Mental Health Standards for Community Managed Organisations Practice Governance Standard
Service providers have a responsibility to the community for continuous improvement of the safety and quality of their services, and ensuring that they are person‑centred, recovery‑oriented, culturally competent and secure, safe and effective.
The intention of this standard is to implement a practice governance framework that ensures consumers, their families and carers receive safe and high‑quality care.
Practice governance, leadership and culture
Service providers establish and use practice governance systems for their care services to improve the safety and quality of care.
Practice governance, leadership and culture
Action 1.01
The governing body:
- Provides leadership to develop a culture of safety and quality improvement, and satisfies itself that this culture continues to exist within the organisation
- Provides leadership to ensure partnering with consumers, their families and carers
- Endorses priorities and strategic directions:
- For ethical, safe, high-quality, recovery-oriented care, and ensures these are communicated effectively to the workforce, consumers, their families and carers
- That recognise, respect, and nurture the unique cultural identities of Aboriginal and Torres Strait Islander people, and provides for the delivery of services that are culturally safe
- Endorses the organisation’s practice governance frameworks
- Ensures that roles and responsibilities are clearly defined for the governing body, management and members of the workforce and they are orientated into the organisation
- Fosters a positive culture of reporting adverse incidents and monitors the action taken as a result of analyses of adverse incidents and trends
- Reviews reports and monitors the organisation’s progress on safety, quality, performance and effectiveness
- Endorses principles and practices within governance frameworks that support the organisation’s ability to adapt to technology as it changes
- Ensures conflicts of interest are proactively managed, and perceived and actual conflicts of interest are documented
- Endorses systems for integrating care with other service providers involved in a consumer’s care and monitors the effectiveness of these systems
Key tasks
- Incorporate consumer perspectives in organisational planning, governance decision‑making and in the development and implementation of policies
- Establish mechanisms to ensure that service delivery is culturally safe and reflect the needs of Aboriginal and Torres Strait Islander communities, this could include establishing Aboriginal and Torres Strait Islander representation on the governing body
- Define the roles, responsibilities, and authority of the governing body, management and workforce, particularly regarding quality and safeguarding measures
- Acknowledge, document and manage any perceived or actual conflicts of interest to protect the safety and quality of service delivery for consumers
- Establish a system to ensure the governing body can monitor the organisation’s performance in quality of service provision, alongside their other monitoring responsibilities
- Board and leadership teams establish clear pathways for reporting and responding to adverse incidents that are solution‑focused and proactive
Examples of evidence
- Policies that outline how to partner with consumers, families and carers to support the development of safe and quality service delivery and promote lived experience leadership within governance structures
- A Board meeting standing agenda item to discuss quality and safeguarding, with minutes reflecting actions taken to address the issues identified at each meeting
- Policy and a register to document identified conflicts of interest
- Up‑to‑date and regularly reviewed position descriptions for all roles within an organisation to support role clarity and responsibilities
- Memoranda of understanding with other services and agencies to support integrated care
Action 1.02
The service provider implements and monitors strategies that:
- Meet its safety and quality priorities for diverse population groups, including Aboriginal and Torres Strait Islander people, people with physical and intellectual disabilities, people from culturally and linguistically diverse (CALD) backgrounds, individuals who identify as lesbian, gay, bisexual, transgender, intersex, queer and questioning (LGBTIQ+) people at risk of homelessness and other diverse population groups
- Provide culturally safe and inclusive services in the planning and delivery of health care by identifying and addressing the specific needs of these diverse population groups and their families and carers
- Identify groups of people who experience mental ill health who may be at risk of harm
- Incorporate information on the diverse and higher-risk groups into the planning and delivery of the service
- Demonstrate knowledge of, and engagement with, other service providers or organisations with diversity expertise and or programs relevant to the unique needs of its community
Key tasks
- Prioritise understanding of the uniqueness of each individual, and then demonstrate inclusion of these details into service delivery.
- Actively support, promote, and uphold a consumer’s right to practice their culture, diversity, values, and beliefs during service delivery: this could include being flexible about delivering services at varied times to accommodate consumers who may wish to attend specific cultural events and including cultural activities, or referrals to culturally specific services of significance to a consumer in their care and recovery plans
- Ensure workforce supervision, mentoring and reflective practice promotes respect and responsiveness to culture, diversity, values, and beliefs
- Develop organisational partnerships with services that have the skills and knowledge to best respond to the cultural and diverse needs of consumers, for instance, partnerships with Aboriginal and Torres Strait Islander led organisations or LGBTIQ+ advocacy services
- Recruit a workforce with diverse backgrounds, including peers with lived experience of mental health conditions or psychosocial disability, and match workers with consumers appropriately
- Use interpreting and translating services when required and seek support from Aboriginal or Torres Strait Islander or multicultural identified workers, including peer workers, to best support inclusive practice
- Undertake research and evaluation to identify the specific needs of the population groups engaging with your service
Examples of evidence
- Policies which outline your organisational approach to the acknowledgement, respect and integration of consumers’ culture, values, and beliefs in service delivery
- Acknowledgement of Country statements are displayed at service delivery sites and included appropriately in events, meetings, e‑communications, etc.
- Rainbow flags and other symbols of cultural welcome are
- Mission statement, policy or other public document outlining the organisation’s commitment to meeting diverse community needs
- Records generated during partnership processes with diverse groups, such as consultation on the development of policies and processes, notes from ongoing partnership meetings, arrangements for diverse community members to contribute to governance committees
- Records of processes undertaken to facilitate workforce implementation of policies relevant to cultural safety, such as training records, audit‑and‑feedback processes, changes to documentation formats to prompt documentation of cultural needs
Action 1.03
The service provider considers safety and quality issues and applies ethical principles in its business decision making about the design, development and delivery of services
Key tasks
- Collaborate with consumers, their families and carers in the development and implementation of an ethical framework for service delivery within the organisation
- Report ethical issues identified in the design, development and delivery of mental health services and review using the appropriate internal or external bodies
- Incorporate ethical principles in strategic and business plans
- Ensure that the ethical principles informing service delivery practice can be measured effectively and used in decision‑making processes as ethical dilemmas arise
- Ensure all workers are familiar with the organisation’s ethical principles
Examples of evidence
- A documented ethical framework for service delivery within the organisation
- Strategic and business plans that incorporate ethical principles
- Processes to review ethical questions, in collaboration with consumers, families and carers
- A code of conduct that embeds ethical principles
Care leadership
Action 1.04
The service provider establishes and maintains a practice governance framework and uses the processes within this framework to drive improvements in safety, quality and performance
Key tasks
- Implement policies that describe the practice governance framework
- Ensure all members of the workforce have clear understanding of the meaning of the practice governance framework
- Ensure that members of the workforce are provided with appropriate resources and training deliver service consistent with the practice governance framework
- Partner with consumers, their families and carers in the review of your practice governance framework
Examples of evidence
- Documented practice governance framework
- Evaluation reports on the effectiveness of the practice governance framework
- Documentation of actions taken that demonstrate quality improvement, for instance, a risk register and quality improvement register
- Training register, including training offered, attendance rates and evaluation
Action 1.05
The service provider:
- Has processes to support the workforce to understand and perform their delegated safety and quality roles and responsibilities
- Engages the workforce in the practice governance of the service
- Monitors and responds to the needs of the workforce to ensure a mentally healthy workplace
- Supports the workforce to undertake reflective practice supervision
Key tasks
- Provide leaders with evidence‑based mental health training to improve their recognition of and response to mental ill health and related risk factors in the workplace, including responses to traumatic events30
- Ensure roles and responsibilities are clear and understood
- Ensure regular formal practice supervision is in place for members of the workforce, as well as relevant resources being readily accessible to support workers’ self‑care and mental health
- Invite members of the workforce to provide feedback on work practices and workplace health and safety
- Partner with an Employee Assistance Program to facilitate external and confidential access to mental health support for all members of the workforce
- Regularly review relevant information and records such as reporting systems including incident reports, workers’ compensation claims, workforce surveys, absenteeism, and workforce turnover data to support the identification of psychosocial hazards
Examples of evidence
- Records of supervision sessions conducted with members of the workforce
- Policy outlining how supervision and other supports are provided to members of the workforce, including frequency, roles and responsibilities
- Evidence of coaching and mentoring resources, and external professional development opportunities offered
- Evidence of training for supervisors in how to provide effective supervision
- Reports on follow‑up and analysis of incidents involving safety
- Evidence of best practice support for workers with lived experience and managers of peer workers
Safety and quality systems
Safety and quality systems are integrated with practice governance processes to enable the service provider to actively manage and improve the safety and quality of care.
Legislation, regulations, policies and procedures
The service provider has processes to:
- Set out, review and maintain the currency and effectiveness of policies, procedures and protocols
- Monitor and take action to improve adherence to policies, procedures and protocols
- Review compliance with legislation, regulations and jurisdictional requirements
- Monitor and respond to legislative changes
Key tasks
- Implement a schedule to monitor, review and update policies using a risk management approach. Don’t rely on a reactive approach to reviewing policy in response to incidents
- Establish an organisational process to be followed when a policy or procedure is to be developed or is due for review. This should include
- A process for drafting the new or updated policy which involves consultation with consumers and members of the workforce along with a review of relevant literature, legislation and standards
- A process for approval by the appropriate level of organisational governance
- An implementation plan which includes a process for communicating policy updates to members of the workforce, determining any training required and any implementation monitoring which may be needed
- Ensure your organisation is accredited by an accepted industry‑recognised accreditation body
Examples of evidence
- Policy registers which include review dates and alerts. It should be evident that policies are routinely reviewed and improved
- Evidence that reviews of policies include consultation with consumers and members of the workforce regarding the accessibility of current processes
- Documented evidence on how your service meets its legislative and compliance requirements against the required standards – this could be through internal or external audits, or a formal evaluation
Measurement and quality improvement
Action 1.07
The service provider uses quality improvement systems that:
- Identify safety, outcome and quality measures including surveys to monitor people’s experience of services provided
- Monitor variation in service delivery against expected outcomes and identify targets for improvement in safety and quality
- Review service performance against external measures
- Implement safety and quality improvement initiatives
Key tasks
- Seek non‑identified feedback from consumers on their experience of service delivery – for example, through anonymous message boxes, internal organisational questionnaires or surveys such as the YES‑CMO survey
- Conduct formal evaluation of existing programs or practice frameworks from a consumer and workforce perspective – consider what outcomes are most relevant to your service – for example, reductions in involuntary community treatment orders, and stable tenancy arrangements
- Create an internal audit schedule and undertake regular audits across all operational areas; document and share results with members of the workforce to contribute to continuous quality improvement
- Develop resources to support members of the workforce to address identified actionable items arising from internal audits
Examples of evidence
- Quality management system or register – this could be as simple as an excel spreadsheet, or as complex as a dedicated software program depending on the size and scope of your organisation
- Corresponding quality improvement actions
- Internal audit policy that outlines the process and intended outcomes from completing the internal audits; corresponding documentation such as audit schedule, plan, and templates, as well as reported outcomes of prior audits including what was actioned or improved as a result
- Documentation of feedback from members of the workforce and consumers, their families and carers through surveys, verbally, or through web channels
Action 1.08
The service provider ensures timely reports on safety and quality systems and performance are provided to:
- The governing body
- The workforce
- Consumers, their families and carers
Key tasks
- Develop a schedule to report to relevant stakeholders regarding safety and quality performance and include the time periods in relevant policies
- Institute scheduled checks for any updated legislation and regulations
- Routinely report to the governing body, the workforce, consumers, their families and carers
- Ensure all members of the workforce are aware of their reporting duties to their respective line managers
- Provide members of the workforce with adequate time to undertake reviews and take action on desired outcomes
Examples of evidence
- Reports on quality and safety systems data that have been provided to the governing body, a funder, the workforce, or consumers, carers and their families
- Documented feedback on the reported quality and safety systems performance from the governing body, an accreditation authority, the workforce, or consumers, their families and carers
- Documented actions undertaken to ensure identified outcomes are met
- Memoranda of understanding or contracts which determine reporting requirements
Organisational risk management
The service provider:
- Identifies and documents service risks including risks to consumers, risks associated with service delivery and risks to families and carers
- Uses data collections to support risk assessments
- Acts to reduce risks
- Regularly reviews and acts to improve the effectiveness of the risk management system
- Reports on service risks to the workforce and people who use the service
- Integrates information from the risk management system into service delivery
- Plans for and manages internal and external emergencies and disasters
Key tasks
- Identify potential organisational risks
- Embed a systems approach to risk management
- Establish and maintain a risk register to assess the strategies in place to mitigate the identified risks
- Train members of the workforce and provide resources to assist members of the workforce to understand their roles and responsibilities when managing and mitigating risks
- Identify the skills and capabilities members of the workforce need to respond to an emergency or disaster when recruiting and onboarding members of the workforce
- Manage service delivery during times of external emergencies and disasters, to ensure that safe continuity of service to consumers is provided
Examples of evidence
- Risk management policies which include a risk management framework and matrix Corresponding documentation could include risk or hazard identification forms, and standard risk assessment templates
- Evidence of risk management simulations or role‑plays – for example, evacuation drills or responding to a consumer experiencing significant distress or crisis
- Risk registers which include the identification of risks and monitoring of actions taken to mitigate or minimise the risk
Incident management systems and open disclosure
Action 1.10
The service provider has incident management and investigation systems and:
- Assists the workforce to recognise and report incidents and comply with the required incident management procedures and mandatory reporting
- Assists consumers, their families and carers to communicate concerns or incidents
- Involves the workforce, consumers, their families and carers in the review of incidents
- Provides timely feedback on the analysis of incidents to the governing body, the workforce, and consumers, their families and carers
- Uses incident analysis information to improve safety and quality
- Incorporates risks identified through incident analysis into the risk management system
- Regularly reviews and acts to improve the effectiveness of the incident management and investigation systems
- Has a policy and process to support workers during and after critical incidents
Key tasks
- Clearly define what constitutes an incident in your organisation
- Review jurisdictional incident reporting requirements, which may include definitions of incident types for which there is mandatory reporting
- Have this documented and communicated to all members of the workforce to ensure that there is a shared understanding within your organisation
- Establish and maintain an incident management system that is trauma‑informed and mindful of the wellbeing of consumers
- Ensure that members of the workforce receive adequate training and supervision so that they have the skills, knowledge and support necessary to respond appropriately when an incident occurs and successfully manage the organisational processes to be followed after each incident such as investigation, mandatory reporting and open disclosure
- Members of the workforce must be aware of, and follow, any policy guidelines and understand the circumstances in which an incident must be reported externally, in line with relevant mandatory reporting and legislative requirements
- Routinely check in with members of the workforce to gauge their confidence and capacity to manage incidents safely, and that they are utilising a trauma‑informed approach
- Clearly communicate to members of the workforce any actions or changes in service provision that arise following an incident review and ensure these are implemented as soon as is practicable
- Discuss incidents and related outcomes at team meetings, to facilitate learning and development, and prevent future incidents occurring
Examples of evidence
- Organisational policies on how to best support and assist consumers, their support networks, and other stakeholders through the review of incidents
- Standardised incident or accident report template
- Evidence of incident review processes and initiation of quality improvement implementation
- Incident management policies informed by governing legislative and mandatory reporting requirements
- Incident and accident register
- Incident reports which capture the perspectives of the consumer, their support networks, the service provider, and any other key stakeholders including members of the workforce
Action 1.11
The service provider uses an open disclosure program that is consistent with the Australian Open Disclosure Framework
Key tasks
- Ensure members of the workforce are aware of the open disclosure process and are appropriately trained to adopt the framework in the event of a consumer being harmed
- Ensure the incident management system is consistent with the Australian Open Disclosure Framework
- Establish a clear process to manage complaints that have the potential to result in legal action against the organisation or individual worker
Examples of evidence
- A documented policy for implementing the Australian Open Disclosure Framework
- Consumer records which include documented open disclosure following an adverse event and actions in progress or concluded
- Evidence of resources and training materials regarding open disclosure
- Open disclosure as a part of orientation process – incorporated into the checklist
Feedback and complaints management and resolution
Action 1.12
The service provider:
- Has processes to seek regular feedback from consumers and their families and carers about their experiences of the service and outcomes of care, and these processes have the capacity to gather feedback from consumers who have left the service
- Uses this information to improve safety, quality, performance and effectiveness
- Provides timely information to stakeholders about feedback received, including service successes
Key tasks
- Routinely seek feedback from consumers, their families and carers, and respond in a timely way to any identified quality and safety issues
- Ensure key stakeholders, including the Board of the organisation is aware of feedback received from consumers
- Seek permission from consumers to be contacted following their exit from services
- Inform consumers as to how their perspectives are reflected in quality improvement activities including changes to policy
- Ensure members of the workforce have the skills and knowledge to engage respectfully with consumers, their families, and carers as well as support them to provide transparent and open feedback regarding service delivery
- Members of the workforce should clearly communicate to consumers that any feedback will not lead to a refusal of service or lower the level of services provided in the future
Examples of evidence
- Records of consumer feedback from survey responses, program evaluations and reports
- Analysis of consumer feedback for trends or themes which may assist the organisation to identify areas for improvement
- Examples of quality improvement actions that have been implemented following specific feedback from consumers, their families, or carers
- Survey forms distributed
Action 1.13
The service provider has a complaints management system, and:
- Encourages and assists consumers, their families and carers to report complaints
- Involves consumers, their families and carers in the review of complaints
- Works to finalise complaints in a timely way
- Provides timely feedback to the governing body, the workforce, and consumers, their families and carers on the analysis of complaints and actions taken
- Uses information from complaints analysis to inform improvements in safety and quality
- Records the risks identified from complaints analysis in the risk management system
- Regularly reviews and acts to improve the effectiveness of the complaints management system
- Ensures the competency of all members of the workforce in complaints handling and monitors compliance with policies
- Provides information to consumers, their families and carers on how to access relevant external complaints authorities
Key tasks
- Regularly review your organisation’s complaints process and ensure that consumers’ views are sought to inform the accessibility of the complaints processes
- Provide consumers with information about how to make a complaint
- Ensure the complaints mechanism is accessible and user‑friendly for consumers, carers and their families
- Any written complaints templates should be free of jargon, and available in a variety of communication forms to meet the diverse cultural and language needs of consumers, carers and families
- Ensure that the consumer is regularly informed about the progress of their complaint and are told that they can be involved in the resolution of the complaint and be informed of any outcomes or actions taken because of the complaint
- Ensure members of the workforce understand their roles and responsibilities when managing formal complaints
- Ensure members of the workforce are trained and have the skills to utilise a trauma‑informed approach when working with consumers, carers, and families in the review of complaints
- Provide members of the workforce debriefing sessions following a complaint and use these as a means of identifying areas of improvement and training opportunities
Examples of evidence
- A policy which outlines your organisation’s processes for receiving, recording, and responding to complaints
- A complaints process which includes a register of the actions and outcomes from complaints
- Evidence of resources such as fact sheets or online information provided to assist consumers and others who may wish to make a complaint
Consumer care records and information
The service provider has consumer care record systems that:
- Obtain consumer consent to collect, use and retain or disclose their information
- Communicate to the consumer and their family and carer how their information will be stored and used
- Support the creation and maintenance of accurate and timely consumer care records
- Comply with security and privacy legislation and regulations
- Support the systematic audit of consumer information and the technical operation of the consumer care record
- Integrate multiple information systems, where they are used
Key tasks
- Information and a verbal explanation are provided to consumers upon initial engagement with your organisation, or within service agreements about how and when consent must be obtained, what and why the information is collected, how it is stored, how long it will be kept and who has access to it
- Your organisation must have clear policies regarding obtaining consumer consent to collect, use, store and share their personal information
Examples of evidence
- Existing policies about obtaining informed consent from consumers including standardised consent forms; privacy and confidentiality; and information and records management
- Consent or refusal to consent documentation counter‑signed clearly by member of the workforce member involved
- Examples of information provided to consumers and resources and training provided to members of the workforce
- Training register includes provision of onboarding workforce training on roles and responsibilities regarding privacy and consumer records
- Policy concerning storage and sharing of information for members of the workforce
Workforce qualifications and skills
The workforce has the right qualifications, competencies, skills and values to ensure the delivery of safe and high-quality mental health care to consumers, their families and carers.
Safety and quality training
The service provider has processes to:
- Assess the competency and training needs of its workforce, including competency in providing for cultural safety
- Implement a training and orientation program to meet its requirements
- Provide access to training to meet its safety and quality training needs
- Monitor the workforce’s participation in training
Key tasks
- Establish orientation and on‑boarding training requirements for all new members of the workforce
- Include identification and discussion of professional development opportunities in workforce performance and probation reviews
- Put personal development plans in place for all members of the workforce to identify areas of growth and upskilling
- Seek feedback following workforce training to assess the effectiveness of the training provided
- Maintain records of quality and safety training completed by members of the workforce in your organisation
- Facilitate the opportunity for workers to participate in communities of practice as a means of skill development and resource sharing
- Ensure consumers continue to receive supports while members of the workforce are receiving training
Examples of evidence
- Training register which includes required training for specific roles and responsibilities and completed training
- Schedule for future training
- Documented professional development plans and refresher training for individual members of the workforce
- Evidence of online, easily available resources and information and training modules to assist members of the workforce in their work
Workforce qualifications and performance management
Action 1.16
The service provider has processes to ensure members of the workforce:
- Work within a defined scope of practice
- Have the necessary skills, experience and qualifications and values to fulfil their role including skills in working with vulnerable people
- Provide current evidence of clearance to work with vulnerable people, including National Police Checks and, where relevant, Working with Children Checks
Key tasks
- Check and retain documented records at recruitment and subsequent specified intervals to ensure worker screening checks, qualifications and registrations are valid and current
- Ensure selection criteria and role descriptions are up‑to‑date and reviewed to reflect the needs of consumers
- Clearly identify and document the skills, knowledge and expertise required for each role within your service and confirm these are understood by members of the workforce
- Provide a clear outline of the responsibilities, limitations, time allocated for the service provided and reporting lines for each role
- Establish clear requirements for volunteers, students on placement, and employees that are studying or training whilst in the workplace and ensure that these people have the resources they need to fulfil their role and support their performance
Examples of evidence
- Qualifications and experience register includes requirements and renewal dates of any credentials for allied healthcare staff working in your organisation, as well as checks for working with vulnerable people and working with children
- Policy setting out organisational pre‑employment requirements, for example, reference checking, telephone screening prior to formal interviews
Action 1.17
The service provider has valid and reliable performance review processes that:
- Require members of the workforce to regularly take part in a performance review
- Include the creation of professional development plans and access to support to implement those plans
- Address performance issues, including discriminatory practices
- Incorporate information on training requirements into training systems
Key tasks
- Conduct performance reviews for all members of the workforce at least annually, and conduct probation performance reviews for new members of the workforce three to six months after commencing their role
- Provide members of the workforce with regular feedback on their performance and support them to access professional development
- Provide opportunities for feedback on workforce performance from consumers, their families, and carers to help inform the organisation’s review of workforce capacity and capability
Examples of evidence
- Standardised performance review and probation review templates
- Policy regarding management of workforce performance
- Documented feedback on workforce performance and professional development progress
- Copies of professional development plans
- Code of conduct
- Examples of resources and training materials used to perform an appraisal and train members of the workforce to conduct them
- Policy would also include disciplinary procedure following an event and grievance and dispute resolution
Action 1.18
The service provider ensures non-discriminatory practices and equitable access to services by monitoring and responding to performance issues associated with prejudice, bias and discrimination in the workforce
Key tasks
- Facilitate workforce participation in regular supervision to ensure their practice is free from harm, and actively prevents any incidents of prejudice, bias, and discrimination from occurring
- Ensure that the model of practice supervision used encourages critical reflection to assist members of the workforce to identify any personal prejudices and biases to mitigate any risk of harm to consumers
- Implement routine training to ensure members of the workforce are equipped to use evidence‑based approaches which safeguard against harmful, inequitable practices
Examples of evidence
- Code of conduct signed by all members of the workforce and volunteers
- Procedures on how to best support consumers through reporting allegations of prejudice, bias and discrimination, such as facilitating access to an advocate
- Protocols which include advice on recording, reviewing, and investigating any allegations or incidents, and what action your organisation is taking to prevent future incidents
- Training to support members of the workforce working with consumers from diverse cultures and communities in a culturally safe and competent manner
Safe environment for the delivery of care
The environment promotes safe and high-quality care for consumers, their families and carers.
Safe environment
Action 1.19
The service provider maximises the safety and quality of care:
- Through the design of the environment
- By maintaining buildings, plant equipment, utilities, devices and other infrastructure that are fit for purpose
- Through the design of services, arrangements for use of information technology systems and internal access controls
Key tasks
- Actively involve consumers in co‑design processes, demonstrating how you support and listen to consumers, taking into consideration their opinions and ideas regarding accessibility and the service delivery environment
- Members of the workforce monitor the accessibility of the service delivery locations and advocate for changes as require
- Implement an internal audit schedule which includes a regular review of the physical service environment
- To support and maximise engagement with the service, be flexible in how services can be delivered to meet consumers’ unique needs and choices
Examples of evidence
- Records of routine maintenance end enhancement of the physical environment
- Meeting agendas and minutes reflect discussion of workplace health and safety issues, including consultations with consumers and carers
- Results of ligature audits and evidence of action taken to reduce ligature points
- Results of general safety audits and evidence of action to improve safety
Action 1.20
The service provider facilitates access to services and facilities by using signage and directions that are clear and fit for purpose
Key tasks
- Conduct an audit of the environment and signage used
- Ensure that there are clear directions for entry and exit points to rooms and buildings, with the pathways properly lit and clear of obstructions
- Provide clear details regarding how to access your service, and any transport and parking details
Examples of evidence
- Clear and visible signage and directions, in the physical and online environments where the service is delivered
- Documentation of environmental audits completed and reviewed by members of the workforce and consumers
- Documentation of information regarding access, transport and parking, opening times and after‑hours service referral
Action 1.21
The service provider demonstrates a welcoming environment that recognises the importance of the cultural beliefs and practices of diverse population groups including Aboriginal and Torres Strait Islander people, people with physical and intellectual disabilities, people from CALD backgrounds, people who identify as LGBTIQ+, people at risk of homelessness and other diverse population groups
Key tasks
- Collaborate with representatives from diverse communities and groups to identify and assess how the service can be welcoming and inclusive.
- Reflect the diversity present in the wider community by employing members of the workforce from diverse backgrounds, including those with lived experience of mental health and co‑existing conditions
- Provide members of the workforce with resources and training to work effectively with interpreters and understand the issues surrounding using carers or family members or community members known to the consumer to interpret
- Provide members of the workforce with resources and training regarding cultural competency to support their understanding of mental health in a cultural context for some diverse communities and groups
- Establish consumer advisory or reference groups (youth, CALD, Aboriginal and Torres Strait Islander, LGBTIQ+ groups, etc.)
Examples of evidence
- Service website offering information and resources in a variety of languages and formats to meet diverse communication and literacy needs
- Handrails and ramps for people with a physical disability
- Rainbow flags in common areas to indicate safety for gender and sexually diverse people
- Acknowledgement of Country and local Aboriginal artworks to demonstrate a safe space for Aboriginal and Torres Strait Islander people
- Feedback from consumers regarding the accessibility and inclusivity of the service to match their socio‑cultural needs
- Non‑gendered toilet amenities if available
- Register of engagement with interpreting and translation services to support effective communication with consumers
Action 1.22
The service provider:
- Identifies environmental factors that may cause distress or agitation
- Identifies any reasonable adjustments to the service delivery environment to ensure it is fit for purpose to address the consumer’s mental and physical needs
- Develops strategies to minimise the environmental risks of harm for consumers, their families and carers and the workforce
- Provides access to a calm and quiet environment when it is required
- Provides for a sexually safe environment for consumers, their families and carers and workers
Key tasks
- Provide reasonable adjustments for consumers to safely access the service
- Promote sexual safety and manage allegations of sexual assault, abuse, neglect and exploitation
- Train members of the workforce to provide services utilising a trauma‑informed practice approach and understand the impact of trauma
- Provide resources and training on trauma‑informed care and practice to members of the workforce and information to consumers, their carers and families
- Ensure safety plans are in place which include strategies for the consumer should they be concerned for their health and safety and that these are easily accessible in a consumer’s records to support mitigation of distress and agitation for consumers in the service environment
- Respond transparently following incidents and provide opportunities for meaningful reflection, repair and further safety planning beneficial for consumers and for family members or carers, as well as for members of the workforce
Examples of evidence
- Resources and training materials regarding trauma‑informed care and practice; cultural competence and sexual safety
- Feedback for members of the workforce and consumers that the organisation is safe environmentally and from a sexual safety perspective
- Evidence of strategies to minimise risk
- Templates for safety plans and risk management plans
- Resources and information for workers, consumers and carers
Action 1.23
The service provider has designed the service environment and has policies in place to minimise the risk of harm for children and young people while using a service, consistent with the National Principles for Child Safe Organisations
Key tasks
- Ensure that the organisation embeds the National Principles for Child Safe Organisations in their governance and culture which is reflected in its policies, work practices, workforce training and documentation.
- Utilise a trauma‑informed practice approach that highlights safety at its core and aligns with the National Principles for Child Safe Organisations
- Ensure members of the workforce understand and have the capacity to work in alignment with the United Nations Convention on the Rights of the Child and have the skills to communicate these rights to children, young people and their families
- Confirm that all members of the workforce interacting with children hold a Working with Children Check (or equivalent) approval (where relevant) and undergo a National Police Check
- Provide training to members of the workforce so that they are aware of mandatory reporting requirements and are proactive in responding to child protection concerns
- If safe to do so, it is best practice to be transparent with parents that a report to the child protection agency is being made
- Members of the workforce practice professional judgement as to whether telling a parent a report is being made will place the child at further risk of harm
Examples of evidence
- Policy that describes the provisions in place for ensuring that children and young people are protected from harm, including mandatory reporting requirements
- Practice guidance provided to members of the workforce working with children and young people
- Code of conduct
- Working with Children Check registers (or equivalent) and probity checks conducted for all members of the workforce working with children and young people
- Risk management framework which includes provisions for preventing and mitigating risks relative to working with children and young people
- Examples of resources provided to children and young people and the members of the workforce working with them
- Examples of training materials for members of the workforce
Action 1.24
The service provider, when caring for consumers in their home, works with the consumer to identify potential risks and ensure a safe service delivery environment
Key tasks
- Train members of the workforce to understand how to identify risks in the support delivery environment and safely provide services in a home environment including where services are provided digitally
- Ensure that risk assessments are conducted prior to members of the workforce working in any new service delivery location, including a consumer’s home or when transporting a consumer in a car
- Provide opportunities for consumers to freely express any anxieties they may have regarding home visiting
- Ensure risk assessments are current, with risk reviews conducted periodically or when there is a change of circumstances
Examples of evidence
- Policy outlining safety and risk management in service delivery locations, including in the consumer’s home, when providing transport or going into a consumer’s home digitally
- Risk assessment template or matrix for service delivery locations which are off‑site from the organisation
- Evidence of safety plans or risk mitigation strategies put in place to manage any identified risks which are easily accessible in consumer records
- Home visiting work health and safety checklist
- Resources and information provided to the worker, consumer and carer
Action 1.25
The residential service provider has protocols for flexible visiting arrangements to meet the needs of the consumer, their family and carer
Key tasks
- Provide consumers of the service, their carers and family with written information about any limitations to their visiting rights, including times, wearing of masks and bringing in of any food and equipment
- Provide information in multiple communication formats, and languages
- Advise consumers and their families about any change to the restrictions due to – for example, infection outbreaks
Examples of evidence
- Welcome pack information in multiple languages
- Survey of consumer and carer experience of service
- Resources and information provided to workers
- Notices to visitors about access to residential care facility
Privacy
Action 1.26
The service provider has privacy policies that:
- Are easy to understand and transparent for consumers, their families and carers
- Are readily available to consumers, their families and carers before accessing and while using the services
- Uphold consumer’s rights and choices to the extent that these do not impose serious risk to the consumer or others
- Address the issue of sharing confidential information with families and carers and with other services the consumer uses
- Comply with privacy laws, privacy principles and best practice
Key tasks
- Train members of the workforce so they have a clear understanding of the privacy policies and can effectively answer any questions from consumers and carers
- Develop clear protocols as to what specific information may be shared when information needs to be shared with other providers
- Ensure members of the workforce understand what information can be disclosed to a consumer’s family, with the consumer’s permission, or shared because they are a nominated substitute decision-maker
- Ensure members of the workforce are aware of relevant legislation surrounding guardianship and administration
- Uphold the specific decision‑making rights described in a guardianship order
- Ensure privacy policies are current and regularly reviewed
- Make your privacy policy easily accessible and available to consumers
Examples of evidence
- Documented privacy and confidentiality policies with reference to the relevant governing legislation
- Resources available to consumers about their privacy rights
- Members of the workforce can demonstrate knowledge of privacy policies that operate in the context of service delivery
- Documented protocols to ensure that consumer information cannot be accessed by unauthorised persons
- Training material for onboarding privacy training
Action 1.27
The service provider advises consumers, and where relevant, their families and carers, of changes to privacy policies in a timely and comprehensible way
Key tasks
- Include a requirement outlined in relevant policies to advise consumers and, where relevant, their support networks of any substantial or material change to a privacy policy
- Allocate clear roles and responsibilities for notifying consumers of the change to the privacy policy
- Provide privacy policy update notices to consumers in one or more ways to maximise transparency – for example, by email or by using a pop‑up notice on the service provider’s website
- Implement a process to re‑obtain consumer consent when there has been a substantial or material change to the privacy policy, including discussing those changes in detail with the consumer and their carers
Examples of evidence
- Policy that describes the service provider’s requirement that consumers be advised of changes to privacy policies in a timely way
- Documented information provided to consumers about changes in privacy policy