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Mental Health Standards for Community Managed Organisations Model of Care Standard

Service providers implement and maintain systems for the delivery of  safe and high-quality care and supports consistent with an agreed model of care to achieve the consumer’s recovery goals and to minimise the risk of harm to consumers, their families and carers and others.

The intention of this standard is to:

  • ensure that consumers receive supports that are consistent with a clearly defined model of care that is grounded in best practice and evidence. The supports provided align with the consumer’s expressed recovery goals and needs
  • ensure that the risk of harm to consumers, their families and carers is minimised and managed

Planning for delivery of care and supports

Systems are in place to support the workforce in the safe delivery of care and supports.

Planning for delivery

Action 3.01

Where the service provider is responsible for establishing the model of care, the service provider:

  1. Partners with consumers, their families and carers in the co-design of the model of care
  2. Recognises national, state and regional planning approaches and collaborates with relevant funders and policy setters to reduce system fragmentation and strengthen system integration
  3. Has policies and procedures that specify the intent of the model of care for each service and the context in which it will operate
  4. Defines the intended consumer demographic and matches the model of care to the consumers, their families and carers
  • Clearly communicate the purpose and intent of the service
  • Partner with consumers, families and carers to design, develop, document and communicate a model of care that is tailored to meet the needs of the intended consumers
  • Review literature relevant to the type of service you intend to provide
  • Develop a program logic tool with key stakeholders and consumers to identify the intended service outcomes and describe how they will inform the development of the model of care
  • Acknowledge the role of lived experience and peer workers within the model of care 
  • Policy outlining the evidence‑based model of care for the service
  • Training and resources that include tools which support the co‑design or co‑production of the model of care
  • Agendas and minutes of meetings that demonstrate partnership with consumers, their families and carers in the design and development of the model of care and its evaluation

Action 3.02

The service provider has systems that monitor the delivery of their service to:

  1. Ensure service delivery is consistent with the model of care
  2. Ensure service delivery is based on best available evidence and best practice
  3. Evaluate the performance and effectiveness of the model of care
  4. Assign accountability for maintaining and improving the effectiveness of the model of care
  • Develop a program logic to support evaluation of the model of care which identifies what should be measured and when
  • Partner with key stakeholders, including consumers, their families, and carers in developing the program logic and when assessing the outcomes of service delivery especially from the consumer and carer perspectives
  • Ensure monitoring and evaluation is applied early in the development of a model of care to assess its effectiveness, and whether it is consistent with the practice approach that underpins the model
  • Assign clear roles and responsibilities within the organisation for maintaining and improving the effectiveness of the model of care
  • Provide reports at specified times to align with the organisation’s KPIs or funding requirements
  • Budget for the evaluation of service delivery, including allocating funds for lived experience partners in evaluation activities
  • Reports on feedback and outcomes shared with managers and members of the workforce in the organisation
  • A model of care evaluation framework
  • Training and resources that include outcome measures
  • Audit of service delivery in line with the model of care elements
  • Report including consumer and carer feedback

Action 3.03

The workforce has the training and competencies required to deliver the model of care and:

  1. In partnership with the consumer, their family and carers and other relevant service providers, develop care and recovery plans that comprehensively identify the consumer’s mental and physical needs and recovery goals
  2. Implement care and recovery plans and provide supports and services to consumers in the setting that best meets their needs
  3. Ensure timely referral of consumers with specialist healthcare or other needs to relevant services
  • Provide orientation, education and training to members of the workforce so that they understand their roles, responsibilities and accountabilities in delivering supports in line with a consumer’s care and recovery plan
  • Ensure members of the workforce are aware of the evidence base underpinning the model of care being provided
  • Ensure workers are trained in developing recovery plans collaboratively with consumers and other supports including the use of and have skills in supported decision making, and motivational interviewing skills
  • Train members of the workforce in how to apply a trauma‑informed, recovery‑oriented approach to the task of developing an integrated care plan
  • Work with consumers, their families and carers to identify their goals for recovery and how these can be integrated into their care and recovery plans
  • Ensure members of the workforce understand the service scope of practice and the available resources and services within the community
  • Ensure members of the workforce can facilitate consumer referrals to more appropriate or additional services when needed to ensure a holistic approach to service delivery 
  • Policy documents that outline processes used to deliver services that are consistent with the model of care
  • De‑identified examples of care and recovery plans
  • Training and resources on supported decision making
  • A directory of local support services
  • A survey conducted to collect data about consumers’ service experience, including questions about whether their goals for care and actions for support were clearly communicated and developed in partnership with them

Action 3.04

The service provider uses its processes to deliver or facilitate access to:

  1. Programs and or interventions to meet the consumer’s needs and address agreed recovery goals
  2. Programs that support the consumer to build their capacity and resilience to meet their everyday living needs and recovery goals
  3. Programs, even if provided by partner organisations, that meet the needs of a diverse range of consumers including those from Aboriginal and Torres Strait Islander communities, people with physical and intellectual disabilities, CALD communities, LGBTIQ+ communities or those at risk of homelessness
  • Enable consumer preferences and meaningful participation in their care and support planning
  • Facilitate access to the services and supports within the organisation and with external partner services as needed
  • Match consumers to a worker’s skillset and experience
  • Ensure that the workforce is culturally competent and able to meet the needs of diverse populations
  • Policy documents or processes for referral pathways to dedicated cultural services – for example, Aboriginal and Torres Strait Islander led and run services, LGBTIQ+ services, disability support services
  • Recovery planning, supported decision making, cultural competence and co‑design
  • Information for consumers, carers and workers about service supports and recovery planning
  • Evidence of the programs and interventions utilised in your service, such as, community outreach, counselling, peer support, education, diversity and awareness programs

Access and entry

The service provider has a documented entry process that: 

  1. Specifies the inclusion and exclusion criteria
  2. Defines pathways with service-specific entry points
  3. Minimises delay and the need for duplication in assessment
  4. Provides for consent for referral, confidentiality and information sharing
  5. Communicates information about the entry process to consumers, families, carers, referrers and other service providers and stakeholders
  6. Enables access to alternative care for people not accepted by the service
  • Develop information material about eligibility criteria for the service and make this readily available
  • Determine key points when communication with consumers and referrers must take place, relevant to your intake process – for example, referral received, assessment scheduled, assessment completed, panel discussion scheduled, outcome of referral
  • Have templates for written communication at these points, that have been developed in partnership with consumers and families
  • Consider the information you need to collect prior to entry to the service, balancing the need for information to support your decision‑making against the risk of collecting large volumes of detailed personal information for people who may not be accepted into your service
  • Use a consent process in place prior to intake, ensuring that prospective service users understand what information will be collected prior to intake, how it will be used and for how long it will be stored
  • Facilitate a referral process for consumers who would be more appropriately supported by another service
  • Develop processes for managing a waiting list, including regular communication with people who are waiting for a service and the referrers
  • Policy outlining the criteria for entry to the service and exit from the service
  • Training and resources about the service and eligibility criteria
  • Any partnership memoranda of understanding or agreements between organisations
  • Audit and analysis of number of referrals accepted compared with number of referrals received
  • Results of an evaluation of waiting list management

Delivering care and supports

The workforce partners with consumers, their families and carers, to deliver safe and high-quality care and supports to achieve the consumer’s recovery goals.

Screening and assessment

Action 3.06

The workforce, using a trauma-informed approach, engages consumers, their families and carers in screening conversations on presentation, during history taking and when required during care:

  1. To identify mental, physical and cognitive needs and potential risks
  2. To identify the consumer’s social circumstances
  3. To explore the consumer’s recovery goals, values and preferences
  • Undertake assessment which identifies specific needs for practical or emotional support, advocacy, skills capacity building or consolidation
  • Advise consumers that their safety before, during and after the assessment is a priority
  • Provide an assessment form template which prompts the person completing the assessment to consider all relevant aspects of the person’s situation
  • Assess consumers’ diverse social and cultural needs, including spiritual, religious, gender, sexuality, and language needs
  • Identify both mental health needs and physical health needs
  • Identify strengths and protective factors including current ways of coping with distress
  • Consider whether a formal re‑assessment process is appropriate for your model of care, and if a formal re‑assessment will be part of your service delivery, set a minimum frequency for this to occur
  • Policy outlining screening and assessment processes including templates
  • Training on conducting assessment in a trauma‑informed way
  • Screening tool audit
  • Consumer feedback

Action 3.07

The workforce partners with consumers, families and carers to comprehensively assess the needs, recovery goals and risks identified through the screening process

  • Ensure the service provider allocates an appropriate amount of time to work with consumers, families, and carers in the assessment process
  • Ensure that the environment in which the assessment is to be conducted is suitably private and represents a safe environment as confirmed by the consumer
  • Ensure that organisational policies around working with carers and families reflect legislation and jurisdictional requirements relating to privacy, confidentiality, information sharing and carer recognition
  • Train members of the workforce to understand when and how to involve carers and families, including how to balance confidentiality and carer involvement in a nuanced way during the assessment process
  • Co‑develop tools and resources with people with lived experience to support consumers, families, and carers to best understand the assessment process and its purpose
  • Work with peer workers to ensure the assessment process is tailored to meet consumer needs and minimises the risk of triggering re‑traumatisation
  • Policy outlining person‑centred assessment and recovery planning
  • Carer and family inclusion in assessment processes
  • Training on person‑led approaches to planning and support including supported decision making
  • Documented feedback from consumers, carers and families regarding their experience and involvement in the assessment process

Action 3.08

The workforce has a system to document the findings of the screening and assessment process, including any relevant alerts, in the consumer’s care record

  • Ensure a policy is in place that outlines how records can be maintained in a way that minimises the risk of information being miscommunicated or lost, particularly at transitions of care
  • Train members of the workforce to use and protect documentation in a way that supports the delivery of safe, high‑quality and continuous consumer and carer supports
  • Ensure high‑quality documentation is person‑centred, relevant, accurate, complete, up to date and accessible to workers whose role it is to support consumers and carers
  • Designate a person in the organisation with responsibility to oversee the management of documentation and ensure that records are up‑to‑date and stored appropriately
  • Standardised assessment and screening templates
  • A file entry system that alerts workers to necessary updates and follow‑up procedures
  • Information about safe record keeping and use and provided to workers
  • Information for consumers and carers about their records and their rights to access information concerning their records

Developing the care and recovery plan

The workforce engages with consumers, families and carers to develop care and recovery plans that:

  1. Address the consumer’s mental health needs and recovery goals
  2. Identify potential risks, agreed goals and actions for care
  3. Support the consumer to make informed choices, exercise control, maximise their independence and autonomy
  4. Identify family members and carers that a consumer wants involved in communications and decision making
  5. Incorporate information from the consumer’s advance care plan
  6. Include a monitoring plan and strategies for known early warning signs of deterioration in mental state, agreed positive coping strategies and agreed pathways for escalating care
  7. Include the agreed services to be delivered and any conditions attached to the delivery of those services
  8. Include an individualised exit plan, with ongoing follow-up arrangements to promote recovery, and information on how to re-enter the service if needed
  • Develop a process to ensure that a recovery plan is co‑designed with the consumer to reflect their mental health needs and their identified recovery goals
  • Support the consumer to make informed choices and maximise their independence and autonomy in designing recovery plans
  • Include family members, carers and other service providers in recovery planning if a consumer has identified them to receive communications and be part of decision‑making
  • Include agreed pathways for escalating supports should a deterioration of the consumer’s mental health be evident
  • Ensure members of the workforce know how to work with consumers to set goals which are relevant to the type of service being provided: ideally, goals should be achievable within the timeframe between development of the plan and the next scheduled plan review; when the consumer has longer‑term goals, members of the workforce should work with them to break those goals down into achievable steps to help them keep progressing
  • Co‑designed care and recovery plan templates
  • Signed consent forms
  • MOUs with partnering organisations

Implementing the care and recovery plan

The workforce partners with consumers, families and carers to:

  1. Deliver the care and supports to meet the consumer’s needs and their recovery goals
  2. Review the care and recovery plan:
    • at agreed timeframes consistent with the model of care
    • at other times to adapt to changes in the consumer’s recovery
    • at the request of the consumer
  3. Make agreed changes to the care and recovery plan to meet the revised recovery goals 
  • Ensure that the care and recovery plan is co‑designed meets the specific needs and goals of each consumer
  • Use systems such as team care reviews and supervision to support members of the workforce to reflect on how successfully the care they are providing is supporting the consumer to work towards their goals, including whether there are any evidence‑based techniques they have not tried or where the implementation process could be improved
  • Review and revise the recovery plan at the consumer’s request
  • Amend the recovery plan to align with the consumer’s current circumstances and agreed recovery goals
  • Implement performance monitoring to ensure that care plans are being reviewed and updated within the minimum frequency
  • Policy documents or processes for the routine recovery planning with each consumer
  • Co‑designed care and recovery plans and review templates
  • Results of monitoring of completion of care plan reviews
  • Outcome evaluation reports of recovery plans including consumer input conducted at service exit

Continuity of care

The service provider has systems to ensure:

  1. Day-to-day operations are managed in an efficient and effective way to avoid disruption and ensure continuity of care
  2. Where changes or interruptions are anticipated or unavoidable, alternative arrangements are negotiated with the consumer and their family and carers
  • Clear communication pathways and guidelines are provided for members of the workforce to follow in the event of disrupted service provision to minimise the impact on consumers and their families and carers
  • The service has a team approach to the care of consumers so alternative support is available for the consumer if their allocated worker is away
  • Workers have open conversations with consumers when developing recovery plans to discuss how best to provide support without interruption and seek their input for continuity planning
  • Develop procedures for circumstances, such as workforce leave and workforce turnover: ideally, if another person is taking over the role of key worker on an extended temporary or permanent basis, there should be a face‑to‑face introduction session between the outgoing workforce member, the incoming workforce member, the consumer and, where relevant, their personal support people
  • Policy outlining contingency planning to ensure there is no interruption to service delivery
  • Management of service provision in the event of an unexpected circumstances, emergencies, or disasters
  • Training and resources that include collaborative teamwork
  • Risk register

Integration

The service provider works with the consumer, their family and carer to:

  1. Identify other providers involved in the delivery of integrated care
  2. Identify the role of each provider, relative to the service provided by the CMO, and map how consumers may use each service if needed in the recovery journey
  3. Confirm the extent of, and any limits on, the consumer’s consent to collaborate with other providers
  4. Collaborate in a coordinated approach with other care providers involved in the consumer’s care
  5. Make and facilitate internal and external referrals to other care providers
  6. Provide information to the consumer’s other relevant care providers
  • Ensure consumers are receiving appropriate supports at the right time
  • Ensure that referrals are followed up, and that consumer engagement has been initiated by the referred service
  • If the organisation has capacity to do so, allocate dedicated care coordination roles to provide support with accessing external referrals and provide comprehensive handovers
  • Ensure appropriate information is shared between service providers, particularly in assisting to clarify roles, responsibilities, and relationships
  • Arrange care coordination discussions with the consumer and their other service provider
  • Develop processes to support the identification of risks to service duplication and misperceptions for consumers
  • Policy for identifying and working with external agencies
  • Memoranda of understanding and service level agreements with partnering organisation
  • Current service directory
  • Meeting minutes from multi‑disciplinary recovery plan development and reviews
  • Results of monitoring of involvement of other services in care plan reviews
  • Results of monitoring of referrals and follow‑up of referrals
  • Documented communications with external organisations and agencies

Recognising and responding to acute deterioration, crisis or distress and minimising harm

Service providers have systems in place to support the workforce to recognise and respond to early signs of deterioration, crisis or distress in a consumer’s circumstances. The workforce engages with consumers, their carers and families, to identify early signs of distress or crisis and implement strategies to prevent the risk of harm.

Recognising early signs of crisis or distress

The workforce partners with consumers, their families and carers to:

  1. Identify consumers who may experience distress related to deterioration in their mental state or other circumstances
  2. Engage with consumers at risk of acute crisis or distress
  3. Assess possible causes of acute crisis or distress when change in the consumer’s behaviour, cognitive function, perception, physical function or emotional state are observed or reported
  4. Determine the required level of observation to maintain the safety of the consumer and others
  • Assessing risk should not be a one‑off task but should be assessed regularly over time
  • Develop information about response processes, including information about when crisis intervention is required by legislation, with this information made available to consumers, their families, carers and the workforce
  • Ensure the workforce are appropriately trained in evidence‑based practices to engage effectively with consumers, their families and carers in working with deterioration in a person’s mental state, acute crisis and distress
  • Ensure the workforce understands their responsibilities regarding ongoing risk assessment and management
  • Policy outlining the process for responding to deterioration in a person’s mental health
  • Training for the workforce on balancing their duty of care and supporting the consumer to exercise choice and control
  • Risk assessment tools and templates
  • Audits of risk assessments and re‑identification of risk
  • Audits of consumer involvement in safety planning

Responding to acute mental or physical distress

Action 3.14

The service provider supports the workforce to respond to a consumer’s acute crisis or distress through:

  1. Engaging the consumer in practising the coping strategies they have identified in their care and recovery plan
  2. Accessing additional support through agreed escalation pathways
  • Ensure workers are aware of, and use, the appropriate escalation processes in place in their service
  • Ensure that the development of care and recovery plans includes provision for the consumer, their family and carer to identify what coping strategies from their experience are most effective in responding to acute crises or distress
  • Train members of the workforce to recognise the scope of their expertise and engage other team members if a person is experiencing deterioration in mental, physical, or cognitive function, which is outside their professional scope
  • Provide workers with access to ongoing professional development to support their knowledge and skills in responding to acute crises and distress
  • Emergency information and contact details are clearly identified in the service in posters on the wall or on information boards
  • Policy for escalating care
  • Training and resources that include duty of care and what to do when a consumers mental health deteriorates
  • Information for consumers, carers and their families
  • Audit of adherence to the requirement to develop personal safety plans with each consumer
  • Review of incidents, evaluating whether there was a personal safety plan in place and whether the agreed escalation protocol was followed

Action 3.15

The service provider ensures that the workforce is competent to provide first aid to consumers who experience physical deterioration, while awaiting assistance from emergency services or a qualified practitioner

  • With consumer consent, intake and assessment processes gather information from the consumers’ health practitioners about underlying health issues which may require specific responses
  • With consumer consent, workers create medical emergency plans in collaboration with the consumer’s primary healthcare provider as well as their informal support network
  • Periodically provide refresher first‑aid and cardio‑pulmonary resuscitation (CPR) training to all members of the workforce
  • Intake and assessment processes gather information about all the medications prescribed to the consumer for all their mental and physical health conditions and about other over the counter non‑prescribed medications that they may be using
  • Information should also be gathered concerning illicit substances that a consumer may use
  • Policy for responding to medical emergencies
  • Medical and medication information clearly identifiable within the consumer’s file
  • Training on how to respond to critical and non‑urgent health situations
  • A register which includes information concerning incidents in the service and reviews of outcomes following an incident

Escalating care

Action 3.16

The service provider supports the workforce to:

  1. Use protocols that specify criteria for escalating care and to call for emergency assistance
  2. Use agreed collaborative pathways with appropriate partner services to address deterioration in a timely way
  3. Notify a consumer’s other care providers, family and carers when their mental health care is escalated
  • The consumer’s emergency contact details are readily accessible during service delivery
  • Workers routinely check emergency contact details with the consumer and record dates of checks in the consumer’s file
  • Workers develop safety and risk management plans in collaboration with the consumer and their identified support networks to best understand how the consumer may express emerging health concerns and ask for help
  • Consumer recovery plans need to identify consumer personal responsibilities, including children and pets, in the event of an urgent health situation or crisis
  • Policies for risk management, including the processes for responding to medical emergencies and the escalation processes necessary
  • Visible poster of escalation pathways and contact numbers
  • Evaluation training register includes medical emergency training and professional development

Action 3.17

The service provider:

  1. Shares information with consumers, their families and carers about how to recognise and respond to acute deterioration, crisis or distress
  2. Has processes for consumers, their families and carers to directly escalate care
  • Ensure care and recovery plans include clear processes for consumers, carers and families to recognise and respond to acute deterioration, crisis or distress
  • Support access to resources on mental health first aid training
  • Ensure that consumers, carers and families have information packs made available to them and that the information is understood by them in terms of format and language
  • Escalation pathways for consumers, their families and carers to use
  • Review of complaints and feedback from consumers

Working with consumers with thoughts of self-harm and suicide

The service provider has processes to support collaboration with consumers, their families and carers and other care providers to:

  1. Identify when a consumer is at risk of self-harm and/or suicide
  2. Respond to consumers who are distressed, have thoughts of self-harm or suicide, or have self-harmed
  3. Take action to prevent self-harm and/or suicide in situations of acute risk
  4. Ensure follow-up arrangements are developed, communicated and implemented for people who have harmed themselves or reported suicidal thoughts
  • Establish trauma‑informed, recovery‑oriented practice that effectively responds to consumers at risk of self‑harm and/or suicide
  • Ensure the workforce have open and transparent conversations with consumers, their carers and families in the development of care and recovery plans about self‑harm and suicide
  • To assist in identifying and supporting at‑risk consumers, communicate the organisational processes to respond to self‑harm and suicide, and put in place prevention strategies with the consumer, carers and families
  • Ensure the workforce are appropriately trained in the skills and knowledge of identifying and responding to self‑harm and suicide
  • Review the physical environment of the service to identify and mitigate any factors which may increase risk
  • Use the reflective practice supervision system to allow members of the workforce to safely review their responses to situations of increased suicide risk or suicidal behaviour
  • Use the incident management and investigation systems to review incidents of suicidal behaviour
  • Policy for identifying and responding to consumers at risk of self‑harm or suicide
  • Suicide prevention training
  • Suicide prevention material provided to consumers, carers and families
  • Training register or documents which demonstrate capacity‑building for members of the workforce in working with consumers at risk of self‑harm and suicide
  • Demonstrated peer involvement in the development and provision of training to members of the workforce

Predicting, preventing and minimising the risk of aggression and violence

Action 3.19

The service provider has processes to identify and mitigate situations that may precipitate aggression

  • Review the physical environment of the service to identify any factors which increase the risk of violence, aggression, or reduce the capacity of members of the workforce to call for help should violence or aggression occur, for example, isolated areas
  • Provide a duress system
  • Provide resources and training to members of the workforce to employ a trauma‑informed approach that helps to understand the lived experience of trauma, and its range of impacts
  • Provide members of the workforce with training in de-escalation strategies
  • Policy for assessing and minimising risk and addressing aggression and violence in the workplace
  • Managing and supporting members of the workforce and others during and after a critical incident
  • Training and resources that include trauma‑informed practice and how to manage difficult and aggressive situations

Action 3.20

The service provider has processes to support collaboration with consumers, their families and carers and other care providers to:

  1. Identify consumers at risk or becoming aggressive or violent
  2. Implement de-escalation strategies
  3. Safely manage aggression and minimise harm to consumers, families and carers and the workforce
  4. Ensure post-incident debriefing is accessible to the workforce, consumers and where relevant, their families and carers
  • Integrate the principles of trauma‑informed practice into policies, supporting safe practice in the organisation’s premises and when members of the workforce are working offsite with consumers, in their homes and elsewhere
  • Provide training, coaching and mentoring in the use of de‑escalation skills
  • Understand the person’s triggers, and the reasons why they can become aggressive
  • Have a plan on what to do and who to contact if this is required
  • Recognise the potential signs of distress and be able to act to prevent violence
  • Identify dangerous situations and respond appropriately
  • Always seek support and self‑care from colleagues following an event
  • Ensure that lived experience participation is a means to foster a collaborative and supportive culture that demonstrates shared power between consumers and workers
  • Involve members of the workforce in assessing and evaluating the service’s current strengths and challenges when responding to a challenging event. From these discussions a plan for building the organisation’s practices can be developed
  • Ensure members of the workforce are provided with a safe space to discuss organisational practices, challenges, frustrations and success stories
  • Policy for preventing and safely managing aggression
  • Training and resources that include de‑escalation strategies
  • Incident reporting system
  • File note examples following incidents outlining actions and follow up after an event

Eliminating and minimising coercive and restrictive practices

Action 3.21

The service provider has processes to minimise the use of coercive and restrictive practices, with the aim to eliminate their use

  • Build workers’ capacity through individual practice and group supervision to support them to enact an understanding of the issues around restrictive practices and the potential risks associated with those practices
  • Use restrictive practices only within a positive behaviour support framework that includes proactive, person‑centred, and evidence‑informed interventions
  • In developing a care and recovery plan that includes restrictive practices, workers must take all reasonable steps to reduce and eliminate the need for the restrictive practice
  • Organisational statements which endorse a commitment to the reduction and elimination of restrictive practices in service design and delivery
  • Policy for predicting, preventing and managing aggression and violence
  • Training on identifying and mitigating situations that may precipitate aggression and de‑escalation strategies
  • Restrictive practices register including follow up actions
  • Quality improvement projects aimed at reducing use of restrictive practices
  • Analysis of reviews of incidents in which seclusion or restraint occurred

Action 3.22

Where restrictive practices are used the service provider has processes that:

  1. Train members of the workforce to understand which practices are coercive or restrictive and the risks associated with those practices
  2. Promote alternatives to the use of restrictive practices
  3. Communicate the use of restrictive practices and risks associated with their use to consumers, their families and carers consistent with the National Principles for Communicating about Restrictive Practices with Consumers and Carers
  4. Govern the use of restrictive practices in accordance with national guidelines and legislation and any authorisation, support plan and reporting requirements
  5. Train workers in safe techniques for application of restrictive practices that minimise harm to the consumer, the workforce and others
  6. Report incidents involving the use of restrictive practices to the governing body of the service provider, and to external commissioning or regulating bodies as required
  7. Involve consumers, their families and carers in the review of incidents, to evaluate the effectiveness of current approaches to eliminating restrictive practices
  • Train the workforce to understand coercive or restrictive practice and the associated risks
  • Promote and use alternatives to restrictive practices and demonstrate skills in safe techniques for application of restrictive practices that minimise harm to the consumer, the workforce, and others
  • Communicate with consumers, their families, and carers consistent with the National Principles for Communicating about Restrictive Practices with Consumers and Carers concerning the use of restrictive practices and risks associated with their use
  • Use restrictive practices in accordance with national guidelines and legislation and any authorisation, support plan and reporting requirements
  • Maintain a register to document and report incidents involving the use of restrictive practices to the governing body of the service provider, and to external commissioning or regulating bodies as required
  • Involve consumers, their families, and carers in co‑design processes to review incidents and evaluate the effectiveness of current approaches to eliminating restrictive practices
  • Training and resources that include human rights and restrictive practice and de‑escalation strategies
  • Restrictive practices register
  • Minutes of codesign and evaluation review meetings 

Preventing delirium and working with people with cognitive impairment

The service provider has a system in place for working with people with cognitive impairment or delirium that supports the workforce to: 

  1. Recognise, prevent, and manage cognitive impairment
  2. Seek clinical assessment of a person who may have delirium
  3. Collaborate with consumers, their families and carers
  4. Implement individualised strategies that minimise anxiety or distress 
  • Utilise evidence‑based screening tools to support the identification of cognitive impairment
  • If delirium is considered a possible cause for impairment the consumer should be offered medical care as soon as possible
  • Ensure the workforce receive appropriate training and resources to support their work with people living with cognitive impairment, with particular focus on identifying and recognising when consumers are experiencing cognitive impairment and how this may impact day‑to‑day functioning, and provide training to build capacity in supporting cognition through supports tailored to attention, memory, planning and organising
  • Collaborate with health professionals (e.g. neuropsychologists, psychiatrists) to ensure appropriate identification and management of cognitive impairment or delirium 
  • Policy for workforce to identify cognitive impairment and delirium and initiate steps to prevent and manage harm
  • Training and resources that include early recognition and effective responses to deterioration in mental state
  • Information about delirium and escalation pathways

Preventing and managing pressure injuries

The service provider providing services to consumers at risk of pressure injuries has systems for screening for risk and preventing pressure injuries that are consistent with current best practice guidelines

  • Provide evidence‑based information to consumers, families and carers about preventing and managing pressure injuries
  • Establish evidence‑based risk‑assessment tools which include assessment of risk of pressure injuries for consumers
  • Develop referral and linkage pathways to ensure primary care support for consumers managing pressure injuries
  • Use the incident system to review pressure injuries and identify whether any improvements in risk identification and mitigation are needed
  • Policy for prevention and treatment of pressure ulcers
  • Access to expert advice
  • Information about the prevention of treatment of pressure ulcers for workers, consumers, carers and their families
  • Incident register, including the identification and monitoring of injuries

Preventing falls and harm from falls

The service provider providing services to consumers at risk of falls has systems that:

  1. Are consistent with current best practice guidelines for falls risk screening and prevention, minimising harm from falls and post-fall management
  2. Provide consumers, families and carers with information about reducing the risk of falls and falls prevention strategies
  • Identify all environmental areas in the organisation that might present a falls risk and develop a risk management system to mitigate and minimise falls risk for consumers
  • Provide access to equipment and devices that support mobility and reduce risk of falls
  • Incorporate programs into service delivery which support mental and physical wellbeing and contribute to fall prevention (e.g. yoga or other evidence‑based mobility practices), identify the need for these programs as part of the care planning process and make appropriate referrals
  • Use the incident system to monitor and review falls incidents to identify whether any improvements in risk identification and mitigation strategies are needed 
  • Policy documents or processes for falls prevention that are consistent with best practice guidelines
  • Training and resources for preventing falls and harm from falls provided to workers, consumers, carers and families
  • Incident register and actions taken file
  • Review of assessments completed and care plans made, to determine whether falls risk is consistently considered

Nutrition and hydration

The service provider who provides overnight care has systems for the preparation and distribution of food and fluids that:

  1. Include nutrition care plans based on current evidence and best practice
  2. Meet consumer's nutritional, cultural and religious needs and requirements
  3. Monitor the nutritional care of consumers at risk, including making adjustments for any recorded food allergies
  4. Identify, and provide access to, nutritional support for consumers who cannot meet their nutritional requirements with food alone
  5. Support consumers who require assistance with eating and drinking
  • Establish intake processes which support the identification of any specific nutritional needs and preferences
  • Ensure consumers actively participate in the development of their nutrition care plans
  • Ensure workers responsible for assisting consumers with eating and drinking are well trained to respond appropriately to potential safety incidents such as coughing, choking, or allergic reactions
  • Evaluate nutrition plans regularly with consumers, carers and their families
  • Nutritional care plan template
  • Policy on safe preparation, transport and delivery of food to consumers
  • Process for contacting and referring to nutritionists and dietitians
  • Information for workers, consumers, carers and their families about nutrition and safe food preparation, as well as possible side effects of certain foods and medications used for both mental and physical health conditions
  • Documented nutritional care plans

Communicating for safety

Service providers have systems in place for effective and coordinated communication that facilitates the delivery of safe and high‑quality care for consumers, their families and carers.

Correct identification

The service provider has processes to:

  1. Identify consumers and match them to their care
  2. Protect the anonymity of consumers, where this is part of the model of care
  3. Use identifiers for consumers that are consistent with best-practice guidelines
  4. Ask consumers on admission if they identify as Aboriginal and/or Torres Strait Islander origin and to record this information in administrative and customer information systems
  5. Ask consumers if they identify as person from a CALD community or with a preferred first language other than English and to record this information in administrative and consumer information systems
  • Train the workforce to build the competence and confidence to work with diverse population groups and when collecting identification information
  • Provide the workforce with training in cultural safety
  • Partner with Aboriginal and Torres Strait Islander service providers, elders or communities to design and improve the service provider’s processes for asking consumers if they identify as Aboriginal and/or Torres Strait Islander
  • Partner with culturally diverse groups including the LGBTIQ+ community and people from other religious and linguistically diverse communities
  • Policy describing the service provider’s processes for the identification and protection of anonymity for consumers, carers and families
  • Describing administrative and consumer information systems
  • Training on the importance of correct identification for Aboriginal and Torres Strait Islander consumers and communities

Communication to support consumer referral and collaborative integration

The service provider supports its workforce to refer consumers within and between services and collaborate with other care providers by:

  1. Collaborating with consumers, their families and carers to identify other services involved in their care
  2. Determining the consumer’s wishes regarding collaboration with other services and seeking consent for information-sharing
  3. Using best practice structured communication processes that identify the minimum information content to be communicated when care is transferred
  4. Communicating information that is current, comprehensive and accurate
  5. Assessing the consumer’s risks, goals and preferences for care and including these in communicated information
  6. Having a process for accepting a consumer’s information at the commencement of care, and transferring information at discharge/exit or transfer of care
  • Establish policies for accepting, storing, and transferring consumer information during and post exit transfers of care
  • Ensure assessment information is accurate, up‑to‑date and that it documents risks, goals and preferences for care
  • When referring a consumer to an external service, follow up with them to enquire about the quality and safety of their supports with their other providers
  • Seek consumer consent to share certain information as necessary to other providers
  • The organisation is well connected to all parts of the service system and other human services through: interagency meetings, communities of practice, cross‑sectoral training, and education opportunities including that which is provided by peak bodies in their state or territory
  • Policy that outlines process for communicating critical information
  • Policy on storage, and sharing of information during transition of care and discharge planning
  • Documentation that demonstrates consumers, carers and families understand what information has been transferred
  • Consent form completion

Communication of critical information

The service provider has processes to:

  1. Communicate when critical information, including alerts and risks about a consumer’s care, emerges or changes
  2. Enable consumers, their families and carers to communicate critical information and information on risks to their service provider
  • Define what constitutes critical information for your service, for example, changes to the consumer’s goals, their financial and other circumstances, relationships and responsibilities, their mental state, their medication regimen, housing, substance use, general health and wellbeing
  • Identify when and to whom communication about critical information, alerts or risks should occur, including when to communicate with consumers and their informal and formal support networks
  • Conduct risk assessments following the sharing of critical information and provide alerts regarding risks to the service provider or referral services
  • Provide resources, educate, train and support workers about the organisation’s policies, processes, resources, and tools for communicating critical information, how these tools are used, and identify workers’ responsibilities to effectively communicate in key high‑risk situations
  • Policy that outlines what types of critical information are relevant to your service
  • Training about communicating critical information
  • Standard templates to support communication of critical information

Communication at service exit

The service provider has processes to ensure a smooth transition by:

  1. Collaborating with consumers, their families and carers to plan for the post-exit period
  2. Having a process for transferring care that is clearly communicated to the consumer
  3. Ensuring that the consumer’s exit from the service is communicated to any ongoing services
  4. Completing a written summary of services provided and providing this to appropriate ongoing services
  • Conduct safety planning when consumers are transitioning from your organisation
  • Facilitate a handover meeting with the new provider and the consumer to discuss their needs and aspirations
  • Transition plan template
  • Service summary template
  • Example transition risk assessment which includes management and mitigation strategies to address any identified risks
  • Use of a performance indicator for completion of the Service Summary within a set period after exit

Documentation of information

The service provider has processes to contemporaneously document information in the consumer care record and communicate this to relevant staff including:

  1. Critical information and alerts
  2. Reassessment processes and outcomes
  3. Changes to the care plan
  4. Any nominated family and carer involvement
  • Develop and implement systems to support the contemporary documentation of critical information in consumer care records
  • Ensure designated or principal care providers and substitute decision‑makers details are included in documentation and are regularly checked for currency
  • Ensure the workforce are aware of their roles, responsibilities, and accountabilities in completing and using documentation and communicating the information to consumers and others
  • Establish organisation‑wide expectations for how information is recorded and communicated 
  • Policy outlining processes for documentation and record keeping including referrals and exit transition to other services
  • Training and resources on record keeping, communicating for safety and privacy
  • File audits
  • Orientation and training register

Preventing and controlling infections

Evidence‑based systems are used to prevent and control infections. Consumers presenting with, or with risk factors for, infection or colonisation with an organism of local, national or global significance are identified promptly, and receive the necessary management and treatment. The service environment is clean and hygienic. 

Standard and transmission-based precautions

Action 3.32

The service provider has policies and procedures to apply standard and transmission-based precautions that are fit for the setting and consistent with principles outlined in the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare, and relevant jurisdictional laws and policies, including work health and safety laws

  • Identify infection and prevention control legislation and policies relevant to your service and its service delivery contexts
  • Establish how standard and transmission‑based precautions are communicated across the organisation and with other services that are providing supports to consumers
  • Develop resource materials and information for workers, consumers, their carers and families, and ensure that the materials are available in formats that can be accessed and are understood
  • Communications to the organisation regarding inflection prevention and control requirements
  • Resources and communications for consumers, their carers and families
  • Training and resources that include how risk of infection or communicable disease is assessed and how to respond to infection risks
  • Data on cleaning regime

Action 3.33

The service provider has processes in place to support the workforce, consumers, their families and carers with:

  1. Effective hand hygiene
  2. Respiratory hygiene and cough etiquette
  3. Safe sharps handling and use
  4. Access to personal protective equipment
  • Provide training on hand hygiene processes to all members of the workforce
  • Ensure the service environment has the required resources to practice hand hygiene, including alcohol‑based hand sanitiser and hand washing facilities
  • Display promotional material in the service environment to support members of the workforce and consumers to practice hand hygiene
  • Promote key messages regarding respiratory hygiene and cough etiquette across the organisation and with consumers
  • Policy documents or processes for the prevention and control of infections and communicable disease
  • Training and resources that include documents relating to hand hygiene
  • Information available to the workforce and consumers regarding respiratory hygiene, cough etiquette and physical distancing
  • Training syllabus, attendance records or competency assessments relating to hand hygiene

Workforce screening and immunisation

The service provider has screening and immunisation systems in place to prevent and manage infections in the workforce

  • Identify the physical health characteristics of the service’s targeted consumer population
  • Keep up to date with government health advice regarding vaccination and worker screening requirements
  • Ensure your workplace has sufficient resources to support the worker screening and vaccination requirements of workforce, such as supply of rapid antigen tests
  • Facilitate access to required vaccinations
  • Facilitate access to alternative control measures where medical exemptions to vaccinations apply to workers
  • Ensure all members of the workforce are aware of their roles and requirements in preventing and managing infections in the workforce 
  • Policy for required workforce vaccinations and their rationale for the inclusion
  • Training and resources that include vaccinations required within the workforce and reason for the requirement
  • Workforce vaccination record and medical exemption for vaccination register

Antimicrobial stewardship

The service provider supports consumers with appropriate antimicrobial usage when relevant

  • Use clinical guidelines consistent with Therapeutic Guidelines
  • Use antimicrobials only when needed – avoiding use where there is no evidence of benefit.
  • Select antimicrobials wisely – using narrow spectrum therapy where possible, keeping broader‑spectrums agents in reserve
  • Using safe and effective doses – using correct doses and limiting duration to what is needed according to evidence
  • Ensure that members of the workforce who do not have clinical qualifications have basic training in understanding antimicrobials
  • Policy for antimicrobial stewardship
  • Training and resources that include understanding microbial use
  • Incident register

Medication safety

Service providers describe, implement and monitor systems to ensure safe and quality use of medicines and the workforce uses these systems. Service providers have systems in place to support consumers who self-administer prescribed and over the counter medicines.

Medicines scope of practice

The service provider has processes to define and verify the scope of practice for prescribing, administering and monitoring medicines for relevant members of the workforce

  • Establish policies that describe the roles and responsibilities of workers to ensure the safe and quality use of medicines
  • Provide resources and training to ensure workers are skilled and competent to undertake their designated role
  • Implement systems that record the safe and quality use of medicines by consumers assisted by designated workers of the service 
  • Resources and information provided to workers and consumers, their carers and families
  • Orientation and training materials
  • Register of workforce and scope of practice
  • Policy documents or processes for obtaining a medication history as soon as possible in the episode of care
  • Training and resources that include legal and safety requirements for the prescribing, administering of medicines
  • Consumer wellness plan
  • Information on what treatments, including medications, have been effective in the past, and which have caused problems

Documentation, provision and access to medicines-related information

Action 3.37

A service provider that prescribes or administers medicines has processes to ensure members of the workforce work within their scope of practice to:

  1. Ensure a consumer’s medicines-related information, including medicine allergies and adverse drug reactions, is documented in their consumer care record
  2. Partner with consumers, families and carers in the management of their medicines as needed
  3. Support consumers to maintain a current and accurate medicines list
  4. Encourage consumers to share their medicines list with other healthcare providers involved in their care and or does so on a consumer’s behalf with their consent
  5. Use information from a consumer’s medication history to minimise risks in the planning and delivery of mental health care
  • Establish policies to ensure a consumer’s medicines‑related information, including medicine allergies and adverse drug reactions, is documented in their consumer care record
  • Ensure that the worker responsible for administering or supervising the management of medication has all the information contained in consumer care record necessary to perform their role
  • Ensure that workers are trained to partner with consumers, families, and carers in the management of their medicines as required
  • Support consumers to maintain and share with relevant other service providers a current and accurate list of medicines, dosage and when and how they must be taken, for instance, with food
  • Use information from a consumer’s medication history to minimise risks in the planning and delivery of other aspects of their mental health care
  • Policy for documenting all medication related information, including risks and shared care arrangements
  • Training and resources that include medication management and scope of practice
  • Completed medication forms and record templates

Action 3.38

The service provider has processes to ensure members of the workforce work within their scope of practice to:

  1. Take action when a consumer, their family, carer or a member of the workforce identifies a suspected medicines-related problem
  2. Document suspected adverse drug reactions experienced by consumers during service delivery in the consumer care record
  3. Report suspected adverse drug reactions to other healthcare providers involved in the consumer’s care, in the organisation-wide incident reporting system and to the Therapeutic Goods Administration, in accordance with its requirements
  • Establish policies to support members of the workforce work within their designated scope of practice
  • Ensure systems are in place to record adverse events and report them appropriately within the organisation, to other services and the Therapeutic Goods Administration, in accordance with its requirements
  • Develop resources and information for workers, consumer, their carers and families
  • Policy for managing adverse medication events and reporting and sharing of information
  • Reporting of adverse drug reactions to all significant parties
  • Standardised tools for recording documentation of adverse drug reactions
  • Incident register
  • Records of actions taken following an event

Safe and secure storage and distribution of medicines

The service provider complies with manufacturer’s directions, legislation and jurisdictional requirements for the:

  1. Safe and secure storage of medicines
  2. Disposal of unused, unwanted or expired medicines
  • Establish policies and processes for the safe and secure storage and disposal of expired or unwanted medicines in line with the legislation and judicial requirements
  • Ensure that relevant workforce are trained in the safe and secure storage and disposal of expired or unwanted medicines according to the organisation’s guidelines
  • Establish a system to record the storage and safe disposal of medication and audit the system at specified regular intervals
  • Policy for storing, administering and disposing of medication safely
  • Training and resources that include safe and secure storage and disposal of medication
  • Records of actions taken to ensure safe storage and disposal of medicines

Last updated: 29 April 2026