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:

  • 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.

Workforce

  • 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.

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