• An outbreak management plan, such prevention and control procedures
as for COVID-19, gastroenteritis or influenza, that include risk assessment and risk
that explains how the organisation management strategies, and instructions
will prepare for, identify and manage for the workforce.
any outbreaks. Evidence of how the • Data that is used to monitor infections
organisation will educate the workforce and resolution rates and the effectiveness
on outbreak management and their roles of the infection prevention and
and responsibilities. control program.
• Evidence of IPC training delivered to all staff • Action plans for improvement based on the
when they begin employment at the facility risk assessment of the organisation’s
and ongoing training annually or more infection prevention and control systems.
frequently as required.
• Care and services plans that identify
consumer infections and any transmission
based precautions implemented by the
workforce. Relevant details of how
a consumer’s infectious status is clearly and
sensitively communicated if care is shared.
• A current list of infectious diseases that
the organisation needs to tell government
authorities about. Contacts at relevant
state or territory government departments
that can help prepare for, identify and
manage any outbreaks are documented
and readily available to relevant members
of the workforce.
Standard 4 |
Standard |
4
Standard 4
Services and supports
for daily living
Standard 4 |
Consumer outcome 4 (3) (c) Services and supports for daily

I get the services and
4 (1)
living assist each consumer to:
(i) participate in their
supports for daily living community within and
that are important for outside the organisation’s
service environment; and
my health and well-being (ii) have social and personal
and that enable me to do relationships; and
the things I want to do. (iii) do the things of interest
to them.
4 (3) (d) Information about the
Organisation statement consumer’s condition, needs
and preferences is communicated
4 (2) T he organisation provides within the organisation, and
safe and effective with others where responsibility
for care is shared.
services and supports 4 (3) (e) Timely and appropriate
for daily living that referrals to individuals, other
organisations and providers
optimise the consumer’s of other care and services.
independence, health, 4 (3) (f) Where meals are provided,
well-being and quality they are varied and of suitable
quality and quantity.
of life. 4 (3) (g) Where equipment is provided,
it is safe, suitable, clean
and well maintained.
Requirements Meaning of services and supports

4 (3) The organisation demonstrates for daily living
the following: Services and supports for daily living
4 (3) (a) Each consumer gets safe and include, but are not limited to, food services,
effective services and supports domestic assistance, home maintenance,
for daily living that meet the transport and recreational
consumer’s needs, goals and and social activities.
preferences and optimise their
independence, health, well-being
and quality of life.
4 (3) (b) Services and supports for daily
living promote each consumer’s
emotional, spiritual and
psychological well-being.
Standard 4 |
Purpose and scope Socially including consumers isn’t just

of the Standard about giving them opportunities to join
in on activities that the organisation
A consumer might have some challenges in
provides. It’s also about making sure that
their health and abilities, but they still have
consumers feel socially connected, can have
goals they want to achieve. They also have
relationships they choose, have control
roles that have meaning, and they want to
over their lives, have privacy and are able
manage their day-to-day life and live as well
to contribute.
as they can. Services and supports for daily
living cover a wide range of options that aim Care and services are expected to be
to support consumers live as independently delivered in a way that enables all a person’s
as possible and enjoy life. They may be any needs to be met. This includes making
services (other than clinical or personal sure that enough time is allocated to allow
care services) that an organisation provides staff to provide care and treatment in
Standard |
under the Quality of Care Principles, 2014. accordance with the person’s assessed
needs and preferences. There should be
Examples of services and supports for daily
policies and procedures that support staff
living include:
•d omestic help, such as cleaning, laundry,
to deliver care and treatment in accordance
with the requirements detailed in the care
4
gardening and home maintenance services and services plan.
• f ood services, including meals, food advice, Organisations are expected to provide
delivery and preparation services and supports in line with the
• s ervices to encourage and support consumer’s assessed needs, goals and
consumers to take part in social and other preferences, and any care and services
activities they are interested in, including plan, or service agreement in place with the
community life. consumer. An organisation may not directly
Delivering services and supports to improve provide all the services and supports that
a consumer’s well-being and quality of life are important to the consumer’s well-being.
requires a consumer-centred approach. However, it’s expected that the organisation
This means treating the consumer would help the consumer to access other
as a whole person and considering their services or supports, including those that
physical and mental health, and spiritual, the wider community may provide.
emotional and social life. Their relationships,
attitudes, cultural values and the influences
of those around them, including family
and community are all important.
Standard 4 |
Linked Standards
this Standard
organisations need to demonstrate All aspects of services and
that they: supports for daily living needs to
• understand the requirement treat consumers with dignity and respect
and support them to make choices. It’s also
important that services and supports are
delivered in a way that is culturally safe.
and services
the requirement and the outcomes Standard 2
they achieve Assessment and planning of the
consumer’s needs, goals and
preferences promotes the delivery of safe
and effective services and supports.
to keep improving.
Standard 7
culture and diversity. In particular, the
qualifications and knowledge to deliver safe
and effective services and supports for daily
living and promote consumers’ health, well-
being and cultural safety.
Standard 8
of safe and quality services and supports.
Standard 4 |

• Aged Care Act 1997 (Cth), User Rights • Australian Meals and Wheels Association
Amendment (Charter of Aged Care Rights) (2016). National Meal Guidelines: A Guide
Principles 2019 for Service Providers, Caterers and Health
• Privacy Act 1988 (Cth), Schedule 1, Professionals Providing Home Delivered
Australian Privacy Principles and Centre Based Meal Programs
• Anti discrimination legislation nationally for Older Australians 1
• Work health and safety legislation nationally • Beyondblue (2014). What works to promote
emotional well-being in older people:
• State and Territory mental health,
A guide for aged care staff working
guardianship and administration, enduring
in community or residential settings 2
power of attorney and medical directive/
advance care planning legislation • Dieticians Association Australia, Healthy
Eating, Healthy Ageing 3
Standard |
• State and Territory food safety and handling
legislation and regulations • International Dysphagia Diet
Standardisation Initiative 4
• Meaningful Ageing Australia (2016).
National Guidelines for Spiritual Care 4
in Aged Care 5
• Meaningful Ageing Australia, Quality
Standards spirituality videos 6
• New South Wales Government, Eating Well
– A nutrition resource for older people and
their carers 7
• Victorian Government,
Department of Health, Well for life 8
• Tasmanian Government, Department
of Health, Malnutrition in older people
online training 9
1 http://www.mealsonwheels.org.au/wp-content/uploads/2016/10/NationalMealsGuidelines2016.pdf
2 https://das.bluestaronline.com.au/api/BEYONDBLUE/document?token=BL/1263A
3 https://daa.asn.au/marketplace/publications/resources-available-for-purchase/
4 https://iddsi.org/
5 https://meaningfulageing.org.au/wp-content/uploads/2016/08/National-Guidelines-for-Spiritual-Care-in-Aged-Care-DIGITAL.pdf
6 https://meaningfulageing.org.au/product/short-animations-aged-care-quality-standards-spiritual-care/
7 https://www.cclhd.health.nsw.gov.au/services/nutrition/nutrition-resources/
8 https://www2.health.vic.gov.au/ageing-and-aged-care/wellbeing-and-participation/healthy-ageing/well-for-life
9 https://www.dhhs.tas.gov.au/healthyageing/online_training/for_healthcare_workers_supporting_people_with_malnutrition
Standard 4
Requirement (3)(a)
Each consumer gets safe

and effective services and
supports for daily living that
meet the consumer’s needs,
goals and preferences and
optimise their independence,
health, well-being and
quality of life.

Receiving safe and effective services and
supports for daily living can help consumers How does the organisation know that
to be as independent as possible and the services and supports for daily living
maintain a sense of well-being. When it provides are in line with the consumers
these are tailored to their needs, goals care and services plan?
and preferences, this helps to improve the How does the organisation know that
consumer’s quality of life. the services and supports are safe
and effective?
The level and number of services and
supports for daily living a consumer uses will
What networks has the organisation
vary. What’s valuable and important to one
developed to help provide services
consumer isn’t always important to another.
and supports for daily living to meet a
It’s expected that the consumer’s services consumer’s needs goals and preferences?
Standard |
and supports for daily living are safe and
effective and delivered in line with their How does the organisation measure how
assessed needs, goals and preferences. Safe
and effective services and supports includes
safe and effective their services and
supports are in improving a consumer’s 4
effective management of incidents and ‘near independence, health, well-being and
misses’ and documentation and review of quality of life?
these to inform continuous improvement. How does this occur when care is shared?
Risks associated with the services and
supports of each consumer should be Does the organisation apply a problem-
managed in line with the consumer’s solving approach to manage risks
care and services plan. This is so that the to consumers?
organisation supports them to safely Does the organisation take a balanced
maintain their best possible level of approach to reducing risks to maintain
independence and function. For example, the safety of consumers, the workforce
catering services may need to avoid and others, while supporting
particular foods for some consumers (due to consumer preferences?
allergies, diabetes or cultural needs). Or, the
texture of food might need to be changed for
consumers who have difficulty swallowing.
Examples of actions and evidence • The workforce can describe how they know
Consumers the services and supports they deliver are
• Consumers say they are satisfied that the safe and effective.
services and supports for daily living they • Workforce orientation, training or other
receive and the services and supports help records that show how the organisation
them do the things they want to do. supported the workforce to meet
• Consumers can explain how the services this requirement.
and supports for daily living have improved Organisation
their independence, health, well-being and • Consumer needs, goals and preferences
quality of life. are documented and made available to the
• Consumers say they feel safe in the way workforce to inform the type of services and
services and supports are delivered and supports provided to the consumer, and the
when using any equipment, device or item. way that they are provided.
• Consumers say members of the workforce • Records reflect that the consumer and
are flexible and can modify services and others they want to involve, are involved
supports so they can continue to do things in deciding how the organisation delivers
of interest to them, including at times when their services and supports.
they feel less able to participate fully. • Records reflect strategies and options
• Consumers can describe how they provide to deliver services and supports for daily
feedback to change the services and living that reflect the diverse needs and
supports they receive. characteristics of consumers.
Workforce and others • Records reflect processes in place to
• The workforce can describe how they come support problem solving, including where
to understand what consumers want to risks arise, so that consumers optimise
continue to do for themselves. They can their independence, health, well-being
also describe what the consumer needs to and quality of life.
do to stay safe and well, and what they want • Records of incidents and ‘near misses’ and
to be able to do or keep doing. actions taken in response are documented.
• The workforce can describe how the • Evidence of improvements adopted after
organisation tailors the delivery of services reports of incidents or ‘near misses’
and supports for daily living to meet the investigations or feedback.
consumer’s needs, goals and preferences. • Evidence of how the organisation’s
• The workforce can describe how they work approach to providing services and
with consumers to help them do as much as supports for daily living, helps consumers
they can for themselves and maintain their stay active, involved and doing as much
independence and quality of life. for themselves as possible.
Standard 4
Requirement (3)(b)
Standard |
Services and supports 4
for daily living promote
each consumer’s
emotional, spiritual and

This requirement focuses on how an
organisation’s services and supports for How is the understanding of the
daily living can promote the emotional, consumer as a person, with their own
spiritual and psychological well-being of story and experiences, used to provide
consumers. This involves understanding and opportunities for growth, reflection, sense
meeting the goals, needs and preferences of connectedness and fulfilment?
of the consumer and delivering services
and supports for daily living in a culturally How does the organisation support
safe way. This is important for consumers to the workforce to understand, value and
realise their potential and have quality of life. support consumers’ emotional, spiritual
Consumers who need help to stay at home and psychological well-being?
or who live in residential care may be
experiencing challenges, change or loss, How does the workforce build and maintain
including to relationships, independence, trust with each consumer?
self-worth, mobility and flexibility. They Do interactions between consumers
could also be experiencing a reduced sense and the workforce show that consumers
of purpose and meaning. Approaches receive services and supports that meet
that promote emotional, spiritual and their emotional, psychological and spiritual
psychological well-being will minimise the needs, goals and preferences?
risk of stress, depression or anxiety, and help
consumers experience meaning and purpose. How does the organisation help consumers
This could be through specific pastoral access a diverse range of spiritual care
care, cultural, or religious activities that are practitioners to meet their needs, goals
meaningful to the individual consumer, or and preferences?
through everyday encounters that promote a This may include community leaders,
sense of connection and community. cultural or religious communities, chaplains
or pastoral care practitioners.
How an organisation achieves this, will
depend on the consumer’s experience,
values and beliefs and their personal
situation. It will also depend on the type
of services and supports being provided
by the organisation. Promoting empathy,
compassion and connection between the
consumer and members of the workforce
in their day to day interactions, will support
this approach.
Organisation
Examples of actions and evidence • Strategic documents, policies and
Consumers procedures show how the organisation
•C
onsumers say they feel connected and provides services and supports to help
engaged in meaningful activities that are consumers’ emotional, psychological
satisfying to them. and spiritual well-being.
•C
onsumers say they can acknowledge • Records show that the organisation
and observe sacred, cultural and religious delivers services and supports in line with
practices. They can also celebrate days that the consumer’s emotional, spiritual and
are meaningful to their culture or religion. psychological needs, goals and preferences.
•C
onsumers say that their services and • Evidence that shows how the organisation
supports promote their spiritual, emotional uses cultural and other expertise to help
and psychological well-being. the workforce interact with consumers
and promote emotional, spiritual and
Standard |
•M embers of the workforce describe how
they have supported the emotional, • Evidence of how the organisation
monitors, reports and keeps improving
psychological and spiritual well-being
of consumers. its performance against this requirement. 4
• T he workforce can give examples of
cultural awareness in their everyday
practice and how they recognise diversity
to provide services that are meaningful
to the consumer.
this requirement.
Standard 4
Requirement (3)(c)
Services and supports

for daily living assist each
consumer to:
(i) participate in their
community within
and outside the
organisation’s service
environment; and
(ii) have social and personal
relationships; and
(iii) do the things of interest
to them.

Consumers’ well-being and quality of life
are improved by their relationships with How engaged is the organisation with
others and doing things they enjoy and find its local community?
meaningful, providing a sense of purpose Does it ask for the advice of consumers
and identity. However, declining health and and others on how to change, innovate and
changed life circumstances, such as the loss improve its services and supports to meet
of a partner or becoming less mobile, can changing consumer needs?
lead consumers to be less socially involved.
The way each consumer wants to interact or Do the activities offered within the
take part in their community, or with others, organisation provide meaning and a sense
will be different. How often consumers want of purpose?
to interact with others will also be different. Are there opportunities for unplanned
Standard |
It’s important to understand the consumer’s and self-directed activities?
situation. This includes personal and social
relationships that are important to them and How is the workforce supported
their existing supports and networks. This to recognise and engage with consumers 4
will help organisations tailor and coordinate who are at risk of being socially isolated
the services and supports they, and other or feeling lonely?
organisations or community networks,
provide for the consumer. When a consumer can’t manage day to day
activities like they used to, does the
organisation take a reablement approach
to delay decline?
Does it help the consumer stay
engaged in the community and
in meaningful activities?

Consumers • Evidence of how the organisation has
• Consumers say they get the most out of their maintained social supports for consumers
social life and can follow their interests. and increased opportunities for
• Consumers say they are supported to social interaction.
maintain personal relationships to the • Evidence of how the service has tackled
level they wish. barriers that prevent consumers from taking
• Consumers say they can take part in part in their community and other activities.
community and social activities the way • Records show that the organisation designs
that they want to and as much as they want. services and supports with the consumer
• Consumers say they have day-to-day and that they adjust these to reflect
control over what they take part in, how the consumer’s changing needs, goals
they take part and who they socialise with. and preferences.
• Consumers say members of the workforce • Evidence that the organisation works
and the organisations who provide their with external groups offering tailored and
services and supports understand what’s culturally safe services and supports to
important to them. a consumer or group of consumers.

• The workforce can describe how
they work with other organisations,
advocates, community members or
groups to help consumers follow their
interests, social activities and continue
community connections.
• The workforce tackles barriers that prevent
consumers from being active in their
communities. They also tackle barriers
preventing consumers from connecting
socially, maintaining personal relationships
and doing what interests them.
• The workforce can provide examples of
how the organisation adapts services and
supports when a consumer’s situation
changes. This makes sure they are still
meeting the consumer’s needs, goals and
preferences for social connection and
meaningful relationships.
supports the workforce to meet
this requirement.
Standard 4
Requirement (3)(d)
Standard |
Information about the 4
consumer’s condition,
needs and preferences
is communicated within
the organisation, and with
others where responsibility
for care is shared.
Intent of this requirement There are many different situations where

This requirement focuses on the this requirement applies. Including how an
communication processes that organisations organisation communicates information
are expected to have, so that their workforce about a consumer’s condition, needs, goals
has information about delivering safe and and preferences:
effective service and supports for daily • if their regular member of the
living and understanding the consumer’s workforce changes
condition, needs, goals and preferences. • when members of the workforce change
The information the workforce has access between work shifts
to should help them provide and coordinate • when a consumer is transferred to hospital
services and supports that respects the for specialist treatment
consumer’s choices. Good information
• when the consumer’s condition, needs,
management systems mean the consumer
goals or preferences have changed.
doesn’t have to keep repeating their story.
How information is communicated can
If organisations transfer important
vary, but the method needs to be efficient
information about a consumer’s services
and fit the situation. Organisations need to
and supports within and between
collect and share the consumer’s personal
organisations that are responsible for the
information in a way that complies with
consumer’s services and supports, they
relevant privacy legislation. The organisation
can improve outcomes for the consumer. If
is also expected to find ways to include
the consumer’s condition, needs, goals and
consumers, their representatives and
preferences are known to those involved in
others the consumer wants involved,
the consumer’s care it will:
in communication processes.
• improve the safety, effectiveness and
consistency of care and reduce the risk
of harm
• improve the consumer’s experience
of care and deliver care which reflects
their choices.
When two or more organisations deliver What tools and supports does the
services and supports, is it clear which organisation provide for relevant
organisation needs to communicate members of the workforce to understand
changes about a consumer’s condition, and communicate information about
needs, goals and preferences? the consumer’s services and supports
Is it clear who this should be needs and preferences?
communicated to?
When two or more organisations share the workforce to see that part of their
services and supports, or where there are job is to work together to improve
integrated services, what arrangements day-to-day services and supports
Standard |
does the organisation have to share and be clear on instructions on how
relevant information promptly? to best support consumers?
How do they plan and deliver services
and supports? What systems does the organisation have 4
in place to include consumers, and others
they want to include, in communication
about their services and supports?

Consumers • T he workforce can describe how the
• Consumers say they are fully informed and organisation tells them about a consumer’s
able to consent to information being shared condition, needs, goals and preferences
with others about them. as it relates to their own roles, duties and
responsibilities. The workforce can also
• Consumers say that their services and
describe how they share this information.
supports are consistent. They have
continuity of services and supports and •R elevant members of the workforce show
don’t have to repeat their story or their a clear understanding of information
preferences to multiple people. sharing and different types of consent.
• Consumers say the organisation •R elevant members of the workforce can
coordinates their services and supports describe how accurate, up-to-date and
well. They benefit from different relevant information is shared with others
organisations working together and sharing as consumers move between care settings,
information about them. such as between home and hospital.
• Consumers say they have quality services • T he workforce can describe the different
and supports because all members of the situations where they shared documents
workforce involved have correct and up to or communicated information about
date information. This includes replacement the consumer’s services and supports
members of the workforce and those from and how they complied with relevant
different organisations. privacy obligations.
• Consumer representatives say that the •W orkforce orientation, training
organisation has processes to support or other records that show how the
continuity of services and supports. It also organisation supports the workforce
has processes to communicate important to effectively coordinate care and to meet
information about a consumer’s services this requirement.
and supports and how to delivers them.
Organisation
•E
vidence of an effective system to manage
information that keeps suitable controls
to maintain privacy and is in line with
relevant legislation.
•E
vidence that the organisation is actively
communicating with others, internally
and externally, to make sure that service
and supports are delivered without
any disruptions.
•E
vidence that the organisation monitors
how the workforce manages information
in relation to information gaps, pending
Standard |
and missing information and that follow
up occurs.
•R
ecords reflect how the organisation asks
for consent to release or share information 4
using methods suitable for each consumer
and in accordance with privacy legislation.
•E
vidence that relevant members of the
workforce have access to consumer records.
•C
onsumer care and service plans show
evidence of updates, reviews and
communication alerts. This includes
information from multiple sources, updates
from reassessments and their results.
•P
olicies and procedures that show how
the organisation communicates important
information about a consumer when they
share the responsibility for services and
supports with other service providers,
or have transferred a consumer to
another organisation.
Standard 4
Requirement (3)(e)
Timely and appropriate

referrals to individuals,
other organisations and
providers of other care
and services.

An organisation may not be able to provide
all the services and supports for daily living How has the organisation identified
that a consumer needs to have meaning, individuals, organisations or providers that
purpose and connectedness in their life. can deliver services and supports to better
However, it’s expected that organisations meet consumer choices?
support and help the consumer to follow
activities they are interested in, take part in When more than one organisation is
social activities and maintain and develop responsible for the services and supports
social and personal relationships. To do this, of a consumer, is it clear to everyone who
organisations can connect consumers with is responsible for providing the service
services and supports that others in the or support at any point in time?
wider community provide.
Standard |
Other individuals, organisations or specialist What are the barriers to timely referrals?
providers may be better able to deliver Does the organisation actively work
specific services and supports safely and to remove these barriers?
effectively and which better line up with 4
consumer choices. Organisations that
provide aged care services and supports
are expected to refer consumers to other
individuals, organisations or providers
as needed.
Having an active network of other individuals,
organisations or providers they can refer
or collaborate with, means the organisation
can meet the diverse needs of consumers.
It is expected that organisations do this in
line with the Quality of Care Principles, 2014.
Organisations will need to meet obligations
relating to privacy of information when
co-ordinating care with other organisations,
services or individuals.

Consumers • The organisation’s strategic and operational
• Consumers say that where the organisation planning describes activities that maintain
has been unable to provide a suitable a network of individuals, organisations
service or support they have helped or providers they can refer consumers to.
organise someone else to provide it. • Evidence that the organisation has made
• Consumers say the organisation has links with individuals, organisations
referred them to the appropriate or providers, to make sure consumers
individuals, organisations or providers have access to a range of service and
to meet their changing services and supports for example memorandums
supports needs. of understanding.
• Consumers believe referrals happen • Consumers’ care and services plans show
promptly when their needs, goals that the organisation collaborates with
or preferences change. other individuals, organisations or providers
• Consumers say they are satisfied with the to support the diverse needs of consumers.
services and supports delivered by those • Records that show the organisation
they’ve been referred to. They also say regularly reviews the individuals,
the services and supports from the other organisations or providers they refer to,
individuals, organisations or providers are to make sure their services remain safe
delivered in a culturally safe way. and effective and quality care and services
are being delivered.
• The workforce can identify individuals, • Consumer records show that the
organisations or providers they can organisation makes timely referrals to other
make referrals to and any referral criteria individuals, organisations or providers
that applies. to meet the services and supports needs
of consumers.
refer consumers to other individuals, • Evidence of referral processes, outcomes
organisations or providers and how they for consumers, and projects that show
collaborate to meet the diverse needs quality improvement.
of consumers.
consumer is actively involved in decisions
and about referrals and consent
is obtained.
this requirement.
Standard 4
Requirement (3)(f)
Standard |
Where meals are provided, 4
they are varied and of
suitable quality and quantity.
Intent of this requirement It’s expected that organisations monitor

The intention of this requirement is to make nutritional and hydration intake to prevent
sure that consumers have enough nutrition dehydration, weight loss or weight gain.
and hydration to maintain life and good Food can be a powerful social symbol
health and reduce the risks of malnutrition for connecting consumers with moods,
and dehydration. Meals and the dining emotions and rituals related to their
experience are a very significant part identity. Mealtime habits built over time can
of day-to-day life. They play an important inspire feelings of comfort and familiarity
role in connecting consumers socially for consumers. This is why it’s important
and supporting a sense of belonging. for an organisation to take into account
This requirement applies when an a consumer’s preferences, religious and
organisation provides the nutritional cultural backgrounds when providing food
or hydration needs of a consumer as part and drinks or hosting meals.
of their care or services. Where it’s part
of their role, organisations are expected
to make sure that consumers have enough
to eat and drink to meet their nutrition and
hydration needs and to provide consumers
with the support they need to eat and drink.
This is expected to be based on assessed
needs and address:
• what is needed to sustain life and support
ongoing good health
• any dietary intolerances, allergies
or medication contraindications
• the level of support or help the
consumer needs
• consumer’s preferences, and religious
and cultural considerations
• timing of meals.
How does the organisation make sure How does the organisation involve
nutrition and hydration needs are met? the consumer in menu planning
How does the organisation make sure or food preparation?
these needs are reviewed? How does the organisation know it’s
Does the provision of meals and meeting the consumer’s medical, cultural,
drinks recognise any risks relating religious or other meal needs?
to a consumer’s nutritional and
hydration status? How does the organisation make sure
the presentation of each meal, such as
How is the workforce supported to know its texture, flavour, smell and appearance,
when a referral for specialist nutritional support good appetite and good
advice is needed? food consumption?
Standard |
How is this advice accessed and how does
the organisation make sure it is followed?
How does the organisation optimise 4

the benefits of mealtimes?
This can include the atmosphere,
interpersonal and social aspects of
the dining experience.

Consumers • The workforce can describe how they create
• Consumers say they can choose from an engaging mealtime experience that
suitable and healthy meals, snacks and encourages consumers to eat and drink.
drinks. They can also take part in planning • The workforce can describe how they
their menu. assess food and drinks outside of normal
• Consumers say that the organisation catering hours.
consistently provides their meal and drink • Members of the workforce can describe how
preferences and menu selections. They say they make sure that meals vary and are of
the menu also meets their medical, cultural, suitable quality and quantity.
religious or other needs. • The workforce can demonstrate that they
• Consumers feel their dining experience know consumers’ nutrition and hydration
is comfortable and not rushed. They also needs and preferences and how to support
feel that any help they need to eat and consumers’ independence. This includes
drink is readily available and provided in a preferred meal size, dietary or cultural
dignified way. needs and any support they need to
• Consumers are satisfied that they receive, prepare food or drinks.
or are helped to prepare, a variety of well • The workforce can describe when specialist
proportioned, quality meals. They say the nutritional advice is required and how
dining experience supports their quality to access it.
of life. • The workforce know how to report any
• Consumers say if they are hungry or thirsty changes to a consumer’s appetite or eating
a member of the workforce will get them habits, or concerns about weight loss
something to eat or drink. or dehydration.
• Observations that food and drink are put • The workforce can describe how to
within the reach of consumers and given make any changes to meals or drinks the
in a way that the consumer can eat and consumer requests and say that changes
drink. This may include finger food, cut up are made in a timely manner.
or modified meals or thickened drinks, • Workforce orientation, training or other
where appropriate. records that show how the organisation
this requirement.
Organisation
•E
vidence of processes in place to plan and
deliver nutrition and hydration in line with
consumers’ needs and preferences.
•E
vidence of how a range of consumers are
consulted in developing menus. This makes
sure that the menu includes varied meals
and reflects the diversity of consumers.
•S
ystems that demonstrate ordering, storing
and preparation of food and drinks occurs
in a way that maintains their freshness
and quality.
•E
vidence of an individual and flexible
Standard |
approach to preparing and delivering meals
and for vulnerable consumers. This includes
consumers living with dementia or receiving
palliative care. 4
•R
ecords reflect menus have been reviewed
for nutritional balance.
•R
ecords confirm food safety and any other
legislative requirements are met.
Standard 4
Requirement (3)(g)
Where equipment
is provided, it is safe,
suitable, clean and
well maintained.

Equipment that organisations provide
for consumers to use outside the service How does the organisation assess and
environment (for example the consumers’ plan how they provide equipment in a way
own home) needs to be fit for purpose. that makes sure consumers have safe
This means it needs to be safe, suitable, and suitable equipment that meets
clean and well maintained. their needs?
This includes equipment for routine and
specialised care, consumer lifestyle, Are all members of the workforce using
housekeeping and cleaning, gardening, the equipment trained in its use?
transport and maintenance. Each consumer’s How do members of the workforce know
equipment needs and preferences will vary. when the equipment is no longer safe
They will be based on their care, lifestyle, or suitable?
Standard |
mobility, communication, housekeeping
and other needs, goals and preferences. Are manufacturers’ instructions on use,
The organisation is responsible for storage, maintenance and cleaning
making sure that third parties who may available and followed? 4
be subcontracted, have the equipment they
need to meet this requirement. For example, How does the organisation communicate
a subcontracted transport service must to the consumer what their responsibilities
have a safe and suitable wheelchair ramp are for cleaning, maintaining and storing
to access the vehicle if they provide services the equipment?
and supports to consumers who use
a wheelchair.
If a consumer owns the equipment they
need in delivery of services and support,
the organisation needs to take reasonable
steps to make sure that it’s clean, safe and
suitable for the consumer to use. This would
include raising any concerns with the
consumer, or their representative, so that
the equipment can be maintained, cleaned
or reassessed.

Consumers • The organisation has suitable arrangements
• Consumers say they feel safe when they are for purchasing, servicing, maintaining,
using the equipment and they know how to renewing and replacing equipment.
report any concerns they have about safety. • Evidence that the organisation does risk
• Consumers say that the equipment the and other assessments before they give
organisation provides is suitable, meets equipment to consumers.
their needs and they can access it when • Evidence that equipment is used,
they need. stored and maintained in line with
• Consumers are satisfied the equipment is manufacturers’ instructions.
clean and well maintained. • Evidence that equipment is used for its
Workforce and others intended purpose and the consumer who
• The workforce can describe how the it’s provided for is the one that uses it.
organisation has trained them to safely • Contract management or other documents
use the equipment. They can also show how the organisation ensures that
describe any responsibilities they share sub-contractors have equipment to meet
with the consumer for safety, cleanliness this requirement
and maintenance. • Clear responsibilities are documented for
• The workforce can explain how they would the safe use, ongoing suitability, cleanliness
identify any potential risks to the safe use and maintenance of equipment where these
of the equipment. They can also describe are shared between the organisation and
how they would report when the equipment the consumer or a third party.
was no longer suitable for a consumer.
describe how the organisation plans and
follows maintenance and cleaning routines
for equipment.
this requirement.
Standard 5 |
Standard |
5
Standard 5 |

I feel I belong and I am
5 (1)
the following:
safe and comfortable 5 (3) (a) The service environment
in the organisation’s is welcoming and easy
to understand, and optimises
service environment. each consumer’s sense
of belonging, independence,
interaction and function.
5 (3) (b) The service environment:
Organisation statement
(i) is safe, clean, well maintained
5 (2) T he organisation provides and comfortable; and
a safe and comfortable (ii) enables consumers to move
freely, both indoors
service environment that and outdoors.
promotes the consumer’s 5 (3) (c) Furniture, fittings and equipment
independence, function are safe, clean, well maintained
and suitable for the consumer.
and enjoyment.
Meaning of service environment
An organisation’s service environment means
the physical environment through which
care and services are delivered, but does
not include an individual’s privately owned
or occupied home at which in-home services
are provided.
Standard 5 |
Purpose and scope This Standard covers how an organisation’s

of the Standard service environment:
Standard 5 applies to the physical service • supports the consumer’s ability to take part
environment that the organisation provides in the community and engage with others
for residential care, respite care and day • minimises confusion so consumers can
therapy centres. It doesn’t apply to home recognise where they are and see where
care services where the environment is they want to go
the consumer’s home. And it doesn’t apply • encourages consumers to make their living
to other environments that consumers visit, areas more personal
such as bowling clubs or libraries. • welcomes consumers and their family
This Standard is for organisations providing or visitors and provides spaces for culturally
a physical service environment. It makes safe interactions with others
sure that the service environment, furniture • is safe, well maintained and clean
and equipment support a consumer’s quality
• helps consumers to move freely
of life, as well as their independence, ability
in the environment (including access
and enjoyment. This means that the service
to outdoor areas)
environment suits the consumer’s needs
and is clean, comfortable, welcoming and • subtly reduces risk where needed so safety
well maintained. It includes how the safety features don’t dominate the environment
and security, design, accessibility and layout • provides security arrangements in line with
Standard |
of the service environment encourage best practice to protect consumers when
a sense of belonging for consumers. lawful and necessary.
The furniture, fittings and equipment
provided at the service are also covered 5
by this Standard. It is expected that these
are safe, clean, well maintained and suitable
for the consumer.
This Standard doesn’t replace work, health
and safety laws, or requirements under
building legislation.
Standard 5 |
Linked Standards
this Standard
organisations need to demonstrate A well considered service
that they: environment promotes consumers’
• understand the requirement independence, privacy and cultural safety.
•a pply the requirement, and this
is clear in the way they provide care Standard 7
and services The workforce focus on maintaining
•m onitor how they are applying a physical environment which is
the requirement and the outcomes safe, comfortable and welcoming promotes
they achieve consumers enjoyment of their surroundings.
• r eview outcomes and adjust their
practices based on these reviews Standard 8
to keep improving. The organisation’s governing body
is accountable for the delivery of
safe and quality care, services and supports,
including the physical environment in which
these are delivered.
Standard 5 |

•A
ged Care Act 1997 (Cth), User Rights •D ementia Training Australia (2017).
Amendment (Charter of Aged Care Rights) Environmental Design Resources.
Principles 2019 Richard Fleming and Kirsty Bennett.
University of Wollongong. 1
• ‘Long-term care for people with dementia:
environmental design guidelines’,
International psychogeriatric, vol. 22, no. 7,
pp. 1084-96, 2010. Richard Fleming and
Natin Purandare. University of Wollongong. 2
•V ictorian Government, Department of
Health. Dementia Friendly Environments 3
•A lzheimer’s WA, How to design dementia-
friendly care environments 4
Standard |
5
1 https://www.dta.com.au/wp-content/uploads/2017/02/Intro_Resource1-31.1.17.pdf
2 https://pdfs.semanticscholar.org/49bf/a44d8a5cb54943a6bea071f9fc1e6347bb5f.pdf
3 https://www2.health.vic.gov.au/ageing-and-aged-care/dementia-friendly-environments
4 https://www.alzheimerswa.org.au/wp-content/uploads/2017/06/Helpsheet-Environment03_HowToDesign_english.pdf
Standard 5
Requirement (3)(a)
The service environment

is welcoming and easy to
understand, and optimises
each consumer’s sense of
belonging, independence,
interaction and function.

This requirement is about creating a service
environment that is well designed and How does the organisation ask for
welcoming for all consumers and encourages advice to create a welcoming and
a sense of belonging. easy-to-understand service environment
for all consumers?
Consumers will experience service
How have they used this advice?
environments differently, depending
on their backgrounds, situations and
What signals does the service environment
what they expect from an organisation.
give about who the organisation accepts
A service environment that’s designed
and provides care and services for?
to be inclusive helps all consumers feel
Do the posters, photographs, artwork,
welcome. A service environment that looks
magazines or reading materials in public
familiar to a consumer helps them feel that
areas show that this is an inclusive
the organisation is welcoming them. It lets
service environment?
them know they can be themselves in the
service environment.
How does the organisation make sure the
The physical, emotional and social features service environment maximises support
of a space are all important parts of creating for consumers’ independence and ability?
a welcoming service environment for What environmental strategies are
consumers. This includes design, the feeling in place to improve function and
Standard |
of being supported, and the quality of the independence for consumers with sensory
relationships consumers develop with the loss, such as hearing or vision loss
workforce and other consumers and visitors
to the service environment.
or a cognitive impairment?
For example, noise management,
5
A service environment that’s easy lighting, colour contrast, signage, textures
to understand is particularly important. and design.
Age-related changes and disabilities
can make it more difficult for consumers How does the organisation deal with any
to understand and get around in buildings challenges that consumers are having
and spaces. Such impairments can include getting around the service environment?
hearing or sensory loss, and declining
mobility and cognitive impairment.
For example, the service environment
can help maximise a consumer’s function
by reducing the level of unnecessary or
competing noise or clutter.

Consumers • Observations of the service environment
• Consumers say the service environment show that consumers’ rooms have
is welcoming to them, their friends, a personal character and feel
family visitors (and pets where agreed). • Evidence that the organisation takes steps
They say the service environment to understand how consumers experience
encourages a sense of belonging. the service environment.
• Consumers say they have spaces to interact • Evidence that the organisation monitors
with others and spaces for quiet reflection. and can adapt the service environment
They also have spaces for religious to support a consumer’s changing needs
or cultural practices and private spaces such as a decline in mental or physical
if they need them. ability. This means the consumer can
• Consumers say they can find their continue to do the things that are important
way around easily and can easily get to them.
to key locations, such as dining areas
or a suitable bathroom.
• Consumers say they decide on the
decoration, furnishings and layout of their
bedroom. This includes bringing their own
furniture and fittings (where agreed).
organisation removes barriers that might
exclude some consumers. This makes sure
the service environment is welcoming
to all consumers.
• The workforce can describe strategies
to support consumers to get around the
service environment at their own pace and
with dignity.
• The workforce can show how different
consumers can use the service environment
in different ways. This means the service
environment supports all consumers’
independence and ability.
supports the workforce in this requirement.
Standard 5
Requirement (3)(b)
The service environment:

(i) is safe, clean, well
maintained and
Standard |
comfortable; and
(ii) enables consumers
to move freely, both
5
indoors and outdoors.

This requirement is about the expectation
that the service environment is safe, clean, How does the organisation avoid
well maintained and comfortable. It also environmental risks to keep
covers the need for consumers to be consumers safe?
able to move freely around the service How does the organisation monitor and fix
environment, indoors and outdoors. any safety issues, obstacles, barriers, poor
The service environment is expected lighting, glare or hazards?
to be fit for purpose in line with statutory
requirements and national best practice. How does the organisation look after
Each service environment is different. the safety of each consumer?
This means that organisations should For example, how would a consumer who
consider the layout, the potential number is hearing impaired know an emergency
of consumers using the service, and alarm is going?
their needs to make sure the service
environment is safe, clean, well maintained Can the atmosphere, size and shape
and comfortable. It can include buildings, of spaces in the service environment
access points, parking areas, gardens and the be changed?
service environment’s general appearance Can the service environment be controlled
and homeliness. so that the level of stimulation in spaces
meets consumers’ diverse sensory and
The service environment is expected
comfort needs?
to promote the free movement of consumers
(including to access outdoor areas). It may
How do workforce attitudes and their
be important that the service environment
understanding of risk and safety, affect
is secure or access to certain areas are
a consumer being able to move freely
restricted to help create a safe service
in the service environment, indoors
environment for consumers. Arrangements
and outdoors?
to protect consumers require assessment,
documentation in care and services plans,
How do workforce attitudes and their
informed consent from the consumer and
understanding of dignity of risk, affect
regular monitoring and review, in line with
a consumer being able to move freely
best practice and legislation.
indoors and outdoors?
If third parties provide maintenance or other
services, the organisation should clearly define Is the level of security in place in balance
their responsibilities in regard to the service with the care and services being delivered?
environment. Organisations are responsible
for monitoring and dealing with any issues that
come up with contracted services.

Consumers • Evidence the organisation has a range
•C
onsumers say the service environment of strategies to create a relaxed,
makes them feel welcome. welcoming, peaceful, safe and comfortable
service environment in line with consumers’
•C
onsumers say they feel safe in the service
needs and preferences.
environment and know how to let the
workforce know if they don’t feel safe. • Observations that risks to consumers
are unobtrusively managed and any
•C
onsumers say the service environment
security measures in place in the service
is clean, well maintained and comfortable.
environment reflect the consumer’s
•C
onsumers say the service environment assessed needs.
has plenty of natural light and fresh air and
• Observations that the service environment
they can change the lighting, air flow and
enables consumers to move safely about
heating to make the service environment
the service indoors and out.
more comfortable.
• Evidence that the organisation asks
•C
onsumers say they can move freely within
for consumers’ opinions when making
the service environment and access the
decisions about the layout of the
parts of the service they use independently,
including the outdoor environment.
• Evidence that the organisation asks for
Workforce and others consumers’ opinions about how space in
Standard |
• T he workforce can describe their the service environment is used so that
responsibilities to protect consumers consumers can keep active and move around
from avoidable harm. as much as possible.
• T he workforce demonstrates their • Evidence that any restriction in place at
5
knowledge of how to respond to a safety the service environment which impacts
incident, hazard or emergency. a consumer is based on the least restrictive
• T he workforce can describe strategies option. The basis for any restriction is also
to make sure consumers who can’t move up-to-date, evidence-based, transparent
about on their own can access the outdoors and able to be reviewed.
if they wish. • Evidence the organisation has
• T he workforce can explain how landmarks arrangements to maintain the internal and
in the service environment help consumers external service environment. This makes
find their way around and support sure the environment is comfortable, safe
consumers’ independence. For example how and secure.
discrete safeguards mean consumers living • Records that the organisation has
with dementia can safely access areas, such arrangements for cleaning the internal and
as kitchenettes. external service environment. This includes
•W orkforce orientation, training or other removing general and hazardous waste.
has supported the workforce in
this requirement.
Standard 5
Requirement (3)(c)
Furniture, fittings
and equipment are safe,
clean, well maintained and
suitable for the consumer.

This requirement covers the need for
furniture, fittings and equipment in the How does the organisation assess and plan
service environment to be safe, clean, what furniture, fittings and equipment
well maintained and suitable for consumers they provide to make sure consumers have
to use. suitable and safe items?
The furniture, fittings and equipment
in each service environment are different. How do furniture design and the layout
This means that organisations should of furniture and fittings help consumers
consider how they will make sure equipment who are frail, less flexible and less mobile
is safe, clean, well maintained and suitable. to be comfortable and independent?
If a consumer owns the equipment they
need, the organisation needs to make How does the organisation ask for and
every effort to make sure that it’s clean, consider consumers’ opinions about
safe and suitable for the consumer to use. furniture, fittings and equipment?
This would include raising any concerns
What are the systems for ensuring that
with the consumer, or their representative,
any equipment used in the course of the
so that the equipment can be maintained,
provision of care and services, including
cleaned or reassessed.
equipment owned by the consumer,
Standard |
is clean safe and well maintained?

Consumers • Observations that the furniture, fittings and
• Consumers say they have access to a range equipment are safe, clean, well maintained
of good-quality equipment and furnishings and suitable for the consumer.
that meet their needs and preferences. • Evidence that the organisation can
• Consumers say they feel safe when using purchase, service, maintain, renew and
the furniture, fittings and equipment. replace indoor and outdoor, furniture,
• Consumers are confident the workforce fittings and equipment.
knows how to safely operate the • Evidence that the organisation acts
equipment they use to support their promptly when furniture, fittings and
health and well-being. equipment need to be maintained
• Consumers say the design of furniture or replaced.
and fittings helps them to be independent • Records of arrangements with third-
and adds to the comfort of the party contractors and the systems in
service environment. place to make sure any safety, cleaning
or maintenance of the service environment
undertaken by third-party contractors
is delivered as arranged.
organisation’s options for adapting or
replacing furniture, fittings or equipment • Records of arrangements with third-
that doesn’t suit the consumer’s needs. party contractors and the systems
They can also describe how they in place to make sure any furniture,
assess this. fittings or equipment provided
by third-party contractors meet the
• The workforce understands that when
organisation’s specifications.
multiple consumers use equipment
and devices, they must be cleaned
and disinfected between each use.
They also understand that single-use
and single-consumer devices mustn’t
be reused or shared.
• The workforce says that equipment
is suitable and there’s enough equipment
to support them to deliver quality service.
• Evidence that suitably qualified members
of the workforce are involved in the
assessment of suitability of furniture,
equipment and fittings to meet
consumers’ needs.
• Workforce orientation, education other
records show that the organisation
supports the workforce in this requirement.
Standard 6 |
Standard |
Standard 6 |

I feel safe and am
6 (1) 6 (3) The organisation demonstrates
the following:
encouraged and 6 (3) (a) Consumers, their family, friends,
supported to give carers and others are encouraged
feedback and make and supported to provide
feedback and make complaints.
complaints. I am 6 (3) (b) Consumers are made aware of
engaged in processes and have access to advocates,
language services and other
to address my feedback methods for raising and
and complaints, and resolving complaints.
appropriate action 6 (3) (c) Appropriate action is taken in

response to complaints and an
is taken. open disclosure process is used
when things go wrong.
6 (3) (d) Feedback and complaints are
reviewed and used to improve
the quality of care and services.
The
6 (2) organisation
regularly seeks input
and feedback from
consumers, carers,
the workforce and
others and uses the
input and feedback
to inform continuous
improvements for
individual consumers and
the whole organisation.
Standard 6 |
Purpose and scope Organisations are expected to demonstrate

of the Standard open disclosure. This is in line with up-to-
date practices of open communication
Standard 6 requires an organisation to have
and transparent processes. It includes
a system to resolve complaints. The system
acknowledging and apologising when
must be accessible, confidential, prompt and
the organisation has made mistakes.
fair. It should also support all consumers
to make a complaint or give feedback. Consumers should feel safe and comfortable
Resolving complaints within the organisation giving feedback to the organisation.
can help build the relationship between the Some consumers have barriers that make
consumer and the organisation. It can also it difficult for them to raise complaints.
lead to better outcomes. These could be cognitive or communication
difficulties, language or cultural
The Standard covers key elements
differences. The nature of a complaint can
of an effective complaints management
also be particularly sensitive or private.
system that:
Organisations are expected to look for ways
•e ncourages consumers to give positive and to tackle these barriers and create a culture
negative feedback to their organisation that welcomes feedback and supports
about the care and services they receive consumers to make complaints.
• r esponds to feedback and complaints
consumers and others make formally
and informally, written or verbally
to the organisation
•h elps organisations keep improving,
Assessment against
informs improvements to care this Standard
and services and resolves issues For each of the requirements,
for consumers and others. organisations need to demonstrate
that they:
Standard |
and services 6
the requirement and the outcomes
they achieve
to keep improving.
Standard 6 |

Standard 6 links to: • Aged Care Act 1997 (Cth), User Rights
Standard 1 Principles 2019
All aspect of care and services need
to treat consumers with dignity and Resources and references
respect and support them to make choices. • Aged Care Quality and Safety Commission
It’s also important that care and services Fact Sheet – Resolving concerns about
are delivered in a way that is culturally safe. aged care 1
Feedback and complaints systems support • Aged Care Quality and Safety Commission,
the consumers to let the organisation know Open Disclosure Framework 2
when this does not occur. • Commonwealth Ombudsman (2009). Better
Practice Guide to Complaint Handling 3
Standard 7 • Department of Health, The National
Workforce interactions with Aged Care Advocacy Program 4
consumers need to be kind, caring • Department of Social Services, Better
and respectful of each consumer’s identity, Practice Guide to Complaint Handling
culture and diversity. In particular, the in Aged Care Services 5
workforce needs to be capable of supporting • Older Persons Advocacy Network
consumers to raise feedback and complaints (2018). National Elder Abuse Prevention
about any aspect of these Standards. and Advocacy Framework 6
• Victorian Government, Department
Standard 8 of Health, Open Disclosure Following
The organisation’s governing body Adverse Events in Hospitals 7
of safe, and quality care, services and
supports. It is expected organisation wide
governance systems include feedback
and complaints. The systems should
support a culture of open disclosure and
continuous improvement.
1 https://www.agedcarequality.gov.au/sites/default/files/media/acqsc_resolving-concerns-factsheet_0.pdf
2 https://www.agedcarequality.gov.au/resources/open-disclosure
3 http://www.ombudsman.gov.au/publications/better-practice-guides
4 https://agedcare.health.gov.au/support-services/the-national-aged-care-advocacy-program
5 ttps://agedcare.health.gov.au/programs-services/complaint-handling-toolkit/better-practice-guide-to-complaint-handling-in-
h
aged-care-services
6 https://opan.com.au/elder-abuse/
7 https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/clinical-risk-management/open-disclosure
Standard 6
Requirement (3)(a)
Consumers, their family,

friends, carers and
others are encouraged
and supported
to provide feedback
and make complaints.
Standard |

This requirement describes how
organisations need to welcome feedback and How does the organisation make
complaints as an opportunity to learn about sure everyone is aware of their right
ways in which they can improve outcomes to provide feedback or make a complaint
for consumers. to the organisation?
Organisations must recognise that How is the complaint handling
consumers have the right to raise concerns process publicised?
and make complaints about the care and
services they receive from the organisation.
everyone knows how to use advocacy
The organisation must have in place best
and complaint agencies outside
practice complaint handling and resolution
of the organisation?
systems that facilitate and support
How are advocacy services publicised?
consumers to make complaints. Once made,
the system follows principles of procedural
Are tools and information about feedback
fairness and natural justice and is managed
and complaints handling and resolution
in line with better practice guidelines.
systems in plain English?
The organisation is expected to demonstrate Or in the consumer’s language?
that they encourage and support consumers Are they presented in a format that
and their representatives to provide can be easily understood?
feedback or complain about the care
and services they receive. This is based How does the organisation support diverse
on consumers’ trust and confidence that and vulnerable groups to give feedback
there won’t be negative consequences if they and make complaints about their care
raise concerns or complain. and services?
It is expected consumers are made aware
of and supported to access alternative, Does the workforce know how to
external complaints handling options, access translation services and other
including the role of the Aged Care Quality communication and hearing support
and Safety Commissioner. services to help consumers give feedback
and make complaints?

Consumers • Evidence of the organisation’s approach
•C
onsumers and their representatives to feedback and complaints that describe
understand how to give feedback or make the way it encourages and supports
a complaint. consumers, their representatives,
the workforce and others to give feedback
•C
onsumers and their representatives
and make complaints.
say when they give feedback or make
a complaint they feel comfortable and • Evidence that the organisation prioritises
safe and aren’t treated in a negative way appropriate receipt and management
because of their feedback or complaint. of complaints by consumers, their
representatives, the workforce and others.
•C
onsumers and their representatives can
describe what has been done in response • Policy or process about the organisation’s
to their feedback or complaint. system to manage complaints, including
what consumers, their representatives,
Workforce and others the workforce and others can expect when
• T he workforce can describe how they they provide feedback or make a complaint.
encourage and support consumers
• Evidence that shows how the organisation
to provide feedback and make complaints.
protects the identity of those who
• The workforce demonstrate they are aware want to give anonymous or confidential
of and understand the operation of the feedback or make an anonymous
organisation’s complaint handling system. or confidential complaint.
• T he workforce can describe what they • Availability of information about complaints
do when they receive feedback or and how complaints are managed by the
a complaint and how the complaint organisation, that consumers, their
handling process is in line with best representative, the workforce and others
practice complaint management. can easily access.
• T he workforce can describe how they • Complaints records or other evidence that
Standard |
are able to provide feedback where they show how the organisation has applied best
identify issues in the delivery of care and practice in handling complaints.
services by the organisation.
• Evidence that the organisation monitors,
reports and continuously improves its
6
records that show how the organisation has performance against this requirement.
supports the workforce in how to handle
feedback and complaints and the systems
for complaints resolution.
Standard 6
Requirement (3)(b)
Consumers are made

aware of and have
access to advocates,
language services
and other methods
for raising and
resolving complaints.

This requirement is intended to make
sure that all consumers can easily make How does the organisation let consumers
a complaint, whatever their culture, know about advocacy services?
language or ability. The organisation’s How does it let consumers know
complaints system should give every about using external agencies
consumer equal access to make a complaint. to resolve complaints?
Consumers may have barriers to using
Is information about complaints available
the complaints system, such as diversity
in languages and formats consumers
of culture or language. Poor vision, hearing
can use?
loss, or cognitive impairment can also make
it difficult for some consumers to make
How do members of the workforce
a complaint.
recognise when a consumer needs help to
It is expected consumers are also made use an advocate or other support service?
aware of and supported to access
services that can assist them to make Do the complaints the organisation
a complaint. This includes support to access receives reflect the diversity of consumers
alternative, external complaints handling using the service?
options, including the Aged Care Quality If not, are there barriers to some
and Safety Commissioner. consumers making a complaint
or accessing an advocate?
Standard |

Consumers • Evidence that the organisation has
• Consumers and their representatives involved advocacy services and community
know how to access advocates. They know groups, which represent the diversity
how advocates can help them raise and of its consumers, to improve consumers’
resolve complaints. opportunities to raise issues and
resolve complaints.
• Consumers can describe how the
organisation has used language • Meeting records or other evidence that
services, hearing assistance and other the organisation actively asks for feedback
communication aids to support them from advocates and access language
to communicate their complaint directly services when consumers need assistance.
or via an advocate. • Evidence of an effective assessment
process that identifies the support that
consumers need to make a complaint.
• Members of the workforce can describe how
they identify consumers who may need help • Evidence of how the organisation
to raise a complaint or use an advocate. monitors, reports and keeps improving
its performance against this requirement.
• The workforce know how to contact
advocacy and language services.
Members of the workforce can describe
how they have helped consumers to
communicate issues and make complaints
via advocates and using interpreters.
Standard 6
Requirement (3)(c)
Appropriate action
is taken in response
to complaints and
an open disclosure
process is used when
things go wrong.
Standard |

This requirement covers the actions
that an organisation is expected to take What systems does the organisation have
in response to complaints. It’s expected to make sure complaints are followed
that the organisation will have a best up and appropriate action is taken?
practice system for managing and resolving
complaints for consumers. When things go wrong, how does
the organisation go about understanding
To create an environment that reduces
what has happened?
harm to consumers, organisations need
a culture where people feel supported
How does the organisation
and are encouraged to identify and report
involve consumers?
negative events. This gives organisations
How are consumers able to add
opportunities to find and act on things that
to information about a negative event
can improve their systems. This includes
and, where possible, take part in the
how the organisation recognises when
incident review and in finding solutions
something has gone wrong that could harm,
and outcomes from complaints?
or has harmed, someone. The organisation
is expected to tell the consumer about this, When things go wrong, are there clear
apologise, and explain what has happened. responsibilities within the organisation
They should also explain why it happened for communicating with consumers and
and what they are doing to prevent it from their representatives so that they receive
happening again. the information they need to understand
what happened?
What has the organisation done

to promote and support a culture
of learning from mistakes?
What has it done to implement and sustain
the changes needed in care and services
from lessons learned?
How does the organisation use the

advice of advocates and community
representatives to understand the best
and most appropriate way to resolve
a complaint for a consumer?

Consumers • Records that show application of a best
•C
onsumers and their representatives practice complaints management system
are confident that the organisation in operation for the organisation.
acts appropriately and promptly when • Evidence that shows the organisation
responding to feedback and complaints. has clear responsibilities and timeframes
•C
onsumers are involved in finding options for responding to complaints.
to resolve a complaint. • Documented complaints and incidents.
•C
onsumers feel that the organisation has Evidence shows that the organisation has
given them an honest explanation from included consumers to find solutions and
the organisation when things have gone taken appropriate action.
wrong and are reassured that it won’t • Policies and procedures that show how
happen again. the organisation asks for feedback from
•C
onsumers aren’t afraid the organisation consumers and representatives about
will treat them badly after making how satisfied they are with the complaints
a complaint. management system.
• Evidence that communication by the
organisation after adverse events is open,
• T he workforce can describe the
honest and timely. This may include
complaint handling system in place
communication between consumers, their
in the organisation, and give examples
representatives, members of the workforce
of responding to complaints.
and where relevant, between organisations.
•M embers of the workforce can provide
examples of communicating with
a consumer about a complaint and what the
organisation is doing to resolve it.
• I f something has gone wrong, members
Standard |
of the workforce can describe how the
organisation took an open disclosure
approach to communicating with
consumers, their representatives 6
and others.
• T he workforce say the organisation
encourages them to acknowledge mistakes
without being afraid of the consequences.
this requirement.
Standard 6
Requirement (3)(d)

are reviewed and used
to improve the quality
of care and services.

The organisation is expected to have a best
practice system to manage feedback and How does the organisation monitor, analyse
complaints. Organisations should use this and use feedback and complaint data to
system to improve how they deliver care improve the quality of its care and services?
and services.
How does the organisation share what
As well as encouraging complaints and
it has learnt?
asking for feedback, the organisation should
How does it share improvements
provide timely feedback to the organisation’s
that have come out of feedback
governing body, its workforce and
or complaints internally and with other
consumers on complaints and the actions
relevant organisations?
the organisation took. It’s expected that
the organisation will use information from
How does the organisation involve
complaints to make improvements to safety
consumers and the workforce in reviewing
and quality systems and regularly review and
information from feedback and complaints
improve how they manage complaints.
to improve their care and services?
Standard |

Consumers • The workforce can describe how the
• Consumers and their representatives are organisation records, analyses and acts
confident the organisation uses feedback on feedback and complaints to improve the
and complaints to improve the quality quality of their care and services.
of their care and services. • The workforce can describe how feedback
• Consumers can describe a range of ways and complaints are used to improve the
they can be involved in finding solutions quality of care and services delivered.
to issues that they have raised in feedback • Workforce orientation, training or other
or complaints. records show how the organisation
• Consumers can describe how the supports the workforce in using feedback
organisation informs them of processes and complaints to continuously improve
available to escalate complaints if required. the service.
• Consumers can describe ways that the Organisation
organisation has learnt from complaints • Evidence that the organisation monitors
and made improvements to their service. feedback and complaints.
• Evidence that complaints are escalated
so that they go to a member of the
organisation with authority to make
a change.
Human resources
Standard 7 |
Human resources
Standard 7 |

I get quality care and
7 (1) 7 (3) The organisation demonstrates
the following:
services when I need 7 (3) (a) The workforce is planned to
them from people who enable, and the number and mix
are knowledgeable, of members of the workforce
deployed enables, the delivery
capable and caring. and management of safe and
quality care and services.
7 (3) (b) Workforce interactions with
consumers are kind, caring and
respectful of each consumer’s
Organisation statement identity, culture and diversity.
The
7 (2) organisation has 7 (3) (c) The workforce is competent and
members of the workforce have
a workforce that is the qualifications and knowledge
sufficient, and is skilled to effectively perform their roles.
and qualified to provide 7 (3) (d) The workforce is recruited,
trained, equipped and supported
safe, respectful and to deliver the outcomes required
quality care and services. by these standards.
7 (3) (e) Regular assessment, monitoring
and review of the performance
of each member of the workforce.
Human resources
Standard 7 |
Purpose and scope This includes delivery of any new

of the Standard or developing training in areas such
as, but not limited to, outbreak management
This Standard requires an organisation
and infection
to have and use a skilled and qualified
workforce, sufficient to deliver and manage Assessment, monitoring and review
safe, respectful, and quality care and To meet this Standard, an organisation
services, which meet the Quality Standards. needs to regularly assess, monitor and
This Standard includes four key concepts: review its workforce through an effective
human resources system. This includes
The sufficiency of the workforce
the workforce makeup, suitability and
Organisations providing care and services performance. This is vital to delivering safe,
are expected to have enough skilled and respectful and quality care and services that
qualified staff to meet consumers’ needs. meet consumers’ needs and preferences.
Organisations are responsible for using
Other than noting that compliance
Australian Government funding to make
by organisations will be required, this
sure they have the staff numbers and mix
Standard does not consider work health and
of skills needed to provide consumers with
safety or areas of human resources that deal
quality care, including engaging or appointing
with in other Acts, legislation or codes.
infection prevention control (IPC) lead(s).
The attributes, attitude and performance
of the workforce
The workforce need the right skills,
qualifications and knowledge. They Assessment against
are expected to be able to do their job this Standard
effectively and be able to communicate For each of the requirements,
and build positive relationships with organisations need to demonstrate
consumers. A focus on consumer-centred that they:
care encourages the right interactions • understand the requirement
with consumers to find their strengths and
understand their goals.
Organisational support for the workforce and services
Organisations should respect their workforce • monitor how they are applying
for their diverse skills and qualities. the requirement and the outcomes
Standard |
They need to support them to deliver the they achieve

outcomes the Quality Standards describe. • review outcomes and adjust their
Organisational support means that the practices based on these reviews
service gives the workforce the time and to keep improving. 7
the tools needed to deliver quality care
to consumers every day, while maintaining
the health and safety of their workforce
in the event of an outbreak.
Human resources
Standard 7 |

Standard 7 supports all of the other Quality • Aged Care Act 1997 (Cth), User Rights
Standards. This is because it supports how Amendment (Charter of Aged Care Rights)
the organisation focuses on workforce Principles 2019
planning to demonstrate it has the capacity • Age Discrimination Act 2004 (Cth)
to run the organisation and deliver safe, • F air Work Act 2009 (Cth)
effective and quality care and services,
•R acial Discrimination Act 1975 (Cth)
in a safe comfortable environment.
It requires the organisation to support the •S ex Discrimination Act 1984 (Cth)
workforce to deliver the outcomes required • State and Territory anti-discrimination
by these Standards. and equal opportunity legislation
Resources and references

and Quality in Health Care (2015).
Health Literacy Infographics 1
• Australian Health Professionals
Regulation Agency 2
• Medical Board of Australia 3
• Volunteering Australia, The National
Standards for Volunteer Involvement 4
1 https://www.safetyandquality.gov.au/publications/health-literacy-infographics/
2 https://www.ahpra.gov.au/
3 http://www.medicalboard.gov.au
4 https://www.volunteeringaustralia.org/resources/national-standards-and-supporting-material/#/
Standard 7
Requirement (3)(a)
The workforce is
planned to enable,
and the number and
mix of members of the
workforce deployed
enables, the delivery
and management of
safe and quality care
and services. Standard |
Human resources
Intent of this requirement Regularly reviewing workforce levels and

This requirement expects organisations their mix of skills is expected. This includes
to have a system to work out workforce adapting these levels to respond to the
numbers and the range of skills they need changing needs and situations of consumers.
to meet consumers’ needs and deliver safe As part of this, organisations need to manage
and quality care and services at all times. growth and changes in workforce needs.
This system needs to be in line with current The organisation’s approach is expected
legislation and guidance where it applies. to include ways to promptly identify
The system for managing the workforce and manage issues and risks that might
may be different for each type of care and result in not having enough members of
service. It’s expected that an organisation the workforce, such as an influenza or
uses a structured approach for rosters and coronavirus (COVID-19) outbreak. They also
schedules, hiring and keeping members need to anticipate and think about ways to
of the workforce, managing different types deal with shortages across the workforce.
of leave and the use of contracted staff. In addition to having enough staff to deliver
Organisations are expected to consider the the usual work of the organisation,
different levels of skills and abilities needed it is expected that the organisation will
to meet consumers’ needs. This includes have considered its staffing needs during
working out the registered professional an internal or external emergency.
and support staff needed, and the
supervision and leadership needed.
Human resources
Is there a system to calculate How does the organisation consider

the workforce numbers and range of skills continuity of care and services for
the organisation needs so they can assess, consumers in their planning workforce
plan and coordinate care and services strategies and processes?
to meet the needs of consumers and
deliver safe and quality care and services How does the organisation identify short
at all times? or long-term shortages in the capacity
How is this worked out? or skills of its workforce, and how are these
shortages addressed?
What processes does the organisation use
to enable the workforce to give feedback on Does the organisation use innovative
the number of staff and mix of skills needed ways of working, tailored to the needs
to deliver care and services and any deficits? of consumers?
What processes does the organisation How does the organisation identify
use to enable volunteer Managers to give contingencies for an outbreak, including
feedback on the number of volunteers finding staff through labour hire agencies
and mix of skills needed to support and within the wider organisation?
person-centred care?
How does the organisation use influenza
How has the organisation considered and coronavirus (COVID-19) vaccination
the skills needed to meet consumers’ needs rates to inform workforce planning?
across the different types of competencies
of the workforce?
This includes registered professionals,
support workers, supervision and
leadership roles.
How does the organisation regularly review

and adapt the workforce levels and mix
of skills to respond to the changing needs
and situations of consumers?
How does the organisation know that
Standard |
the workforce is sufficient and can carry out

the care and service needs of consumers?
Human resources
Examples of actions and evidence • The workforce say they know what
Consumers to do when the organisation is experiencing
• Consumers say they know the members staff shortages and are confident
of the workforce who care for them and that management will respond.
they have continuity of care. • The workforce can describe how there are
• Consumers say they get quality care enough staff rostered to meet consumers’
and services. preferences. This includes showering
at a particular time, or asking for a member
• Consumers say the organisation delivers
of the workforce of a specific gender to care
their care and services as planned
for them.
and safely.
• Volunteers are aware of, and have access to,
available training to support them to
have the time to deliver care and services
perform their roles.
and they don’t feel care and services are cut
short or rushed. Organisation
• Consumers say that they have access to • Evidence of a system for planning and
volunteers to feel supported and connected. managing the workforce that shows
the organisation has the right number
of workforce members, with the right
• Observations of workforce numbers and blend of skills, delivering care and services
mix deployed at the service in relation at any time.
to the consumers’ care and services plans.
• Work schedules or rosters for the workforce
• Observations that the delivery of particular show how the organisation makes sure
care and services is undertaken by suitably there are enough workforce members
qualified members of the workforce to provide safe and quality care and
consistent with safe and quality care. services every day.
• The workforce say the organisation has • Records show that when the organisation
enough staff and the right mix of staff has a workforce shortage, they act on this
to plan and deliver care and services so promptly. This makes sure consumers
that consumers get safe and quality care. receive safe and quality care and services.
organisation allocates staff to support
continuity of care and services and build
relationships of trust with consumers.
Standard 7
Requirement (3)(b)
Workforce interactions
with consumers are kind,
caring and respectful of
each consumer’s identity,
culture and diversity.
Standard |
Human resources

The way the workforce interacts with
consumers can have a big impact on the How does the organisation know that
outcomes of their care and services, the workforce interacts with consumers
including their safety, health and well-being. in a kind, caring and respectful way?
With this requirement, it’s expected that How does it drive this culture?
the workforce behaves in a kind, caring and
respectful way. How does the organisation support the
workforce with up-to-date information,
In day-to-day interactions with consumers,
tools and resources to respond
the workforce is expected to treat each
to consumers’ life experiences, culture
consumer as an individual with their own
and diversity?
unique life experiences, preferences, needs
and abilities. A consumer-centred approach
Does the organisation include the
needs the workforce to work with consumers
behaviours it expects from its workforce
in a flexible and responsive way. This means
in its public documents, job statements and
consumers receive the best possible care
position descriptions?
and services.
How does the organisation respond
when a member of the workforce does
not respect consumers’ identity, culture
or diversity or show kindness and
a caring attitude?
How does the staffing model at the

organisation support a culture of care
and respect?
Does the staffing model support the

consumer’s gender and diversity needs
and preferences to be met?
Are any workforce policies or practices

creating barriers to caring and
inclusive care?
Human resources

Consumers • Evidence of communications that show
• Consumers say members of the workforce the organisation is committed to respectful
treat them with kindness and the workforce care and services.
cares about them. • Evidence of the organisation’s recruitment
• Consumers say that the workforce respects processes that consider value based
their identity, culture, and diversity and requirements such as a caring and
the care and services choices they make. compassionate nature.
• Consumers say they have a trusting • Feedback or records that show consumers
relationship with members of the workforce have interactions with the workforce
supporting them and the relationship that are kind and caring. Interactions are
is respectful and caring. also respectful of their identity, culture
and diversity.
• Observations of the delivery of care and
services that show the workforce interacts
with consumers in a way that is kind, caring
and respectful.
describe how they lead a culture of respect
for diversity. They can also describe how
they monitor whether consumers have
positive interactions with the workforce.
are proactive about diversity. They can
also describe how they respond to the
diversity of consumer’s needs, backgrounds
and identities.
• The workforce can provide examples from
their day-to-day practice of respectful care
and services.
• The workforce can describe what they
would do if they saw other members
Standard |
of the workforce being disrespectful

or unkind to consumers.
Standard 7
Requirement (3)(c)
The workforce is
competent and members
of the workforce have
the qualifications and
knowledge to effectively
Human resources
Intent of this requirement How does the organisation test the

This requirement is intended to make competence and skills of its workforce
sure the workforce has the skills, and ensure they continue to develop skills
qualifications and knowledge they need relevant to their roles?
for their role to provide care and services.
The requirement covers an organisation’s How does the organisation keep
systems to regularly review the roles, up-to-date on policies and the scope
responsibilities and accountabilities of practice requirements for registered
of their workforce. If personal or clinical health practitioners?
care is provided, it’s expected that the
organisation has systems to monitor How is the workforce supported to manage
whether staff are working within the scope conditions that are common in aged care?
of their practice, responsibilities and skills. For example understanding how to support
The way staff delivering clinical care work consumers with memory problems,
needs to be in line with current legislation, arthritis, visual or hearing loss?
guidance and the organisation’s clinical
governance framework in accordance with How does the organisation demonstrate
relevant public health orders. that training for all staff in infection
management and control is contemporary
and in line with best practice, including
Reflective questions those specific requirements for IPC lead(s)?
Has the service appointed an infection How do staff access information about and
prevention control (IPC) lead(s), which understand their individual role(s) in the
report to the approved provider? Outbreak Management Plan?
Has the IPC lead(s) completed an identified
IPC course? Has ongoing infection control Has the service consulted and prepared
and prevention training occurred for with their workforce a plan to respond
all staff? effectively to an outbreak?
How does the organisation know that only

suitably skilled and competent members
of the workforce are delivering care
and services?
Standard |
How does the workforce know their

responsibilities and accountabilities?
How does the organisation assess the
workforce against these? 7
Human resources
Examples of actions and evidence • Staff, including the IPC lead(s) can describe
Consumers how outbreak management planning and
preparedness occurs within the service,
• Consumers say they have confidence
including implementation and quality
in the workforce. They feel the workforce
improvement policies, processes and
is trained, competent and skilled.
practices are managed within the service.
• Consumers say the workforce is able
• The workforce is satisfied with the
to meet their social, cultural, religious,
supervision and support they receive from
spiritual, psychological and medical care
the organisation when they are learning
and support needs.
new skills.
• Consumers say the organisation has
• The workforce believe that colleagues and
collaborated with other providers when
subcontractors who deliver care and services
their care and service needs are beyond the
have the skills, qualifications and knowledge
ability of the workforce to provide.
base to competently perform their roles.
• Consumers say the workforce has
• The workforce can describe regular
communicated their outbreak management
professional development or training
plan and it is available upon request.
to improve their knowledge so they can
• Consumers feel supported and connected effectively perform their roles.
through volunteers.
• The workforce feels safe to come to work
Workforce and others and confirm that they are supported
• Observations that the delivery of care to undertake their role, particularly in
and services is by suitably competent the context of a pandemic.
and qualified members of the workforce Organisation
consistent with safe and quality care and
• Evidence of records that show the
scope of practice.
organisation assesses and checks that
• Observations that delivery of care and members of the workforce, including IPC
services is provided by members of the lead(s), have the skills, qualifications and
workforce consistent with their assessed knowledge to be competent at their job.
needs, goals and preferences and any risks
• Evidence that systems to identify if the
associated with the care and service.
workforce has the right mix of skills,
• The workforce can describe how they qualifications, knowledge and competencies
work within their skills, qualifications and are operating and gaps identified
knowledge base. are addressed.
• The IPC lead(s) can describe how they meet • Evidence that the organisation acts
the requirements of their role to support promptly on any workforce shortages.
design, implementation and continuous
• Volunteers feel supported by the
improvement of infection prevention policies,
organisation to perform their volunteer roles.
procedures and practices within the service.
• Organisations are proactive in ensuring
• Volunteers are aware of, and have access
volunteers have access to training to
to, available training to support them to
support the role they undertake in
supporting the consumer.
Standard 7
Requirement (3)(d)
The workforce is recruited,

trained, equipped and
supported to deliver
the outcomes required
by these standards.
Standard |
Human resources

This requirement covers the organisation’s
support for the workforce to deliver the Does the organisation’s current
outcomes for consumers in line with the recruitment, training programs,
Quality Standards. Meeting this requirement workforce support and resources meet
will support the workforce in their day-to-day the outcomes required by these Standards?
practice and can protect against risk and
improve the care outcomes for consumers. Are recruitment processes fair,
reasonable and transparent?
When recruiting, organisations should
identify the specific requirements of roles
When a third party carries out recruitment
and reflect on the outcomes required
and checks on new employees, how does
by these Standards. It’s expected that
the organisation make sure that practices
workforce induction prepares members
and checks are complete and satisfactory?
of the workforce for their role. The
organisation needs to make sure members
How does management of the organisation
of the workforce are supported, skilled
learn about and respond to members
and ready to carry out their roles. Where
of the workforce who feel they don’t have
appropriate, members of the workforce
enough training or support to do their job
should be supervised until they can show
and aren’t meeting these Standards?
that they have the competence they need
to carry out their role unsupervised.
It’s expected that members of the workforce
receive the ongoing support, training,
professional development, supervision and
feedback they need to carry out their role
and responsibilities.
Organisations need to review the training,
learning and development needs of the
workforce regularly and when practices
change. It’s expected that organisations
support members of the workforce to take
up training, learning and development
opportunities, so they can meet the needs
of their role.
Human resources

Consumers • Evidence of effective recruitment and
selection processes and appropriate
• Consumers say they are satisfied that the
checks being undertaken for the workforce.
organisation trains, supports and prepares
This includes police and reference checks.
its workforce enough.
• Records of selection and interview
• Consumers say they have confidence in the
processes that check the accuracy
ability of members of the workforce that
of applications.
deliver their care and services.
• Evidence of induction and other training
• Consumers say they can take part in training
and development programs for all
of members of the workforce who provide
members of the workforce relevant
their care and services to make sure the way
to these Standards.
they deliver the care and services meets
their needs, goals and preferences.
• The workforce can describe the training,
support, professional development and
supervision for them to be able to carry out
their role.
• The workforce can describe how they give
input and feedback to the organisation
about their training and support needs
and how to improve the training and
support provided.
describe how they work out what
training will be needed for the workforce
in line with new or the changing needs
of their consumers.
Standard |
Standard 7
Requirement (3)(e)
Regular assessment,
monitoring and review
of the performance
of each member
of the workforce.
Human resources

All members of the workforce are expected
to have an appropriate person regularly Are there policies and procedures
evaluate how they are performing their to make sure the organisation monitors
role, and identify, plan for and support any each member of the workforce’s duties
training, and development they need. This and responsibilities?
requirement looks at how organisations need What about the workforce’s overall
to regularly assess the performance and ability to provide safe and quality care
the capabilities of the workforce as a whole. and services?
Performance reviews can also support
continuous improvement and development How does management of the organisation
of the members of the workforce. respond when performance reviews find
a lack of knowledge, skills and ability
in the workforce to deliver care and
services against the Standards?
How does the organisation assess

and monitor the performance of members
of the workforce who are subcontractors?
Standard |
Human resources

Consumers • Evidence that the organisation regularly
• Consumers say they are satisfied the assesses and monitors the performance
workforce providing their care and services of members of the workforce. This includes
perform their roles well. during probation periods.
• The organisation involves consumers with • Evidence the organisation uses
diverse life experiences and characteristics performance assessments to work out
in assessing, monitoring and reviewing the training needs. It also uses performance
workforce at all levels of the organisation. assessments to review duties and
responsibilities, and maintain the
Workforce and others workforce’s overall ability to provide safe
• Members of the workforce can confirm they and quality care and services.
have had a performance review or have • Records or schedules detail the percentage
one scheduled. of staff with completed performance
• Members of the workforce can describe reviews and follow up of those who don’t
how the organisation’s ongoing take part.
assessment of their duties, responsibilities
and performance happens. They can
describe how this links into their
performance development.
• Members of the workforce can describe
how they assess the safety and quality
of the care and services they deliver.
They can also describe how they monitor
their own work performance and any areas
for further training and support.
Standard 8 |
Standard 8
Organisational
governance
Standard |
8
Standard 8 |
Consumer outcome 8 (3) (c) Effective organisation wide

I am confident the
8 (1)
governance systems relating
to the following:
organisation is well (i) information management
run. I can partner in (ii) continuous improvement
improving the delivery (iii) financial governance
(iv) workforce governance,
of care and services. including the assignment
of clear responsibilities
and accountabilities
(v) regulatory compliance
(vi) feedback and complaints.
The
8 (2) organisations’ 8 (3) (d) Effective risk management
governing body systems and practices, including
but not limited to the following:
is accountable for (i) managing high-impact
the delivery of safe or high-prevalence risks
and quality care associated with the care
of consumers
and services. (ii) identifying and responding
to abuse and neglect
of consumers
(iii) supporting consumers to live
Requirements the best life they can
8 (3) The organisation demonstrates (iv) managing and preventing
the following: incidents, including
8 (3) (a) Consumers are engaged the use of an incident
in the development, delivery management system.
and evaluation of care and 8 (3) (e) Where clinical care is provided –
services and are supported a clinical governance framework,
in that engagement. including but not limited
8 (3) (b) The organisation’s governing to the following:
body promotes a culture of safe, (i) antimicrobial stewardship
inclusive and quality care and
(ii) minimising the use
services and is accountable
of restraint
for their delivery.
(iii) open disclosure.
Standard 8 |
Purpose and scope There are also particular requirements

of the Standard related to the following key areas:
The intention of this Quality Standard • managing high-impact or high-prevalence
is to hold the governing body of the risks in the care of consumers
organisation responsible for the organisation • identifying and responding to abuse
and the delivery of safe and quality care and and neglect of consumers
services that meet the Standards. • antimicrobial stewardship
The governing body sets the strategic • minimising the use of restraint
priorities for the organisation. It’s expected • practicing open disclosure.
to promote a culture of safety and quality, How the governing body and governance
and to include this in the organisation’s structures are organised will depend on the
governance systems. The governing organisation’s setting, size and the nature
body is expected to drive and monitor of care and services being provided. It will
improvements to make sure the organisation also depend on the level of responsibility
is committed to quality care and services and control the organisation has for
and the best interests of consumers. consumer outcomes and the risks involved
Including, a clear understanding of the risks in delivery of care and services. The evidence
at the service. needed to meet this Standard will reflect
While governance systems are a foundation these things.
for most businesses, this Standard
is focused on how these systems support
the delivery of safe and quality aged care
services. It’s expected the organisation has
governance systems in place to assess,
monitor and drive improvement in the
quality and safety of the care and services Assessment against
they provide. This includes making sure this Standard
consumers have a quality experience. For each of the requirements,
Organisations are expected to plan for, and organisations need to demonstrate
manage internal and external emergencies that they:
and disasters and have effective infection
prevention and control procedures in place.
and services
the requirement and the outcomes
they achieve
to keep improving.
Standard |
8
Standard 8 |
Linked Standards Governance

Standard 8 supports all of the other Quality • Aged Care Quality and Safety Commission
Standards. This is because it supports – Clinical Governance resources 2
how the organisation focuses on the • Aged Care Quality and Safety Commission,
requirements of each Standard strategically Open Disclosure Framework
to make sure they run the organisation well. • Department of Health and Ageing (2012).
Relevant legislation Decision-making tool: Supporting Restraint
Free Environment in Residential aged care
• Aged Care Act 1997 (Cth)
• Accountability Principles 2014 • Aged Care Quality and Safety Commission,
Effective incident management systems:
• User Rights Amendment (Charter of Aged
Best practice guidance (2021)
Care Rights) Principles 2019
• Anti discrimination legislation nationally • Aged Care Quality and Safety Commission,
Serious Incident Response Scheme:
• Privacy Act 1988 (Cth), Schedule 1, Australian
Guidelines for residential aged care
Privacy Principles
providers (2021)
• Records Principles 2014
• Department of Health, Guide for reporting
• Quality of Care Principles 2019
reportable assaults
• State and Territory food safety and handling
legislation and regulations • National Health and Medical Research
Council (2010). Australian guidelines for
• State and Territory mental health,
the prevention and control of infection
guardianship and administration, enduring
in healthcare
power of attorney and medical directive/
advance care planning legislation • Aged Care Quality and Safety Commission
• State and Territory Public Health Orders – Webinar: Accountability of Governing
Bodies in Aged Care 3
• State and Territory work health and
safety legislation • Australian Commission on Safety and
Quality in Healthcare – Resources 4
Resources • Australian Institute of Company Directors
Antimicrobial stewardship – Good Governance Principles and Guidance
• Australian Government, Department of for Not for Profit Organisation 5
Health & Department of Agriculture (2015). • Australian Institute of Company Directors
• Responding to the threat of antimicrobial – Not-for-profit Governance Principles 6
resistance: Australia’s first National
Antimicrobial Resistance Strategy 2015-2019 1
2 https://www.agedcarequality.gov.au/providers/quality-care-resources/clinical-governance
3 https://www.youtube.com/watch?v=5OjL5FeQ-f4&feature=youtu.be
4 https://www.safetyandquality.gov.au/publications-and-resources/resource-library?f%5B0%5D=topics%3A42
5 http://www.companydirectors.com.au/~/media/cd2/resources/director-resources/nfp/pdf/nfp-principles-and-guidance-131015.ashx
6 https://aicd.companydirectors.com.au/resources/not-for-profit-resources/not-for-profit-governance-principles
Managing infection-related risks • National Guidelines for Public Health

• Australian Health Protection Units in the Series of National Guidelines,
Principal Committee 7 Communicable Diseases Network
• Australian Health Sector Emergency Australia (CDNA) 15
Response Plan for Novel Coronavirus, • Communicable Diseases Information,
Department of Health 8 Transmission of respiratory diseases and
• Coronavirus Disease 2019 (COVID-19) managing the risk, Department of Health 16
Outbreaks in Residential Care Facilities, • COVID-19 and the Commonwealth Home
Communicable Diseases Network Support Programme – information for
Australia (CDNA) 9 clients, families and carers, Department
• Coronavirus resources, Department of Health 17
of Health 10 • Communicable Diseases Information,
• COVID-19 Escalation Tiers and Aged Care How to wash and dry hands, Department
Provider Responses 11 of Health 18
• Coronavirus (COVID-19) National aged care • Communicable Diseases Information,
guidance aged care visitation guidelines 12 How to clean hands using an alcohol based
liquid or hand rub, Department of Health 19
• Guidelines for the Prevention and Control
of Infection in Healthcare, National Health • 5 moments for hand hygiene,
and Medical Research Council 13 Hand hygiene Australia 20
• Infection Control Expert Group (ICEG) 14 • Outbreak management planning in aged care,
Aged Care Quality and Safety Commission 21
7 https://www.health.gov.au/committees-and-groups/australian-health-protection-principal-committee-ahppc
8 https://www.health.gov.au/resources/publications/australian-health-sector-emergency-response-plan-for-novel-coronavirus-
covid-19
9 https://www.health.gov.au/resources/publications/cdna-national-guidelines-for-the-prevention-control-and-public-health-
management-of-covid-19-outbreaks-in-residential-care-facilities-in-australia
10 https://www.health.gov.au/resources/collections/novel-coronavirus-2019-ncov-resources
11 ttps://www.health.gov.au/sites/default/files/documents/2020/11/coronavirus-covid-19-national-aged-care-guidance-escalation-
h
tiers-and-aged-care-provider-responses.pdf
12 ttps://www.health.gov.au/sites/default/files/documents/2020/11/coronavirus-covid-19-national-aged-care-guidance-aged-care-
h
visitation-guidelines.pdf
13 https://www.nhmrc.gov.au/health-advice/public-health/preventing-infection
14 https://www.health.gov.au/news/australian-health-protection-principal-committee-ahppc-statement-on-the-infection-control-
expert-group
15 https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm
16 https://www1.health.gov.au/internet/main/publishing.nsf/Content/transmission-of-respiratory-diseases-and-managing-the-risk
17 ttps://www.health.gov.au/sites/default/files/documents/2020/09/covid-19-and-the-commonwealth-home-support-programme-
h
information-for-clients-families-and-carers_0.pdf
18 https://www1.health.gov.au/internet/main/publishing.nsf/Content/how-to-wash-and-dry-hands
19 https://www1.health.gov.au/internet/main/publishing.nsf/Content/how-to-clean-hands-using-an-alcohol-based-liquid-or-hand-rub
Standard |
20 https://www.hha.org.au/hand-hygiene/5-moments-for-hand-hygiene
21 https://www.agedcarequality.gov.au/sites/default/files/media/acqsc_omp_v12.pdf
8
Standard 8
Requirement (3)(a)
Consumers are engaged

in the development,
delivery and evaluation
of care and services
and are supported
in that engagement.

Organisations are expected to have
an organisation wide approach to involve How does the organisation involve
consumers in developing, delivering a diverse range of consumers in developing,
and evaluating their care and services. designing and evaluating their care
This is an essential part of an organisation’s and services?
governance for a consumer-centred aged
care service. Does the organisation have a range of ways
consumers can provide feedback?
Organisations are expected to ask for input
Do the feedback options help consumers
from a wide range of consumers about their
from diverse backgrounds to take part?
experience and the quality of the care and
services they have received. Organisations
What systems are in place to ask for, and
are expected to review and respond to the
act on, feedback from consumers to keep
information they get from consumers.
evaluating and improving the service?
This includes addressing, and working to fix,
any issues consumers raise, and using the
What relationships does the organisation
information to plan improvements and show
have with consumer advocates and
that they have been made.
community representative groups?
How does it involve them in developing,
delivering and evaluating care and services?
Standard |
8

Consumers • Records that show the organisation involves
• Consumers can describe how the consumers in the development, delivery
organisation supports and encourages and evaluation of care and services.
them to be involved in designing and • Planning or budget documents that have
improving care and services. They can also identified effective times and places
describe how this has made a difference. to engage with consumers.
• Consumers can describe a range of ways • Evidence that shows groups responsible
they can take part in influencing how care for directing development and redesign
and services are developed, delivered and projects include consumer representatives
evaluated. They also say how these meet who can reflect what consumers want
their diverse needs. and need.
Workforce and others • Records of meetings, consultations
• Management of the organisation can or forums with consumers and their
describe the different ways the organisation community about issues important to them
involves consumers in developing, (this could cover any issues such as the
delivering and managing care and services. cultural safety of care and service programs,
They can also describe how it has made quality of meals or the arrangement
a difference to their approach. of the service environment).
• The workforce can demonstrate they • Evidence and examples of how the
understand the organisation’s commitment organisation shows, monitors and reports
to and processes for involving consumers. how it has performed against this Standard.
• The workforce can provide examples Examples of continuous improvement
of how the organisation uses the results against this requirement.
of consumer feedback to improve how they
deliver care and services.
records that show how the workforce
is supported to involve consumers and
the ways members of the workforce can
help consumers to be involved.
Standard 8
Requirement (3)(b)
The organisation’s
governing body
promotes a culture
of safe, inclusive and
quality care and services
and is accountable for
their delivery.
Standard |
175 175
8
Intent of this requirement What priorities and strategic directions has

This requirement states the governing the governing body set and communicated
body of the organisation is responsible to the organisation for safe, inclusive and
for promoting a culture of safe, inclusive quality care and services?
and quality, care and services in the How are priorities reviewed and
organisation. The governing body communicated during emergencies and
of the organisation is also responsible disasters, including during infectious
for overseeing the organisation’s strategic outbreaks?
direction and policies for delivering care
to meet the Quality Standards. How does the governing body promote
A culture of safe inclusive and quality care timely access to precautionary infection
and services is one that is embedded in all control measures including COVID-19
aspects of organisational life and owned by vaccinations and, in the event of an
everyone. It is the organisation’s governing outbreak, timely access to prescriptions?
body that enables this through its leadership,
What information does the governing
decisions made and directions set for the
body ask for about the organisation’s
organisation. It will be reflected in how the
performance and continuous improvement
organisation communicates its meaning and
to meet the Quality Standards?
purpose to the workforce, consumers and
those outside the service.
How does the governing body look
at how inclusive the organisation’s care
and services are for a diverse range
of consumers?
How does the governing body know it
How has the governing body shown is meeting what consumers, the workforce,
it’s committed to, and leads, a culture the community and others expect for safe,
of safety and quality improvement inclusive and quality care and services from
in the organisation? the organisation?
How is the extent of this culture
in the organisation known?
Has the governing body communicated

the importance of their workers being
vaccinated against influenza and
coronavirus (COVID-19) to promote
the key role vaccination plays in the
delivery of safe, inclusive and quality
care and services?

Consumers • Evidence that members of the governing
• Consumers are confident the organisation body have the right experience to govern
is run in their best interests and their views an organisation providing care and service
and needs shape how the organisation to vulnerable consumers.
is run. • Evidence of how the governing body
• Consumers feel the service culture (the way decides, explains, assigns and puts their
things get done) supports their health, quality, safety and cultural goals into action
safety and well-being and is inclusive within the organisation.
of their identity, culture and diversity. • Evidence that the governing body asks
• Consumers can describe ways the for and receives the information and advice
organisation asks for their opinions it needs to meet its responsibilities under
to improve the service culture. this requirement.
• Strategic, business and diversity action
plans that describe the priorities
and strategic directions for inclusive
governing body promotes a culture of safe,
care endorsed by the governing body.
inclusive and quality care and services.
Evidence of how the organisation
They can also describe how the governing
implements, monitors and improves these.
body tries to understand how things are
done in the organisation. • Evidence that the governing body
understands and sets priorities to improve
• The workforce describes how management
the performance of the organisation against
of the organisation demonstrates the
the Quality Standards and consistent with
behaviours and values the governing
the Charter of Aged Care Rights.
body promotes. They say this gives them
confidence to do the same.
organisation’s vision, aims or strategic
objectives that affect their practice.
They say the organisation is run in a way
that supports consumer outcomes.
• The workforce can give examples that
show how the organisation includes safe,
inclusive and quality care and services
in the organisation.
Standard |
8
Standard 8
Requirement (3)(c)
Effective organisation wide

governance systems relating
to the following:
(i) information management
(ii) continuous improvement
(iii) financial governance
(iv) workforce governance,
including the assignment
of clear responsibilities
and accountabilities
(v) regulatory compliance
(vi) feedback and complaints.
Intent of this requirement (ii) Continuous improvement

Organisation wide governance is about Continuous improvement systems and
how the organisation applies and controls processes assess, monitor and improve
authority below the level of the governing the quality and safety of the care and
body. Authority flows from the governing services provided by the organisation.
body to the Chief Executive Officer (or similar This includes the experiences
role), then, to the executive or management of consumers. These systems help
team and throughout the organisation. the organisation to identify where
This requirement lists the key areas quality and safety is at risk. They also
that an organisation needs for effective help an organisation to respond
organisation wide governance systems. appropriately and promptly to these
These systems should take into account the risks. Organisations must have a plan for
size and structure of the organisation. They continuous improvement and check their
should also help to improve outcomes for progress against this plan to improve the
consumers. quality and safety of care services.
The key areas for organisation wide (iii) Financial governance
governance systems are: Financial governance systems and
(i) Information management processes manage the finances and
Effective information management resources that the organisation needs
systems and process give appropriate to deliver safe and quality care and
members of the workforce access services. Organisations are expected
to information that helps them to include the capital and revenue costs
in their roles. It also makes sure of maintaining safety and quality in their
consumers can access information financial planning. Effective financial
about their care and services. These management and reporting systems give
systems cover how an organisation the governing body the assurance they
maintains, stores, shares and destroys require to be satisfied of compliance
information and how it controls privacy with this requirement.
and confidentiality. Information that
supports consumers to make decisions
should be relevant and accurate and
provided in a timely manner.
Standard |
8
(iv) Workforce governance Reflective questions

– including assigning clear
responsibilities and accountabilities Does the organisation have a documented
Workforce governance systems whole-of-organisation governance
and process make sure workforce framework, which includes personal
arrangements are consistent with and clinical care if delivered?
regulatory requirements. They also
need to make sure the organisation has Does the governance framework focus
enough skilled and qualified members on strategic needs?
of the workforce, including a designated
member of the nursing staff who has Does the organisation have systems
completed an identified IPC course. to monitor and evaluate how they perform
The organisation must support and against strategic and other objectives for
develop its workforce to deliver safe safe and quality care and services?
and quality care and services. Members
Does the organisation support
of the workforce need to have clear
a culture of evaluation that includes
responsibility and accountability for
transparency, openness and a two-way
managing the safety and quality of care
sharing of information and advice across
and services, and sufficient authority
the organisation?
to do this.
(v) Regulatory compliance If services are not performing at peak level,
Regulatory compliance systems and does the organisation move resources
process make sure the organisation to ensure appropriate consumer outcomes?
is complying with all relevant
legislation, regulatory requirements, What measures are in place for the
professional standards and guidelines. organisation to effectively monitor IPC
This requirement doesn’t measure how practices to determine where shortfalls
an organisation complies with other may exist? What processes are in place
legislative frameworks, but provides to ensure changes are made when
an understanding of whether the a shortfall is identified?
organisation itself undertakes this task.
(vi) Feedback and complaints How does the organisation demonstrate
Feedback and complaints systems and that policies and procedures are
processes actively look to improve contemporary and in line with best
results for consumers. The system practice documents, including those which
used is relevant and proportionate outlines requirements for IPC lead(s) and
to the range and complexity of care outbreak management?
and services the organisation delivers,
as well as its size and scale. The system
follows principles of transparency,
procedural fairness and natural justice
and meets best practice guidelines.
How does the organisation demonstrate Examples of actions and evidence

that an outbreak management plan Consumers
is in place, and that staff are aware of their • Consumers say the organisation asks for
roles and responsibilities as part of that their opinions about the care and services,
plan, including when any changes are made? listens to them and makes improvements
as a result.
Does the organisation use regular
• Consumers say they are confident their care
reviews and evaluation to identify new
and services are well managed.
needs and tackle current continuous
• Consumers say the organisation has made
improvement priorities?
changes when something has gone wrong
to prevent it happening again.
How do the organisation’s risk and
responsibility systems and processes • Consumers say they can review information
include ethical decision-making on the safety and quality of care and
in the organisation? services the organisation delivers.
Where the organisation uses services from • Management of the organisation can
other specialist providers, are the different describe their role in developing governance
levels of responsibility for governance and frameworks to support the governing body’s
monitoring clear to everyone? strategies for safe, inclusive and quality
care and services.
What systems are in place to manage • The workforce can describe how the
communications and engagement with organisation supports openness,
families of residents and community? discussion, engagement, respect, trust and
a culture of good governance.
Does the organisation undertake audits • The workforce can describe how they take
of all key aspects of their outbreak part in activities that identify, measure and
management plan, including testing evaluate problems within the organisation
organisational processes, staff knowledge and in the care and services it delivers
and practices, consumer outcomes and to consumers. They can also describe how
regulatory compliance? improvements are made.
• Members of the workforce are clear on their
Does the organisation have effective
authority to make decisions to meet the
governance systems relating to regulatory
strategic or planned objectives of the
compliance, which includes compliance
organisation. They say policies that inform
with jurisdictional public health orders, and
decisions are easy to understand and
record-keeping and reporting requirements
accessible to all members of the workforce.
under the Accountability Principles 2014
• Members of the workforce can describe how
and Records Principles 2014?
the organisation makes sure the processes
in their particular areas are efficient
Are there effective organisation-wide
and effective. They say the organisation
systems for preventing, managing and
Standard |
prevents, responds to and manages

controlling infections?
risks appropriately.
8
• Demonstrate that the IPC lead(s) has the • Evidence of continuous improvement across
level of clinical expertise and influence the organisation.
at a service. • Evidence that the organisation is mindful
• Workforce orientation, training or other of the key risks associated with the service
records that show how the organisation and the individual people receiving care
supports the workforce to meet at the service and can demonstrate
this requirement. how this has influenced their outbreak
• Members of the workforce can describe management planning and response.
different channels of communication
and providing updates to staff from the
organisation and governing body.
Organisation
• Evidence of systems and processes, from
the care and service level through to the
governing body level, for managing and
governing all aspects of care and services.
• Performance monitoring records given
to the governing body show whether the
organisation is performing at peak level
and meeting its policy, planning and
operational goals.
• Evidence the IPC lead(s) reports to the
organisation, which retains overall
responsibility for compliance with
IPC requirements.
• Evidence that the organisation has systems
in place to support outbreak management
planning and practices, including
it remains aligned with contemporary
best practice, and is practiced within the
• Committee and meeting records show
management of the organisation and the
governing body have information, data and
options to make informed decisions.
• Evidence of policies and instruments
of delegation that make it clear to the
workforce, and help them to understand,
the organisation’s compliance and
other obligations.
Standard 8
Requirement (3)(d)
Effective risk management

systems and practices,
including but not limited
to the following:
(i) managing high-impact
or high-prevalence risks
associated with the care
of consumers
(ii) identifying and
responding to abuse and
neglect of consumers
(iii) supporting consumers to
live the best life they can
(iv) managing and
preventing incidents,
including the use
of an incident
Standard |
management system.
8
Intent of this requirement (ii) Identifying and responding to abuse

Organisations are expected to have systems and neglect of consumer
and processes that help them identify and All Australians have rights, which do not
assess risks to the health, safety and well-being diminish with age, to live dignified, self-
of consumers. If risks are found, organisations determined lives, free from exploitation,
are expected to find ways to reduce or remove violence and abuse. The organisation
the risks in a timeframe that matches the level is expected to have systems to provide
of risk and how it’s affecting consumers. appropriate protections and safeguards
around the delivery of care and services,
It’s expected that the organisation’s risk
to respond effectively to incidents
management system identifies and evaluates
of abuse, to report this according
incidents and ‘near misses’ (both clinical
to the law, and to raise awareness
incidents and incidents in delivering care and
in the organisation to lower the risk
services). A near miss is when an occurrence,
of elder abuse.
event or omission happens that does not
result in harm (such as injury, illness or danger (iii) Supporting consumers to live the best
to health) to a consumer or another person life they can
but had potential to do so. It’s also expected Organisations are expected to have
that the organisation uses this information systems and processes to reduce the
to improve its performance and how it delivers possibility of risks and the impact they
quality care and services. have on consumers however, this should
Organisations are expected to escalate be in consultation with consumers
risks to the health, safety and well-being to support them to live the best life they
of their consumers within the organisation can. These systems underpin outcomes
or to a relevant external service or organisation. under Standard 1 and delivery of care
It’s also expected that organisations continue and services under Standards 3 and 4.
to monitor risks to consumers and others and (iv) Managing and preventing incidents,
take action if a risk has increased. including the use of an incident
Effective risk management systems and management system
practices encompass requirements in the Organisations are expected
following areas: to effectively prevent and manage
incidents, including through the use
(i) Managing high-impact or high-
of an incident management system
prevalence risks associated with
that enables incidents to be identified,
the care of consumers
responded to, and notified to the
While organisations need to manage all
Commission (as required). Incidents
risks related to care and services, some
should be resolved in consultation with
risks are more common and have a higher
consumers and staff, and incident data
impact on the health and well-being of
should be used to identify trends, drive
consumers. Preventable harm from these
continuous improvement to improve
risks continues to happen in aged care.
the quality of the care and services, and
Sound governance systems are required
prevent similar incidents from occurring.
to support the delivery of care under
Standard 3 – Personal and Clinical Care.
Does the organisation have systems for How does the organisation escalate
identifying risks and incidents, minimising incidents and near misses to understand
and managing risks and responding and respond to risks? How is incident data
to incidents to support the safety and well- used to drive continuous improvement
being of consumers? and to prevent similar incidents occurring
in future?
What are the systems to manage high-
impact, high-prevalence risks and how are How are consumers and their
these systems reviewed to keep improving representatives involved in understanding
outcomes for consumers? risk, identifying and responding
to incidents and driving continuous
How does the organisation make improvement? How does communication
information about current procedures and occur with consumers and their
guidance for managing risks and incidents representatives when incidents happen?
available to consumers, representatives Are open disclosure processes used?
the workforce and others?
Does the workforce know what harm,

abuse and neglect look like?
How does the organisation support Examples of actions and evidence
its workforce to understand their roles Consumers
and responsibilities for preventing and • Consumers say organisational decisions
reporting abuse? on how to reduce possible or real risks are
made with them and they feel their opinions
Does the organisation have strategies are heard.
to make sure that responses • Consumers say the organisation responds
to allegations of harm use the principles promptly to incidents, or concerns about
of natural justice? harm, abuse and neglect.
Does the organisation support all parties • Consumers feel comfortable with how the
during an investigation? organisation balances risks and quality
of life. They feel they are living the best life
How does the organisation support they can.
the workforce to use a problem-solving • Consumers say that if they are involved in
approach to respect a consumer’s wishes an incident, the organisation communicates
to act independently, but also to identify with them and engages them in the
and reduce risks so they can support their resolution of the incident, including how
independence as safely as possible? similar incidents will be prevented in future.
Standard |
8
Workforce and others Organisation

• The workforce can describe how they try • Records show how staff are trained and
to reduce common and high-impact or high- supported to assess or evaluate the use
prevalent risks to health and well-being. of restraints in order to minimise or eliminate
They can also describe how the way they their use.
do this supports consumers’ dignity and • Evidence of how the organisation monitors
quality of life. and reports on the use of restraints.
• The workforce can describe how the • Records show the organisation continually
systems and processes for safely delivering monitors risks to consumers and takes
clinical care are reliable. They also say they appropriate action if a risk has increased.
have the chance to take part in designing, • Evidence that the organisation uses incident
monitoring and evaluating these systems data and information to identify and analyse
• The workforce can demonstrate their trends and common incidents, and that quality
knowledge of the organisation’s legislative improvements are made as a result.
requirements to report incidents as these • Evidence that the organisation communicates
relate to their role and responsibilities. with consumers and their representatives in
• The workforce can describe the the identification of risk, if incidents occur,
organisation’s reporting systems for ‘near and in the resolution of incidents, including
misses’ and incidents, including of harm, through the use of open disclosure processes.
abuse and neglect. They can also describe • Evidence that the organisation uses effective
the processes for managing risks and investigation as soon as it’s aware of any
responding to incidents and near misses allegation or evidence of harm, abuse or
related to their role in the organisation. neglect. Evidence shows that the organisation
• Evidence that the organisation’s training also refers the case to the correct body in line
around safeguarding is delivered with legislation.
in a way that is relevant to different roles. • Evidence that the organisation monitors
The workforce can describe how they systems that can identify possible abuse
are able to recognise different types of such as reports of incidents and complaints.
abuse or neglect and the ways they can Evidence shows that the organisation also
report concerns and use the organisation’s takes steps to stop the abuse and reports
incident management system to record and it as required by law.
respond to incidents. • Evidence of ways in which the organisation
• The workforce can give examples of has strengthened systems for prevention
respecting consumers’ wishes and how they of abuse and neglect. This can include asking
have identified and reduced risks to support for specialist advice or support.
their independence as safely as possible. • Records show the organisation notifies
• The workforce can give examples of how the Commission (and others as relevant)
they identify and manage incidents using the of reportable incidents appropriately.
organisation’s incident management system, • Evidence and examples of how the
including how incident data has been used organisation shows, monitors and reports
to prevent similar incidents recurring. how it performs against this Standard.
Examples of continuous improvement against
this requirement.
Standard 8
Requirement (3)(e)
Where clinical care

is provided – a clinical
governance framework,
including but not limited
to the following:
(i) antimicrobial
stewardship
(ii) minimising the
use of restraint
(iii) open disclosure.
Standard |
8
Intent of this requirement (ii) Minimising the use of restraint

Clinical governance is the set of relationships Restraint means any practice,
and responsibilities between the device or action that interferes
organisation’s governing body, executive, with a consumer’s ability to make
clinicians, consumers and others to achieve a decision or restricts a consumer’s
good clinical results. It puts systems in free movement. Where restraint
place for delivering safe, quality clinical care is clinically necessary to prevent harm,
and for continuously improving services. the organisation should have systems
Clinical governance usually includes to manage how restraints are used.
involving consumers, clinicians, clinical This is in accordance with legislation
review, training, risk management, use and the organisation’s policies
of information and workforce management. on reporting the use of restraints.
This requirement describes the clinical (iii) Practicing open disclosure
governance and safety and quality This means organisation wide systems
systems that are required to maintain and to support communication with
improve the reliability, safety and quality consumers about incidents that have
of clinical care, and to improve outcomes caused harm. Open disclosure usually
for consumers where organisations includes an apology and explaining
provide clinical care. The following areas the facts of what happened. It also
are included: includes listening to the consumer’s
experience of what happened and
(i) Antimicrobial stewardship
explaining the steps the organisation
In Australia, the increasing number
has taken to prevent it happening again.
of antibiotic-resistant infections
appearing in the community represents
a looming public health issue.
This means aged care organisations
need to do their part to change those
practices that have contributed
to the development of resistance and
implement new initiatives to reduce
inappropriate antibiotic usage and
resistance. Effective organisation
wide systems are required for
preventing, managing and controlling
infections and antimicrobial
resistance. This contributes to the
broader national effort and improves
outcomes for consumers.
Do management of the organisation Does the organisation have processes

and members of the workforce have to support identifying and getting involved
particular areas of responsibility for clinical early when risks associated with clinical
leadership and systems that improve safety care are identified?
and quality? Does it have processes for members
of the workforce to identify these risks?
What are the systems to ensure that
best practice evidence is embedded How does the organisation understand
in the organisation’s clinical care? and support safety and quality
in the clinical services it provides?
How does the organisation review This includes how it collects and uses
how effective the clinical governance data to inform safety and quality.
framework is?
Does the organisation take timely actions to
tackle any aspects that aren’t working well?
Standard |
8

Consumers • Evidence of strategies and practices
• Consumers say they receive safe, effective, that aim to make sure antimicrobials
quality clinical care that is right for them. are prescribed according to best
practice guidelines.
discuss their clinical care with them, • Records that show use of restraint is always
including risks and benefits of any clinical as a last resort, the application of restraint
treatment and the appropriate use is documented and the safety and well-
of antibiotics. being of the consumer is monitored.
• Consumers say if things have gone wrong, • Evidence of appropriate authorisation
the organisation has apologised and taken and consent for the use of restraints
steps to make sure the same thing doesn’t in compliance with legislation.
happen to them again or to others. • Records show that the organisation has
a systematic approach to clinical audit
and data comparisons that supports
• The workforce can describe their
improvements in clinical care.
accountabilities and responsibilities
for the effectiveness, safety and quality • The organisation has records of governance
of clinical services. arrangements for clinical care that
is given in non-clinical care settings,
or by contracted members of the workforce,
collect data to inform clinical performance
or by third parties.
indicators, they say the indicators are
meaningful and can describe how they lead
to improvements in clinical care.
• The workforce say open disclosure is
part of the organisation’s practice when
a negative event happens. They can also
describe the open disclosure process.
records that show the organisation
trains the workforce in this requirement.
They also show the organisation supports
clinical governance leadership roles with
ongoing training.
Glossary Advance care directive
A written advance care planning document
completed and signed by a competent
consumer who still has decision-making
capacity. In Australia, advance care
directives are recognised by specific
legislation or common law. Advance
care directives can record the person’s
preferences for future care and/or appoint
a substitute decision-maker to make
decisions about the person’s health care.
Advance care planning
The process of planning for future health and
personal care, whereby the person’s values,
beliefs and preferences are made known
so they guide decision-making at a future
time when that person cannot make
or communication their decisions.
Antimicrobial
A medicine that kills microorganisms like
bacteria or stops them growing. Antibiotics
and antifungals are antimicrobials.
Antimicrobial resistance
Failure of an antimicrobial (such
as an antibiotic) to work against
microorganisms (such as bacteria,
viruses, and some parasites).
This can mean treatments no longer work
and infections continue and can spread
to other people.
Antimicrobial stewardship
Efforts by an organisation to reduce the
risks related to increasing antimicrobial
resistance and to extend the effectiveness
of antimicrobial treatments. It can
include a broad range of strategies,
such as monitoring and reviewing how
antimicrobials are used.
Glossary
Best practice (for clinical care) Cognitive impairment

Diagnosis, treatment and care are timely Loss of some mental or thinking functions.
and based on the best available evidence, A person with cognitive impairment
which is used to achieve the best possible can find it difficult to learn new things,
outcomes for consumers. to concentrate, or make decisions. The most
Carer common causes of cognitive impairment
A person who provides personal care, in older people are dementia and delirium.
support and help to a consumer. This does Consumer
not include members of the organisation’s A person to whom an organisation provides
workforce, or people the organisation or is to provide care through an aged care
contracts or pays to provide those services, service. Reference to consumer in this
or people who provide the services guidance for the Quality Standards includes
as a volunteer. This definition is in line with reference to a representative of the
the Carer Recognition Act 2010. consumer, so far as the provision can apply
Clinical care to a representative of the consumer.
Care provided by doctors, nurses, A consumer representative includes:
pharmacists, allied health professionals • a person appointed under relevant
and other regulated health practitioners. legislation to act or make decisions
Organisations providing clinical care are on behalf of a consumer; and
expected to make sure it is best practice, • a person the consumer nominates to be
meets the consumer’s needs, and optimises told about matters affecting the consumer.
the consumer’s health and well-being. Consumer-centred care
Clinical governance Care and services that are designed around
An integrated set of leadership behaviours, an individual’s needs, preferences and
policies, procedures, responsibilities, background. It includes a partnership
relationships and monitoring and between consumers and providers.
improvement mechanisms that are directed Continuity of care
towards ensuring good clinical outcomes. Processes that ensure that everyone who
Effective clinical governance systems ensure cares for a consumer knows, and has
that everyone – from unregulated care information about their care and service
providers, to employed or external regulated needs, choices and preferences. Continuity
health practitioners, to managers and of care helps to ensure that there are
members of governing bodies such as boards no gaps when the responsibility for the
– is accountable to consumers and the delivery of care and services is transferred
community for the delivery of clinical care between individuals or organisations.
that is safe, effective, integrated, high quality
and continuously improving. Continuous improvement
A systematic, ongoing effort to raise
Cognitive function or ability an organisation’s performance in achieving
Functions that relate to mental and thinking outcomes for consumers under the Quality
processes, such as memory, attention, Standards. Continuous improvement:
language and learning.
Glossary
• responds to the needs and feedback Dignity of risk means respecting this right.
of consumers, Care and services need to strike a balance
• supports the workforce to improve and between respect for the individual’s autonomy
innovate in providing safe and quality care and the protection of their other rights
and services, and (such as safety, shelter), unless it is unlawful
• can address practices, process or outputs or unreasonably impinges on the rights
to achieve a desired outcome. of others.
Contractor and subcontractor Diversity
Any person who carries out care and Consumers’ varied needs, characteristics and
services, or administration or maintenance life experiences. Consumers may have specific
for an organisation under contract. social, cultural, linguistic, religious, spiritual,
The organisation that receives funding from psychological, medical, and care needs. The
the Australian Government is expected term also refers to peoples’ diverse gender
to make sure its workforce (including and sexuality identities, experiences and
contractors) meets the relevant Quality relationships, including lesbian, gay, bisexual,
Standards. Contracts requiring compliance transgender or intersex (LGBTI).
with the Standards and effective contractor End of life care
management are essential. The care provided to a consumer in the
Cultural safety period when they are nearing the end
Care and services that are planned and of their life. It can include physical, spiritual
delivered in a way that is spiritually, socially, and psychological support.
emotionally and physically safe and Governance
respectful for consumers. Culturally safe The rules, practices, processes and systems
care and services also ensure that a person’s an organisation uses to direct and manage
identity is respected so that who they are and that organisation and its services.
what they need is not questioned or denied.
Governing body
Decision making The individual or group of people with overall
Consumers making choices about their responsibility and ultimate accountability for
lifestyle and activities of daily living, the organisation. This includes responsibility
their care, and services and end of life for the strategic and operational decisions
choices. Supported decision making is the that affect the safety and quality of care
process of enabling a person who requires and services.
decision-making support to make, and/or
High-impact
communicate, decisions about their own life.
A risk that can have a significant effect
The decision-making is supported, but the
on a person’s safety, health or well-being.
decision is theirs.
High-prevalence
Dignity of risk
There are a large number of people
The concept that all adults have the right
in a particular group that are affected
to make decisions that affect their lives
by the same condition or risk.
and to have those decisions respected,
even if there is some risk to themselves.
Glossary
Incident It involves an expression of regret and

An event or circumstances that resulted a factual explanation of what happened,
or could have resulted in unintended the potential consequences and what steps
or unnecessary harm, loss or damage are being taken to manage this and prevent
to a person. it happening again.
Infection prevention and control program Organisation
The plan and processes an organisation The provider of care and services.
uses to prevent and manage the spread Currently, aged care legislation uses
of infection. For example, hand washing the term ‘approved provider’, but this
is the most effective means of preventing term doesn’t include providers that
infection transmission. deliver Commonwealth Home Support
The scope and complexity of a program Programme (CHSP) and certain grant-
will depend on the nature of the care the funded National Aboriginal and Torres
organisation provides, the context and risk. Strait Islander Flexible Aged Care Program
Influenza infection control program (NATSIFACP) services. As the Standards apply
The plan and processes that an organisation to all organisations that receive Australian
has in place to manage influenza infections. Government subsidies or funding to provide
aged care (whether they are currently
If an organisation provides residential aged
an approved provider or not), the term
care, their program includes workforce
‘organisation’ has been used. The Standards
influenza vaccinations.
apply to organisations providing:
Macular degeneration • residential care
A group of eye diseases that cause • home care
progressive loss of a person’s central vision.
• flexible care, including innovative care
Medication contraindication services, multi-purpose services (in line with
A situation when a medicine should the spirit and intent of the Standards), short-
not be used because it may be harmful term restorative care and transition care
to the person. • CHSP
Natural justice • NATSIFACP services.
Decisions are made and people are treated Others
fairly and without bias. Anyone a consumer wants to have involved
Notifiable in their care decisions. This could be formally
Events, things or incidents, such as serious through an appointment of a guardian,
infectious diseases, that must be reported or informally, such as a family member
to the right authorities. that has been nominated by the consumer.
A consumer may have different people they
Open disclosure want involved for different decisions and
Open discussions with consumers, their at different times.
family, carers and other support people
of incidents that have caused harm, or had
the potential to cause harm to the consumer.
Glossary
Outcomes Respectful
Describe the impact or result of a service Understanding a person’s culture,
or support, such as an improvement acknowledging differences, and being
in an individual’s well-being. ‘Outcomes’ actively aware of these differences.
are different from ‘outputs’. Outputs It is about understanding that each
cover the delivery of services or supports, consumer is unique and has a right to be
such as training. Outcomes can be short- treated in an inclusive and respectful way.
term (such as a consumer being involved Restrictive practices
in service planning) through to long-term The use of interventions and practices that
(such as a consumer being able to manage have the effect of restricting the rights
daily activities on their own after support or freedom of movement of a person with
and reablement). disability. These primarily include restraint
Partnership and seclusion.
A working relationship between two or more Chemical restraint means a restraint that
people. In these Standards, partnership is, or that involves, the use of medication
refers to organisations finding ways to work or a chemical substance for the purpose
with consumers and listening to their needs, of influencing a person’s behaviour,
goals and preferences, to plan their care other than medication prescribed for
and services. the treatment of, or to enable treatment
Personal care of, a diagnosed mental disorder, a physical
Services such as bathing, showering, illness or a physical condition.
dressing, feeding and going to the toilet. Physical restraint means any restraint
Quality management other than:
The systems and processes an organisation (a) a chemical restraint; or
has in place to monitor, review, plan, control (b) the use of medication prescribed for
and make sure they deliver quality services, the treatment of, or to enable treatment
supports or products. of, a diagnosed mental disorder,
Reablement a physical illness or a physical condition.
A consumer-directed process to support This guidance adopts the general
restoration of function or adapt to some loss principle that restrictive practices are
of day-to-day function and regain confidence only implemented as a last resort;
and capacity for daily activities. It may are implemented for the least amount
promote consumer independence, capacity of time possible; are recorded, monitored
or social and community connections. and reviewed; have tight safeguards
Supports could include training in a new in place that are focused on minimising
skill, modification to a consumer’s home risk to consumers, staff, and others; and
environment or having access to equipment are undertaken with a focus on ensuring
or assistive technology. decency, humanity and respect at all stages.
Glossary
Risk Workforce
The chance of something happening that People working in an organisation who
will have a negative impact. It is measured are responsible for its maintenance
by the consequences and likelihood. In this or administration, or the care and services,
guidance it usually refers to the risk of harm support of, or involvement with, consumers.
to a consumer. A member of the workforce is anyone
Scope the organisation employs, hires, retains
The range of things that are covered or contracts (directly or through an
or included in each Standard. employment or recruitment agency)
to provide maintenance or administration,
Service and supports for daily living
or care and services under the control
Services other than clinical and personal
of the organisation. It also includes
care that include but are not limited to:
volunteers who provide care and services
food services, domestic assistance, home
for the organisation.
maintenance, transport and recreational
and social activities. For clarity, people in an organisation’s
workforce include:
may also be services that support • employees and contractors (this includes
consumer emotional, spiritual and all staff employed, hired, retained
psychological well-being. or contracted to provide services under
the control of the organisation)
Service culture • allied health professionals the
The way things get done. The culture organisation contracts
of an organisation is characterised by how
• kitchen, cleaning, laundry, garden and
people behave, what is prioritised and how
office staff the organisation employs either
processes are owned and improved by the
directly or under contract.
workforce. A culture of safety and quality will
People who are not part of an organisation’s
be consumer-centred, driven by information,
workforce include:
and organised for quality and safety.
• visiting medical practitioners, pharmacists
Service environment and other allied health professionals and
The physical environment where they services a consumer has asked for, but the
deliver care and services. It does not include organisation doesn’t contract
a consumer’s private home where in-home
• trades people who don’t work under
services are provided. Overall surroundings
the control of the organisation (such as
where aged care services are being delivered
independent contractors), for example,
are included, such as the building, fixtures,
plumbers, electricians or delivery people
fittings and factors such as lighting,
who work on a needs basis.
air temperature and water supply.
Staff
People working in an organisation who are
responsible for the care, administration and
support of, or involvement with, consumers.
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Quality Standards Guidance Resource Sep22

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Guidance

Aged Care Quality and Safety Commission

Published September 2022

1800 951 822

Organisations providing Commonwealth The Quality Standards are made

Each of the Standards is expressed in relation to best practice provision of aged

Consumer outcome Requirements

Purpose and scope Identity, culture and diversity

Choice In all cases, it’s expected that organisations

Linked Standards Resources and references

Each consumer is treated

Intent of this requirement Reflective questions

Examples of actions and evidence Organisation

Care and services

Intent of this requirement Reflective questions

Examples of action and evidence Workforce and others

Each consumer is supported

Intent of this requirement Reflective questions

Examples of actions and evidence Organisation

Each consumer is supported

Intent of this requirement Reflective questions

How does the organisation support

Examples of actions and evidence Organisation

Intent of this requirement Reflective questions

Examples of actions and evidence Workforce and others

Intent of this requirement Reflective questions

Examples of actions and evidence Organisation

Consumer outcome Requirements

health and well-being. 2 (3) (b) Assessment and planning

Assessment and planning,

Examples of actions and evidence Workforce and others

Assessment and planning

Assessment and planning:

The outcomes of assessment

Care and services are

Examples of actions and evidence Organisation

Consumer outcome 3 (3) (b) Effective management of high-

Purpose and scope The guidance in this Standard is not clinical

Linked Standards Relevant legislation

Resources and references • Australian Government, Department

Each consumer gets safe

Intent of this requirement (ii) tailored to their needs

Examples of actions and evidence Organisation

Intent of this requirement The organisation is expected to educate

 ow does the organisation tell the

Examples of actions and evidence Organisation

The needs, goals and

Intent of this requirement Reflective questions

Intent of this requirement However there is evidence that warning signs

 hat systems and policies are in place

Examples of actions and evidence Organisation

Intent of this requirement There are many different situations where

Examples of actions and evidence situations where they shared care

Timely and appropriate

Intent of this requirement Reflective questions

Examples of actions and evidence Organisation

Intent of this requirement Control Expert Group, Communicable Disease

Using antimicrobials incorrectly, including What is the organisation’s plan for

Organisation • Evidence of antimicrobial stewardship

Consumer outcome 4 (3) (c) Services and supports for daily

Requirements Meaning of services and supports

Purpose and scope Socially including consumers isn’t just

Relevant legislation Resources and references

health and well-being. 2 (3) (b) Assessment and planning

Consumer outcome 3 (3) (b) Effective management of high-

Intent of this requirement (ii) tailored to their needs

ow does the organisation tell the

hat systems and policies are in place

Consumer outcome 4 (3) (c) Services and supports for daily

appropriate action 6 (3) (c) Appropriate action is taken in

Consumer outcome 8 (3) (c) Effective organisation wide