CHCAGE004 Learner Guide V1.0

Learner Guide
CHCAGE004 Implement Interventions with Older People at Risk

Table of Contents
Unit of Competency ............................................................................................................................. 5
Application ........................................................................................................................................... 5
Performance Criteria ........................................................................................................................... 6
Foundation Skills .................................................................................................................................. 8
Assessment Requirements................................................................................................................... 9
1. Assist with the preparation for a risk assessment ........................................................................... 11
1.1 – Confirm assessment requirements with supervisor or relevant health professional ................... 12
Providing a service ............................................................................................................................. 12
Assessing a client ............................................................................................................................... 13
Confirming requirements................................................................................................................... 13
1.2 – Encourage participation of the older person and their carer in assessment and further actions 15
Participation in care requirements .................................................................................................... 15
Determining actions........................................................................................................................... 16
A person-centred approach ............................................................................................................... 16
1.3 – Provide information to the older person and/or carer to clarify own role, responsibilities and
accountability ........................................................................................................................................ 18
Clarifying your role............................................................................................................................. 18
Duty of care ....................................................................................................................................... 18
Duty of care in law ............................................................................................................................. 19
Confidentiality.................................................................................................................................... 21
1.4 – Provide information to the older person and/or carer explaining the assessment process,
including explanation of results ............................................................................................................. 24
The process explained ....................................................................................................................... 24
Explaining results ............................................................................................................................... 25
Alleviate tensions surrounding clients’ rights .................................................................................... 25
1.5 – Communicate in a supportive and encouraging manner that is respectful of the older person and
carer’s, rights, level of understanding and cultural background ........................................................... 28
Communicating in a supportive manner ........................................................................................... 28
Cross-cultural communications ......................................................................................................... 28
Improve your communications .......................................................................................................... 30
Check information is understood ...................................................................................................... 31
1.6 – Seek older person’s permission and cooperation in the assessment process .............................. 32
Lead College Pty Ltd RTO No: 41489 CRICOS Code: 03636F
Learner Guide – CHCAGE004 Implement Interventions with Older People at Risk Page 2
Seek permission first .......................................................................................................................... 32
Human rights ..................................................................................................................................... 32
2. Contribute to the identification of risks .......................................................................................... 34
2.1 – Identify and review factors in the older person’s lifestyle that might affect their level of risk .... 35
Looking at risks .................................................................................................................................. 35
Major issues ....................................................................................................................................... 35
Risks for older people ........................................................................................................................ 35
2.2 – Use appropriate tools and methodologies, within scope of role, to determine risk based on
physical indicators presented by the older person ................................................................................ 41
Make use of tools and methodologies............................................................................................... 41
Trends and risks ................................................................................................................................. 42
2.3 – Assist with risk assessment ensuring to minimise unnecessary discomfort to the older person
and maximises their participation ......................................................................................................... 45
2.4 – Use the support of carers to identify risks .................................................................................... 45
Perform a risk assessment ................................................................................................................. 45
Older person and carer involvement ................................................................................................. 46
2.5 – Recognise the older person’s risk factors based on medical history, measurements and findings,
in collaboration with supervisor and/or relevant health professional .................................................. 47
Recognising risks ................................................................................................................................ 47
Collaborate with professionals .......................................................................................................... 48
2.6 – Identify the older person’s needs, issues and concerns outside scope of own practice and refer
to appropriate supervisor and/or health professional .......................................................................... 49
Scope of practice ............................................................................................................................... 49
Assisting the older person ................................................................................................................. 49
3. Implement risk minimisation strategies.......................................................................................... 51
3.1 – Identify and explain options to minimise risk to the older person and/or carer .......................... 52
Using strategies.................................................................................................................................. 52
Inform on the possible options .......................................................................................................... 52
3.2 – Work with the older person and carer to identify risk minimisation strategies that are consistent
with the older person’s safety needs, priorities and specific requirements.......................................... 54
Risk minimisation strategies .............................................................................................................. 54
3.3 – Implement strategies in a safe and effective manner that minimises the older person’s
discomfort.............................................................................................................................................. 57
3.4 – Support carer in contributing to the implementation of strategies, where appropriate ............. 57
Implementing strategies .................................................................................................................... 57
Carer support ..................................................................................................................................... 57
4. Monitor risk minimisation strategies .............................................................................................. 59
4.1 – Monitor the effects of the strategies on the older person ........................................................... 60
4.2 – Identify any indicators of increased risk ....................................................................................... 60
A system to monitor strategies .......................................................................................................... 60
Check for an increase in risk .............................................................................................................. 61
Report your findings .......................................................................................................................... 61
4.3 – Identify when strategies are not having the desired result and possible reasons for this ........... 62
4.4 – Reassess and identify more appropriate strategies ...................................................................... 62
When a strategy doesn’t work ........................................................................................................... 62
Reassess strategies ............................................................................................................................ 63
4.5 – Work with the older person and carer to assess the outcomes of risk minimisation strategies .. 64
Assessing the outcomes ..................................................................................................................... 64
Follow procedures and legal requirements ....................................................................................... 65
Feedback ............................................................................................................................................ 65
4.6 – Discuss feedback from the older person and carer with supervisor and/or relevant health
professional ........................................................................................................................................... 66
Take time to obtain feedback ............................................................................................................ 66
Provide feedback to others ................................................................................................................ 66
4.7 – Complete, maintain and store all relevant documentation and reports according to organisation
policy and protocols in a timely manner ............................................................................................... 67
Documentation .................................................................................................................................. 67
Written documents ............................................................................................................................ 68
Verbal reports .................................................................................................................................... 68
Structuring notes ............................................................................................................................... 69
Storing documentation ...................................................................................................................... 70
Classifying folders/documents ........................................................................................................... 70
Sorting documents ............................................................................................................................. 70
Filing documents ................................................................................................................................ 70
Mandatory notification ...................................................................................................................... 71
Summative Assessments........................................................................................................................ 72
References ............................................................................................................................................. 73
Unit of Competency
Application
This unit describes the skills and knowledge required to work in partnership with older people and their
carers to implement interventions in the context of an individualised plan to reduce risk.
This unit applies to support workers in a residential or community context. Work performed requires a
range of well developed skills where some discretion and judgement is required. Workers will take
responsibility for their own outputs under direct or indirect supervision.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation,
Australian/New Zealand standards and industry codes of practice.
Unit Sector
N/A
Performance Criteria
Element Performance Criteria
Elements describe the Performance criteria describe the performance needed to
essential outcomes. demonstrate achievement of the element.
1. Assist with the 1.1 Confirm assessment requirements with supervisor or

preparation for a risk relevant health professional
assessment 1.2 Encourage participation of the older person and their carer
in assessment and further actions
1.3 Provide information to the older person and/or carer to
clarify own role, responsibilities and accountability
1.4 Provide information to the older person and/or carer
explaining the assessment process, including explanation of
results
1.5 Communicate in a supportive and encouraging manner that
is respectful of the older person and carer’s, rights, level of
understanding and cultural background
1.6 Seek older person’s permission and cooperation in the
assessment process
2. Contribute to the 2.1 Identify and review factors in the older person’s lifestyle that
identification of risks might affect their level of risk
2.2 Use appropriate tools and methodologies, within scope of
role, to determine risk based on physical indicators
presented by the older person
2.3 Assist with risk assessment ensuring to minimise
unnecessary discomfort to the older person and maximises
their participation
2.4 Use the support of carers to identify risks
2.5 Recognise the older person’s risk factors based on medical
history, measurements and findings, in collaboration with
supervisor and/or relevant health professional
2.6 Identify the older person’s needs, issues and concerns
outside scope of own practice and refer to appropriate
supervisor and/or health professional
3. Implement risk 3.1 Identify and explain options to minimise risk to the older
minimisation person and/or carer
strategies 3.2 Work with the older person and carer to identify risk
minimisation strategies that are consistent with the older
person’s safety needs, priorities and specific requirements
3.3 Implement strategies in a safe and effective manner that
minimises the older person’s discomfort
3.4 Support carer in contributing to the implementation of
strategies, where appropriate
Element Performance Criteria
Elements describe the Performance criteria describe the performance needed to
essential outcomes. demonstrate achievement of the element.
4. Monitor risk 4.1 Monitor the effects of the strategies on the older person
minimisation 4.2 Identify any indicators of increased risk
strategies 4.3 Identify when strategies are not having the desired result
and possible reasons for this
4.4 Reassess and identify more appropriate strategies
4.5 Work with the older person and carer to assess the
outcomes of risk minimisation strategies
4.6 Discuss feedback from the older person and carer with
supervisor and/or or relevant health professional
4.7 Complete, maintain and store all relevant documentation
and reports according to organisation policy and protocols in
a timely manner
Foundation Skills
The Foundation Skills describe those required skills (such as language, literacy, numeracy and
employment skills) that are essential to performance.
Foundation skills essential to performance are explicit in the performance criteria of this unit of
competency.
Assessment Requirements
Performance Evidence
The candidate must show evidence of the ability to complete tasks outlined in elements and
performance criteria of this unit, manage tasks and manage contingencies in the context of the job role.
There must be evidence that the candidate has:
Ø Assisted with the assessment of risk and the implementation and evaluation of risk
minimisation strategies for at least 2 older people, 1 in a simulated environment and 1 in the
workplace, in a manner that is respectful of the older person’s dignity and privacy.
Knowledge Evidence
The candidate must be able to demonstrate essential knowledge required to effectively complete tasks
outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in
the context of the work role. This includes knowledge of:
Ø The tensions which may exist between an individual’s rights and the organisation’s
responsibility to individuals
Ø Legal and ethical considerations for working in aged care:
o duty of care
o human rights
o privacy, confidentiality and disclosure
o work role boundaries – responsibilities and limitations
Ø The major issues, trends and policies relating to the health and wellbeing of older people
Ø Standardised tools for risk assessment and the management and monitoring of risks
Ø Major risk areas for ageing population:
o depression and anxiety
o isolation
o abuse (sexual, emotional, physical, financial, system)
o falls
o medication
o dehydration and malnutrition
o dysphagia
o continence
Ø Documentation requirements including the importance of accurate and appropriately detailed
records.
Assessment Conditions
Skills must have been demonstrated in an ageing support workplace with the addition of simulations
and scenarios where the full range of contexts and situations have not been provided in the workplace.
These are situations relating to emergency or unplanned procedures where assessment in these
circumstances would be unsafe, impractical or threatens the dignity of the older person.
The following conditions must be met for this unit:
Ø Use of suitable facilities, equipment and resources, including relevant assessment tools.
Overall, assessment must involve some real interactions with older people, colleagues, families/carers
and the use of individualised plans.
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF
mandatory competency requirements for assessors.
Links
Companion volumes from the CS&HISC website - http://www.cshisc.com.au
1. Assist with the preparation for a risk assessment
1.1. Confirm assessment requirements with supervisor or relevant health professional
1.2. Encourage participation of the older person and their carer in assessment and further actions
1.3. Provide information to the older person and/or carer to clarify own role, responsibilities and
accountability
1.4. Provide information to the older person and/or carer explaining the assessment process,
including explanation of results
1.5. Communicate in a supportive and encouraging manner that is respectful of the older person
and carer’s, rights, level of understanding and cultural background
1.6. Seek older person’s permission and cooperation in the assessment process
1.1 – Confirm assessment requirements with supervisor or relevant health
professional
By the end of this chapter, the learner should be able to:

Ø Identify the relevant supervisor(s) and/or health professional(s) from whom they
should seek confirmation of assessment requirements
Ø Seek confirmation of assessment requirements from supervisor or relevant health

professional.
Providing a service
Interventions may be required for older people with health or care concerns. They ensure that the
correct measures are taken to maintain health and wellbeing in an environment that is supportive to
the older person and their family and/or carer(s).
When working within the health and care industry for older people, a full assessment of their support
requirements will be needed. This may be carried out by a government ACAT team (Aged Care
Assessment Team) or by an independent service provider.
This will determine if health and care intervention is required and to what extent. Assessments should
be made periodically to check that health and care needs are always met.
An assessment provides understanding of an older person’s current health, how situations are being
managed, and how to identify and determine all future wellbeing needs. From this, the appropriate care
and welfare solutions can be identified, and any risks to health can be recognised and managed.
You will need to know:

Ø Their physical and mental condition
Ø Any diagnosed conditions
Ø Any medical needs including medication

and/or treatments
Ø Functioning requirements
Ø The lifestyle of the older person
Ø If they have a carer (or carers) and/or

dependants.
At your place of work, make sure that all assessment requirements are understood and confirmed with
your supervisor/appropriate health professional. You will need to have the correct, relevant client
information to hand, such as health and care records.
The older person may have specific physical needs such as poor mobility or a debilitating health
condition, or they may have mental health problems. Knowing what you are assessing for is paramount
to delivering the right care and for assessing the associated risks.
Assessing a client
An assessment includes:
Ø Identifying and diagnosing conditions, including complex care needs and dual diagnosis
Ø Both medical and functioning requirements of the older person
Ø Performing a person-centred approach to care needs
Ø Recognising potential risks and hazards for the older person.
A risk assessment should look at all potential situations that may cause harm to the older person, for
example, if the older person is at home on their own for long periods of time. From this recognition of
risk, the hazards may include an increased chance in falls occurring, poor nutrition if the older person is
unable to prepare and cook food and personal hygiene needs.
Confirming requirements
Assessment requirements should be confirmed with a supervisor, or a relevant health professional.
Assessment requirements may vary according to the specific needs of the client and the services for
which they are eligible.
Relevant health professionals may include:

Ø Doctor
Ø Dietician
Ø Diversional therapist
Ø Drug and alcohol worker
Ø Geriatrician
Ø Home care worker
Ø In-home respite worker
Ø Nursing assistant
Ø Pain specialist
Ø Palliative care specialist
Ø Psychiatrist
Ø Psychologist
Ø Registered nurse
Ø Wound consultant.
Ensure that you are familiar with the procedure for confirming assessment requirements within your
own organisation, including the identity of the relevant supervisor(s) and/or health professional(s).
1.2 – Encourage participation of the older person and their carer in assessment
and further actions

Ø Take a person-centred approach to assessment by encouraging the participation of the
older person and the carer. This may involve:
o discussing personal preferences and requirements
o answering client and carer questions about the assessment process
o confirming with client and/or carer that information is accurate
o obtaining consent for examination, treatment or collaboration from the client.
Participation in care requirements

To achieve the correct assessment for care, you should ensure that the older person and their carer (if
applicable) participate in this process.
This will provide:

Ø Accurate accounts and information on the older person’s situation
Ø Answers to questions you have on health and care issues for the older person
Ø Recognition of risks and associated hazards
Ø Development of a person-centred approach to care
Ø Individual needs to be recognised and taken into consideration
Ø Honest and open discussions on preferences and meeting health and care needs.
By making decisions on health and care needs with the older person and their carer(s), you can develop
care that is both beneficial and will integrate into existing routines.
Encourage participation through friendly communications that are warm, honest and sincere. Establish
a rapport with the client (older person) and their carer and include them in the development of their
support needs. This will help you to build upon trust and to develop a working relationship with the
client and carer and will promote joint responsibility.
Determining actions
From working together for the assessment and with other medical and health professionals look to
establish the actions that should be taken to ensure optimum health and quality of life is made and
maintained.
Actions may include:

Ø Medical treatments and visits/appointments
Ø Adjustments to the environment to remove risks to the older person, such as:
o ensuring flooring is non-slip and has no trip hazards
o handrails and/or walkways (if needed)
o rearrangements to room layouts
Ø Supporting care, including:
o daily activities
o personal care routines
o meal provisions
o administering medications and dressing

wounds
o assistance with shopping
o assistance with living requirements such as

paying bills
o social/leisure activities
o respite care needs.
A person-centred approach
A person-centred approach to care is when the older person/client is included in the processes,
decisions and considerations that are being made for their own care needs. The older person working
together with the organisation/support worker to help the process of assessment and any subsequent
health and care needs. It is looking at the person as an individual and understanding that they are able
to make choices that are in their best interest.
A person-centred approach may involve:

Ø Putting people and carers at the centre of service delivery
Ø Including people in decision-making relating to their care
Ø Involving people in discussions about service delivery options and issues
Ø Obtaining the person's consent to examine, treat or work with them
Ø Effective customer service
Ø Listening to and addressing complaints

within scope of own work role.
1.3 – Provide information to the older person and/or carer to clarify own role,
responsibilities and accountability

Ø Clarify and communicate own role to the older person, including the provision of
information about own responsibility and accountability
Ø Communicate information about duty of care requirements
Ø Communicate information about client confidentiality.
Clarifying your role

As part of your working requirements, you should clarify
your role within aged care to those you work with. This will
make others aware of your level of involvement and
professional capacity.
Clarifying your role includes:

Ø Defining your responsibilities to others
Ø Providing understanding on your

accountability
Ø Communicating how you can support those

under your care.
Make certain that the people you work with, and for, have the correct understanding on your
involvement. If you are unsure on any part of your role, you should speak with your manager to clarify
this. By informing the older person and any others on your work role, you can ensure that all parties
have the same understanding and can help prevent errors occurring.
Your role will include ethical, legal and adherence to organisational policy and procedures.
Duty of care
Duty of care is a legal duty to take all reasonable care to avoid others being harmed and to ensure that
all health and community workers provide a good standard of care, with due attention. This involves the
application of and adherence to ethical standards and acknowledges that people have a right to be
cared for in safe environments which are free from neglect and abuse. It also involves identifying risks
and responding in the most appropriate way. It does not require perfection; moreover, it is the effort to
ensure that the person is protected. It acknowledges that you may lack resources and abilities that
would enable said perfection.
Reasonable care includes considering the safety, privacy, confidentiality and needs of clients and others.
In the aged care industry, other responsibilities may include management of the client’s benefits and
always the prevention of age discrimination. In instances where the health and care of children are
concerned, all children should be protected against risk factors to their health and wellbeing. Be aware
of any circumstances that may cause concern and seek advice.
Everyone has a duty of care responsibility – for example, the employer and employees are both
responsible for safety in the workplace. When working with disabled people, this applies in potentially
risky situations, where duty of care will need to be exercised to ensure hazard prevention.
You must ensure that all of your work meets the duty of care requirements. Policies and procedures
which take into account things like WHS and legal responsibilities should be followed. A WHS officer
should be appointed to ensure all workers and people in the vicinity of work comply with these
requirements.
Employers have a duty of care to provide a safe work place and systems of work in consultation with
their team and to keep their team informed about changes in WHS legislation. To assist you in ensuring
that your organisation is compliant with WHS legislation, you can download a copy of the WHS
Compliance Self-Assessment from the Safety at Work process. You should also check the specific
legislation, codes of practice and standards that apply in your location to ensure compliance at work.
The objective of the WHS Act is to ensure that a safe workplace is created free from risk or illness or
injury. For that end, compliance must be demonstrated in regards to:
Ø A safety management system
Ø Responsibilities and Accountabilities
Ø Consultation
Ø Risk management
Ø Information, instructions and training
Ø Managing injuries
Ø Record keeping
Ø Monitoring, review and improvement
Ø Resource management
Ø Corporate risk.
If you are able to work through the document and tick yes the whole way through, then you are
complying with current legislation. Care should be taken; this is not a one off process. Managers are
required to ensure the continuous compliance with the legislative system.
Duty of care in law

Duty of care comes under the ruling of tort law i.e. a civil wrong as opposed to a breach of contract. It
requires an individual to provide a standard of reasonable care while carrying out any activity that could
potentially harm others. Breaching duty of care means that you, as an individual, are liable to legal
action from the claimant.
Duty of care has been developed through common law i.e. it exists based on past related court rulings –
therefore, there is no exact legal definition of things like duty of care and negligence.
Negligence is when damage/harm occurs to another person as a result of someone else not exercising
reasonable care. Duty of care requires that an acceptable standard of care is exercised, where it is
reasonably practicable, to ensure the health and safety of yourself and others.
Duty of care also means that everyone has a responsibility to ensure a safe and healthy working
environment.
This can include the following people:
Ø Community and disability service workers
Ø Doctors
Ø Solicitors
Ø Financial advisors
Ø Drivers
Ø Local governments.
Duty of care is written legally into the Workplace Health and Safety Act 1995 – it is a moral duty to
anticipate possible hazards and causes of injury and do everything reasonably practicable to
prevent/remove/minimise these causes.
This means that duty of care cannot be delegated – all adults in the workplace are responsible for health
and safety.
Courts will determine breaches of duty of care based on the following criteria:
Ø What is typically expected of another person in the same situation
Ø The person's roles and responsibilities within their organisation
Ø The experience/level of training for the individual
Ø The practicalities of the situation
Ø What is deemed acceptable practice within the community
Ø Generally acceptable standards in the situation
Ø Relevant laws e.g. the Workplace Health and Safety Acts,

Regulations and Codes of Practice.
For negligence to be successful, the following must be proven:
Ø A duty of care is owed by the plaintiff to the defendant
Ø In exercising the duty of care, the defendant failed to function according to a

reasonable standard of care
Ø The failure to function according to a reasonable standard of care (breach) caused the
damage suffered by the plaintiff
Ø The loss or damage suffered by the plaintiff was reasonably foreseeable.
Negligence laws
In order to restrict the number of negligence claims, there are laws in place; in Queensland laws
related to professional liability for damages related to negligence:
Ø Personal Injuries Proceedings Act 2002 (Qld)
Ø Civil Liability Act 2003 (Qld).
The following principles apply to negligence:

Ø It does not apply if the risk of the activity was obvious/made clear
Ø What is expected is dependent on the skill level/experience of the worker
Ø People are given a reasonable amount of information to make informed decisions on

optional actions (e.g. medical treatment)
Ø Apologies/expressions of regret do not amount to admitting liability/fault and will hold

no weight in court
Ø First aid personnel have no liability in emergency situations, as long as their actions are
in good faith and without reckless disregard for safety.
Confidentiality
Confidentiality is required by law in certain respects; the privacy of patient and client
records is the most important aspect of confidentiality in the care industry. Failure to
maintain privacy of customer records is punishable by law and organisations can be
sued by the patient. This would mean not sharing certain information in your
communications, such as networking. Information cannot be disclosed to those not
directly involved in the patient’s/client's case. Measure should be implemented
within your workplace and you will probably find that your organisation already has
certain policies and procedures in place.
The only situation where this private information can be disclosed is when there is a
serious threat or risk of injury to the client or others. Other than that, the
patient/client may choose to disclose their information – but it is their choice only.
Clients will need to give permission (normally in writing) for their information to be
released to others; if they are unable to do this through disability or death, advocates can grant
permission.
Client records
Clients also have a right to view their records – this information should be supplied only by authorised
personnel in that field. If access is denied the client should be informed why and given details of when
the decision can be reviewed. Any comments they make should be attached to their notes in an
addendum.
There should be policies in place to deal with workers who breach confidentiality – these will depend on
your specific industry. Breaching confidentiality can, however, give clients a right to open legal action
against you and if the individual or organisation is found responsible, accreditation and awards could be
removed from the culprit.
Staff must be versed in all confidentiality legislation, organisational policies and which information
should be treated as confidential. They need to know the policies and procedures for every possible
situation, so regular training is essential.
Confidentiality covers:
Ø Physical privacy of patients in facilities, such as
surgeries, hospitals and residential care homes
Ø Controlling/not sharing records
Ø Monitoring access to records
Ø Disclosure to third parties, such as employers, other

patients, family members, insurance companies
Ø Use of audit trails to monitor who has accessed records and when
Ø Encrypting electronic records
Ø Protection of Personally Controlled Electronic Health Records (PCEHR)
Ø Not selling or communicating data to other companies.
These are examples; as a rule, any information relating to the patient/client, in terms of:
Ø Medical records
Ø Financial information
Ø Personal details.
These should all be treated as sensitive information and be treated accordingly. Privacy is governed by
the Privacy Act 1988, which regulates the handling of personal information.
Organisations usually have their own measures and control procedures in place regarding
confidentiality, which will operate within the requirements of the law.
Other legislation that may impact upon your work role includes:
Ø Aged Care Act 1997
Ø Aged Care (Transitional Provisions) Act 1997
Ø Aged Care (Accommodation Payment Security) Act 2006
Ø Australian Aged Care Quality Agency Act 2013
Ø Age Discrimination Act 2004.
1.4 – Provide information to the older person and/or carer explaining the
assessment process, including explanation of results

Ø Effectively explain the assessment process to the older person and/or carer
Ø Clearly explain the results of assessment
Ø Reassure the older person or their carer in regards to their own rights
Ø Provide further information in response to questions or concerns from the older person
or carer.
The process explained

Ensure that you explain the full process of assessment to the older person and their carer (as
applicable).
The process of assessment may include:

Ø Discussing the older person’s medical history
Ø Obtaining test results
Ø Obtaining referral records
Ø Checking progress notes
Ø Confirming medication and treatments
Ø Identifying multidisciplinary care needs
Ø Discussing the older person’s medical and care needs with other health and care
specialists
Ø Determining risks to client health and care
Ø Setting goals/achievements
Ø Documentation of the assessment.
This process will occur over a period of time and will depend upon the condition and situation of the
older person as to the duration of this. This may be affected by other medical and care specialists
involved, identification of services and work flow. Always inform the older person and their carer of the
expected timeframes and on the progress of the assessment. You should ensure that all results are
discussed and explained to the older person and/or carer, so a full understanding can be made.
Explaining results
All results of assessment should be clearly communicated to the older person and/or their carer,
including further explanation of what these results mean.
Following assessment, you should explain to the older person:

Ø The results of assessment
Ø What these results mean – this may be a medical explanation (i.e. if health problems
have been revealed) or an explanation of the impact of results in other terms (i.e. if the
older person’s lifestyle or environment is putting them at risk)
Ø What will happen as a result of the assessment results.
Information should be communicated clearly and carefully, and the older person and/or their carer
should be given opportunity to ask questions. Further information may be provided in a written format,
such as an information booklet or brochure. The older person and/or their carer may also be referred to
resources for further support and advice.
Your organisation may also have procedure in place for sending letters to the older person and/or their
carer following an assessment as a record of the results and to more formally explain any future
intervention.
Alleviate tensions surrounding clients’ rights

Causes of tension
Tensions may arise between the organisation and a client at times when the client feels that their rights
are being violated.
For example:
Ø When a client does not agree with the options they are given for support and/or care
Ø When a worker is obligated by

law to report issues or concerns
that the client does not want to
be shared
Ø When there is difficulty in

balancing the rights of the older
person with the rights of the
organisation and the
community; for example, if an
older person’s behaviour
becomes erratic or dangerous to
those around them.
All older persons/clients have specific rights, regardless of whether they are in their own environment
or within a residential care home. These are specified in and protected by the Aged Care Act 1997.
Clients have the right to:

Ø Appropriate care for their needs
Ø Access information about their own medical details
Ø A choice of suitable treatments
Ø Be treated with dignity and respect
Ø Live free from abuse and/or neglect
Ø Not be discriminated against
Ø Not be victimised
Ø Not be exploited
Ø Have privacy afforded to them
Ø Be safe and secure in their environment
Ø To be able to move around the building freely
Ø To be treated as an individual
Ø To have their individual preferences respected and considered
Ø Maintain religious practices
Ø Use their preferred language
Ø Maintain social and personal relationships with others
Ø Freedom of speech
Ø Be able to make their own decisions
Ø Control their own finances
Ø Retain their own possessions
Ø Choose which activities and similar they participate in
Ø To have access to generally-available community services and activities
Ø Have a say over their living arrangements
Ø Access to information about their rights
Ø The right to complain
Ø Not be afraid of reprisals arising and a result of complaint or query.
This list is not exhaustive but is meant as an example and a brief overview. Information on these rights
should be available through your workplace and staff should be trained about them. It is part of your
duty of care as a care professional to support these rights and clients who act upon them.
If an older person/client is denied their rights and freedom to make decisions around their own care
needs, this can result in misconduct. Always check with the older person first to ensure the correct
decisions are made and are agreed. This will avoid causing frustration and tension on both sides.
Your organisation should be equipped with the correct resources to enable client preference and
decision-making. The individualised care plan and assessment results should enable your organisation to
take the necessary preparations and put the appropriate care measures in place. Your organisation will
have rights to ensure the health and wellbeing of the older person is maintained but this should be with
the knowledge and agreement of the older person.
Clients have the right to make decisions about their care and daily lives, as is explained previously.
Clients should also be encouraged and given the opportunity to make smaller decisions on a day-to-day
basis.
Decisions that clients should make include:

Ø What to wear
Ø What to eat
Ø Who to talk to
Ø What to do
Ø What activities to participate in
Ø What to watch on television
Ø Whether to go out into the garden or not
Ø If they want to call their friends or families
Ø Whether to read the paper
Ø Which paper to read.
1.5 – Communicate in a supportive and encouraging manner that is respectful of
the older person and carer’s, rights, level of understanding and cultural
background

Ø Use communication methods and techniques that are supportive and respectful
Ø Adapt communication to be appropriate and respectful towards individual differences,

including language barriers, disability, memory loss and cultural differences
Ø Confirm that the older person and/or carer have understood any information that has
been conveyed.
Communicating in a supportive manner

Communications should be carried out professionally, via
techniques and methods that suit the older person and their
carer(s) and/or family. For example, a person who is hard of
hearing will require appropriate forms of communication such
as face-on communications that allow for lip-reading and
important information given in a written form. Make sure that
you prepare your communications before engaging with your
client and the client’s carer and take into account the best
ways to perform this and to foster discussions.
Information should be:

Ø Written or spoken in words that accurately describe the situation/circumstance
Ø Clear and concise in the use of language, grammar and spelling
Ø Clarified with those involved – use and encourage active listening skills (where the
other party/parties repeat back information to show they have understood this)
Ø Provided in a manner whereby the individual(s) are able to understand, such as use of
sign language, an interpreter or use of Braille communication.
Always adhere to established organisational protocols and standards for your communications. Use
terminology that is accurate and explain this fully as needed. Discuss information with sensitivity and an
awareness of the feelings that may be experienced by others.
Cross-cultural communications
In a health care situation, you will come across people from a variety of cultures. It is important that you
recognise these and don't discriminate against them.
Culture refers to values, beliefs and common behaviours of a certain group. These groups can be
determined by a variety of factors, such as location, age, upbringing, religion, interests etc. An
individual's culture is often determined by many of these factors, rather than one thing. You can also be
part of more than one culture (or subculture).
Communication requirements can vary greatly from one individual to another and from one cultural
group to another. This can be more pronounced and significant in the care industry, where clients’
needs and wellbeing is at the forefront of every action; this means that their needs and wants need to
be communicated properly and clearly. The service user should also have relevant information
communicated to them in a manner which is understandable and friendly.
There can be many different communicative issues encountered by people requiring care, which can
range from hearing issues to memory problems. Adjustments should not just be made on the basis of
need, but should also meet the clients’ ‘wants,’ in order to show respect and make people as
comfortable as possible.
Individual differences may include:

Ø Hearing difficulties
Ø Memory issues
Ø Language barriers
Ø Accent/regional speech differences.
Cultural differences may include:
Ø Religion
Ø Lifestyle
Ø Different values
Ø Different views about personal space
Ø Hierarchy
Ø Conversational preferences.
Aspects that cause difficulty in communication, such as memory
problems need to be worked around to a satisfactory level.
Cultural issues should also be met wherever possible, as failure to do this, or disregarding requests can
fall under cultural discrimination.
Where clients have specific personal preferences, they will usually make them known. These wishes
should be met wherever possible and when not conflicting with medical requirements. Staff are
protected from having to do anything demeaning, dangerous or preferential for single clients. Requests
can involve anything from asking to be called a preferred name, having someone knock before they
come in the room or making sure you smile.
Cultural misunderstandings
Because of the variety of cultures that you will encounter, it is likely that cultural misunderstands will
occur. This can happen when you are communicating with someone who has a different culture (or
language) to yourself.
You will need to be patient and recognise that meanings of words, gestures and other non-verbal
communication will differ. You may have to clarify things more often than you are used to.
To minimise the chance of cultural misunderstandings:

Ø Avoid using jargon
Ø Ask the other person if they understand what you are saying
Ø Practice listening to accents
Ø Listen carefully to what is said.
Using interpreters
When needing to use an interpreter, e.g. for Aboriginal and Torres Strait Islanders, you should be clear
on the resources that are available to you through organisational channels.
Government agencies are required to provide and pay for professional interpreters when people are
seeking government-related services that have difficulties speaking English.
The Translating and Interpreting Service (TIS) National provides free interpretation services to non-
English speaking Australian citizens or permanent residents who need to communicate with approved
groups and individuals, such as medical professionals.
Interpreters may be:

Ø Registered – these are professional people whose work involves travelling and
mediating for multiple people/groups.
Ø Other multilingual people not related to the person – these may be people on your
staff who have multilingual abilities, but this is not their main duty at work.
A cultural broker can also be helpful for your communications. They act as a mediator between
people/groups of different cultures, to enable effective communication and reduce conflict. They act as
more than just an interpreter – in colloquial terms, they would be known as a "middle man".
Improve your communications

As well as considering how you perform your communications
the following can help you to improve your effectiveness in
delivery of information and aid understanding.
These include:
Ø Listening skills, such as active and reflective
listening
Ø Being mindful of other people’s emotions
Ø Showing empathy for others’ situations
Ø Use encouragement to help the speaker to relay their communication/message.
Check information is understood

Always check that the persons involved in the communication understand what is being said to them.
Ensure that you allow for any disturbances or background noise and take time to explain/relay your
information clearly. If the person does not speak English very well, use simple, clear sentence
structures, write important information down clearly for them, or seek the help of an interpreter.
Equally, be aware of any persons who have difficulty in hearing or in communicating and seek further
assistance as may be needed.
If information is of a sensitive nature, allow time for the other person to absorb what is being
communicated. You should be aware of how another person may feel in response to the information
they are receiving. Assess the situation and approach and confirm their understanding accordingly.
You can:
Ø Ask if the information has been understood
Ø Check if further information is required
Ø Repeat key points/information (as a summary)
Ø Encourage a discussion to confirm that

understanding has been made
Ø Provide supporting written information.
1.6 – Seek older person’s permission and cooperation in the assessment process

Ø Seek permission from the older person to conduct an assessment and to complete any
other processes that require their informed consent, e.g. sharing their medical
information
Ø Follow organisational policy and procedure for seeking permission and cooperation
from an older person.
Seek permission first

You should always seek the permission and cooperation of the older person when performing an
assessment, and on the parts of the assessment that require their participation and decision-making.
For example, you may have to seek permission from an older person to:
Ø Conduct an assessment
Ø Share information with their doctor or other healthcare professional
Ø Obtain information from their doctor or other healthcare professional.
An older person may find an assessment a difficult process as it will highlight their current health
situation and any other issues surrounding their care needs. It can also show areas of concern that may
not have not been previously addressed or even recognised. The older person will need to be ready for
this process and may need time and information on this before they are ready to give their agreement
and cooperation. As such, you should look to provide support and show compassion and understanding
in your communications; never force a decision to be made.
An assessment can change how the older person perceives their health and life. Although an
assessment will work towards ensuring the best care and health management is made, this can still be a
daunting process.
Always follow your organisational policy and procedures when seeking permission, your organisation
will have policy in place for the procedures you need to follow. Policy will be developed to ensure that
codes of conduct, industry standards and legislation are followed; this will protect you, the older person
and their carer(s). Relevant legislation includes data privacy, confidentiality, anti-discrimination and
human rights.
Human rights
Older people should not have their human rights or dignity taken away from
them. The Australian Human Rights Commission has a responsibility under the
Australian Human Rights Commission Act 1986, Age Discrimination Act 2004,
Disability Discrimination Act 1992, Racial Discrimination Act 1975 and the Sex
Discrimination Act 1984 to investigate complaints of alleged discrimination and breaches of human
rights.
Human rights relevant to older people include:

Ø Acceptable standards of living, including food, clothing and housing
Ø High standards of physical and mental health
Ø Safe and free from violence
Ø Free from cruelty, abuse and inhumane treatment
Ø Having privacy and a voice/opinion that is heard
Ø Non-discrimination and fair working conditions in the workplace.
Problems faced around human rights for older people include:

Ø Workplace discrimination
Ø Working and caring for others
Ø Access to appropriate aged care facilities and healthcare
Ø Abuse (including financial, physical and psychological)
Ø Homelessness and poor living standards.
2. Contribute to the identification of risks
2.1. Identify and review factors in the older person’s lifestyle that might affect their level of risk
2.2. Use appropriate tools and methodologies, within scope of role, to determine risk based on
physical indicators presented by the older person
2.3. Assist with risk assessment ensuring to minimise unnecessary discomfort to the older person
and maximises their participation
2.4. Use the support of carers to identify risks
2.5. Recognise the older person’s risk factors based on medical history, measurements and findings,
in collaboration with supervisor and/or relevant health professional
2.6. Identify the older person’s needs, issues and concerns outside scope of own practice and refer
to appropriate supervisor and/or health professional
2.1 – Identify and review factors in the older person’s lifestyle that might affect
their level of risk

Ø Recognise and identify a range of risk factors in an older person’s lifestyle and
environment.
Looking at risks
As a person gets older, or their condition changes or worsens, additional health and care requirements
may be needed. A person’s lifestyle in their younger years may not be conducive to a healthy lifestyle in
their older years.
It is beneficial to identify and take measures to avoid all risks that can have an adverse effect on an
older person’s health and wellbeing. Review the older person’s situation and check if their current
lifestyle is detrimental to maintaining health.
Lifestyle factors may include:

Ø Excessive drinking and/or smoking
Ø High sugar diet
Ø Limited or no exercise taken
Ø Too much exposure to the sun.
Lifestyle diseases can result from poor lifestyle choices; these include obesity, high blood pressure, high
cholesterol, which can in turn lead to conditions such as hypertension strokes and heart attacks. There
are also other risks to the health and wellbeing of older people who receive care in residential care
homes and in their own home; some of these can be seen below.
Major issues
There are many major issues that facing elderly people today. As well as the implications for physical
and mental health that come with aging, the aged population is also faced with issues relating to lack of
suitable housing in the private sector for the aged, social exclusion, abuse
and ageism, as well as many others.
Some of these issues are being combatted through the use of targeted
policies, such as the Age Discrimination Act 2004.
Risks for older people

Depression and anxiety
Older people may suffer from depression or anxiety through a change in
circumstances or lifestyle, for example, retirement, health problems or
bereavement of a person close to them. As an older person, they may feel
that isolation from others and an inability to connect with modern society is an issue. This can prevent
older people from maintaining a normal life.
Symptoms include:
Ø Sadness
Ø Fatigue
Ø Loss of interest in hobbies or pastimes previously undertaken
Ø Social withdrawal/isolation
Ø Loss of appetite/weight loss
Ø Problems with sleeping (e.g. loss or increase in sleep or change in sleep pattern).
Assessment options include:

Ø Asking questions to assess the individual’s state of mind
Ø Using a checklist of statements with individuals, these indicate levels of wellbeing

(Geriatric depression scale or a distress thermometer).
Treatment can include therapy, such as cognitive behaviour therapy and behaviour therapy, making
lifestyle changes or through medication.
Isolation
This may occur to older people who have lost touch with friends and colleagues or have experienced the
loss of a family member (or members). Increasingly an older person may lose contact with others due to
mobility or health issues, or with a decrease in involvement within the community and in their options
for social interactions.
Similar to depression or anxiety, symptoms may include sadness, lack of energy and withdrawal from
society. The individual may also experience a loss of confidence in participating in interactions with
others or low self-esteem. By encouraging the older person to join appropriate social or community
groups, or actively seeking to make social arrangements, you can help an individual to prevent isolation
as a long-term problem.
Abuse (sexual, emotional, physical, financial, system)

Elderly abuse is defined as any instance where someone takes advantage of an elderly
person, or does something against their will. All forms of abuse should be recognised
for what they are and never used on any individual.
This can include:

Ø Sexual abuse – contact with an older person without their consent
which may be a physical sex act or making them watch sex acts,
pornography or forcing them to undress
Ø Emotional abuse – causing distress or emotional pain, also known as psychological
abuse, such as threats, intimidation, social isolation or ignoring the individual
Ø Physical abuse – the use of force on a person to control, cause pain, injury or disability
and includes violent assaults and restraint
Ø Financial abuse – using an older person’s money/assets without their knowledge or

consent and may include stealing money, forging credit cards/cheques/accounts,
forging the older person’s signature, identity theft and investment fraud
Ø System abuse – this is abuse of the system that is in place to care for the older person,
this may include overcharging for services, charging for care not provided, over/under
medicating and Medicare fraud.
Signs of abuse may include:

Ø Sexual abuse:
o bruises around genitals
o unexplained genital infections or STDs
o unexplained vaginal/anal bleeding
o torn/stained clothing
Ø Emotional abuse:
o experience of threatening, bullying or controlling behaviour from caregiver
o dementia-like behaviour from elder – rocking, mumbling, sucking thumb
Ø Physical abuse:
o unexplained injuries
o broken bones/sprains/dislocations
o medication irregularities
o broken glasses
o signs of restraint
o caregiver refuses to let elder be seen alone
Ø Financial abuse:
o unexplained withdrawals from elder's accounts
o sudden changes in financial situation
o missing items/cash from the elder's house
o suspicious will/policy/power of attorney

changes
o addition of names of documents
o unpaid bills/lack of medical care (despite a healthy financial situation)
o financial activity taking place when the older person is incapacitated
o unnecessary services being provided
Ø System abuse:
o duplicate medical bills
o evidence of over/under-medication
o evidence of inadequate care pertaining to the amount paid
o problems in the care facility.
Falls
With age, falls can become an increasing problem due to a lack of mobility or through other health
conditions that may make you prone to a fall. As an older person, the ability to bounce back without
injury diminishes; you may break bones or damage tendons and muscles as a consequence from a fall
which either take longer to heal or require further medical treatment to correct.
To reduce the risk of a fall:

Ø Eat healthily and drink enough fluids to keep
well and hydrated
Ø Take part in gentle exercise to help maintain

flexibility and muscle strength
Ø Wear comfortable footwear that fit well, offer

protection and have grip
Ø Ensure the home/care environment is hazard

free, e.g. flooring is trip-free and spills are
wiped up straight away
Ø Keep lighting at adequate levels, especially during the night
Ø Install safety aids, e.g. hand rails and an emergency alarm.
Medication
In the care of older people, administering the correct doses and types of medication (as needed for the
care of an individual) is essential. Medical assessments should be carried out periodically to check that
the medication is working as required, is at the correct dosage and that the older person receiving this is
not suffering from side effects that are new or unknown to the medical specialist/doctor.
It is not uncommon for older people to be on a combination of drugs for different ailments and it is vital
that all instructions are followed when taking medication. There may be a required order of medication,
and different dosages. Make sure that the older person has a careful control over taking any prescribed
medication/treatments and that if help is required, that this is given.
Dehydration and malnutrition

As we get older, it becomes increasingly important to look after our bodies with the right nutrition and
food types. This may be down to medical conditions or lifestyle factors.
Factors that may impede nutritional health:

Ø Fixed income – money needs to stretch for older people in retirement or care, and
cheaper, less nutritional foods, may be eaten
Ø Residential care homes – lack of resources to provide assistance at meal times to
ensure clients eat meals, to provide food that stays hot and food that is appetising for
the clients to eat
Ø Older people can lose their appetite due to mobility issues or health conditions
Ø Medical conditions, such as dementia, prevent the older person from maintaining meal
times and a balanced nutritional diet.
It is also important to ensure that the correct intake of fluids is made. Many older people may neglect or
not realise the need for maintaining fluids; as we get older this is vital for maintaining kidney function
and health.
Dysphagia
Dysphagia (difficulty in swallowing) is a common problem
and concern for older people. This condition can occur when
muscles used for swallowing become weaker with age, when
neurological damage occurs e.g. through a stroke or when
suffering from dementia and with other health problems
associated with the oesophagus, mouth or throat.
Symptoms include:
Ø Food sticking in the throat
Ø Coughing
Ø Choking
Ø Nasal/oral regurgitation.
Assessment options include:
Ø Referral to speech pathologist for swallow assessment
Ø 'Modified barium swallow'
Ø Endoscopy
Ø Full barium swallow (with video recording)
Ø Manometry.
Treatments are available, such as swallowing therapy, dietary changes, feeding tubes, medication and
surgery. The treatment given to the individual will be determined upon the type, severity and symptoms
of dysphagia.
Continence
Issues of maintaining continence (control) with bodily functions can be a problem as we age. This could
be due to other health conditions, such as urinary tract infections or when using medications; it can also
be caused through a weakening of the muscles that help us to control our bladder and bowel.
Symptoms include:
Ø Involuntary loss of urine through activities such as sneezing and coughing
Ø A strong urge to urinate, followed by an immediate bladder contraction which causes
urine to leak
Ø Inability to empty bladder or bowels completely when using the toilet
Ø An increased need to urinate at night
Ø Painful urination
Ø Blood in urine.
There may also be instances, due to the physical/mental condition of the older
person, where the individual is unable to get to the toilet in time or recognise when
they need to use it.
Managing incontinence may include:

Ø Bladder or bowel re-training
Ø Pelvic floor exercises
Ø Prompted toileting
Ø Timed toileting
Ø Dietician advice with nutrition and hydration requirements.
2.2 – Use appropriate tools and methodologies, within scope of role, to
determine risk based on physical indicators presented by the older person

Ø Select and use appropriate assessment tools to determine risk
Ø Work within their own organisation’s methodology and assessment framework to

determine risk
Ø Undertake work tasks that are only within scope of own role.
Make use of tools and methodologies

To determine any associated risks with the health and care of an older person, you should use the tools
and methodologies that are available to you within your organisation to aid your assessment.
Assessment tools should be quick and easy to use, have a high useability rate throughout your
organisation/care industry and have good inter-rater reliability so your professional peers will reach the
same/similar results as yourself.
Assessment tools are the established set of questions, determined scales of evidence and other known
information that are specific to the requirements of a particular type of assessment. These have been
developed and used to determine factors and make an understanding of a health/care issue. These can
help health and care professionals in the overall assessment process and in recognising risks.
They should be used to assist you in reaching decisions, not to determine outcomes solely from their
use (be mindful not to follow predetermined routes).
Tools include:
Ø Descriptive tools
Ø Diagnostic screening tools
Ø Risk factor checklists
Ø Risk prediction tools.
The Barthel Scale

An example of a complex assessment tool is the Barthel ADL Index (activities of daily living scale). This
looks to determine how an older person is able to carry out daily living tasks in the home; each task on
the scale is awarded a number of points. The higher the score, the better able the older person is in
maintaining their daily needs and independence. This can be used to assess an older person after a long
stay in hospital or when determining if an older person is still able to look after themselves at home.
The older person is assessed on their ability to carry out daily tasks. Factors such as time to perform the
tasks, plus assistance requirements, are considered and applied when points are given.
The requirements for the Barthel ADL Index include:
Ø Determining incontinence problems
Ø Using the toilet
Ø Maintaining personal hygiene
Ø Ability to cook/prepare meals
Ø Mobility issues.
Methodology
Methodology for assessment should follow a systematic process for determining the risks and in finding
ways in controlling or eliminating these. Your organisation should have systems in place for you to
follow. Make sure that you follow the correct processes and complete the steps that are required of you
in your work role.
Scope of role
The scope of your role refers to the pre-determined requirements of your working role; i.e. the tasks
that need to be performed and have been made known to you. Agreement of these tasks and the
requirements to do these should be made between you and your organisation.
Your role may also involve attending regular training sessions, as change within the health and care
industry occur or to ensure that you have the necessary skills and development training. When meeting
older people/clients and their family or carer(s) you will also need to maintain the professionalism of
your organisation when carrying out work tasks. Being supportive, caring and compassionate should be
a part of your role.
Trends and risks

Most people needing care are those of an older age (as the population lives for longer). This is a trend
that has emerged within the care sector and brings demand for care within the home, support for older
people and their carers, community care and residential care requirements.
The philosophy for care is to help the older person to stay in their home for as long as possible through
providing a variety of health and care packages and services. This is aided by appropriate medical care
and through the work of a support/care worker.
Keeping the older person within their home has proved to be beneficial to the older person’s quality of
life and wellbeing. As long as the correct support is in place to allow this, this can help an older person
to maintain their health and to live the lifestyle that they would like to (within the parameters of
predetermined health and care needs). Those receiving care have limitations to daily living activities,
assistance is required predominantly in the areas of mobility, self-care and in communicating needs.
The risks to this will be focussed upon
Ø Environmental hazards – such as mobility issues, e.g.an
inability to use stairs or steps safely or through falls; care aids
and adaptive equipment may be needed in the home to
assist the older person
Ø Care hazards – such as ensuring the older person is looked

after correctly, this is vital and can be managed through the
help of the carer(s), friends and support services; careful
assessment and monitoring will be needed, this includes:
o hygiene requirements
o nutritional needs
o medication and treatments
o social interaction/activities
Ø Abuse – this can come from visitors to the older person, those who are appointed to
help and from external influences such as cold calling; risks will need to be identified as
to the potential scenarios for this to happen and managed appropriately.
Trends for care requirements in older people also include:

Ø Complex care needs
Ø Living with two or more conditions
Ø Dementia care
Ø The demand for higher quality care and services
Ø Community care needs
Ø More flexibility and choice in care to suit the many types of people and their specific
circumstances
Ø Marrying up potential divides in care services with those on a higher income and those
on a low income.
The risks to providing care to older people will therefore be specific to the older person receiving care.
Al risks should be assessed on an individual basis and managed appropriately.
Risks may include:
Ø Isolation/being left on their own for long periods of time
Ø Not taking prescribed medication or attending treatments as needed
Ø Difficulty in managing dual conditions
Ø Not being able to seek immediate help if an emergency occurs.
Carers of older people

Carers are predominantly family members; a partner
or spouse will most likely be a carer to an older
person. Older carers may also have health and care
needs of their own, for example due to their age or
through having an existing condition or disability.
There is a risk that the carer’s health may deteriorate
and an inability to be able to care could occur. Carers
should be supported through other services such as
respite care, community care and through a
care/support worker.
2.3 – Assist with risk assessment ensuring to minimise unnecessary discomfort
to the older person and maximises their participation
2.4 – Use the support of carers to identify risks

Ø Complete a risk assessment using appropriate tools and methods of documentation,
e.g. a risk assessment form
Ø Encourage participation and contribution from the older person to identify their
perception of their own risk
Ø Encourage the contribution of carers to support the identification of risk factors in the
lifestyle and environment of the older person.
Perform a risk assessment

The process of a risk assessment will be to look at the situation of the older person and to evaluate any
risks that may arise from the health and care needs required for them. The development of an
individualised care plan and its implementation will need to include the identification of risks/hazards
and the preventative measures that need to be taken to control and manage these.
Risks are the danger factors that an individual is exposed to; the hazard is the consequence of a risk
factor. You will need to produce a checklist of risk factors which are applicable to the older person and
their situation. This is so you can systematically work through and identify the impact of each one and
apply preventative measures to control these.
An example of a risk assessment form:
Potential Who is at Existing control Risk Preventative Responsibility for

Risk/hazard risk measures taken rating measures measures taken
E.g. Carer Older Carer takes an Low The older person has The carer and
suffers from person and Anti-epileptic drug an alert button to support worker
epilepsy the carer notify if a problem
occurs
A risk assessment should include:
Ø Observing and identifying the risks and associated hazards, these may be physical or
mental
Ø Evaluating and prioritising the risks so that action can be taken to control/eliminate
these in the order of high to low risk
Ø Deciding upon the preventative measures
Ø Taking action to implement the preventative measures
Ø Regular monitoring and reviewing of measures in place.
Older person and carer involvement

When performing a risk assessment you should include the participation of the older person and the
carer(s). This involvement will allow them to give their views on potential situations of risk and on how
they can be managed. It also allows them to bring up risk factors they are aware of, which may not have
been known.
This will encourage a person-centred approach with the older person’s care needs.
The older person and the carer(s) will be crucial to your assessment; they will have a better grasp and
understanding of the day-to-day activities and routines that may incur risks.
The process should be managed and carried out in a timely fashion. Being organised and prepared will
prevent any additional discomfort to the older person. The older person may find the assessment tiring
or even difficult to participate in; for example, this may be due to mobility issues or if suffering from
chronic pain.
If the older person is suffering from a mentally debilitating

condition, such as dementia, it may be difficult to sustain or
to be able to have their participation. You should ensure that
the carer(s) and/or family are able to participate on their
behalf.
2.5 – Recognise the older person’s risk factors based on medical history,
measurements and findings, in collaboration with supervisor and/or relevant
health professional

Ø Use an older person’s medical history to identify risk factors
Ø Use key measurement findings as the basis for determining potential and actual risk
Ø Work with relevant health professionals to identify further risk factors
Ø Collaborate with supervisor to discuss and identify risk factors.
Recognising risks
To help you determine the risk factors to the older person you will need to
have access to the following information.
Medical history – this information is vital to the current health and care
needs of the older person. It provides a complete account of any recorded
illnesses or conditions suffered and the treatments that were made. These
records may have been generated by the older person’s GP, hospitals that
were attended and other healthcare professionals. A medical record
communicates to other health and care professionals, it enables continuity
of care and true evaluations to be made. It also fulfils legal requirements for
documentation needs.
A medical history includes:

Ø Personal details, such as name, date of birth and address,
etc.
Ø Family diseases
Ø Allergies, such as medications or latex
Ø Medical information such as illnesses and conditions, diagnosis, treatments and

outcomes
Ø Notification details (if any notifiable diseases were experienced).
Measurements
Accurate records of the older person’s medical tests can help your risk assessment. Checking
measurements and results from tests made, such as blood pressure testing, bone density testing, allergy
testing and vision tests will give you information on both the older person’s current health and also on
what they should or should not be doing. For example, if the older person has lost some vision in their
eyes which had not been previously disclosed, this will change the outcome of your risk assessment.
From this example you will need to look more closely at the visual elements which will impact upon the
older person, e.g. being able to correctly identify medication and doses to be taken.
Findings
Always be sure to determine and understand the findings from your work before decisions are made. All
decisions should be based around the complete facts of the situation and should be made in
collaboration with all relevant persons.
Collaborate with professionals

Collaboration should be made with your supervisor; they will need to keep a check on your casework
and on the assessments you carry out. Your work should be performed to your organisational
requirements and includes following effective processes that have been established for the safe working
of all persons. Processes should include regular supervision, mentoring and/or any additional training
needs.
You may also need to collaborate and check with other relevant health professionals on aspects of risk
affecting the older person’s health/condition. If the older person is receiving medical treatment or is
under the care of another specialist, you may find their experience and knowledge of the older person
and their condition invaluable to the outcome of your risk assessment.
Risk assessments may be performed on general health and wellbeing, e.g.

to help assess the older person’s ability to live safely at home; they may
also be performed to determine specific health risks that are applicable to
older people.
Specific health risk assessments may include:

Ø Diabetes Type 2 (e.g. the AUSDRISK assessment tool)
Ø Smoking/alcohol related conditions
Ø Mental health
Ø Cardiovascular health
Ø Preventing falls.
2.6 – Identify the older person’s needs, issues and concerns outside scope of
own practice and refer to appropriate supervisor and/or health professional

Ø Evaluate needs, issues and concerns that fall outside scope of own practice and decide
on most appropriate referral option
Ø Gather and document any information necessary to make a referral.
Scope of practice
Your ‘scope of practice’ refers to the actions and procedures that you are permitted to undertake and
usually refers to licensed individuals, such as nurses and paramedics. It generally refers to what you are
licensed to do, though unlicensed workers also have restrictions placed on the actions they can do.
By attributing professionals with a scope of practice, you are providing them with a framework of
guidelines that state what they are and are not allowed to do. This gives the individual the confidence to
know their limitations and also the knowledge to avoid overstepping any boundaries. These boundaries
are particularly important in the care and medical professions, as they prevent individuals attempting to
tackle jobs that they are not qualified to do, which can be dangerous for all parties involved and can also
mean that the individual is not insured if something goes wrong, which can leave all parties at a
disadvantage.
Staff should be fully aware of their expectations and limitations and should
apply this to all the work that they do; they should be ready and willing to
step up to the mark and prepared to draw the line where their authority
ends. If, for some reason, anyone is unsure, they should refer to their
licensing and qualifications or ask a supervisor, as they will usually be
informed of specific job roles and who is qualified to do what.
When any part of the older person’s health and care needs extends outside
your scope of practice, check with your supervisor/identify the correct
professional or service provider and refer to them in a timely fashion.
Assisting the older person

The older person may have specific needs that can only be addressed by other health professionals, you
should recognise when an enquiry needs to be referred and check this with your supervisor, as needed.
There may be issues or concerns that are outside of your field of knowledge or professional capacity.
Referring to other health professionals will include:

Ø Gathering information on the need of the older person
Ø Identifying the correct health professional/service that can assist you
Ø Documenting and following organisational processes for logging your request
Ø Carrying out your communications with the health professional/service.
As a support/care worker, you will not necessarily be able to address all situations or concerns that arise
but you will be in a position to ascertain where you can source the right expertise. Your role should
include acquiring knowledge on the health and care options and services that are available to older
people, and on the health professionals you may need to refer to.
3. Implement risk minimisation strategies
3.1. Identify and explain options to minimise risk to the older person and/or carer
3.2. Work with the older person and carer to identify risk minimisation strategies that are consistent
with the older person’s safety needs, priorities and specific requirements
3.3. Implement strategies in a safe and effective manner that minimises the older person’s
discomfort
3.4. Support carer in contributing to the implementation of strategies, where appropriate
3.1 – Identify and explain options to minimise risk to the older person and/or
carer

Ø Identify suitable care arrangements and/or services that will help to minimise risk to
the older person
Ø Inform the older person of the possible options in a clear and accurate manner
Ø Produce an individualised care plan to document chosen options.
Using strategies
Strategies are the predetermined approaches used for taking actions. These approaches are identified
as being the best for achieving the required results or success needed. Strategies enable you to plan and
map how you will proceed; they provide focus and direction.
Your strategies will be centred on maintaining wellbeing while minimising all risks to the health and care
of the older person.
Strategies may include:

Ø Maintaining safety and wellbeing in the home
Ø Increased social interaction for mental

wellbeing
Ø Maintaining mobility and health through

gentle exercise.
Inform on the possible options

When discussing and exchanging information, you should have open body language and use clear,
accurate language. Clients and carer(s) need to know that they can trust the information you are
providing them with and they also need to be clear and understand what they are being told. Your
delivery of communication should be both professional and warm; those involved will be relying on your
expertise and may need additional reassurance.
Exchanging information is best done face-to-face so that any misunderstandings can be dealt with and
any questions can be asked but you may find that your organisation uses email, for example, as its
established channel of communication, so ensure any written information is clear and concise.
Options to minimise risk may include:

Ø Providing additional care services
Ø Using a’ meals on wheels’ service
Ø Visits with an occupational therapist.
As a support/care worker you can inform the older person and the carer(s) of all the options that are
available to them for providing a safe and effective means of care. By talking through and identifying
how risks can be minimised you can work with them to establish a safe environment.
An individualised plan
For the health and care management of an older person receiving care, an individualised care plan
should be produced to detail care arrangements, how these should be carried out and by whom. They
also detail the strategies that have been developed for the delivery of care, the identification of risks
and how to manage these.
This plan allows a person-centred approach to be made; progress can be recorded and further
assessments/evaluations can be made. This ensures that the care provided is always tailored to the
individual and fulfils any changing needs.
Your plan may include:

Ø Identification of health condition and any illnesses of the person
Ø Healthcare needs of the individual including care, treatment and diagnostic needs
Ø Medications, therapy or other treatments given/required
Ø Information regarding care arrangements, i.e. if a carer looks after the person, or if
other family/friends provide support, such as taking the person out on shopping trips
Ø Information about the client’s living arrangements/needs, if employed, their financial

support situation, any visitors received and lifestyle factors, such as interests or leisure
activities.
To develop a plan that is effective for an older person, recognition needs to be made on their health
(both physical and mental) and consideration should be given to their routines and preferences.
Identifying how the individual lives and how they may respond to suggestions on health and care
support is important for choosing the correct services.
3.2 – Work with the older person and carer to identify risk minimisation
strategies that are consistent with the older person’s safety needs, priorities
and specific requirements

Ø Take into account the full scope of an older person’s specific needs, priorities and
requirements and use these to inform choice of risk minimisation strategy
Ø Collaborate with the older person and/or their carer to identify the older person’s full
scope of needs and suitable risk minimisation options.
Risk minimisation strategies

Every older person will have their own specific set of care needs and these will be further defined by the
severity of condition(s) suffered, their age, the environment and their living arrangements. Alongside
these care needs there will also be associated risks that will need to be managed.
To ensure the older person’s safety is met you should identify and apply risk minimisation strategies in
accordance with your organisational requirements and the requirements of the older person and
carer(s). This will ensure that the care given is done so safely, to the priority and specific requirements
of the older person.
You should work with the older person and carer(s) to find the appropriate
strategies that can be used and integrated safely into the care management. All
persons involved with care and home duties will need to follow the risk
minimisation strategies applicable.
The strategies for common problems to health in older people, as suggested

below, are possible ways to prevent risk of harm to the older person; this will
also depend upon the individual and how they want to manage their condition.
It is important to allow the decision-making process of the older person as this
will encourage their commitment to maintaining their own wellbeing.
The following risk minimisation strategies may apply for the following:
Ø Risk minimisation for depression/anxiety may include:
o introduction of leisure pursuits/activities
o attending a day group to socialise with others
o using a mental health therapist
o use of medication
Ø Risk minimisation for isolation may include:
o joining social groups
o attending a day group
o arranging regular outdoors visits
o inviting friends/family to visit
Ø Risk minimisation for abuse may include:
o requesting the presence of the carer/trusted person when in a vulnerable

situation or a potential situation of distress
o vetting all persons that may provide a service to the older person and seeking
references of services provided
o ensuring that all personal finances and business needs are looked after by a
trusted person or professional organisation
o regular checks with the older person to determine their wellbeing and to check
any concerns
Ø Risk minimisation for falls may include:
o exercise and high dose vitamin D
o occupational therapy and/or podiatry care
o psychoactive medication withdrawal
o optimisation of visual abilities
Ø Risk minimisation for medication may include:
o counting out medication and placing in marked receptacles for required use
o checking and monitoring the health of the older person to determine reactions
and if any side effects are experienced
o a checking procedure to ensure that other unprescribed remedies do not conflict

with medication taken
o keeping a medication diary
Ø Risk minimisation for ensuring

nutrition and hydration may
include:
o cooking foods that the older person likes and enjoys eating
o blending nutritious food into soups and drinks if ingesting solid food is difficult
o providing a meal service to ensure regular meal times are taken
o preparing drinks that the older person can use throughout the day
o keeping a food and drink diary to check on food and fluid intake
Ø Dysphagia
o swallowing therapy
o change of diet to ensure that foods which are hard to swallow or trigger
dysphagia are avoided
o surgery options (if applicable to the person)
o training carer or other worker to help manage the condition and to implement
immediate response treatment
Ø Risk minimisation for continence problems may
include:
o ensuring that toilet facilities are close by/easy

to access
o timed toilet visits (e.g. setting alarms, or using
after meal times)
o seeking the advice of a dietician
o pelvic floor exercises
Ø Risk minimisation for mobility issues may include:
o use of specialist equipment or conversions

within the home
o gentle exercise for movement and to build strength in connective tissue
o encouragement of performing daily activities to retain mobility for as long as
possible
o attending physiotherapy/occupational therapy
Ø Risk minimisation for mental health may include:
o memory aids
o writing down notes and instructions on how to perform daily tasks
o working with a mental health therapist
o attending support groups.
3.3 – Implement strategies in a safe and effective manner that minimises the
older person’s discomfort
3.4 – Support carer in contributing to the implementation of strategies, where
appropriate

Ø Effectively and safely implement strategies. This may involve:
o giving clear instruction to the older person and/or their carer
o providing consistent and careful support and supporting resources
o monitoring progress of strategies and impact on the older person
Ø Support the carer of the older person to understand their own role in the
implementation of new strategies, and to identify any potential obstacles in the
provision of care and/or support.
Implementing strategies
To implement the strategies that have been decided upon, you will need to follow a process that is
considerate to the older person and the carer(s). Your process should be clear, simple and plausible for
those involved to use; they should minimise disruption and discomfort to existing routines.
You should:
Ø Provide clear instruction and guidance on strategies and accompanying actions, e.g.
show how to check the validity of cold callers at the door or on the telephone
Ø Support the older person and carer on the implementation

of strategies and how to apply these to daily activities
Ø Ensure supporting resources are in place to assist the older

person and carer, e.g. making adjustments in the home
Ø Check the progress of the older person and carer and ensure
they have regular communications with you/services in
assistance
Ø Monitor and review the strategies to ensure these are being

carried out correctly and to check how well they are working,
if changes are needed these should be determined.
Carer support
Be aware of the situation of the carer(s) looking after the older person; check their circumstances and
availability to provide care and assistance to the older person.
It may be that the carer is also elderly, or has health problems; they may live with the older person or
have their own home to manage. Carers may be in paid employment (unrelated to their care provision
role) and have their own families and lives that they lead. Never assume the carer doesn’t have other
responsibilities away from the older person.
Carers may be:

Ø A spouse or partner
Ø A family member
Ø A friend/neighbour
Ø An employed carer who is paid to provide care.
Make sure you are aware of their availability to care, i.e. is this full-time or do they visit every day for
two hours? This can make a big difference to your strategies and how these can be implemented in the
course of the care arrangements. You may also find that the caring role is shared between family
members, a neighbour who may shop or provide companionship, and possibly a home carer who is
employed to visit once/twice a week.
You should also consider that the relationship between the older person and
carer may be one that is difficult both emotionally and physically for the carer
to handle. Part of your strategy to risk minimisation with care requirements
may be to introduce respite care or attendance to a day group at certain
times, such as once a week.
Providing the opportunity for the carer to have a break may be beneficial to
all; the carer can take time to look after their own wellbeing, attend to other
responsibilities or just take a break from the responsibility involved with a
caring role.
Establish the patterns and routines of both the older person and their carer(s).
Once you are aware of this, you can look to working with all relevant carers to
help provide consistent and appropriate care which seeks to
minimise/eliminate all situations of risk.
4. Monitor risk minimisation strategies
4.1. Monitor the effects of the strategies on the older person
4.2. Identify any indicators of increased risk
4.3. Identify when strategies are not having the desired result and possible reasons for this
4.4. Reassess and identify more appropriate strategies
4.5. Work with the older person and carer to assess the outcomes of risk minimisation strategies
4.6. Discuss feedback from the older person and carer with supervisor and/or relevant health
professional
4.7. Complete, maintain and store all relevant documentation and reports according to organisation
policy and protocols in a timely manner
4.1 – Monitor the effects of the strategies on the older person
4.2 – Identify any indicators of increased risk

Ø Adhere to their organisation’s monitoring strategy for monitoring the effects of risk
minimisation strategies on the older person
Ø Compile information to complete any necessary reports
Ø Assess whether goals are being fulfilled
Ø Determine whether there has been an increase in an older person’s level of risk
Ø Report findings in accordance with organisational policy and procedure.
A system to monitor strategies

Put a monitoring system in place to check how the strategies to risk minimisation are working.
Monitoring should be performed at regular intervals to check overall progress and to ensure they are
being carried out correctly. It will depend upon the situation of the older person, their condition(s) and
requirements as to how often you should do perform this.
Monitoring includes:
Ø Checking care is being provided safely and effectively, including:
o visiting the older person and carer(s) to observe activities and discuss progress
o checking health reports and progress notes
o assessing the environment and living arrangements are

still suitable
Ø Compiling information and evidence for reporting requirements,

including making recommendations and required actions
Ø Recognising if strategies are working and making changes to

these as needed.
You should also make sure that the older person is adapting to any changes that
may have been made to their environment and to the care systems in place.
Talk/communicate with the older person (and carer) to determine how they are
responding to the changes, their level of wellbeing and whether their health is
being maintained. If there has been a change in health, are these positive
changes due to improvements to systems and care provisions, or are they
negative due to more invasive procedures or diminishing health?
Check if:
Ø Goals are being achieved, i.e. have the situations of risk diminished
Ø Care requirements are being carried out correctly and effectively, i.e. corners are not
being cut when following required strategies
Ø Resources are being provided as needed, i.e. are services being given as expected, or,
are facilities at home accommodating the needs of the older person
Ø The objectives of the care plan are still being met, i.e. have they changed since
implementing the strategies or have the health and care needs changed
Ø A re-evaluation of care requirements or strategies is needed.
Check for an increase in risk

It may be that some of your strategies are not proving to be as successful, for example, this could be
due to a change in the health/condition of the older person, which is out of your control, or they are not
being implemented consistently or correctly.
As a consequence of implementing your risk minimisation strategies, you may also find that areas of
residual risk remain. This is where other instances of risk are caused as a consequence of implementing
the strategies, or where risk still remains – even after making improvements to the older person’s care
needs.
Indicators of increased risk may include:

Ø Anxiety or depression in the older person
Ø Injury or a downturn in health of the older person
Ø An increase in occurrences of concern, e.g. an older person suffering from dementia

found walking in the surrounding area in confusion
Ø Additional strain/stresses placed on the carer
Ø Services are inadequate to the needs of the individual and/or carer.
Ø The environment looks dishevelled or is dirty/unhygienic.
Report your findings

Document any increases in risk to the older person and/or carer, and seek to find alternative
measures. You may need to refer to your supervisor or other relevant health professional
to look at making further structured improvements.
These should be made to ensure the safety of all involved, that suitable activities
are identified and that expectations are realistic and achievable.
4.3 – Identify when strategies are not having the desired result and possible
reasons for this
4.4 – Reassess and identify more appropriate strategies

Ø Recognise when strategies are ineffective
Ø Evaluate the reasons for strategies having little or no positive impact
Ø Reassess current strategies to identify shortfalls
Ø Identify more appropriate or additional strategies that will reduce risk.
When a strategy doesn’t work

To identify the strategies that are not working, you will need to carefully assess the results and findings
of your monitoring activities.
Your reports from monitoring risk strategies in care requirements may include:
Ø Care notes to assess care activities, daily activities and responses from the older person
Ø Communications made with care providers, the older person and their carer
Ø Hazard reports to identify if hazards still exist
Ø Incident reports to document incidents of concern that may have occurred
Ø Risk reassessment to make a further assessment of the risks.
Strategies may fail or not provide the expected results for various reasons. These may be due to
environmental factors, medical influences or changes to care services/carer situation.
Reasons may include:

Ø The level of care being provided needs to be
increased, e.g. for a degenerative condition such as
Parkinson’s disease
Ø The individualised care plan is not being followed

correctly
Ø The carer is not physically able to carry out some

strategies, e.g. providing personal care hygiene
where lifting/assistance is required
Ø The carer isn’t able to devote additional time to

maintain all/some strategies
Ø The older person is not able to apply the same strategies as identified and used by the
carer and/or other care services
Ø The home environment is no longer the best environment for the older person and
their care needs.
Reassess strategies
Perform a reassessment of strategies and consult with your supervisor and/or the appropriate health
professionals to determine further strategies for care.
You may need to make a new risk assessment with the older person and review relevant criteria and
medical/health information to determine new actions.
New actions may include:

Ø Providing additional services for home care, e.g.
o domestic help
o transportation
o social support
o allied health support, such as

physiotherapy or podiatry
o nursing care
Ø Providing more support through additional home visits and communications
Ø Reassessing the level of home care package provided
Ø Looking at providing care in an aged care home.
4.5 – Work with the older person and carer to assess the outcomes of risk
minimisation strategies

Ø Assess the outcomes of risk minimisation strategies in accordance with organisational
policy and procedure
Ø Obtain feedback from older person and their carer to assist in assessing outcomes
Ø Determine the positive and negative outcomes of implemented strategies.
Assessing the outcomes

From your review on strategies and the subsequent care activities that have taken place, you should
work with the older person and carer(s) to assess the outcomes. Working with the older person and
carer(s) will enable you to fully determine the measure of success and provide a consistent
understanding to all on the progress made.
Make sure that a prearranged appointment is made to visit the older person and carer(s) and that you
have fully explained the purpose of your visit so that the older person and carer have time to consider
the strategies that have been put in place. You should ensure that the older person and carer(s) are fully
compliant on your request and visit.
Outcomes of risk minimisation strategies may be positive and/or negative.
Construct a checklist
Before your discussions with the older person and carer(s) take place, make sure you have organised
and produced a set of requirements. This will help you to predetermine the criteria for the assessment
of risk outcomes and put together the correct information for working with the older person and
carer(s).
You will need to know:

Ø How the strategies have impacted
upon activities and daily routines?
Ø Have these been difficult to

implement or maintain?
Ø Have you seen/experienced positive

results from these?
Ø Have there been difficulties for the

older person as a result of the
strategies?
Your organisation may have standard questionnaires or forms that you can use for your assessment, if
so, make sure that the standard questions and information will cover all that you need to know.
Follow procedures and legal requirements

Follow your organisational procedures, adhering to all legal aspects and duty of care to your client and
their carer(s). Information discussed should be treated confidentially and with the utmost respect for
the older person and carer(s).
The dignity of the older person should be preserved and you should remember to conduct your
communications sensitively as information about the older person and their care arrangements will be
openly discussed.
Feedback
Your work with the older person and carer(s) will give you
invaluable feedback on care services and how these are working
with the implemented risk minimisation strategies.
Working together to assess outcomes will enable you to collate

first-hand experiences; you can also observe how these strategies
are carried out through activities. This will give you both a verbal
and visual confirmation on their effectiveness and will show if the
level of care needed is being met.
4.6 – Discuss feedback from the older person and carer with supervisor and/or
relevant health professional

Ø Obtain feedback directly from the older person and/or their carer
Ø Discuss this feedback with their supervisor and/or relevant health professionals.
Take time to obtain feedback

Feedback can be given verbally and in writing and will depend upon how your communications are
conducted in the course of your work duties. For care of an older person, feedback is best gained
directly from the persons involved, i.e. the older person, the carer(s) and any other service providers.
Conducting a verbal/face-to-face communication will provide you the opportunity to:

Ø Pick up on emotional responses
Ø Interpret body language
Ø Engage in discussions
Ø Be open and caring in your communications
Ø Clarify information
Ø Be supportive with the care needs of the older person
Ø Provide reassurance over care concerns.
Provide feedback to others

To progress your requirements for risk minimisation and to provide the correct care intervention, you
should discuss the feedback gained with your supervisor and any other relevant health professionals.
You will need to analyse the feedback provided and assess

whether:
Ø Feedback is objective
Ø Feedback provides clear accounts/details
Ø There are influences prompting feedback, e.g.

has the older person or carer been influenced
by other persons or received information from
other sources.
Feedback is vital to making improvements to your care plan and to the health and wellbeing of the older
person (and their carer(s)). Being involved in the care of others will involve making objective decisions
while keeping a focus on providing a person-centred approach to your client’s care needs.
4.7 – Complete, maintain and store all relevant documentation and reports
according to organisation policy and protocols in a timely manner

Ø Complete relevant documentation and reports for the cases they handle in a timely
manner
Ø Ensure that all documentation and reports are written concisely, accurately and
objectively
Ø Maintain and update documentation as required
Ø Store documentation and reports in accordance with organisational policy and

procedure
Ø Comply with mandatory reporting requirements.
Documentation
When creating reports and workplace documents, you
need to comply with organisational reporting
requirements at all times.
In order to keep track of quality of service, it is

important to have good documentation practices in
place. Many records and work documentation are
created and accessed on computers and database
systems; you may also need to keep paper copies.
Each person receiving care services must have a care

plan in place to monitor their ongoing needs. This plan should contain progress notes, as these will be
used to review care needs in the future. Besides being useful, this documentation is a legal requirement
and will directly affect how much government funding the person in care receives.
The following general tips are useful in all cases:

Ø Documentation should be completed as soon as possible after any event/incident
Ø Progress notes are legal documents. They must be filled out the following way:
o using black ink and printed
o no correction fluids (tip-ex, whiteout) to be used
o corrections must be indicated by a line drawn over the mistake. initial the
correction and re-write the information
o draw a line to the end of the page where documenting information does not fill
all the allocated lines (as per a personal cheque)
o date all notes and include the time of the incident
o sign all notes a print documenter's name and position/status.
Written documents
Ensure progress notes are written in the active voice rather than the passive, as this gets the message
across more directly and helps with concise writing. Written documents can include progress reports,
case notes and incident reports.
Documents should be:

Ø Concise
Ø Objective
Ø By exception
Ø Appropriate in language and terminology (no slang, unless recording direct speech)
Ø Include only necessary information.
Concise documentation
This means including the right amount of information – not too little or too much. You need to get to
the point in as few words as possible; use appropriate words, sentence structures and avoid frivolous
information that is not relevant.
Objective documentation
This involves only including the facts in documentation and no opinions or bias affecting what is
recording. Subjective information is based on assumptions and feelings and will not accurately portray
the incident.
Documentation by exception
This means to only include events and information that affect the care plan. Such examples could be
changes in client behaviour, emotions and physical ability, as well as incidents involving the client.
You need to think in terms of things that:

Ø Will affect the direction of care plan
Ø Relate to the health of the client
Ø Involve client care refusals, care omissions, client

complaints
Ø Involve client behaviour affecting their health and

wellbeing.
Verbal reports
These can be done face-to-face or over the telephone. You should use this
method of reporting when communication is required urgently, or in an
emergency situation i.e. those involving the immediate safety of carers or the people in care. The same
principles apply to verbal reporting as to written reporting – keep it concise, objective and include only
relevant information.
Structuring notes
When thinking of what information to include in notes, use the following as a guide:
Ø Who is it about?
Ø Where did it happen?
Ø When did it happen?
Ø What happened?
Ø Why did it happen?
Ø How did it happen (if factual evidence exists)?
Ø What did you do (if applicable)?
Types of documentation
There is a wide range of documentation that may pass through your service; some may be standard and
familiar to the running of the service, such as a referral document, while others may be less used. Most
will include medical terminology regarding conditions, diagnosis and treatments.
Documentation may include:

Ø Applications for services
Ø Claim forms
Ø Patient/client records
Ø Medical/health cards
Ø Supply/medical stores documentation
Ø Information on services for clients
Ø Certificates
Ø Medical reports
Ø Care reports
Ø Staff documentation.
Note: never disclose information to those other than the relevant health and care professionals
involved and always seek permission from the older person if you need to pass information to other
services/professionals.
Storing documentation
Documentation must be filed in accordance with organisation policy and protocols – this ensures it can
easily be located at a later time. For instance, there may be a dispute about the quality and level of care,
which can easily be resolved to accessing and consulting the documents relevant to the time.
Filing is something many people have problem with; organisation cannot only make you more
productive, it can also simplify your workload and make it less stressful to file or look for a specific
document in the future. Being organised doesn’t take a complicated filing system.
Make sure that all electronic/computer records are saved and stored appropriately; access to records
should only be given to those persons who have permission. All paper copies should be stored in a
suitable filing system that is kept secure and is easy to navigate.
Classifying folders/documents
Depending on the nature of your job role, you will create folders that will best fit the needs of your
tasks, duties and responsibilities.
For example:
Ø Administration staff who work in the warehousing department will probably have
folders classified as: orders received, ordered processed, orders picked and packed,
ordered despatched, damaged and missing goods, follow ups etc.
Sorting documents
Go through them, one at a time. Pick up each document or folder and decide what needs to be done
with it. If you do not need any parts make sure you dispose of them appropriately (shredding any
personal/confidential information). When you see printouts of emails – read through the printout and
determine if any further follow up is required. If you have kept a digital copy of the email, and no other
follow-up is required, the printout can be put through the paper-shredding machine. If you find some
documents that should not be sitting with you, try to send it to the appropriate personnel.
Filing documents
After sorting the documents, you will be ready to file them into their respective folders. If files need to
be stored securely (under lock and key) to comply with client confidentiality requirements, make sure
this is carried out. All electronic files should have restricted access rights, so that only those with
permission can view and use these.
Documents may be filed according to:

Ø Alphabetical order (according to clients’ names,
companies’ names etc.)
Ø Chronological order (oldest to the most current date etc.)
Ø In each financial year (2011-2012 or 2012-2013)
Ø Series numbers.
Mandatory notification
It important that you are able to identify and report any issues that require mandatory notification. You
should pass these on to your supervisor and/or the appropriate authority.
Issues requiring mandatory notification may include:

Ø Protection of children and others identified to be at risk
Ø Issues defined by jurisdictional legislation and/or regulatory requirements
Ø Issues specifically identified under organisation policies.
It is a legal requirement that these issues are reported; if you fail to do so, the consequences can be
quite severe and you may be putting clients and colleagues at risk.
Summative Assessments
At the end of your Learner Workbook, you will find the Summative Assessments.
This includes:
Ø Skills assessment
Ø Knowledge assessment
Ø Performance assessment.
This holistically assesses your understanding and application of the skills, knowledge and performance
requirements for this unit. Once this is completed, you will have finished this unit and be ready to move
onto the next one – well done!
References
These suggested references are for further reading and do not necessarily represent the contents of
this unit.
Websites
Aged Care Assessment Team (ACAT) assessments: http://www.myagedcare.gov.au/eligibility-and-
assessment/acat-assessments
‘Older People Safety’, ROSPA (The Royal Society for the Prevention of Accidents):
http://www.rospa.com/home-safety/advice/older-people/
Assessment for Aged Care, Australian Department of Human Services:

https://www.humanservices.gov.au/health-professionals/services/assessment-aged-care
Publications
Rhonda Nay, Sally Garratt, Older People: Issues and Innovations in Care, Elsevier Australia 2009
Ageing in Australia, AASW (Australian Association of Social Workers),

https://www.aasw.asn.au/document/item/4356
All references accessed on and correct as of 18/11/16, unless other otherwise stated.

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Learner Guide

CHCAGE004 Implement Interventions with Older People at Risk

1. Assist with the 1.1 Confirm assessment requirements with supervisor or

The following conditions must be met for this unit:

Companion volumes from the CS&HISC website - http://www.cshisc.com.au

By the end of this chapter, the learner should be able to:

Ø Seek confirmation of assessment requirements from supervisor or relevant health

You will need to know:

Ø Any diagnosed conditions

Ø Any medical needs including medication

Ø The lifestyle of the older person

Ø If they have a carer (or carers) and/or

Ø Both medical and functioning requirements of the older person

Ø Performing a person-centred approach to care needs

Ø Recognising potential risks and hazards for the older person.

Relevant health professionals may include:

Ø Drug and alcohol worker

Ø Home care worker

Ø In-home respite worker

Ø Palliative care specialist

By the end of this chapter, the learner should be able to:

o discussing personal preferences and requirements

o answering client and carer questions about the assessment process

o confirming with client and/or carer that information is accurate

o obtaining consent for examination, treatment or collaboration from the client.

Participation in care requirements

This will provide:

Ø Recognition of risks and associated hazards

Ø Development of a person-centred approach to care

Ø Individual needs to be recognised and taken into consideration

Actions may include:

o ensuring flooring is non-slip and has no trip hazards

o handrails and/or walkways (if needed)

o rearrangements to room layouts

Ø Supporting care, including:

o personal care routines

o administering medications and dressing

o assistance with shopping

o assistance with living requirements such as

o respite care needs.

A person-centred approach may involve:

Ø Including people in decision-making relating to their care

Ø Obtaining the person's consent to examine, treat or work with them

Ø Effective customer service

Ø Listening to and addressing complaints

By the end of this chapter, the learner should be able to:

Ø Communicate information about duty of care requirements

Ø Communicate information about client confidentiality.

Clarifying your role

Clarifying your role includes:

Ø Providing understanding on your

Ø Communicating how you can support those

Ø Responsibilities and Accountabilities

Ø Information, instructions and training

Ø Monitoring, review and improvement

Duty of care in law

Ø The person's roles and responsibilities within their organisation

Ø The experience/level of training for the individual

Ø The practicalities of the situation

Ø What is deemed acceptable practice within the community

Ø Generally acceptable standards in the situation

Ø Relevant laws e.g. the Workplace Health and Safety Acts,

For negligence to be successful, the following must be proven:

Ø In exercising the duty of care, the defendant failed to function according to a