Aged Care Quality Standards (Australia)

Show that the safety, health, wellbeing and quality of life of individuals is what drives service delivery decisions.

• Statement of purpose or policy placing individual wellbeing ahead of operational convenience
• Governing body and management minutes showing decisions tested against individual wellbeing
• Care review records where an operational option was rejected on wellbeing grounds
• Worker interview records

• Policy states the principle but rostering, budget or throughput decisions show no wellbeing test
• No documented trade-off decisions to evidence the principle in practice

Support individuals to understand and make informed decisions about their agreements, fees and invoices.

• Plain language fee schedules and sample invoices
• Records of fee explanations given to individuals
• Complaints or queries about fees and how they were answered
• Evidence of itemised invoicing

• Fees disclosed only in the agreement and never explained
• Invoices not itemised so charges cannot be checked

Show that the provider understands and values each individual's identity, culture, ability, diversity, beliefs and life experiences.

• Individual profiles capturing identity, culture, beliefs and life history
• Diversity and inclusion policy and training records
• Evidence that profile information changes how care is delivered
• Feedback from individuals and supporters about being known and valued

• Identity information collected at intake and never used again
• Diversity treated as a training topic with no link to care delivery

Show that services are developed together with individuals and tailored to their needs, goals and preferences.

• Care and services plans showing individual input and signature or recorded agreement
• Records of goals and preferences expressed in the individual's own words
• Evidence of service adjustments made after individual input

• Plans written for the individual rather than with them
• Template goals repeated across many individuals

Deliver services in a way that is free from discrimination, abuse and neglect, treats individuals with dignity and respect, and respects personal privacy.

• Policy prohibiting discrimination, abuse and neglect
• Incident records and their outcomes
• Observation records of care delivery and privacy practice
• Complaints relating to dignity, respect or privacy and how they were resolved

• Policy exists but incidents are not analysed for dignity or discrimination themes
• Privacy breaches during personal care treated as routine rather than reportable

Understand the Statement of Rights and maintain practices that ensure the provider acts compatibly with it.

• Documented practices mapped to the Statement of Rights
• Worker training records covering the Statement of Rights
• Records of decisions tested for compatibility with the Statement of Rights
• Evidence the Statement of Rights is made available to individuals

• Statement of Rights displayed but not built into any operating practice
• No mechanism to test a decision for rights compatibility

Support individuals to exercise choice and make decisions about their services, and provide decision support when they want or need it.

• Supported decision making policy and procedure
• Records showing choices offered and the option taken
• Evidence of supporter involvement where the individual wanted it
• Training on supported decision making

• Choice recorded only at intake
• Substitute decision making used where supported decision making would suffice

Provide individuals with timely, accurate, tailored and sufficient information about their services in a way they understand.

• Information materials in accessible and translated formats
• Records of interpreter and communication aid use
• Evidence that information was checked for understanding
• Feedback on clarity of information

• Information provided only in English and only in writing
• No check that the individual actually understood

Support individuals to exercise dignity of risk so they can achieve goals and maintain independence and quality of life.

• Dignity of risk policy and risk conversation records
• Documented risk discussions showing the individual's decision and the supports put around it
• Evidence that a refused activity was reconsidered rather than simply prohibited

• Blanket restrictions applied for organisational risk aversion
• Risk conversations documented as warnings rather than as supported choices

Before entering any service agreement, give individuals the opportunity to exercise autonomy, the time they need to consider it, and an opportunity to seek advice.

• Service agreement process documentation showing a consideration period
• Dated records of agreement provision and signature
• Evidence that individuals were told they could seek independent advice

• Agreement signed on the day of first contact with no consideration period
• No record of the opportunity to seek advice being offered

Engage in meaningful and active partnerships with individuals to inform organisational priorities and continuous improvement.

• Terms of reference and minutes of consumer advisory bodies
• Evidence that individual input changed an organisational priority
• Survey results and the actions taken from them
• Feedback loop showing what was reported back to individuals

• Consultation held but no evidence any decision changed
• Advisory body exists on paper with no recorded meetings

Encourage and support individuals and others to make complaints and give feedback about service delivery without reprisal.

• Complaints policy and accessible complaint channels
• Complaints register with outcomes and timeframes
• Evidence individuals were informed of advocacy and external complaint options
• Evidence of no detriment following a complaint

• Complaints accepted only in writing
• Individuals not told about external complaint pathways

Acknowledge and transparently manage all complaints and feedback, and use them to contribute to continuous improvement.

• Complaints register showing acknowledgement dates and resolution
• Analysis of complaint themes
• Improvement actions traceable to complaint themes
• Evidence of what was communicated back to complainants

• Complaints handled individually with no thematic analysis
• No traceable link from complaints to improvement register

Ensure information recorded about an individual is accurate and current, and can be accessed and understood by the individual, their supporters and those involved in their care.

• Record keeping policy and audit results on accuracy and currency
• Evidence of individual access to their own records
• Records in a form understandable to those who need them
• Correction requests and how they were handled

• Records accurate clinically but inaccessible to the individual
• No process for an individual to request correction

Keep information about individuals confidential and manage it appropriately in line with their informed consent.

• Privacy and confidentiality policy
• Consent records covering information sharing
• Access control records for individual information
• Privacy breach records and responses

• Consent obtained once and treated as open ended
• Information shared with third parties outside the scope of consent

Demonstrate that the provider understands and manages its workforce needs and plans for the future.

• Workforce plan covering current and projected need
• Vacancy, turnover and agency usage data
• Evidence the plan responds to changes in demand or acuity
• Governing body oversight of workforce risk

• Workforce plan is a headcount budget with no skills or acuity view
• Chronic agency reliance with no documented mitigation

Deliver services through aged care workers who are skilled and competent in their roles, hold relevant qualifications and have relevant expertise and experience.

• Position descriptions with required qualifications
• Verified qualification and registration records
• Competency assessment records
• Evidence of scope of practice controls

• Qualifications collected at hire and never re-verified
• Workers performing tasks outside assessed competence

Provide aged care workers with the training and supervision they need to effectively perform their roles.

• Training matrix by role with completion rates
• Supervision and performance review records
• Evidence training content reflects the actual care delivered
• Post training competence checks

• Training completion tracked but competence never assessed
• Supervision informal and unrecorded

Demonstrate that emergency and disaster management planning considers and manages risks to the health, safety and wellbeing of individuals and aged care workers.

• Emergency and disaster management plan
• Evidence of exercises or drills and lessons captured
• Individual level emergency needs recorded
• Continuity arrangements for critical services and supplies

• Plan addresses the building but not the individuals in it
• Plan never exercised or reviewed after a real event

The governing body leads a culture of quality, safety and inclusion that supports aged care workers, focusing on continuous improvement, diversity and worker safety, health and wellbeing.

• Governing body minutes addressing workforce culture, safety and wellbeing
• Worker experience survey results and resulting actions
• Workforce diversity and inclusion initiatives with outcomes
• Worker safety and wellbeing metrics reported to the governing body

• Worker wellbeing never appears on the governing body agenda
• Culture statements with no measurement or follow through

The governing body leads a culture of quality, safety and inclusion that supports individuals accessing services, focusing on continuous improvement, diversity and their safety, health and wellbeing.

• Governing body minutes addressing individual safety and quality
• Quality and safety metrics reported to the governing body with actions
• Evidence of governing body response to adverse trends

• Quality reporting to the governing body is volume only with no analysis
• Adverse trends noted with no recorded governing body decision

The governing body is accountable for the delivery of quality services and maintains oversight of all aspects of operations.

• Governing body charter and delegation framework
• Reporting pack showing coverage of all operational areas
• Attendance and decision records
• Evidence of oversight of outsourced or subcontracted operations

• Oversight limited to financial performance
• Subcontracted services outside the reporting line

Use a quality system that enables and drives continuous improvement of service delivery.

• Documented quality system and improvement register
• Improvement items showing origin, action, owner and closure
• Evidence of measurement before and after an improvement
• Internal audit schedule and results

• Improvement register lists issues with no closure or measured effect
• Quality system documented but not used to prioritise work

Maintain current policies and procedures that guide how aged care workers perform their roles, and require workers to follow them.

• Policy register with review dates and version control
• Evidence of distribution and worker acknowledgement
• Compliance monitoring or spot check records
• Records of action where procedures were not followed

• Policies past their review date
• No mechanism to detect or address non-compliance with procedure

Use a risk management system to identify, manage and continuously review risks to individuals, aged care workers and the provider's operations.

• Risk management framework and current risk register
• Evidence of risk review cadence and escalation to the governing body
• Individual level risk assessments linked to care plans
• Records showing a risk treatment was implemented and re-assessed

• Risk register covers organisational risk only and omits risks to individuals
• Risks recorded once and never reviewed

Use an incident management system that safeguards individuals and acknowledges, responds to, manages and learns from incidents.

• Incident management policy and system records
• Incident records showing acknowledgement, response, investigation and outcome
• Trend analysis and resulting systemic changes
• Evidence of feedback to the individual affected

• Incidents logged and closed with no cause analysis
• No link between incident trends and improvement actions

Encourage and support aged care workers to make complaints and give feedback about service delivery without reprisal.

• Worker complaints and whistleblower policy
• Records of worker raised complaints and outcomes
• Evidence of protection from reprisal
• Worker survey results on speaking up

• No separate channel for workers to raise concerns
• Worker complaints recorded but outcomes not communicated back

Actively engage individuals, their supporters and others involved in their care when developing and reviewing care and services plans, through ongoing communication.

• Care and services plans evidencing individual and supporter involvement
• Records of planning conversations and who attended
• Evidence of ongoing communication rather than a single planning event
• Consent or preference records about who is involved

• Plans developed by staff and countersigned by the individual afterwards
• Supporters involved only when the individual lacks capacity

Ensure care and services plans describe current care needs, goals and preferences and include strategies for risk management and preventative care.

• Sample care and services plans tested against the required content
• Evidence plans carry preventative care strategies
• Risk strategies within the plan linked to identified risks

• Plans record tasks and schedules but omit goals and preferences
• No preventative care content such as falls, skin or nutrition strategies

Ensure care and services plans are regularly reviewed and are actually used by aged care workers to guide service delivery.

• Review schedule and completed review records
• Evidence workers access the plan at point of care
• Comparison of delivered care against the plan
• Records of plan changes after a change in condition

• Plans reviewed to a calendar but not after changes in condition
• Workers rely on handover rather than the plan

Ensure individuals receive quality services that meet their care needs, goals and preferences and optimise quality of life, reablement and maintenance of function.

• Outcome measures showing function maintained or improved
• Evidence of reablement goals in plans and their review
• Service delivery records matched to stated goals
• Individual feedback on goal achievement

• Service delivery measured by hours delivered rather than outcomes
• Reablement goals set but never reviewed

Ensure services are delivered in a way that is culturally safe and culturally appropriate for individuals with specific needs and diverse backgrounds.

• Cultural safety policy and training records
• Evidence of interpreter and cultural liaison access
• Care plans reflecting cultural and spiritual needs
• Feedback from individuals from diverse backgrounds

• Cultural safety treated as a single induction module
• Interpreter services available in policy but rarely used in practice

Ensure critical information relevant to service delivery is communicated effectively to individuals, between aged care workers, to supporters and to health practitioners involved in care.

• Handover and clinical communication procedures
• Handover records and their completeness
• Evidence of communication with external practitioners
• Records of information passed to supporters with consent

• Handover verbal only with no record
• Critical information stops at the organisational boundary

Ensure risks to individuals and changes or deterioration in their condition are escalated and communicated appropriately.

• Recognition and escalation procedure with defined triggers
• Escalation records and timeliness against triggers
• Evidence of after hours escalation pathways
• Review of missed or delayed escalations

• Escalation depends on individual worker judgement with no defined triggers
• No after hours pathway

Ensure services are planned and coordinated, including where multiple health providers, registered providers and supporters are involved.

• Coordination records where multiple parties are involved
• Named coordination responsibility for each individual
• Evidence of shared care arrangements and information exchange
• Records of coordination at transition points

• No named coordinator so gaps fall between parties
• Coordination happens informally and is not evidenced

When delivering services in an individual's home, support the individual to mitigate environmental risks relevant to those services.

• Home environment risk assessment records
• Evidence of hazards identified and mitigation offered
• Records where an individual declined mitigation and how risk was managed
• Worker safety assessments of the home

• Home assessment done once at commencement only
• Hazards identified with no follow up on mitigation

Where services are delivered other than in the individual's home, ensure individuals can access them in a clean, safe and comfortable environment that optimises belonging, interaction and function.

• Environmental audit and cleaning schedules with completion records
• Maintenance register and response times
• Evidence the environment supports movement and interaction
• Individual feedback on the environment

• Cleaning and maintenance evidenced but no assessment of belonging or interaction
• Reactive maintenance only

Where equipment is used in delivering services or provided to individuals, ensure it is safe and meets the needs of those individuals.

• Equipment register with servicing and testing records
• Evidence equipment is matched to assessed individual need
• Fault reporting and removal from service records
• Competence records for workers using the equipment

• Servicing evidenced but no assessment of suitability for the individual
• Faulty equipment reported but not removed from service

Have an appropriate infection prevention and control system.

• Infection prevention and control policy and program
• Named responsibility for infection prevention and control
• Surveillance data and outbreak records
• Evidence of review after an outbreak

• Policy present but no surveillance data
• No named accountable person

Ensure aged care workers use hygienic practices and take appropriate infection prevention and control precautions when delivering services.

• Hand hygiene and personal protective equipment audit results
• Infection control training and competence records
• Observation records of practice
• Supply records for protective equipment

• Training completed but no practice observation
• Audit results collected with no corrective action

The governing body ensures it continuously improves the safety and quality of clinical care services and that the provider delivers safe and quality clinical care.

• Clinical governance framework approved by the governing body
• Clinical quality and safety reporting to the governing body
• Governing body decisions responding to clinical indicators
• Clinical audit program and results

• Clinical reporting to the governing body is descriptive with no decisions
• No clinical expertise available to the governing body

Have systems and processes supporting coordinated multidisciplinary clinical care delivered in partnership with individuals and supporters and aligned with their needs, goals and preferences.

• Multidisciplinary case conference records
• Referral pathways and their use
• Evidence individuals and supporters participated in clinical decisions
• Shared clinical documentation

• Case conferences held without the individual present
• Allied health input requested but not integrated into the plan

Support early identification of and response to changing clinical needs.

• Clinical observation and monitoring records
• Deterioration recognition tools in use
• Records of response time after a change was identified
• Review of cases where change was identified late

• Observations recorded but not trended
• No tool to support recognition of deterioration

Identify, monitor and manage high impact and high prevalence risks in clinical care delivery so as to ensure safe quality care and reduce the risk of harm.

• Register of high impact and high prevalence clinical risks
• Monitoring data for each identified risk
• Evidence of management strategies and their effect
• Reporting of these risks to clinical governance

• Risks named generically with no monitoring data
• No link between the clinical risk register and care planning

Ensure individuals experiencing acute, chronic or transitory cognitive impairment receive comprehensive services that optimise clinical outcomes and align with their needs, goals and preferences.

• Cognitive assessment records
• Care plans tailored to cognitive impairment
• Evidence of specialist input where indicated
• Worker training in dementia and delirium care

• Delirium not distinguished from dementia
• Cognitive impairment recorded as a diagnosis with no care plan consequence

Identify situations and events that may lead to changes in behaviours.

• Behaviour assessment and antecedent records
• Behaviour support plans identifying known triggers
• Evidence of environmental or routine changes made in response
• Worker training in behaviour support

• Behaviour recorded as an event with no antecedent analysis
• Triggers identified but plans not updated

Recognise and address the needs, goals and preferences of individuals for palliative and end of life care and preserve their dignity in those circumstances.

• Advance care planning and end of life preference records
• Palliative care plans
• Evidence preferences were followed
• Feedback from families after a death

• Advance care planning offered only after deterioration
• Recorded preferences not accessible at the point of care

Ensure the pain and symptoms of individuals are actively managed with access to specialist palliative and end of life care when required.

• Pain assessment and reassessment records
• Symptom management plans
• Records of specialist palliative referral and response
• Availability of anticipatory medicines

• Pain assessed but not reassessed after intervention
• No pathway to specialist palliative care

Ensure supporters of individuals and other people supporting them are informed and supported, including during the last days of life.

• Records of communication with supporters during end of life care
• Bereavement support arrangements
• Evidence supporters were given practical information and access
• Feedback from bereaved families

• Communication with families is ad hoc and unrecorded
• No bereavement follow up

Integrate clinical governance into corporate governance to actively manage and improve the safety and quality of clinical care services.

• Governance structure showing the clinical reporting line to the governing body
• Committee terms of reference linking clinical and corporate governance
• Evidence clinical risk sits on the enterprise risk register
• Minutes showing clinical matters in corporate decision making

• Clinical governance operating as a parallel structure with no board line
• Clinical risks absent from the enterprise risk register

Ensure individuals, aged care workers, health practitioners and others are encouraged and supported to use antimicrobials appropriately to reduce the risk of increasing resistance.

• Antimicrobial stewardship policy and program
• Antimicrobial usage and indication data
• Evidence of prescriber engagement and review
• Education records for workers and individuals

• Stewardship policy with no usage data collected
• No engagement with external prescribers

Ensure infection risks are minimised and, where infections occur, are controlled effectively.

• Infection surveillance data and trend analysis
• Outbreak management records and outcomes
• Evidence of isolation and cohorting decisions
• Post outbreak review and improvements

• Infections recorded but not analysed for source or trend
• Outbreak plans not tested

Encourage and support individuals, aged care workers and health professionals to use medicines in a way that maximises benefit and minimises the risk of harm.

• Medicines management policy
• Medication review records including deprescribing
• Evidence individuals are informed about their medicines
• Education records on safe medicines use

• Medication reviews scheduled but not acted on
• Individuals not informed about changes to their medicines

Ensure medicine is prescribed for the individual before administration, and that medicines are appropriately and safely administered, monitored and reviewed by health practitioners with regard to clinical need and the individual's informed decisions.

• Medication charts showing a current prescription before administration
• Administration records and reconciliation against the chart
• Monitoring and review records by practitioners
• Evidence of individual consent to medicines

• Administration recorded against verbal orders with no prescription
• Charts not reconciled after hospital transfer

Ensure medicine related adverse events are monitored and reported and are used to inform safety and quality improvement.

• Medication incident records and categorisation
• Trend analysis of medicine related adverse events
• Improvement actions traceable to medication incidents
• Reporting to the clinical governance committee

• Medication errors logged as incidents but never analysed as a class
• Near misses not captured

Ensure individuals receive comprehensive, safe and quality clinical care services that are evidence based and person centred and delivered by appropriately qualified practitioners and assistants.

• Clinical procedures referenced to current evidence
• Registration and qualification verification for clinical staff
• Clinical audit results against evidence based standards
• Scope of practice documentation

• Clinical procedures not reviewed against current evidence
• Clinical tasks delegated beyond assessed scope

Ensure clinical care encompasses assessment, prevention, planning, treatment, management and review so as to minimise harm and optimise quality of life, reablement and maintenance of function.

• Clinical records showing the full cycle for sampled individuals
• Assessment tools in use and their currency
• Evidence of review closing the loop on treatment
• Preventative care records

• Assessment and treatment evidenced but review missing
• Prevention absent from the clinical cycle

Partner with individuals to deliver a quality food and drinks service including appetising and varied food and drinks and an enjoyable dining experience.

• Food focus group or menu consultation records
• Evidence menus changed following individual input
• Satisfaction data on food and dining
• Menu review cycle records

• Menus set by the catering contract with no individual input
• Feedback collected but menus unchanged

Demonstrate an understanding of the specific nutritional needs of individuals and assess their current needs, abilities and preferences about what and how they eat and drink.

• Nutritional assessment records including swallowing and texture needs
• Weight and nutrition monitoring data
• Dietitian and speech pathology referrals
• Preference records covering cultural and religious needs

• Nutritional assessment done at entry only
• Texture modified requirements not reassessed after a change in condition

Provide individuals with food and drinks that meet their nutritional needs and are appetising and flavoursome, with variation and choice about what and how much they eat and drink.

• Menus assessed against nutritional standards
• Evidence of choice at the point of service
• Food temperature and quality monitoring
• Records of texture modified and therapeutic diets provided as assessed

• Choice offered on the menu but not available at service
• Texture modified meals not assessed for nutritional adequacy or appearance

Support individuals to eat and drink.

• Assistance requirements recorded in care plans
• Staffing allocation at meal times
• Observation records of mealtime assistance
• Training in safe assistance and swallowing precautions

• Assistance needs recorded but staffing at meal times does not match
• Meals removed uneaten with no follow up

Ensure the dining experience meets the needs and preferences of individuals so as to support social engagement, function and quality of life.

• Dining environment observations
• Evidence of flexible meal times and dining locations
• Individual feedback on the dining experience
• Records of social dining arrangements

• Dining treated as a nutrition task rather than a social occasion
• Fixed meal times with no flexibility

Ensure individuals receive services that optimise their quality of life, promote use of their skills and strengths and enable them to do the things they want to do.

• Lifestyle and activity records linked to individual interests
• Evidence of participation and of non participation follow up
• Quality of life measures and their trend
• Individual feedback on daily living

• Group activity programs with no link to individual interests
• Non participation not investigated

Ensure individuals feel safe in their residential care home.

• Survey or feedback data on feelings of safety
• Records of concerns about safety and how they were resolved
• Evidence of action on resident to resident conflict
• Security and access arrangements

• Physical security evidenced but perceived safety never measured
• Resident to resident aggression handled case by case with no systemic response

Ensure individuals experience a well coordinated transition, whether planned or unplanned, to or from a provider.

• Transition and transfer procedures
• Transfer documentation sent and received
• Records of unplanned transfers such as hospital admissions
• Evidence of follow up on return

• Transfer documentation incomplete for unplanned transfers
• No process to reconcile care and medicines on return

Set out clear responsibility and accountability for service delivery between aged care workers, health practitioners, allied health professionals and assistants, and across organisations.

• Documented responsibility and accountability matrix
• Service agreements with external organisations setting out responsibilities
• Evidence roles are understood by workers
• Records of gaps identified at organisational boundaries

• Responsibilities assumed rather than documented
• External provider responsibilities not defined in any agreement