A policy or procedure update: what it touches

No notification duty in the clauses we hold attaches to this kind of change on its own. Check the regulator's full list: Notifying us of changes in circumstances and Notify us of changes or events.

• New, revised or retired? (new, revised, retired)
• Which registration does this change sit under? (aged care and NDIS, aged care only, NDIS only)
• Which area? (medication, infection prevention and control, incident management, complaints and feedback, restrictive practices and behaviour support, emergency and disaster, privacy and records, whistleblowing, risk management, screening and HR, food, nutrition and mealtimes)
• Have workers been told and trained on it yet?

Each has not sure: a line resting on it stays, as a question.

A date, a label of your own (a site, a role, a service, never a person's name), the date you became aware, and often a status or an owner. Paste it as it is: the type column reads words such as “policy”, “procedure”, “policy update”, “policy change”, “procedure update” and “new policy”. The answers go in one cell as key=value pairs.

Aged Care Quality Standards

• ACQS Rules s 15-15(6): Policies must be current and workers required to follow them.
  evidence to keepPolicy version, approval date and the record of workers told.
• ACQS Rules s 15-15(5): The quality system drives continuous improvement; the update is an improvement entry.
  evidence to keepContinuous improvement entry referencing the update.
• ACQS Rules s 15-30(5): Medicines policy shapes use that maximises benefit and minimises harm. (when: the area: medication)
  evidence to keepMedication policy showing how individuals, workers and practitioners are supported to use medicines to maximise benefit and minimise harm.
• ACQS Rules s 15-25(4): The IPC system must be appropriate. (when: the area: infection)
  evidence to keepIPC policy version and IPC lead.
• ACQS Rules s 15-15(17): Emergency and disaster planning manages risks to individuals and workers. (when: the area: emergency)
  evidence to keepEmergency plan version and test date.
• ACQS Rules s 15-15(13): Information is kept confidential in line with consent. (when: the area: privacy)
  evidence to keepPrivacy procedure version and consent form version.
• ACQS Rules s 15-15(7): The risk system identifies, manages and reviews risks. (when: the area: risk)
  evidence to keepRisk management framework version.
• ACQS Rules s 15-35(2): Nutritional needs and preferences are understood and assessed. (when: the area: food)
  evidence to keepFood and nutrition procedure version.
• ACQS Rules s 15-15(16): Workers need training on the changed policy before they are asked to follow it.
  evidence to keepTraining or briefing record for the updated the policy, with attendance.
• ACQS Rules s 15-15(10): Individuals and others are encouraged and supported to complain without reprisal. (when: the area: complaints)
  evidence to keepPublished complaints information after the update.
• ACQS Rules s 15-35(4): Individuals are supported to eat and drink. (when: the area: food)
  evidence to keepMealtime support procedure version.

Aged Care Act 2024

• Aged Care Act s 164(a): For providers in the categories Rules 164-1 lists, workers are trained on the incident management system at induction, on change and at least annually (Rules 164-35). (when: the area: incident)
  evidence to keepTraining on the changed incident procedure, with attendance.
• Aged Care Act s 165(1)(a) to (c): Workers are trained on the complaints system at induction, on change and at least annually; the published document is kept current. (when: the area: complaints)
  evidence to keepUpdated complaints document as published and the training record.
• Aged Care Act s 162 and Rules 162-15 to 162-40: For a residential care provider (Rules 162-5), s 162 makes restrictive practices a regulated last resort; the policy follows Rules 162-15 to 162-40. (when: the area: restrictive and residential care homes ticked in the first lines)
  evidence to keepRestrictive practice policy version tied to Rules 162-15 to 162-40.
• Aged Care Act s 165(1)(d) to (f): A whistleblower system, policy and management of qualifying disclosures is required. (when: the area: whistleblowing)
  evidence to keepWhistleblower policy version and where it is published.
• Aged Care Act s 152(1)(a) and (b): Screening requirements apply to every worker and responsible person. (when: the area: hr)
  evidence to keepScreening procedure version.
• Aged Care Act s 168: Personal information is used and disclosed only as section 168 allows and protected with reasonable safeguards. (when: the area: privacy)
  evidence to keepPrivacy procedure version and the safeguards it names.
• Aged Care Act s 553: The provider makes sure disclosers are protected by itself, its workers, responsible persons and associated providers. (when: the area: whistleblowing)
  evidence to keepWhistleblower procedure naming who may receive a disclosure and how identity is protected.

NDIS Practice Standards

• NDIS Practice Standards Core 11.1: The quality system defines how requirements are met and is reviewed and updated.
  evidence to keepDocument control entry: version, approver, date.
• NDIS Practice Standards Core 11.3: Continuous improvement draws on data and feedback.
  evidence to keepReason for the update and the data or feedback behind it.
• NDIS Practice Standards Core 26.1: Medication records must identify each participant and dosage. (when: the area: medication)
  evidence to keepUpdated medication chart template.
• NDIS Practice Standards Core 26.3: Medication storage is secure, identifiable and reached only by trained workers. (when: the area: medication)
  evidence to keepStorage procedure and access list.
• NDIS Practice Standards Core 10.4: Risk management covers infection and outbreak prevention and control. (when: the area: infection)
  evidence to keepOutbreak management plan version.
• NDIS Practice Standards Core 15.9: Workers get IPC training with refreshers. (when: the area: infection)
  evidence to keepTraining completion list for the updated IPC procedure.
• NDIS Practice Standards Module 2A, 6.1: Implementing providers keep implementation policies and procedures. (when: the area: restrictive)
  evidence to keepBehaviour support implementation procedure version.
• NDIS Practice Standards Core 16a.8: The plans are communicated to workers, participants and networks. (when: the area: emergency)
  evidence to keepCommunication record for the updated plan.
• NDIS Practice Standards Core 16a.9: Each worker is trained to implement the plans. (when: the area: emergency)
  evidence to keepTraining list for the updated plan.
• NDIS Practice Standards Core 12.4: Documents are handled with processes through to retention and destruction. (when: the area: privacy)
  evidence to keepRecords handling procedure version.
• NDIS Practice Standards Core 5.2: Participants are told about confidentiality policies in a way they understand. (when: the area: privacy)
  evidence to keepAccessible summary given to participants.
• NDIS Practice Standards Core 10.2: A documented, proportionate risk management system is in place. (when: the area: risk)
  evidence to keepRisk management framework version.
• NDIS Practice Standards Core 26a.8: Texture-modified food and fluid procedures are kept. (when: the area: food)
  evidence to keepTexture modification procedure version.
• NDIS Practice Standards Core 15.4: The training system names the training workers need on the changed procedure.
  evidence to keepTraining needs entry for the updated the policy.

NDIS Provider Registration Rules

• Registration Rules ss 73ZBA and 73ZC: Disclosers identity is kept confidential and victimisation prohibited. (when: the area: whistleblowing)
  evidence to keepPolicy clause on confidentiality and no detriment.

NDIS Incident Management Rules

• Incident Rules s 12(1): The incident system is documented and accessible copies given. (when: the area: incident)
  evidence to keepPublished incident procedure and accessible version.
• Incident Rules s 13(3): Workers are trained in the incident management system. (when: the area: incident)
  evidence to keepTraining record for the changed procedure.
• Incident Rules s 10(6): The incident management system provides for its own periodic review; the update is that review's record. (when: the area: incident)
  evidence to keepReview record behind the updated the policy: date, reviewer, findings.

NDIS Complaints Rules

• Complaints Rules s 8(7): How to complain to the provider and the Commissioner is published. (when: the area: complaints)
  evidence to keepPublished complaints information after the update.
• Complaints Rules s 11(3): Workers are trained in the complaints system. (when: the area: complaints)
  evidence to keepTraining record for the changed procedure.
• Complaints Rules s 8(8): The complaints system provides for its own periodic review. (when: the area: complaints)
  evidence to keepReview record behind the updated the policy.

NDIS Worker Screening Rules

• Worker Screening Rules s 12(1) and (2): A written risk management plan covers workers awaiting a clearance. (when: the area: hr)
  evidence to keepRisk management plan for workers awaiting clearance, version.
• Worker Screening Rules s 11: Every role is assessed for whether it is a risk assessed role. (when: the area: hr)
  evidence to keepRole assessment procedure version.

Check one changeSee the specimen registerThe one-page sample register