Implementation guidelines for non-government community services

Standard 2. Safety

Page last updated: 2010

The activities and environment of the MHS are safe for consumers, carers, families, visitors, staff and its community.

The intent of this standard is to ensure that the service provider takes all necessary steps to ensure a safe environment for consumers, carers, visitors and staff. This can be achieved by identification, analysis, treatment or correction, monitoring and review of risks to safety.

Promoting safety (criterion 2.1)
Legislation, regulations and guidelines (criteria 2.6, 2.7)
Staff safety (criteria 2.8, 2.9, 2.10)
Assessment (criterion 2.11)
Review and analysis of risks (criteria 2.12, 2.13)

Promoting safety (criterion 2.1)

Service providers must ensure the safety and wellbeing of consumers, carers, staff and others.

Cultural beliefs are an important aspect of consumer understanding and responses to health care. They should be taken into consideration when reviewing safety issues. Culturally inappropriate care may result in misunderstandings that put the consumer at risk of events which may adversely affect their mental health and recovery.

Services should be aware of the National Safety Priorities in Mental Health. They should ensure that applicable legislation addressing safety and their own policies and procedures are available and complied with.

Evidence that this criterion is met could include:
  • documenting risk management assessments, management plans and review arrangements
  • safety signage being visible at risk locations
  • documenting the training of staff in strategies to identify, prevent or de-escalate agitation, aggression and interpersonal violence
  • documenting that staff have a current basic first aid certificate
  • documenting that new staff received safety awareness information during orientation
  • evidence of regular safety practice exercises involving staff, volunteers and consumers (for example using fire extinguishers, evacuations)
  • a safety suggestion scheme, encouraging staff, volunteers, students and consumers to articulate their ideas or concerns, and giving positive feedback to those that do
  • experts addressing staff meetings on the consequences of incorrect workplace practices in areas such as manual handling or body stressing, stress and fatigue, slips, trips and falls.
National safety priorities (criterion 2.2 is not applicable to the sector, criteria 2.3, 2.4, 2.5 are partially applicable).

Where applicable, criteria 2.3, 2.4, 2.5 and 2.6 should be implemented in line with the National Safety Priorities in Mental Health: a national plan for reducing harm (2005) - and in line with an analysis of risks specific to the individual service provider.

Legislation, regulations and guidelines (criteria 2.6, 2.7)

Applicable safety legislation, regulations and guidelines include, but are not limited to:
  • the Australian Health Ministers' Mental health: statement of rights and responsibilities (1991)
  • state and territory occupational health and safety legislation
  • state and territory mental health legislation and related acts.
Information on infection control should be available to staff, consumers and visitors. Appropriate infection control and work place hygiene standards should be in place. Top of page

Staff safety (criteria 2.8, 2.9, 2.10)

Service providers should employ an appropriate number of staff to ensure their safety and the safety of consumers, carers and others.

The risk assessment of staff working conditions should include, but is not limited to:
  • staff working alone and their access to others at all times
  • personal security on-site as well as off-site
  • violence and aggression
  • lifting and manual handling
  • hazardous substances
  • security of medications and other stores
  • evacuation in the event of a fire or other danger
  • adverse event or incident management.
Staff should be trained in workplace health and safety in accordance with applicable legislation.

Evidence that these criteria are met could include:
  • documenting risk management assessments, management plans and review arrangements
  • safety signage being visible at risk locations
  • visual evidence of a safe environment
  • staff access to mobile phones, pagers, personal security alarms to expedite communication during critical incidents
  • records of staff training in occupational health and safety
  • an occupational health and safety manual
  • documenting staff meetings to demonstrate that safety issues are regularly considered and responded to
  • documenting critical incident debriefings that assist staff after exposure to traumatic incidents. Top of page

Assessment (criterion 2.11)

Regular environmental assessments should be carried out and action taken to mitigate the risk of harm, including sexual abuse, self harm and other interpersonal violence.

Risk assessment of consumers should be conducted on entry and regularly thereafter, to ensure any change to their health status is identified. Timely assessment should be undertaken to minimise the risk of harm to themselves and others. Risk assessment should also be conducted on discharge or exit. In some cases on discharge or exit, risk assessment should be conducted on the carer, such as when the carer is a child or aged person.

Evidence that this criterion is met could include:
  • documenting organisational risk management assessments, management plans and review arrangements
  • documenting analysis of critical events and post-event remedial action
  • documenting board leadership in the development of organisational risk management plans and review arrangements that are being met
  • risk assessments and regular reviews being documented in consumers' files
  • evidence of risk assessments being given to a service to whom care is being transferred
  • where appropriate, documenting risk assessments in relation to a carer. Top of page

Review and analysis of risks (criteria 2.12, 2.13)

There should be evidence of regular organisational reviews of safety, which lead to recommendations that are implemented and regularly reviewed as part of a continuous risk management process. Boards should oversight risk management.

Evidence that these criteria are met could include:
  • documenting organisational risk management assessments, management plans and review arrangements
  • documenting the regular review of risk management plans by boards.
Policies and procedures that demonstrate compliance with standard 2 will include but not necessarily be limited to those that address:
  • organisational risk identification, management and review
  • risk assessments for consumers
  • safe transportation of consumers
  • workplace health and safety
  • arrangements for safe home visits
  • medication and adverse medication event management (as appropriate to the type of service being provided)
  • infection control, workplace hygiene and safe food handling (as appropriate to the type of service being provided)
  • managing verbal and physical violence
  • reporting and management of adverse incidents
  • arrangements for critical incident debriefing for staff, consumers, carers and other visitors when they have been exposed to a traumatic incident within the service.
It is important to remember that policies and procedures alone are not sufficient to demonstrate that a service provider is meeting the requirements of a standard. It is also necessary to demonstrate how the policies and procedures have been implemented and guide organisational practices and behaviours.