NSQHS Accreditation Assessments for HSOs: What’s Changing? 

From July 2023, the National Safety and Quality Health Service (NSQHS) Standards assessment procedure for accreditation of hospitals or day procedure services (Health Service Organisations, or HSOs) will be changing, with mandatory short notice accreditation assessments replacing the existing announced and voluntary assessments.  

Why the change?

The move to short notice assessments is intended by the Australian Commission on Safety and Quality in Health Care (the Commission) to support the continuous implementation of the NSQHS Standards and reduce the administrative burden of preparing for accreditation assessment”.

The new process is designed to move the focus of assessments from preparation for assessment, to assessment of day-to-day practice. It is intended to support and emphasise continuous self-assessment by HSOs of their compliance with the NSQHS Standards, as well as their implementation of continuous quality improvement strategies.

The Commission requires that HSOs have systems and processes in place to keep their self-assessment documentation up to date, and conduct reviews of their self-assessment and their compliance status at least every three months.  

When will we be assessed?

Short notice accreditation assessments will occur: 

  • at least once within each three-year accreditation cycle;  
  • at least 4 months before the HSO’s accreditation expires;   
  • no sooner than 6 months after the previous assessment; and 
  • within 4 years of the previous assessment. 

HSOs therefore need to be ready for an accreditation assessment at any time. HSOs may request up to 20 business days per accreditation cycle to be excluded from assessment. These are days where a short notice assessment would either directly impact the provision of the service to consumers or the consumers of the service would be unavailable.

When will we be given notice of an upcoming assessment?

The notice period for an upcoming assessment will differ depending on the HSO’s location and/or the specific services provided. 

  • If you are an HSO in a metropolitan, rural or regional area with public transport options, you will be given 24 hours’ notice of assessment. 
  • If you are an HSO in a rural or remote area with either no or restricted public transport options, you will be given 48 hours’ notice of assessment.  

For some HSOs where special permissions must be sought to conduct assessment, such as services in some Aboriginal communities, fly-in fly-out services or services operating in prisons, your assessment notice may be up to 4 weeks to accommodate these requirements. 

For more information, see the Commission’s fact sheet, or feel free to contact us if you have any questions about the new assessment changes.

The importance of active, continuous self-assessment

Regular self-assessment of your compliance with the NSQHS Standards will maintain a focus on identifying opportunities to improve your service delivery. It forms an important step in the cycle of active, continuous quality improvement. As well as tracking compliance with each standard, your self-assessment process should also incorporate improvement opportunities that you identify through consumers’ feedback and complaints, and also from any incidents or near misses that occur. 

Ideally, your streamlined self-assessment system should include: 

  • A chronological record of all the compliance gaps and improvement opportunities you identify, and when you’ve addressed them; 
  • The ability to collaborate on and track improvements, including by assigning responsibility for certain tasks to team members;  
  • A compliance status report that you can generate at any point in time; and 
  • The ability to store and link documentary evidence of your compliance with each standard (for example, relevant policies and procedures that are implemented across your organisation).

How SPP can help

Our NSQHS self-assessment modules allow providers to understand the requirements of the Standards in detail, collate all identified improvement opportunities through an individually curated action plan, and review and report on their compliance status at any time.   

They also provide a helpful way to link relevant evidence against each standard, streamlining the self-assessment process and ensuring that your evidence of compliance is kept up to date. 

SPP also has self-assessments for other standards within the National Safety and Quality family, including for: 

  • Digital Mental Health,  
  • Mental Health for Community Managed Organisations, and  
  • Primary and Community Healthcare. 

In addition, SPP provides a deep pool of resources in our Reading Room (such as policy templates and info sheets) covering all aspects of organisational good governance to help HSOs work towards best practice.  

You can find our NSQHS Standards self-assessments in SPP by searching for ‘NSQHS’ in the Standards tab or under the ‘Australian National Standards’ subheading in that same tab. 

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New rules for restrictive practices in aged care

The Australian Government has recently introduced measures to strengthen the regulation of restrictive practices (formerly known as restraints) in residential aged care settings. As of 1 July 2021, key definitions and processes regarding the regulation of restrictive practices in residential aged care have changed.

These changes reflect increased regulation over the area of restrictive practices, greater alignment with the regulations of the National Disability Insurance Scheme (NDIS), and an increased focus on informed consent.

The Aged Care Quality and Safety Commission’s Regulatory Bulletin lays out these changes in greater detail.

Changes from 1 July 2021

The changes are contained in legislative amendments to the Aged Care Act 1997 and Quality of Care Principles 2014, which came into effect on 1 July 2021. They clarify the limited circumstances in which restrictive practices can be used in relation to a care recipient.

The definition of restrictive practices has been changed to include chemical restraint, environmental restraint, mechanical restraint, physical restraint and seclusion.

Use permitted only in limited circumstances, and where specific requirements are met 

Updates to the Quality of Care Principles have changed the circumstances in which restrictive practices can be used, which must be:

  • Only as a last resort to prevent harm;
  • After consideration of the impact of the practice;
  • After best practice alternative strategies have been considered, used and documented;
  • Only to the extent necessary, and in a proportionate manner;
  • In the least restrictive form, and for the shortest time;
  • Where informed consent is given; and
  • In accordance with the care recipient’s care plan, the Aged Care Quality Standards, and the Charter of Aged Care Rights.

Specific requirements have been imposed separately for the use of chemical restraints.

While the restrictive practices are being used, the provider must regularly monitor the care recipient for signs of distress or harm, side effects and adverse events, changes in wellbeing, as well as independent functions or ability to undertake activities of daily living.

Emergency use

The Quality of Care Principles permit the temporary use of restrictive practices in the event of an emergency. In that situation, some of the specific use requirements, including the requirement to obtain consent, do not need to be met. This exemption from the requirements is to allow a provider to respond quickly to ensure the protection of a care recipient or other person from immediate harm. An emergency is a serious or dangerous, unforeseen situation which requires immediate action.

Following the emergency use of a restrictive practice, the provider is required to:

  • Inform the care recipient’s restrictive practices substitute decision maker about the use of the restrictive practice, and document whether this occurred;
  • Obtain consent for the restrictive practice and record as soon as practical; and
  • Once the emergency is over, revert to the usual policies and procedures regarding the application or use of any restrictive practice for the care recipient. This includes documenting the use and consideration of alternative strategies.

Reporting on the use of physical restraint has also been revised with the publication of the National Aged Care Mandatory Quality Indicator Program Manual – 2.0, which also applies from 1 July 2021.

The updated manual states, “For the purposes of the QI Program, physical restraint includes all forms of restrictive practice, excluding chemical restraint.” This means that the quality indicator for physical restraint now includes physical restraint, mechanical restraint, environmental restraint and seclusion.

In line with these reforms, we have updated our Use of Restrictive Practices Aged Care Policy, which aligns with the revised legislation, and with the new QI Program Manual, and includes the following:

  • Change in terminology from “restraints” to “restrictive practices”. This new term is used to describe all forms of “restraint”.
  • Changes to the types and definitions of restrictive practices that may be used. These definitions include chemical restraint, environmental restraint, mechanical restraint, physical restraint, and seclusion.
  • Clarification of existing processes that just be followed regarding consent, monitoring and evaluation, and requiring that any restrictive practice is used as a last resort.
  • Revised definition of “physical restraint” for purpose of recording and reporting data for the National Aged Care Mandatory Quality Indicator Program.

Our policy will help providers and their staff ensure the correct process is followed in relation to use of restrictive practices, and to record and report physical restraint in accordance with the National Aged Care Mandatory Quality Indicator Program.

This resource can be found in the Reading Room by searching “use of restrictive practices”.

Changes from 1 September 2021

Further amendments will commence from 1 September 2021, requiring providers to comply with responsibilities relating to behaviour support plans.

This includes a new requirement for providers to have a behaviour support plan in place for any care recipient who has restrictive practices used as part of their care.

Behaviour support plans will have to include:

  • Alternative strategies for addressing behaviours of concern;
  • Any restrictive practices which are used or applied once alternative strategies have been tried; and
  • Additional key information if the practice is used, and if its use is ongoing.

There will also be new obligations for reviewing, revising and consulting in relation to behaviour support plans.

As these amendments are not yet applicable, we have not yet included them in our updated policy. We will revise our policy again in advance of these changes.

Find key restrictive practices resources on SPP

Access our Use of Restrictive Practices (Aged Care) Policy in the SPP Reading Room.

Advance care planning: the role aged care providers should play

Advance care planning is a process of planning for future health and personal care, which enables a person to set out their values, beliefs and preferences.

The Royal Commission into Aged Care Quality and Safety identified the making and updating of advance care plans as a priority issue in reforms to aged care. The Commission found that providers should be required to assist people receiving care to make and update an advance care plan, if they wished to, and to ensure that these plans are followed. The Commission also recommended that residential aged care providers should be required to provide any advance care directives to paramedics, if a resident is being transferred to hospital via ambulance.

In its response, the Government indicated that periodic reviews of the Aged Care Quality Standards would include consideration of priority issues, including advance care planning. The Government also committed to additional funding to improve transitions of aged care residents between aged care and health care systems.

With this indication that regulations around advance care planning may be strengthened in the future, providers can demonstrate best practice by developing robust policies and processes for advance care planning. 

Advance care planning and the Aged Care Quality Standards

Advance care planning does already feature in the Aged Care Quality Standards (ACQS), Standard 2 – Ongoing assessment and planning with consumers.

Standard 2(3)(b) of the ACQS requires that “Assessment and planning identifies and addresses the consumer’s current needs, goals and preferences, including advance care planning and end of life planning if the consumer wishes.”

The Guidance and Resources for Providers to support the Aged Care Quality Standards document also lists the following examples of evidence for organisations to demonstrate implementation of Standard 2:


  • Consumers have access to advance care planning and end-of-life planning.
  • If a consumer chooses to complete an advance care directive, it is done while they still have decision-making capacity.


  • The workforce can describe advance care planning and advance care directives.
  • Evidence that advance care directive documentation informs end-of-life care and decisions.
  • Evidence of how the organisation makes sure the workforce has undertaken advance care planning training and has a policy to inform advance care directive documentation.
  • Advance care directive documentation should be accurate, up-to-date, complete, shared and stored with relevant care and service providers.

Providers should familiarise themselves with Standard 2 of the ACQS, as evidence of policies and procedures relating to advance care planning may be a key area of focus for assessors conducting an audit of your service. For example, within the Home Services sector, non-compliance with Standard 2(3)(b) was the second highest “top 10” non-compliance noted in the ACQSC’s October-December 2020 Sector Performance Report.

Facilitating advance care planning

Aged care providers play an important role in facilitating advance care planning. Providers can help improve the uptake of advance care planning by older Australians by informing care recipients about aged care plans and encouraging them to make one.

Community and residential aged care providers should implement the following steps:

  • Upon a care recipient’s assessment, receipt of aged care services, or admission to residential care, identify and record details of any existing documents and substitute decision-makers in their health record.
  • If the person does have documentation, make sure to determine whether it’s an Advance Care Directive or advance care plan, and whether a substitute decision-maker has been legally appointed.
  • Provide care recipients and families with straightforward information about advance care planning.
  • Discuss advance care planning and how it relates to the care recipient’s health issues, condition and treatment options.
  • Involve the person’s general practitioner in discussions where possible and appropriate.
  • Encourage the person’s participation in advance care planning if they have capacity and don’t have existing documentation. It is a voluntary process.
  • If the person has decision-making capacity, use an advance care directive. Support the person and their family to document their plan.
  • Encourage the person’s substitute decision-maker to know and understand the person preferences. If the person no longer has decision-making capacity, the substitute decision-maker could document an advance care plan to inform care.
  • Check any draft documents and help to clarify wording or intentions.

Record-keeping and implementation

Whilst it is important that an advance care plan is made, it is just as important that a provider has strong record-keeping and information handling processes in place, to ensure that a person’s wishes can be carried out. For an advance care plan to be effective, it must be known and accessible.

Providers are advised to implement the following processes:

  • Record any discussions about advance care planning and ensure others can access this information if needed.
  • Store copies of advance care planning documents in the person’s health records so they are accessible when needed.
  • Appropriately share and transfer the person’s advance care planning documents with their substitute decision-maker, hospital, specialists, in-reach services, Locum and ambulance services.
  • Ensure that documents are readily available to inform care decisions, if the person is not able to make their own decisions.
  • Encourage review of documents for those with decision-making capacity. This should occur where the person’s needs, goals or preferences change, and after any transition between services.
  • Use the person’s advance care planning documents to inform care decisions, including when the person’s condition deteriorates
  • Engage with community palliative care and residential in-reach/out-reach services to ensure care recipients have access to the care they need in their preferred place.

The steps above should be embedded in organisational policies and procedures, to ensure consistent care outcomes.

It is important to note that legislation and documentation for advance care planning varies across states and territories in Australia.

For more information on the advance care planning process, and the relevant documentation in your state or territory, you can access our advance care planning information sheet and policy template, in the SPP Reading Room.

You may also like to look at the resources provided by Advance Care Planning Australia, including the online learning modules that are available at no cost on their learning site.  And ELDAC also provides a range of helpful resources and toolkits.

Access advance care planning resources on SPP

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COVID-19 in residential aged care – how to respond in the first 24 hours

The prospect of dealing with a case of COVID-19 in your aged care facility is a daunting one. However, preparation is key, and an effective response in the first 24 hours of an outbreak can mitigate the extent of the outbreak dramatically. Here’s why you should get a handle on your response plan now.

The Commonwealth Government Department of Health has released a fact sheet called First 24 hours – managing COVID-19 in a residential aged care facility. This fact sheet walks providers through the steps they should follow in their immediate response to the identification of a COVID-19 positive case. These steps are based on the Communicable Diseases Network Australia (CDNA) national guidelines for the prevention, control and public health management of COVID-19 outbreaks in residential care facilities.

The guidelines identify the following key steps providers should take, in the time periods as follows:

First 30 minutes

  • Isolate and inform the COVID-19 positive case(s)
  • Contact your local Public Health Unit (PHU)
  • Contact the Department of Health
  • Lockdown the residential aged care facility

Minutes 30-60

  • Convene your outbreak management team
  • Activate your outbreak management plan
  • Establish screening protocol
  • Release an initial communication 

Hours 2-3

  • Contact tracing
  • Identify key documents
  • PPE stocktake
  • Communication

Hours 4-6

  • First meeting of the Outbreak Management Team
  • Bolster your staff and plan your roster
  • Conduct testing
  • Clinical management of COVID-positive cases

Hours 6-12

  • Cohorting and relocation
  • Move to a command-based governance structure
  • Rapid PPE supply
  • Infection control

Hours 12-24

  • Clinical First Responder from Aspen to commence
  • Review advance care directives
  • Establish strong induction and control processes
  • Maintaining social contact
  • Follow up communications
  • Continue primary health care
  • Support your staff
  • Continue to monitor state/territory guidelines

Our First 24 hours self-assessment

We’ve built a self-assessment in SPP called Aged Care Facilities – COVID-19 Outbreak First 24 Hours, that follows each of the above steps in the Commonwealth’s guidelines. This self-assessment will serve as a useful tool to prepare your organisation for potential outbreaks. We have broken down the key steps into separate modules and quizzes, which providers can work through to help familiarise themselves with the processes they will need to follow in the event of an outbreak. By self-assessing against the guidelines, you can identify gaps in your existing systems, and download an Action Plan to address these gaps.

We strongly advise that you self-assess against these steps now, well ahead of any outbreak.  Many of the processes required in the first 24 hours following an identified case of COVID-19, will need to have already been established, ahead of time. For example in minutes 30-60 of an outbreak, providers are asked:

“As part of an effective outbreak management plan, has the provider already drafted some pre-prepared email templates for this initial communication?”

Here, it is flagged for providers that they should have email templates prepared, in anticipation of any outbreaks.

Similarly in hours 2-3, providers are asked:

“Does the provider supply the following information to the PHU and the state branch of the Commonwealth:

  • a detailed floor plan which include residents’ rooms, communal areas, food preparation areas, wings, and how staff are apportioned to each area;
  • an up-to-date list of residents, identifying residents with COVID-like symptoms, onset date, testing status, their location in the facility, and staff contacts;
  • a list of all staff employed by the facility; and
  • a list of the respiratory specimens collected and the results of tests?”

This signals to providers what information they will need to have already collected and stored on record somewhere that is easily accessible, if this has not yet been done.

The self-assessment also links to some key resources developed by the Communicable Diseases Network Australia (CDNA), that will be very useful in the event of an outbreak,  including a sample template letter to GPs, and a template report to the local Public Health Unit (PHU).

Our Respiratory Outbreak Preparedness self-assessment

We’ve also made available a self-assessment to guide providers through the components of an outbreak management plan. The self-assessment is based on recommendations from the Department of Health, the Aged Care Quality and Safety Commission, and the NDIS Quality and Safeguards Commission. See our earlier blog post on 6th May 2020 for more information. 

Items to address in an outbreak management plan include:

  • Identifying clients at greater risk and with complex support needs
  • Business continuity plan
  • Communication of the plan to staff, clients and families
  • Preparing a staff contingency plan
  • Maintenance of appropriate levels of necessary stock items
  • Implementation of regular health assessments of clients and staff
  • Preparation of a communications plan for keeping authorities, staff, clients and their families informed after an outbreak is identified
  • Cleaning plan
  • Plan to restrict visitors if relevant

Reviewing your practices against our First 24 Hours and Respiratory Outbreak self-assessments can help ensure your outbreak preparedness planning is up-to-speed, so that your facility is protected and well-prepared.

COVID-19 in aged care - outbreak management

Do you have a clear outbreak management plan? Are you  prepared for the actions you need to take during the first 24 hours of an outbreak?  Sign up to SPP to access our self-assessment, among many other resources.

Promoting emotional wellbeing in aged care

Being involved in activities that promote enjoyment and a sense of purpose is essential for healthy ageing. Older people may be more susceptible to feelings of loneliness, isolation and sadness, and it important for aged care providers to remedy this by offering  a range of activities and services that are aligned with clients’ needs.

Some core principles aged care staff can folllow to promote emotional wellbeing are:

  1. Supporting autonomy and independence.
  2. Encouraging and fostering social connections within and external to the service.
  3. Focusing on strengths, abilities and improving capacity, rather than disabilities.
  4. Promoting personal responsibility.
  5. Providing person-centred services that are flexible and responsive.
  6. Creating relationships with the older person to explore their interests and strengths and to develop their goals.
  7. Respecting an older person’s decision-making ability and preferences.
  8. Working in partnership with other local services and agencies.
  9. Respecting privacy and dignity in relation to consulting friends, families, and service providers.

The kinds of activities that an organisation can offer will depend on the size and resources of the service. Ideally, an organisation should provide, or facilitate access to services and activities relating to the following areas:

  • Physical activity
  • Purposeful activities
  • Music and arts
  • Animals and pet therapy
  • Social relationships and connections
  • Involving family members, carers and friends
  • Spirituality
  • Resilience and coping skills
  • Loss and grief support

For more detailed guidance on how your organisation can best promote emotional wellbeing for its clients, we have developed the following resources, available in the SPP Reading Room:

  • Information Sheet: Emotional Wellbeing in Aged Care
  • Policy: Promoting Emotional Wellbeing (Aged Care)

Nutrition, meals, hydration and hospitality

Access to nutritious and tasty meals is central to client wellbeing and enjoyment – making it a key area for residential aged care and disability service providers to get right. 

Meeting the nutritional needs of older adults

There are a number of factors which can impact the nutritional needs and requirements of older adults, such as susceptibility to malnutrition, difficulties faced during food preparation, isolation and depression. Organisations need to consider these factors when preparing nutrition and meal plans for their clients. In addition to their nutritional needs, older clients may also require assistance to consume foods, for example if they have problems swallowing or using their hands.

Meeting the nutritional needs of people with a disability

Based on self-reported data, around forty-seven percent of people over the age of two with a disability eat less than the recommended serving of fruit and vegetables each day (Australian Institute of Health and Welfare). Food and beverages play an important role in the overall health and wellbeing of people with a disability. They can contribute to a person’s quality of life, help maintain a healthy body weight, protect against infection and reduce the risk of clients developing chronic health conditions.

Hospitality services

If an organisation outsources their catering to an external provider, they should consider the client’s nutritional needs, preferences and cultural considerations. This includes factoring in client input, choice and independence when choosing the catering service for your organisation.

Providers should also make several considerations when selecting laundry and cleaning service providers for aged care clients. Organisations should consider the chemicals services use, whether staff have undertaken cultural competency training and understand the importance of client dignity and independence, hygiene and infection control standards.

BNG has developed resources on nutrition, meals and hydration based on best practice nutrition guidelines. Additionally, our policy template on hospitality services is a great tool for organisations who outsource laundry, catering and cleaning services.

Find the following resources in the Reading Room:

  • Info Sheet: Nutrition, Meals and Hydration
  • Policy: Nutrition, Meals and Hydration
  •  Policy: Hospitality Services