Clinical Care

Outcome 5.1 opens Standard 5 by putting clinical care where the board sits, not where the drug trolley sits. The governing body has to set and communicate the organisation’s priorities for safe, quality clinical care, endorse a clinical governance framework, and then monitor whether clinical systems and performance are actually delivering — using real data: clinical incidents including near misses, complaints and feedback, mandatory Quality Indicator data, clinical trends benchmarked against comparable services, and hospital transfers and the reasons for them. The provider’s job is to operationalise that framework inside corporate governance, so clinical safety is not a parallel universe reported on separately from the finances. The Commission is explicit that the framework must reflect the complexity of the clinical care the service actually provides, which means a small home-care provider and a 120-bed residential home with a high-acuity dementia wing are not expected to produce the same document.

Two Actions here matter directly to me as a visiting GP, and they are genuinely new territory. Action 5.1.4 requires the provider and health professionals to agree on their respective roles, responsibilities and protocols — an actual agreement, which the guidance suggests should cover the older person’s goals of care, a list of responsibilities for clinical care, expected behaviours on both sides, protocols for how clinical information is accessed, shared and edited, a review timeframe, and processes for updating care plans and reporting incidents. In practical terms that turns a lot of unspoken assumptions into something written down: who reviews medications and how often, how I am contacted after hours, what the facility will do to prepare a resident for my visit, whether there is a private room to examine someone in, who acts on my recommendations and by when. The guidance also puts obligations on the provider that I have spent years asking for informally — that workers make the changes arising from my review, including medication changes, and that I am given access to the clinical information system so assessments, medicine lists, charts and notes are available, current and securely stored. Action 5.1.3 is the other clinically load-bearing piece: workers delivering clinical care must be qualified, competent and working within their defined scope of practice, with credentials verified and a committee or named person accountable for registration and scope. That includes contracted and visiting practitioners, and it includes a service culture in which clinical staff can say they cannot safely meet a care need without being punished for it.

For residents and families, the value of this Outcome is mostly indirect but real. Clinical governance is what determines whether a facility notices that its falls or pressure injury or psychotropic numbers are drifting and does something about it, or simply keeps reporting them. You are entitled to expect that the organisation collects and analyses data on the quality of clinical care, including your feedback and complaints, and reports it to the board; that the people delivering clinical care to your relative have had their qualifications and registration checked and are working within their scope; and that where several practitioners are involved, the roles and responsibilities are documented rather than assumed. Action 5.1.5 is worth knowing about too: providers must be working towards a digital clinical information system that connects with national systems using Healthcare Identifiers and My Health Record. "Working towards" is a deliberately soft standard — if a provider does not have such a system, the requirement is that they have surveyed the options, defined what they need and written a detailed plan — so it is fair to ask where a particular service actually sits on that path.

On evidence, a provider needs to show a governing body that sets and communicates clinical priorities, endorses the framework and monitors performance on real data (Action 5.1.1); an implemented clinical governance framework embedded in corporate governance, with roles, accountabilities, measures of success and a review process, and policies that workers can actually find and use (5.1.2); credentialing, scope-of-practice and performance systems for clinical staff, linked to Outcome 2.9 (5.1.3); documented agreements with health professionals, reviewed regularly (5.1.4); and either a conformant digital clinical information system or a concrete plan to get one, with consent and access processes drawn from Outcome 2.7 (5.1.5). Two observations are my interpretation rather than black-letter requirement. First, 5.1.4 is the Action I would expect to be most widely unmet in practice, because the visiting-GP relationship in Australian aged care has historically run on goodwill and habit rather than documented agreement — and a facility that cannot produce one is failing a specific Action, not merely being informal. Second, the honest weakness of any clinical governance framework is the distance between the board papers and the floor: a governing body can receive an immaculate dashboard while the same medication error recurs monthly. The test worth applying is whether the data has ever changed a clinical practice, and whether the registered nurse on an evening shift could tell you what the organisation’s clinical priorities are.

Outcome 5.2 is the clinical half of infection prevention and control, and it sits deliberately on top of Outcome 4.2 under Standard 4. Where 4.2 covers the general IPC system for any aged care environment — hand hygiene, cleaning, PPE, outbreak response, immunisation — 5.2 narrows to infections that arise from clinical care itself, and adds the requirement that is genuinely new to aged care: a documented antimicrobial stewardship system. There are only two Actions, but they are broad. Action 5.2.1 requires an AMS system that complies with contemporary evidence-based practice and fits the service context; Action 5.2.2 requires processes to minimise and manage infection in clinical care, specifically naming clean procedures and aseptic technique, the insertion, management and review of invasive devices including urinary catheters, and minimising both transmission and the complications that follow infection.

This is the Outcome that most directly implicates my own prescribing, and it is worth being blunt about that. Australian residential aged care has among the highest antimicrobial use of any healthcare setting, and successive Aged Care National Antimicrobial Prescribing Survey rounds have consistently found that a substantial share of prescriptions do not meet guideline criteria — a large proportion given for prolonged or indefinite durations, and many started where documented signs and symptoms of infection were absent. The recurring clinical traps are familiar: treating asymptomatic bacteriuria, sending a reflex urine culture for confusion or malodorous urine without other localising features and then treating the result, prolonged prophylactic courses that quietly become permanent, and topical antimicrobials continued on chronic wounds that are colonised rather than infected. The consequences land on my own patients — Clostridioides difficile, resistant Gram-negative urinary organisms, drug interactions and falls — not on some abstract public health ledger. The Standard does not tell me what to prescribe; that remains clinical judgement guided by Therapeutic Guidelines: Antibiotics and the Australian Medicines Handbook. What it does is make the facility responsible for having the system around me: policies promoting appropriate use, named AMS roles, processes for regular clinical review and specialist referral including microbiological testing where required, a route to external AMS expertise, training for workers and contracted health professionals, easy access to those clinical guidelines at the point of care, and monitoring of how often and why antimicrobials are being used. In practice that means a facility should be able to tell me its antimicrobial usage trends, and a worker should know how to escalate a prescription that looks inappropriate — including back to the prescriber, which means back to me.

The device and procedure half of 5.2.2 is where most preventable clinical infection in residential care actually originates. Indwelling urinary catheters are named explicitly, and rightly: catheter-associated urinary tract infection is largely a function of whether the catheter is still there, so the requirement to use, manage and review invasive devices is in effect a requirement to keep asking whether the device is still needed. The same logic applies to subcutaneous lines, PEG tubes, tracheostomies and long-term wound dressings. Aseptic technique for wound care, dressing changes and device insertion has to be protocolised rather than improvised, and the guidance expects the provider to maintain an actual list of the procedures requiring aseptic technique and the invasive devices in use, with protocols for insertion, monitoring and removal, plus the training and the equipment to do it properly. For residents and families, the practical entitlements are that clinical procedures are performed only by people qualified and trained to do them; that a catheter or other device is reviewed rather than left indefinitely; and — a point the guidance makes directly — that the older person is supported to participate in informed decisions about antimicrobials, including being offered information about the risks, benefits and alternatives. A family asking "does she actually need this antibiotic, and what happens if we do not give it?" is asking exactly the question this Outcome contemplates.

On evidence, a provider has to show a documented AMS system with policies, defined roles, clinical review and referral processes, access to external expertise, education for workers and contracted health professionals, monitoring and reporting to the governing body and to prescribers, and quality improvement acting on what the data shows — with the guidance pointing to Chapter 16 of the Antimicrobial Stewardship Book, AC-NAPS participation for residential services, AURA and PBS data as the reference points. Alongside that, a documented IPC system for clinical care covering aseptic and clean procedures, invasive device protocols, senior accountabilities and the IPC Lead role carried over from Outcome 4.2, adequate training, time and equipment, and monitoring of compliance with aseptic technique and device management. Home care providers are not exempt: those that prescribe, supply or administer antimicrobials must run the full system, and those that do not still need one focused on worker education and on giving the older person information to make informed decisions with their prescriber. Two observations are my interpretation rather than black-letter requirement. First, AMS in residential aged care will live or die on whether the facility is prepared to have an uncomfortable conversation with a prescriber, because most of the inappropriate prescribing sits with visiting GPs and after-hours locums rather than with the nursing staff — a stewardship system with no mechanism to feed data or challenge back to prescribers is a training register, not a stewardship program. Second, I would treat surveillance participation as the honest test: a residential service that cannot tell you its own antimicrobial prevalence, or has never taken part in AC-NAPS or an equivalent audit, is not in a position to claim its use is appropriate.

Outcome 5.3 is the medicines Outcome, and it is the one where the provider’s systems and my prescribing meet most directly. The Commission is explicit that the organisation is responsible for creating the conditions — structures, systems, processes and working practices — for consistently safe and appropriate use of medicines, with the Actions drawn from the national Quality Use of Medicines program for residential care, home care and transitions of care. Action 5.3.1 requires a documented medication management system with a governance mechanism over it: in residential services, an expert multidisciplinary group called a Medication Advisory Committee. Underneath that sit policies for procuring, dispensing, prescribing, storing, administering, supplying and monitoring medicines; access to medicines information for residents, workers and health professionals; an up-to-date medicines list available at transitions of care; safe administration by qualified health professionals including assessment of swallowing ability, whether crushing is suitable and provision of alternative formulations; minimal interruption to administration, including timely access to a medicine when one is newly prescribed or urgently changed; a current, accurate record of every medicine including PRN medicines with the clinical reason for treatment; and support for remote access for prescribing. Outcome 5.3 is deliberately read alongside 5.2 for antimicrobials and 5.6 for psychotropics in cognitive impairment.

The Action that reaches furthest into my week is 5.3.2. Medication reviews must happen at commencement of care, at transitions of care and at least annually for ongoing care; whenever there is a change in diagnosis or a deterioration in behaviour, cognition, or mental or physical condition, or the person is acutely unwell; where there is polypharmacy and the potential to deprescribe; whenever a medicine is started or changed; and after any adverse event possibly related to medicines. The guidance acknowledges plainly that the clinician doing the review — the GP or a credentialled pharmacist — is often neither employed nor contracted by the provider, and it responds by making the facility responsible for the surrounding process: communicating that a review is due, following it up where necessary, obtaining documentation of the outcome, and getting the findings and any resulting changes into the care and services plan. In Australian residential practice the usual vehicle is a Residential Medication Management Review with a credentialled pharmacist followed by a GP review, though the Standard does not mandate any particular mechanism — that is my read of how the requirement will be met, not a clause in the Rules. The review questions the guidance sets out are exactly the deprescribing questions worth asking at every visit: is there a documented reason or evidence base for this medicine, does the person still need it, is it still working, what risks does it carry and what monitoring does it need, and what are the risks of stopping it. Action 5.3.4 then singles out high-risk medicines — opioids, anticoagulants, insulin and psychotropics are named — and requires processes to identify, document, monitor and review them, with the level of risk of harm and the mitigation strategies written down, documented communication with external prescribers including GPs and credentialled pharmacists, regular review for dose reduction or deprescribing, and genuine consideration of non-pharmacological alternatives. The obligation to reduce inappropriate psychotropic use is stated in the Action itself.

For residents and families the practical entitlements are concrete. A relative’s allergies and previous adverse reactions to medicines, vaccines or other substances must be documented at commencement and kept updated as new ones emerge (Action 5.3.3). PRN medicines must be recorded with the clinical reason for their use, which makes the standing question — why was this given, how often, and does the pattern point to unmanaged pain or a behaviour being sedated — an answerable one. Swallowing difficulty must be assessed rather than solved informally by crushing whatever is on the trolley, and alternative safe formulations provided where crushing is unsuitable; this matters because crushing modified-release or enteric-coated preparations can convert a day’s dose into an immediate one. Families can expect an annual review at minimum, and a review triggered by any deterioration, new medicine or possible adverse event. They can also ask what the medicine is for and what happens if it is stopped, and expect informed decision-making to be supported rather than assumed. Where a resident is on an antipsychotic or benzodiazepine, "we have always given it" is not an answer this Outcome accepts.

On evidence, a provider has to show a documented medication management system with a governance body over it and defined roles and responsibilities consistent with national and state or territory medicines legislation (Action 5.3.1); processes ensuring reviews occur at each of the specified triggers, with outcomes documented and folded back into the care plan (5.3.2); documentation of allergies and side effects at commencement and on an ongoing basis (5.3.3); identification, monitoring and mitigation of high-risk medicines with documented risk levels and psychotropic reduction (5.3.4); a process for reporting adverse medicine and vaccine events to the Therapeutic Goods Administration (5.3.5); and regular review and improvement of the whole system (5.3.6). Two observations are my interpretation rather than black-letter requirement. First, 5.3.5 is the Action I would expect to be almost universally weak, because TGA adverse event reporting is voluntary and chronically under-done across all of Australian healthcare — a facility that has never lodged a report is not thereby safe, and asking how many reports it has made is a fair and uncomfortable question. Second, the deprescribing intent of 5.3.2 and 5.3.4 will only be met if someone owns the follow-through: a review that generates recommendations which are never actioned, or which the prescriber never sees, satisfies the paperwork and changes nothing. The honest test is whether the number of medicines per resident, and the proportion on psychotropics, has moved at all — and whether the facility can tell you.

Outcome 5.4 is the spine of Standard 5. The Commission describes comprehensive care as the approach that underpins every other clinical Outcome — the loop of assessment, prevention, planning, treatment, management and review that either holds a frail older person together or lets them fall through the gaps. It deliberately builds on work done elsewhere: person-centred care from Outcome 1.1, the assessment and planning system and reablement from 3.1, and evidence-based practice from 2.3. It is not meant to duplicate those; it is meant to make clinical care actually comprehensive rather than a series of disconnected episodes. There are five Actions: partnering with the person to set goals of clinical care (5.4.1), comprehensive clinical assessment at commencement, at least annually and whenever needs change (5.4.2), referral and facilitated access to the right health professionals (5.4.3), coordinated multidisciplinary delivery including after-hours access and notification when things change (5.4.4), and ongoing monitoring and reassessment (5.4.5).

Three Actions here name the GP explicitly, and they change the terms of engagement. Action 5.4.2(a) requires the provider to facilitate access to a comprehensive medical assessment with a general practitioner — not merely to permit it if a GP happens to visit, but to organise it, at commencement, at regular intervals of at least annually, and whenever the person changes. The guidance is specific that this means the person’s preferred GP, with telehealth used where appropriate, in order to support continuity. Action 5.4.4(d) is the one I would put on the wall: the provider must give timely notification to the resident’s GP, their supporters and the other health professionals involved when clinical incidents or changes occur — falls, transitions of care, changes in clinical condition. That converts a chronic irritation of visiting practice, finding out three days later that a patient fell or came back from hospital on a different medication list, into a documented obligation. Action 5.4.4(c) requires real processes for after-hours and urgent clinical care escalation in line with the person’s goals of care, and 5.4.5 requires monitoring and reassessment on any change in diagnosis or deterioration in behaviour, cognition, mental, physical or oral health. The guidance also asks providers to use standardised clinical communication tools such as ISBAR, which is worth encouraging — a structured handover from an anxious carer at 9pm is worth more to me than a narrative one. Two clinical inclusions in 5.4.2 deserve particular attention: the requirement to identify the person’s level of clinical frailty, which if done with a validated instrument rather than an impression is genuinely useful for prognostication and for framing goals-of-care conversations, and the requirement to identify communication barriers, which is where a great deal of undetected pain and delirium hides.

For residents and families the entitlements here are unusually concrete. Your relative should have a comprehensive medical assessment arranged with their own GP, not whoever is available; should have access to allied health with a stated reablement purpose rather than a token review; and should have referral pathways that reach geriatricians and other specialists, dentists and oral health practitioners, specialist nursing, dementia support services, behavioural advisory services and palliative care teams. Oral health is named separately in both 5.4.3 and 5.4.5, which matters more than it sounds — untreated dental disease in residential care drives pain, weight loss, aspiration risk and behavioural change, and it is routinely missed. Equipment, aids and devices the person needs are part of the assessment obligation, not an extra. Goals of clinical care are to be set with you, documented in the plan, and progress towards them evaluated; dignity of risk applies here as it does everywhere else, so a considered refusal of a recommended intervention should be documented and revisited rather than treated as non-compliance. Action 5.4.5 also requires the provider to give residents, supporters, substitute decision-makers, carers and family a way to escalate their own concerns about deterioration — families are frequently the first to notice, and the Standard now expects that channel to exist.

On evidence, a provider needs to show a partnering assessment and planning system with documented goals of care (Action 5.4.1); comprehensive clinical assessment at the specified intervals, covering GP access, clinical risk and exacerbation planning, frailty, communication barriers and equipment (5.4.2); functioning referral pathways with the person’s preferred practitioners and their contact details recorded, and data on referrals including barriers and waiting times (5.4.3); multidisciplinary processes, after-hours and urgent access, and documented notification protocols (5.4.4); and monitoring, escalation pathways, worker training in recognising deterioration, and regular review (5.4.5). Two observations are my interpretation rather than black-letter requirement. First, "facilitate access" is doing heavy lifting across this Outcome and is the phrase most open to being satisfied on paper — a facility can point to a referral that was made while the resident waits nine months for a geriatrician or an oral health appointment that never happens. The guidance does require providers to collect data on barriers and waiting times, so the fair question is not whether referrals were made but whether the person was actually seen. Second, the notification duty in 5.4.4(d) will be the practical test of whether this Outcome is real: if I am still learning about falls, hospital transfers and medication changes incidentally rather than being told, the provider is failing a specific Action, and it is worth naming as such rather than absorbing as normal.

Outcome 5.5 is, in effect, the clinical risk register of the strengthened Standards written into law. Where Outcome 5.4 requires comprehensive care as a process, 5.5 names the specific things that harm older people and requires a documented process for each. The architecture is one system Action plus nine named risk areas: choking and swallowing, continence, falls and mobility, nutrition and hydration, mental health, oral health, pain, pressure injury and wounds, and sensory impairment. The wording of 5.5.1 — "including but not limited to" — matters, because it means the nine are a floor rather than a ceiling. The Commission’s guidance is explicit that assessment may identify other high-prevalence risks needing the same treatment, naming diabetes, enteral feeding and invasive device management as examples. It is also explicit that all of this sits inside shared decision-making and a person’s right to make choices that carry risk to their own health, so 5.5 is meant to be read against dignity of risk under Outcome 1.3 rather than as a licence to restrict.

For the visiting GP, this reads like a list of everything I spend my time on in residential care, and several Actions have real clinical teeth. Action 5.5.8 is the one I would put first: pain must be assessed even where the person cannot report it, which in practice means observational tools such as the Abbey Pain Scale or PAINAD for residents with advanced dementia rather than an assumption that a quiet resident is comfortable — and 5.5.8(c) requires pain management to be available 24 hours a day, which makes an unavailable analgesic at 3am a Standards failure and not just bad luck. Action 5.5.2 pulls swallowing into my prescribing: assessment by a speech pathologist where risk is identified, with screening by a trained registered nurse or GP in the meantime, and it interlocks with Outcome 5.3, where crushing suitability and alternative formulations sit. Action 5.5.3 explicitly requires review of current medicines when bladder symptoms such as urinary incontinence, nocturia or overactive bladder are identified — an anticholinergic burden and diuretic timing review is squarely my job, and it is now the facility’s job to trigger it. Action 5.5.10 deserves more attention than it usually gets: uncorrected hearing and vision loss drives falls, delirium, apparent cognitive decline, misdiagnosed depression and social withdrawal, and a hearing aid sitting flat in a drawer is a clinical problem, not a domestic one. Action 5.5.6 brings mental health in properly, including responding supportively to self-harm and suicidal thoughts — worth taking seriously given that men in the oldest age groups have among the highest age-specific suicide rates in Australia, and that late-life depression in residential care is both common and routinely under-treated.

For residents and families the entitlements here are unusually specific, and they are worth knowing by number. Your relative should be screened for malnutrition regularly, not weighed occasionally and only noticed when clothes stop fitting. They should have oral health assessment arranged with a dentist or oral health practitioner at commencement and regularly thereafter, plus help with daily oral hygiene — the single most neglected area in Australian residential aged care in my experience, and a driver of pain, weight loss, aspiration and behavioural change. They should have routine comprehensive skin inspections rather than a pressure injury discovered at stage three. They should have access to hearing aids, glasses and mobility aids and active support to use them. After a fall they should get post-fall assessment, monitoring and escalation to an appropriate health professional, and the fall itself should be reviewed for cause rather than simply counted. And where a resident chooses to keep eating and drinking despite an identified swallowing risk, that is a legitimate decision to be supported, documented and reviewed — an eating and drinking with acknowledged risk plan — rather than overridden. For residential services, several of these areas also feed the National Aged Care Mandatory Quality Indicator Program, so the facility already has numbers on falls, pressure injuries, unplanned weight loss and incontinence-associated dermatitis, and families are entitled to ask what they show.

On evidence, a provider has to show a working system for identifying, monitoring and managing clinical risk (Action 5.5.1) — validated assessments or timely referral to a qualified health professional at commencement, regularly and on any change or deterioration; outcomes and agreed treatment options recorded in the clinical information system; monitoring to detect deterioration; evidence-based response; multidisciplinary management; and health professionals with the specific competencies for each risk area — plus documented, evidence-based processes for each of the nine areas in 5.5.2 to 5.5.10, with worker training, escalation pathways and monitoring for each. The guidance also asks providers to examine unnecessary hospital transfers as a marker of whether clinical decision-making and escalation are working, which is a genuinely useful signal. Three observations are my interpretation rather than black-letter requirement. First, the structural risk of this Outcome is that it becomes nine parallel checklists: the resident who is malnourished, in pain, sensorily impaired and falling is one clinical picture, not four audits, and the guidance itself asks providers to consider the interaction between risk areas — I would expect integration to be the common weakness. Second, pain in people who cannot report it and oral health are the two areas I would predict are most consistently under-detected, precisely because both depend on someone actively looking rather than on an incident being generated. Third, a note on sourcing: the Actions above are from the finalised strengthened Standards, but the Commission’s detailed guidance material for Standard 5 remains marked as draft with some resource and legislation sections still to be completed, so the supporting detail for several of these Actions may yet be expanded — worth checking the current version before relying on the finer points.

Outcome 5.6 is the cognitive impairment Outcome, and its most important feature is the breadth of what it covers: acute, chronic and transitory. That single phrase puts delirium on exactly the same footing as dementia, which is a deliberate correction of how Australian residential care has historically behaved — dementia is diagnosed and documented, while delirium is frequently missed, mislabelled as "increased confusion" or absorbed into an existing dementia diagnosis. The Commission’s stated intent is person-centred, safe clinical care both for acute changes in cognition such as delirium and for progressive decline from a neurodegenerative disorder such as dementia. There are only three Actions, but they are structural: identify and respond to complex clinical needs (5.6.1), partner with the person and those who know them to understand who they are (5.6.2), and prevent and respond to changes in behaviour by finding the cause (5.6.3). The guidance is clear that the provider’s job is to create the conditions in which workers and health professionals can consistently follow clinical guidelines for cognitive impairment, appropriate to their qualifications and scope of practice — the organisation cannot discharge this by training alone.

For the visiting GP this Outcome is largely about two things: diagnosis and cause-finding. Action 5.6.1 requires processes for identifying older people with symptoms of cognitive impairment, including recording information about the person’s specific diagnosis or considering referral for specialist medical diagnosis. That is a pointed requirement in a sector where a great many residents carry an undifferentiated label of "dementia" with no documented subtype, no cognitive testing, no neuroimaging and no record of who made the diagnosis or when. Subtype is not academic: it changes prognosis, it changes what behaviours are expected, and in Lewy body dementia it changes prescribing decisively, because antipsychotic sensitivity in that group can be severe. Action 5.6.1 also requires screening and clinical assessment, sensitively conducted, when cognitive impairment is first identified and whenever there is any change in cognitive status, including delirium — and requires that workers understand the range of potential contributing factors to cognitive and behavioural change, including clinical, environmental and medication-related factors, and that some of these may be modifiable or reversible. Action 5.6.3(b) is the one I would keep at the front of my mind: when behaviour changes, the process must include identifying potential medical and mental health-related factors that could underlie it, with delirium, pain and medication changes named explicitly. Read plainly, that makes a psychotropic prescribed for "agitation" without a documented search for infection, pain, constipation, urinary retention, dehydration, hypoxia, uncorrected sensory impairment or a recent medication change a departure from the Standard, not merely a shortcut. It also links directly to Outcome 5.3 on high-risk medicines and Action 3.2.7 on restrictive practices, and the guidance names the Psychotropic Medicine in Cognitive Disability or Impairment Clinical Care Standard as a monitoring reference — so the benchmark the facility will be measured against is already published.

For residents and families, Action 5.6.2 is the one worth reading closely, because it is unusual in the Standards for being explicitly about biography rather than clinical process. The provider must collaborate with the person, family, carers and others to understand the person: their history, personality, roles in life, values and beliefs, in order to better identify unmet needs. Preferences, goals and preferred support strategies are to be documented in the care and services plan and, where required, in a behaviour support plan. Behaviour support plans are required in residential care for people with changed behaviours, and the guidance says using them is also evidence-based practice in home care. Action 5.6.3 then requires the provider to proactively implement individual non-medication strategies that are known to be effective and acceptable to that person — access to outdoor spaces, engagement in meaningful activities, pursuit of interests are the examples given — to minimise both distress and the use of restrictive practices, and to identify and mitigate stressors in the care environment and in the day-to-day routines of care that increase the risk of acute changed behaviour. Families are also entitled to expect an escalation route: the guidance requires processes for escalating observations or concerns about cognitive change to health professionals, and families are very often the first to notice that a person is not themselves. The practical translation is that "she has been unsettled all week" should trigger a clinical search for a cause, not a PRN order — and that the answer "that is just the dementia" is not one this Outcome accepts.

On evidence, a provider needs to show policies embedding the person’s rights to dignity, autonomy and choice in how cognitive impairment is identified, monitored and cared for; documented processes for identifying signs of cognitive deterioration and acting on them, including specific diagnosis or referral, assessment of clinical, psychosocial and environmental contributors, escalation to health professionals, and sensitive screening on first identification and on any change including delirium; documented risks, needs and management strategies — mealtime support, memory support, safe mobility, falls prevention — recorded in the care and services plan for each person with cognitive impairment; ongoing monitoring of changing clinical needs, daily care needs, and the need for additional care minutes (5.6.1); collaboration and shared decision-making processes with accessible information in multiple formats and workforce training under Action 2.9.6, with preferences and goals documented (5.6.2); and processes to prevent and manage behaviour change, including immediate safety, cause-finding, involvement of people who know the person, referral to behavioural support specialists where required, and person-centred behaviour support plans within the care and services plan (5.6.3). Monitoring is expected against Quality Indicator Program data on falls, pressure injuries, restrictive practices and psychotropic use, against the psychotropic Clinical Care Standard, and on incident themes and worker and family feedback, with results reported to the governing body. Three observations are my interpretation rather than black-letter requirement. First, the Actions do not name a delirium screening tool or mandate routine screening, and I think that is this Outcome’s weakest point — being "alert to deterioration" is a much softer obligation than screening, and given how poorly delirium is detected without a structured instrument, I would treat use of a validated tool such as the 4AT as the practical way to meet 5.6.1(c), while being clear that the Standard does not require it. Second, behaviour support plans carry an obvious failure mode: a plan written once, filed, and never read by the evening staff who actually encounter the distress satisfies the documentation and changes nothing — the honest test is whether a casual worker on a Sunday shift can tell you what settles that particular resident. Third, on sourcing: the Commission’s guidance material for Standard 5 remains marked draft, and the key resources, legislation and other-obligations sections for Outcome 5.6 are still marked "to be completed", so the supporting material here is likely to expand and should be re-checked before the finer points are relied on.

Outcome 5.7 is the last Outcome of Standard 5 and, read against the sector as it actually operates, the most consequential. Its framing line is that palliative and end-of-life care, like dementia care, is core business for providers — not something that starts when a specialist service is called in. The Outcome runs along a timeline rather than a list of tasks: recognising that someone is in the last years or months of life (5.7.1), having the conversations and keeping the documents current (5.7.2), delivering comprehensive palliative care once that is recognised (5.7.3), and then a distinct set of obligations for the last days of life (5.7.4). The Commission is explicit that prevention and relief of suffering is the highest priority, that care at the end of life is comprehensive care delivered in a coordinated way under Outcome 5.4, and that residential services carry 24-hour responsibility for clinical care so every Action applies to them in full. The guidance also addresses voluntary assisted dying directly: providers have responsibilities under their own state or territory legislation, are expected to be familiar with it, and are expected to respect an older person’s choice to access VAD — and a person’s decision to do so does not change their right to, or their access to, high-quality palliative and end-of-life care.

For the visiting GP this is the Outcome that most directly names our role, and it does so three times. Action 5.7.1 requires the older person’s GP or NP to be involved in discussions about diagnosis and prognosis as the person approaches the end of life; Action 5.7.2 requires the same involvement in discussions about diagnosis, prognosis and options so that end-of-life planning and delivery are coordinated; and Action 5.7.3(f) requires established referral pathways with the GP, specialist doctors and nurses, NPs, specialist palliative care and allied health, with the health professional who will coordinate end-of-life care identified and documented. That last requirement is the useful one to hold a facility to, because the recurring failure in residential palliative care is diffuse accountability at 2am. On recognition, the guidance names the tools plainly: risk prediction and trigger tools, and the surprise questions — would you be surprised if this person died in the next 12 months, and would you be surprised if they died in the next days or weeks. It pairs recognition with a requirement to identify and manage episodes of acute deterioration that may be reversible, which is the correct clinical safeguard against treating every decline as terminal. Three prescribing obligations follow. Action 5.7.1 requires facilitated access to medication review and rationalisation to consider deprescribing or discontinuing and to consider safe administration routes, aligned with goals of care. It requires anticipatory medicines to be planned for, with a process for safe use and administration. And 5.7.4(b) requires that medicines for pain and symptoms, including anticipatory medicines, are prescribed, administered, reviewed and available 24 hours a day — which in practice means the script, the imprest or core stock arrangement, the syringe driver and a nurse competent to use it all have to exist before the Friday night they are needed, not after. Action 5.7.4(d) separately requires recognition of and response to delirium in the last days of life, and the guidance is explicit that workers must be able to assess and respond to symptoms with a potentially reversible cause; terminal restlessness and hypoactive delirium are not interchangeable, and the difference changes what should be given.

For residents and families, the substance here is choice and information. Under 5.7.2 the provider must support ongoing end-of-life conversations at the pace the person chooses, must elicit their wishes about the circumstances, environment and place in which they wish to die, must provide supported decision-making where capacity fluctuates and engage the substitute decision-maker where it is absent, and must keep advance care planning documents identified, stored, accessible and — with consent — shared at transitions of care, in transfer summaries and with paramedics on transfer to hospital. Uploading advance care planning documents to My Health Record is named as an option the person should be supported to understand. The right to decline is written in as clearly as the right to request: 5.7.2(b) covers discussing requesting or declining aspects of personal care, life-prolonging treatment and responses to reversible acute conditions. Under 5.7.3 the person’s preferred place of palliative care and preferred place of death must be identified, with strategies to support them to remain at home or in their preferred place; for Aboriginal and Torres Strait Islander people who wish to die on country, the provider is to collaborate with community members on those decisions in line with the person’s wishes. Families and carers are owed information about the dying process, grief, loss and bereavement (5.7.3(h)), and in the last days 5.7.4(e) requires unnecessary hospital transfer to be minimised where that matches the person’s preferences — the practical answer to the ambulance called reflexively at 3am for a person who had documented that they wanted to die in their own room. For home care, the guidance adds a carer assessment covering the carer’s needs, capacity and the sustainability of their role, and requires a documented plan for safe use of pain and symptom medicines with a named accountable health professional and 24-hour escalation.

On evidence, a provider needs to show documented recognition processes with trigger or risk-prediction tools and engagement of the person, family and GP; facilitated medication review with deprescribing and route considerations; a working anticipatory prescribing process; planned access to equipment and aids with staff trained and confident in their use; and audit, feedback and data analysis on how well end of life is recognised (5.7.1). For planning, it needs advance care planning policies aligned to its own state or territory legislation and understood by workers, documents that are identified, stored, retrievable, reviewed, enacted and shared, trained staff who can hold these conversations, and advance care planning audits reported through the quality system (5.7.2). For delivery, it needs holistic assessment prioritising comfort and dignity, documented cultural, spiritual and psychosocial needs, preferred place of care and death, named referral pathways and a documented coordinating clinician, timely escalation of deterioration, timely access to specialist palliative care, medicines and equipment, and analysis of clinical data on symptom and pain control (5.7.3). For the last days, it needs identification processes, 24-hour anticipatory medicine availability, documented pressure, oral, eye, bowel and bladder care, delirium recognition, trained staff, and audit of investigations, interventions and transfers of care alongside bereaved families’ feedback (5.7.4). Two cautions, both my interpretation rather than black-letter requirement. First, "available 24 hours a day" in 5.7.4(b) is the single most testable line in this Outcome and the one most likely to fail in practice, because it depends on things outside the facility’s walls — after-hours pharmacy, an authorised prescriber, and a nurse able to administer a subcutaneous medicine at 4am — so I would treat a documented, rehearsed after-hours pathway as the real standard of compliance rather than a policy that names one. Second, recognition and reversibility sit in genuine tension: the same Action asks staff to identify people likely to die within twelve months and to identify acute deterioration that may be reversible, and the guidance offers no tool for distinguishing them. That judgement will fall to the GP, and it should be documented when it is made. As with the rest of Standard 5, the Commission’s guidance material remains marked draft and the key resources, legislation and other-obligations sections for this Outcome are still marked "to be completed", so the supporting material should be re-checked before the finer points are relied on.