Evidence-based Care in Aged Care 

The recent publication of a research study by the Australian Institute of Health Innovation highlighted some major areas of concern in the aged care sector. The study focused on the level of adherence to evidence-based care in aged care across 14 different care areas.

What is evidence-based care?

Evidence-based care (or evidence-based practice) involves integrating up-to-date, best practice research with clinical knowledge and experience, and the preferences of the older person. As research and knowledge about a specific clinical care area evolves, an organisation should be reviewing their own processes to ensure that they’re still delivering care that best addresses the needs of older people. Organisations should also ensure that they have effective processes to integrate new or revised evidence into the way they deliver services.

Some factors that may contribute to a person not receiving evidence-based care include: 

  • When an organisation doesn’t regularly check for the latest developments in clinical care areas; 
  • Using outdated, not well supported, or contraindicated evidence as a basis for care;  
  • Failing to adapt care practices to the needs of each older person based on their preferences; and  
  • Failing to implement practices that are based on the latest available evidence. 

Evidence-based care in standards

The requirement to deliver evidence-based care is included in both the National Safety and Quality Health Service Standards (NSQHS) and the strengthened Aged Care Quality Standards (ACQS). Findings of the Aged Care Royal Commission recommended that:

The aged care system should adopt evidence-based and continuous improvement strategies to allow for transparent measurement and reporting of the quality of care being delivered to older people.

Evidence-based (or “evidence-informed”) practice is also a quality indicator of a number of the NDIS Practice Standards, such as those for: 

  • Quality Management; 
  • Responsive Support Provision; and 
  • Behaviour Support.

The Findings of the Research Study

The findings demonstrate that, while some areas of care have relatively high levels of adherence to an evidence-based approach to care, there are also areas that are shockingly low.

On average, the adherence rate across all indicators studied was just over half (53.2%), with a high of 81.3% for continence care, and a low of 12.2% for mental health/depression related care.

Data from Australian Institute of Health Innovation (2024)

Some of these findings match recent results of the Residential Aged Care Quality Indicators from July-September 2023.

Some improvement opportunities

One area of concern is the low adherence to evidence-based practices in medication management, given the high prevalence of polypharmacy in aged care residents, with over a third of aged care residents prescribed nine or more medications.

Another area for improvement is in falls management, where the current ‘best practice’ guidelines date back to 2009. Despite a relatively higher adherence rate to evidence-based care, the trend in falls has remained steady over the past few years, with nearly a third of aged care residents experiencing a fall each quarter during that period. The steady trend reflects the need for continued work to improve knowledge and understanding of clinical care areas in order to aid improvement. New research has informed draft Updated Fall Prevention Guidelines for Residential Aged Care Services, which are currently in a consultation phase. Looking forward,  hopefully the updated guidelines will drive an improvement in fall prevention when they are released, and provide a useful resource for organisations to review their falls management processes and procedures.

A statistically significant area in the recent Quality Indicators that supports the importance of evidence-based care is in continence care. Of the aged care residents who were assessed, 78% were recorded with incontinence, however, only 4% of residents were recorded as having incontinence-associated dermatitis. This indicates that the high level of adherence to evidence-based care in this area is resulting in better outcomes for older people, drastically reducing their likelihood of experiencing incontinence-related issues.

Where to for providers?

This is an opportunity for providers to reflect on their own approach to evidence-based care and practices, especially in the areas of low adherence identified in the research study. In addition, Outcome 5.5 (Clinical Safety) of the Strengthened Aged Care Quality Standards goes into greater detail about many of these areas of care. More specific requirements surrounding specific clinical care areas should act as a tool to guide organisations in providing the level of care older people require.

The Australian Commission on Safety and Quality in Healthcare has some guidance for supporting evidence-based practice, while the NDIS Quality and Safeguards Commission has released their Evidence-Informed Practice Guide, which is a helpful resource to help you consider improvements to processes and procedures.  

BNG and improving care

For further assistance, we have up-to-date policies for many of the areas of care evaluated in the research study, including: 

  • Policy: Promoting Emotional Wellbeing in Aged Care 
  • Policy: Oral Health 
  • Policy: Nutrition, Meals and Hydration
  • Policy: Continence Management
  • Policy: Falls Prevention
  • Policy: Pain Management 
  • Policy: Pressure Injuries
  • Policy: Clinical Deterioration 
  • Policy: End of Life Care and Palliative Care 

In addition, we have information sheets for some topics that provide more in-depth information in areas such as: 

  • Emotional Wellbeing in Aged Care 
  • Nutrition, Meals and Hydration 

Need a refresh on clinical care areas?

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What makes a good Quality Management system?

Managing and continuously improving quality is the core business of every service provider. Quality management is the action you take to make sure that you always provide the best possible service to your clients. It involves:

  • Evaluating your services to ensure they align with performance indicators contained in relevant standards;
  • Listening to clients, workers and other stakeholders, and valuing their feedback;
  • Understanding what is working well;
  • Identifying where improvements are needed; and
  • Taking action in order to best meet the needs of clients, workers and other stakeholders.

All major sets of Standards require organisations to have effective quality management and continuous improvement systems in place.

The quality improvement process

Quality improvement is not a singular action. It requires a cycle of continuous improvement, in which you are reviewing your systems, services and processes to evaluate whether you are providing the best possible service to each client. 

This cycle is commonly known as the ‘Plan/Do/Check/Act’ cycle and follows four key stages.


The planning stage involves evaluating the current state of your organisation and identifying where improvements can be made. In this phase, you should reflect on how you are delivering the services you are providing, your organisation’s compliance with relevant Standards, and feedback and complaints received to determine areas for improvement. Any incidents and near misses that have occurred should also inform your evaluation. The results of this evaluation should be used to plan ways that your service provision can improve, set goals and identify actions to put the plan into practice.


The next step of the quality improvement cycle is to action your planned changes. This could involve implementing improvements in stages, or testing variations of a planned change to determine the best solution in practice. Relevant stakeholders should be informed of the changes, and what that could mean for them. Adequate resources should be allocated for the purpose of executing the changes successfully, whether that involves extra funding, increased staffing, or more time. It is important that you document the decisions made during this stage, as this data will be used in the next stage of the process.


During the checking stage, you should be analysing both qualitative and quantitative results from the changes, to determine whether they are achieving the expected outcomes and resulting in better services. Feedback from stakeholders should be sought on their experiences with the changes, as well as any comments they have on further improvements. You should consider reflective questions during this stage to aid evaluation, such as:

  • Are the improvements delivering the outcomes as we intended?
  • What were the major gaps in our service delivery from our planning process, and have we addressed these gaps?
  • Are there any unforeseen outcomes from the changes?
  • Are there further improvements we can make, or can we make the process more efficient?


In this part of the cycle you should decide whether or not to implement the changes based on your evaluation. If the evaluation results demonstrate the changes were not successful, you should revert back to the planning stage to repeat the process and determine a new plan that is based on learnings from the unsuccessful trial.

If the results do show improvements meeting or exceeding your established goals, you should implement the changes and incorporate them into your regular service delivery. You should inform all stakeholders of the changes, including the differences between the old and new procedures, and ensure that all workers are trained in the new processes. Make sure you also update your policy and procedure documents where appropriate, to reflect the changes you’ve implemented.

Feedback, Complaints, Incidents and Near Misses

One of the most important ways you can gather information about the services you provide is through the information you receive from stakeholders, including workers, clients and their support people. Efficient and accessible feedback and complaints mechanisms ensure that those who are impacted can easily communicate their opinions and experiences with the service. In particular, if there is a lived experience disconnect between your clients and decision-makers in your organisation (for example services for children or young people), feedback is an important way to broaden perspectives in the quality management process.

In addition, encouraging clients to work in collaboration with your organisation to tailor services to their unique needs allows you to both provide the best possible service to your clients , as well as meet wider standards obligations. The requirements in many sets of standards include partnering with clients and providing culturally competent services for each individual. Meeting these standards requirements is part of consistently providing the best possible service to your clients and ensuring quality care.

So, what does a good quality management system look like?

An effective quality management system underpins your organisation’s approach to service delivery, and provides the framework for how you deliver quality and safe services for each individual.  Quality management should be incorporated as a core facet of the service and be explained clearly in your quality management policies and procedures, as well as policies on related areas.

Your quality management system should:

  • Be founded on core policies and procedures that are communicated and understood across your organisation, so that your approach and processes are transparent to everyone, set clear expectations and responsibilities for workers and the organisation, and are consistently followed;
  • Be supported by other, related policies and procedures covering areas such as:
    • risk management;
    • compliance monitoring;
    • complaints management; and
    • incident reporting
  • Be integrated with your Standards compliance status;
  • Allocate responsibilities to team members for identified improvements; and
  • Be easy to manage, and provide you with up-to-date reports on compliance, improvements identified and how you are tracking towards achieving them.

In conclusion, having a good quality management system is important for organisations to ensure they are providing the best possible services for their clients as well as fulfilling their standards obligations.

Improving your quality management system with SPP

SPP has a wide variety of information sheets and templates available to help you reach your quality management goals, from a template quality improvement register and quality improvement plan to a sample quality management and continuous quality improvement policy. We also have a “Towards Best Practice” self-assessment module on Continuous Improvement.

In addition, we have a range of resources on related topics like risk, complaints, and incidents support the delivery of quality service. 

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Cultural diversity and cultural competence in service delivery

The Australian population is incredibly diverse and multicultural. With this diversity comes the challenge of ensuring that all individuals, regardless of their cultural background, have equal access to services and support. 

Organisations providing services to the public must be prepared to respond to the diverse and individual needs of each client and ensure that the organisation and its staff are culturally competent.  

What is cultural competence?

A culturally competent organisation: 

  • understands and responds to the unique needs of individuals from diverse cultural backgrounds; and 
  • improves feelings of cultural safety for clients and staff, making them feel that their background, values, identity and needs are respected and valued for the diversity they bring to society and to the organisation.  

When a client feels culturally safe, they feel as if the organisation cares about them as an individual, and that they are seen as a person, not simply part of a homogenous group. Meeting someone’s cultural needs can indicate that an organisation will take care to meet a person’s other unique needs.

And what is cultural diversity?

Cultural diversity encompasses many forms or aspects of identity, including:

  • Cultural identity
  • Ethnic identity
  • Nationality
  • Class
  • Education
  • Language
  • Religion
  • Spiritual views
  • Gender
  • Sexuality
  • Political orientation
  • Age

Each one of these factors will contribute to a person’s identity, how they see the world and their needs when receiving services. 

It is important to note that a ‘one-size-fits-all’ approach to cultural competence will not adequately address the needs of clients, as multiple aspects of their identities intersect to create unique strengths and vulnerabilities. 

Organisations must therefore prioritise a flexible and adaptable approach to service delivery, and ensure staff are able to respond effectively and appropriately to the varying and individual needs of each client.

Strategies for cultural competence

1. Culturally diverse staff

Having a diverse workforce allows an organisation to have broad perspectives of how different actions may impact on people from varying cultural backgrounds and provide insight into changes to improve the cultural safety of clients. Having staff available who share their cultural background can help clients feel that their cultural identity and needs will be respected and valued during their time engaging with the service. In addition, a diverse workforce helps staff improve their cross-cultural communication skills, which can then flow on to better communication outcomes for clients.

2. Ongoing reflection on services

Cultural competence is not a singular action. As the diversity of the organisation’s clients and staff changes, the organisation must constantly reflect on the services it provides and whether they are appropriate for the current demographics. To improve their cultural competence, especially where client demographics have changed, it may be appropriate to partner or consult with local cultural or community groups to ensure the service meets cultural needs.

3. Client involvement in service delivery

The unique experiences of each client means that what they need from a service may be equally as unique. Allowing clients input into aspects of their experience with your organisation allows them to receive a service that is appropriate for them, improving their sense of cultural safety and their perception of the service. In residential services, this is especially important in making the service feel like a ‘home’ for residents.

Cultural diversity and compliance

Cultural diversity is increasingly being incorporated into quality standards for services. This means organisations must be culturally competent and have strategies for engaging with diverse clients in order to meet their standards obligations. 

All of the major national and state/territory standards have cultural diversity requirementsHere are just a few, by way of example only: 

  • Aged Care Quality Standards

  • Australian Service Excellence Standards

  • Human Services Quality Framework (Qld)

  • Human Services Standards (Vic)

  • National Safety and Quality Health Standards (and a number of aligned standards)

  • National Principles for Child Safe Organisations

  • NDIS Practice Standards

  • RACGP Standards

Self-assessments for all of the above standards are available for providers in SPP. 

BNG and Cultural Diversity

We’ve recently updated some of our cultural diversity and cultural competence resources to better assist service providers with their cultural competence.  

  • Good Practice Guide: Cultural Competence 
  • Info: Cultural Diversity 
  • Policy: Diversity and Cultural Inclusion

Other resources for service providers

Aged Care Diversity Framework action plans four action plans to assist aged care providers when engaging with diverse clients, Aboriginal and Torres Strait Islander clients, CALD clients and LGBTI clients. All four action plans are available as self-assessments on SPP. 

The Centre for Cultural Diversity in Ageing has developed the Inclusive Service Standards and accompanying supportive resources to assist aged care providers in the development and delivery of inclusive services to all clientsSPP also provides a self-assessment for the Inclusive Service Standards. 

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Psychosocial hazards and psychological safety in the workplace

Potential risks to physical safety in the workplace are often easy to identify. However, potential psychological hazards aren’t always as easy to spot, yet can cause just as much harm to a person who is impacted by them.

As an employer, you have a duty to protect your employees from risks to their health, including psychological health. It’s important to note that every jurisdiction has different laws and regulations about psychological safety. Your obligations as an employer will be shaped by the rules that apply to you, however much of the guidance available is useful for employers as best practice even where it is not mandatory.

What are psychosocial hazards?

A psychosocial hazard is a hazard that arises from, or relates to, 

  • the design or management of work, 
  • a work environment, 
  • plant at a workplace, or 
  • workplace interactions and behaviours 

and has the potential to cause psychological harm or injury (Work Health and Safety Regulations 2011 (Cth) section 55A).

Depending on the nature of the workplace, some psychosocial hazards may always be present, while others may temporarily arise due to some change in working conditions. For example, the risk of emotional trauma connected to the loss of a patient in aged care is high and ever-present due to the nature of the work, whereas a psychosocial hazard connected to working increased hours due to staff shortages because of illness is likely to be temporary in nature. In many cases, one or more hazards will interact, and the effects compound to create a greater risk of harm.

Types of psychosocial hazard

There are three broad categories of psychosocial hazards that employers must manage: 

  1. The working environment – includes hazards such as working in high risk areas, working in remote or isolated areas or working unusual shift patterns. 
  2. The work itself – does the work require unusually high or low levels of mental load, does the work involve exposure to traumatic events or material, and is the workload unreasonably high? 
  3. Interpersonal conflicts  including between staff, poor management of the workforce, or mistreatment of staff by consumers. 

Personal issues faced by staff outside the working environment may compound their risk of psychological harm. While employers can’t control these hazards, they may be able to work with staff to ensure that the workplace does not contribute to the staff member’s risk of psychological injury.  

Appendix A of the model Code of Practice – Managing psychosocial hazards at work 2022 (Cth) provides a detailed example list of common psychosocial hazards, and potential control measures for each.

What is the current legislative status?

Most states and territories have implemented the model Work Health and Safety laws. As of April 1 2023, some jurisdictions have updated their Work Health and Safety Regulations and introduced a Code of Practice to specifically cover psychological safety and psychosocial hazards. Victoria’s psychological safety falls under its Occupational Health and Safety Act, and reforms are currently underway to better incorporate psychological safety into the existing occupational health and safety regulations.

See the below table for a brief summary of the psychological safety legislative requirements per jurisdiction, or refer to Safe Work Australia for more detailed information. 

What do I have to do to manage psychosocial hazards?

In all jurisdictions, employers have a duty to ensure the health and safety of their workers where “reasonably practicable”. This includes considering: 

  • whether the hazard was reasonably foreseeable; 
  • the potential severity of the harm that could occur; 
  • whether the organisation or its management knew or should have known about the hazard; 
  • whether there are any available and suitable methods of controlling the risk from the hazard; and
  • the cost of managing the risk. 

Other benefits of good psychological safety

In addition to making sure you’re meeting your legal obligations, good management of psychosocial risks can flow on to benefit the organisation. 

Demonstrating care for the wellbeing of employees and making work a mentally healthy place can boost staff retention rates, while staff who aren’t affected by psychological injury are less likely to require time off work, leading to more predictable and consistent rostering.  

Checking in with the workforce about psychological health can aid the organisation in understanding the challenges and difficulties staff are facing, while reviewing policies and processes for psychological safety can lead to operational changes improving service delivery.  

How SPP can help

We’ve updated these resources for you, which are available in SPP’s Reading Room: 

  • Info Sheet: Psychological Safety in the Workplace
  • Policy: Psychological Safety for Staff

Ready to improve psychological safety?

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How an effective call bell system can improve service provision 

An effective call bell system is a key part of safe and quality care delivery in facilities providing services to care recipients. It can play an important role in risk mitigation, staff management and ongoing continuous improvement processes, and also helps demonstrate to your care recipients your organisation’s commitment to safe and high quality services.  

Promptly responding to call bell requests from care recipients can aid in risk management and the prevention of issues such as falls or pressure injuries. Long or delayed response times for call bells can be a sign of policy or procedure issues relating to the staff model or communication. Monitoring call bell response times and the reasons for the calls can contribute to identifying opportunities to improve service delivery.

It’s therefore vital for organisations to have processes and procedures in place to provide this assistance for their care recipients.  

1. Staff management

One of the most important aspects of a call bell system is the provider’s ability to respond to requests in a timely way. To achieve this, facilities must manage their staffing and rostering to support their staff’s ability to respond to call bells. Failure to roster enough staff, overburdening staff with too many responsibilities, and a lack of communication around expected responsibilities, priorities and processes are all common explanations for high call bell response times. 

2. Standards compliance

While you won’t find call bells specifically mentioned in standards requirements, there’s a lot of indicators that can be supported by good call bell response practices. For example, in a number of Provider Performance Reports, the Aged Care Quality and Safety Commission has referred to call bell response times and reporting as relevant to its assessment of compliance by providers with: 

  • Standard 3(3)(b)Effective management of high-impact or high-prevalence risks associated with the care of each consumer; 
  • Standard 7(3)(a)The workforce is planned to enable, and the number and mix of members of the workforce deployed enables, the delivery and management of safe and quality care and services; and 
  • Standard 8(3)(d) – Effective risk management systems and practices 

As another example, for care facilities following NSQHS, call bell system management and reporting is relevant in relation to the Clinical Governance Standard and the Comprehensive Care Standard 

3. Quality improvement

Reviewing call bell response records can form an important part of an organisation’s continuous quality improvement processes. Accurate records of the reasons for each call bell use, as well as response times, are useful for verifying care recipient and staff feedback and/or complaints and highlighting where improvements can be made in service procedures. Commonly listed reasons for response times outside the target window indicate opportunities for organisations to review current processes and how they impact safe and quality service delivery. 

How SPP can help

We’ve developed a new policy template for providers with call bell systems to optimise their call bell procedures. The template will help providers set response time KPIs, clarify staff responsibilities, and put in place regular reporting and analysis.  

In addition, our SPP self-assessment platform allows providers to link their call bell records as evidence against relevant Standards. 

We're here to help.

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What’s New in Medication Management?

A growing number of Australians are remaining at home as they age rather than living in residential aged care facilities.  Many are moving into facilities at an older age, or when they develop conditions requiring greater care. In addition, the rise of polypharmacy (the use of multiple medicines by one person) and chronic disease raises increased challenges for medication management. In 2019, the Council of Australian Governments Health Council announced the Quality Use of Medicines and Medicines Safety as Australia’s 10th National Health Priority, in recognition of the increased risks of harm relating to the use of medicines.

The Department of Health and Aged Care has recently updated its Guiding Principles in response to this National Health Priority and the societal changes relating to medication management, with three Quality Use of Medicines (QUM) resources. These guidelines are not prescriptive, but demonstrate best practice for providers when managing consumer medications. They ensure consistency of care across the spectrum of care settings, with broadly standardised expectations of healthcare providers in medication management.  

Each set of guiding principles includes some overarching general principles, which inform the implementation of the specific remaining principles. They are designed to be used in conjunction with relevant legislative, profession-specific and accreditation requirements, and affirm a patient-centred, whole-of-organisation approach to care, as well as strong clinical governance. 

All three QUM documents are now consistent with other standards, such as the Aged Care Quality Standards, as well as aligning with each other for a cohesive approach to medication management.  

For example, Guiding Principle 1 (Person-centred care) is common to both the RACF and Community principles, and connects to Guiding Principle 8 (Sharing decision making and information about medicines with the individual receiving care) of Continuity in Medication Management. The diagram to the left shows where principles in the three documents overlap. For more information about the areas of commonality and differences between the three guiding principles, take a look at this guide from the Department of Health. 

1. Guiding Principles for Medication Management in Residential Aged Care Facilities (RACFs)

These Guiding Principles build on the 2012 RACF Medication Management principles, with the addition of two leading principles, Person-centred care and Communicating about medicines. Both align the Guiding Principles with Standard 1 (Consumer dignity and choice) of the Aged Care Quality Standards, and aim to actively engage consumers with their care. Other existing principles have been reorganised, combined, and renamed for greater consistency with the broader network of safety and quality standards. 

2. Guiding Principles for Medication Management in the Community

The Community Medication Management guiding principles have evolved from their 2006 predecessor and, similar to the RACF principles, have new principles relating to person-centred care and communication, to promote a person-centred partnership and systems-based approach when support is being provided to people living at home. The previous guiding principles have also been adjusted to match the wording of the RACF guiding principles, where they share common best practice. 

3. Guiding Principles to Achieve Continuity in Medication Management

Finally, the 2005 Continuity in Medication Management guiding principles have been updated to reflect current priorities and best practices relating to consistent, safe, and quality care across healthcare providers and at transition of care, including the addition of a Safety and quality systems principle.

BNG and Medication Management

We’ve updated our Medication Management policy document to reflect some of the key changes in the new Guiding Principles documents, available now in the Reading Room. In addition, we also have a range of templates that can be used as a starting point for your organisation to develop a comprehensive approach to medication management that:  

  • best suits the needs of your clients and the services you provide, and  
  • ensures your service delivery is in line with current best practice.  

Looking for more information?

The Australian Government Department of Health and Aged Care has created fact sheets for each new set of Guiding Principles, explaining each principle and some key tasks for achieving them: 

Medication management needs work?

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The new Digital Mental Health Standards

Accreditation to the National Safety and Quality Digital Mental Health Standards (NSQDMHS) became available for all organisations on November 1 2022. Digital mental health services provide valuable support to clients, as they can be easier to access for most clients, and they can also offer clients the opportunity to discuss issues anonymously.

Launched in November of 2020, the Standards are not mandatory, however they do provide an opportunity for providers to give greater confidence to users of their services.

Who are the NSQDMHS for?

The Digital Mental Health Standards are available to a variety of mental health support providers. These include providers of:

  • Peer to peer support;
  • Services that provide information about accessing mental health services;
  • Digital counselling; and
  • Treatment services (assessment, triage and referral).

Digital mental health services may be provided via telephone, video conference, online (including web chat), SMS, and mobile applications.

What is in the standards?

There are three standards, and a total of 59 actions within the Digital Mental Health Standards. The three standards are:

  • Clinical and Technical Governance Standard;
  • Partnering with Consumers Standard; and
  • Model of Care Standard.

The standards map directly to the National Safety and Quality Healthcare Standards (NSQHS), however they contain fewer requirements than the NSQHS.

For more information about the content within the National Safety and Quality Digital Mental Health Standards, see our previous blog post on the topic.

Should we consider accreditation to the NSQDMHS?

Accreditation to the Digital Mental Health Standards provides clients with the assurance that their service provider is meeting the expected standards for safety and quality. The standards will also help to refine a provider’s processes, and provide better outcomes for users.

Feedback from organisations who participated in the pilot program for the Digital Mental Health Standards was that the standards helped them to document the processes they already had in place, and helped them to identify if they had any issues or areas for improvement in their processes. Organisations highlighted the data collection and management requirements within the Standards, saying that these assisted in mapping patient care journeys and change management processes.

What is the accreditation process?

Accreditation is provided by independent accrediting agencies who have been approved by the AHSSQA Scheme. The Australian Commission on Safety and Quality in Health Care (the Commission) has a list of accreditors on their website.

The process for accreditation to the National Safety and Quality Digital Mental Health Standards is as follows:

Application and engagement

  • Application – apply to an approved accrediting agency
  • Preparation – implement the NSQDMH Standards and clarify arrangements for an assessment
  • Application for not applicable actions – not all of the actions within the NSQDMH Standards are applicable to all providers, here you will specify which actions are irrelevant

Assessment and remediation

  • Interim assessment – the approved accreditor conducts an interim assessment which includes:
    • Desktop review – a review of evidence submitted by the provider to demonstrate compliance with the NSQDMH Standards
    • Verification – an assessment to verify the safety and quality systems described by the provider
  • Remediation period – a period of 60 business days is allowed in order to address any areas where the service provider does not comply with the requirements of the Standards
  • Final assessment – this assessment is for the actions that were either ‘not met’ or ‘met with recommendations’ during the interim assessment

Outcome, reporting and monitoring

  • Outcome – the provider receives an outcome based on the final assessment
  • Final report – the accrediting agency delivers a final assessment report
  • Submission of data – the Commission is notified of assessment outcomes by the accrediting agency
  • Registration the Commission adds the provider to their register of accredited digital mental health service providers
  • Ongoing monitoring – the service provider continues their monitoring and continuous improvement responsibilities

Further reading and how we can help

Since April 2021 we have had a module available to help providers self-assess against the NSQDMH Standards and ensure that their documented processes are in line with the requirements of the Standards. The module is intended to help to conduct a gap analysis before beginning accreditation, and with ongoing monitoring.

The Commission has developed a resource pack for the Digital Mental Health Standards, which can be found on their website.   

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Moving towards best practice service delivery in aged care

The Aged Care Quality Standards are an important part of an organisation’s quality and compliance benchmarking. However, for providers looking to go beyond their baseline obligations, SPP hosts a number of best practice self-assessments for aged care. These guidelines and standards are designed to complement your ACQS compliance, and provide further guidance across targeted areas of service delivery and governance.

Aged Care – Clinical Governance

The Aged Care Quality and Safety Commission has developed guidance on clinical governance in aged care to assist aged care providers to develop and review their clinical governance framework.

We’ve made digesting that guidance easier for providers.  By working through our Aged Care – Clinical Governance self-assessment module, you can identify key issues that need to be addressed in a clinical governance framework, as well as identify gaps and opportunities for improvement.

Aged Care Diversity Framework

The Aged Care Diversity Framework was developed by the Australian Department of Health and Aged Care. The Aged Care Diversity Framework includes four Diversity Action Plans which are designed to help providers address barriers faced by different groups, being all diverse older people, older Aboriginal and Torres Strait Islander peoples, older CALD people, and LGBTI elders.

We have a self-assessment module for each of the Action Plans, which allows providers to work through three different levels, according to what is most relevant to their organisation: foundational actions, next steps and leading the way.

Inclusive Service Standards

The Inclusive Service Standards were developed by the Centre for Cultural Diversity in Ageing to assist aged care providers in the development and the delivery of inclusive services to all consumers. 

They provide a framework for services to adapt and improve their services and organisational practices so they are welcoming, safe and accessible.

Meeting the performance measures listed in this assessment provides evidence that an organisation has embedded an inclusive, non-discriminatory approach to its delivery of care and services.  

Dementia Australia Quality Care Recommendations

Dementia Australia’s Quality Care Recommendations have been developed by people living with dementia, their families and carers in the context of the new Aged Care Quality Standards. Each of the eight Standards has a dementia-specific recommendation on how that Standard needs to be met when providing any aged care service to a person living with dementia, their families, carers and advocates. 

This module provides organisations with further insight and direction on each of the Aged Care Quality Standards, through the lens of dementia-friendly care.

National Guidelines for Spiritual Care in Aged Care

The National Guidelines for Spiritual Care in Aged Care were developed by Meaningful Ageing Australia, who state:

Spirituality is integral to quality of life and well-being, and should be accessible to all older people in a way that is meaningful to their beliefs, culture and circumstances.

The Guidelines are designed specifically for offering spiritual care and support to older people living in residential aged care, or receiving care and support through home care packages. They are intended to support organisations to embed spirituality into key systems and processes with the goal that all older people (and their loved ones) are offered best-practice in spiritual care.

ACSA Wellness and Reablement Roadmap

The Wellness and Reablement Roadmap was developed by ACSA to help CHSP providers to self-assess their progress in integrating wellness and reablement principles into core service delivery. 

Taking a wellness and reablement approach to service design and delivery enables service providers to focus on outcomes for individuals rather than service outputs.

The Wellness and Reablement Roadmap provides a framework for discussions at all levels within an organisation to help providers identify “what they are doing well” and “what actions need to be taken to improve performance” in progressing, managing and measuring wellness and reablement.

Want to learn more?

Our modules for the standards and guidelines detailed above are available in SPP under the Aged Care – towards best practice drop-down header. They can be accessed and progressed at any time, at your own pace, as relevant to the needs of your organisation. You can automatically generate a quality improvement plan for each specific module you follow.

Access best practice
self-assessments in SPP.

A closer look at the National Quality Framework

The National Quality Framework is a national approach to regulation and quality improvement in early childhood education and care, and outside school hours care services across Australia. The National Quality Framework applies to most childcare providers and services, including centre-based day care, family day care, outside school hours care, and preschool and kindergarten.

The National Quality Framework is made up of the:

  • National Law and Regulations;
  • National Quality Standard; and
  • National Approved Learning Frameworks. 

The National Law and Regulations

The National Law and Regulations outline the legal obligations for providers and explain the functions of the state and territory regulatory authorities. They include things like requirements for staff qualifications and requirements for the number of staff working in services with children.

We have a self-assessment in SPP for the National Law and Regulations which ensures providers are aware of, and monitoring their compliance with, the sections and regulations of the National Law and National Regulations that are most relevant to each of the seven Quality Areas of the National Quality Standard.

The National Quality Standard

The National Quality Standard includes seven quality areas that form the basis of ratings and assessment. Services are assessed and rated against the seven quality areas:

  1. Educational program and practice
  2. Children’s health and safety
  3. Physical environment
  4. Staffing arrangements
  5. Relationships with children
  6. Collaborative partnerships with families and communities
  7. Governance and leadership

We also have modules in SPP for the National Quality Standard, including a stand-alone module which we developed in consultation with a provider of early childhood education and outside school hours care. Our module closely aligns with ACECQA’s self-assessment tool, and allows providers to track each requirement of the National Quality Standard, and make qualitative comments throughout.

The National Approved Learning Frameworks

Under the National Law and Regulations, services are required to base their educational program on one of the approved learning frameworks. There are two nationally approved learning frameworks:

  • Belonging, Being and Becoming: The Early Years Learning Framework for Australia; and
  • My Time, Our Place: Framework for School Age Care in Australia.

Self-assessments for both approved learning frameworks are available in SPP.

Update of the National Approved Learning Frameworks

Both frameworks are currently undergoing a consultation and review process, to ensure that they reflect contemporary developments in practice and knowledge. The review commenced in April 2021 and is being delivered over three stages.

Stages one and two have already been completed and included a literature review, surveys and stakeholder feedback. Some areas for improvement that came out of the discussion papers included strengthening Aboriginal and Torres Strait Islander perspectives throughout the framework, strengthening the principle of ongoing learning, introducing a new sustainability principle and strengthening partnerships to include other professionals. 

Stage three, which is currently underway, involves practitioners piloting the potential updates in their services. We are monitoring this review process and we will update our existing modules in SPP when the updated Standards are finalised. For more information on the updates, you can refer to ACECQA’s website or the Approved Learning Frameworks update website.

Want to access our self-assessments for the National Quality Framework?