Aged Care Quality Standards 2019 (repealed edition)

Maintain a Plan for Continuous Improvement that identifies areas for improvement and tracks actions.

• Documented Plan for Continuous Improvement
• Evidence improvements are implemented

• PCI not maintained or actioned

Implement infection prevention and control, including a designated IPC Lead and outbreak management.

• IPC program and IPC Lead
• Outbreak management plan

• No designated IPC Lead or IPC program

Provide nutritious, varied, culturally appropriate food and adequate hydration with malnutrition screening.

• Nutrition and hydration assessment
• Dining experience and menu review

• Malnutrition/dehydration risks unaddressed

Practice open disclosure when things go wrong, communicating honestly with consumers and families.

• Open-disclosure policy
• Records of open-disclosure conversations

• Adverse events not openly disclosed

Provide palliative and end-of-life care that maintains comfort, dignity and respects consumer wishes.

• Advance care directives
• End-of-life care plans and pain management

• End-of-life wishes not documented/honoured

Treat each consumer with dignity and respect, value their identity, culture and diversity, and support informed choice and risk-taking.

• Consumer charter of rights
• Dignity-of-risk and choice policy

• Care delivered without consumer input

Each consumer is treated with dignity and respect, with their identity, culture, and diversity valued and supported.

• Culturally-safe care procedures
• Consumer dignity audits

• Disrespectful or culturally-unsafe practices

Care and services are delivered in a way that supports consumer choice, independence, and quality of life.

• Consumer choice and dignity-of-risk records
• Support for community connection

• Choice overridden without risk assessment

Each consumer is supported to exercise choice and make informed consent about their care, including the right to refuse care.

• Plain-language information provision
• Informed-consent records

• Care/treatment without informed consent

Conduct ongoing assessment and planning with consumers that supports their needs, goals and preferences.

• Care planning framework involving the consumer

• No consumer involvement in planning

Each consumer's needs, goals and preferences are assessed, documented and regularly reviewed.

• Initial and ongoing assessment records (incl. risks)

• Risks to the consumer not assessed

Care and services are planned with input from the consumer to meet their assessed needs and goals.

• Individualised care/services plan
• Advance care planning records

• Plan not reflecting consumer goals

Care plans are regularly reassessed and updated to respond to changes in consumer needs and preferences.

• Scheduled and triggered reassessment records

• Plans not reviewed after incidents/changes

Deliver safe and effective personal and clinical care that is best practice, tailored, and optimises consumer health and wellbeing.

• Clinical care governance and safe-care procedures

• Unsafe or ineffective care

Each consumer receives safe, effective personal care and clinical care that is best practice, tailored to their needs, and optimises health and wellbeing.

• Best-practice clinical procedures
• High-impact/high-prevalence risk management (falls, wounds, pain)

• Clinical deterioration not recognised/escalated

Effective antimicrobial stewardship and infection prevention and control are implemented.

• Antimicrobial stewardship program
• Minimising infection-related risks

• No antimicrobial stewardship in place

Provide services and supports for daily living that meet the consumer's needs, goals and preferences and optimise independence, health and wellbeing.

• Daily-living services supporting independence and wellbeing

• Services not supporting quality of life

Each consumer receives services and supports for daily living that optimise their independence, health, wellbeing and quality of life.

• Services promoting independence, social/emotional/spiritual wellbeing

• Social isolation not addressed

Services are delivered safely and in accordance with best practice standards.

• Information sharing and timely referrals
• Meal/services delivery records

• Referrals not made when needed

Ensure the service environment is welcoming, easy to understand, optimises sense of belonging, and is safe, clean, well maintained and comfortable.

• Safe, clean, well-maintained, welcoming environment

• Unsafe or poorly-maintained environment

The organisation's service environment is safe, clean, comfortable and enables consumers to move freely, both indoors and outdoors.

• Environment safety and freedom-of-movement controls

• Environment restricting safe movement

Furniture, fittings, and equipment are safe, clean, well-maintained, and suitable for consumers.

• Clean, safe, well-maintained furniture/fittings/equipment register

• Faulty or unhygienic equipment

Regularly seek input and feedback from consumers, carers and others, use it to improve, and have an accessible complaints process.

• Accessible feedback and complaints system

• No accessible complaints pathway

Each consumer and other stakeholder is encouraged and supported to provide feedback and make complaints, and the organisation responds effectively.

• Complaints procedure with advocacy/translation access
• Complaint records and outcomes

• Complaints not acknowledged or actioned

Open disclosure processes are in place for when things go wrong, including informing affected consumers and managing incidents.

• Open-disclosure procedure and records

• Harm not openly disclosed to consumers

Have a workforce sufficient in number, and skilled and qualified, to deliver the outcomes required by these standards.

• Workforce sufficient and competent to deliver safe care

• Insufficient or unqualified workforce

The organisation has a skilled and qualified workforce sufficient to provide safe, respectful and quality care and services.

• Workforce plan ensuring adequate numbers/mix

• Staffing levels compromising care

The workforce is supported to deliver care through ongoing education, training, and supervision.

• Induction and ongoing training records
• Competency assessment

• Workers not trained for their roles

Have effective governance systems, including clinical governance, risk management, information management and continuous improvement.

• Governing-body accountability for safe quality care

• Governing body not engaged in quality/safety

The organisation's governing body is accountable for the delivery of safe, quality care and services.

• Governance framework
• Consumer engagement in governance

• No consumer voice in governance

Effective clinical governance systems and processes are in place to support safe and quality clinical care.

• Clinical governance framework (antimicrobial stewardship, restraint minimisation, open disclosure)

• No clinical governance framework

The organisation implements systems for continuous improvement driven by assessment of performance and consumer feedback.

• Plan for continuous improvement (PCI)
• Improvement actions tracked

• No continuous-improvement system

The organisation identifies and manages risks to consumers, staff, and the organisation, including clinical, financial, and operational risks.

• Risk management framework
• High-impact risk, abuse/neglect, incident management systems

• Risks to consumers not managed