Reading A: Institutional Care in Australia
Reading B: A Mandatory Reporter’s Guide to Selecting a Decision Tree
Reading C: Work Health and Safety
Reading D: Restraint Scenarios
Reading E: Overview of Restrictive Practices
Reading F: Identifying abuse, neglect, and exploitation
Reading G: Developing Personal-Centred Goals
Important note to students
The Readings contained in this Book of Readings are a collection of extracts from various books, articles and other publications. The Readings have been replicated exactly from their original source, meaning that any errors in the original document will be transferred into this Book of Readings. In addition, if a Reading originates from an American source, it will maintain its American spelling and terminology. IAH is committed to providing you with high quality study materials and trusts that you will find these Readings beneficial and enjoyable.
Parliament of Australia. (n.d.). Institutional care in Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Completed_inquiries/2004-07/inst_care/report/c02
All I understood was that I was away from my family, and as bad as they said that situation was, it was still my family, and it was the only way of life I had known.[27]
Institutions
So began my life of fear, confusion, humiliation, and shame as an orphan of the living in the Ballarat Orphanage. (Sub 18)
2.1 Various factors have been used implicitly or explicitly to define institutions, including size, overcrowding, separateness from the community, regimentation, external control, residents who lack identity, choice and autonomy, and physically and emotionally barren environments. Institution is rarely to be taken to be a positive term. An oft-cited 1961 Goffman definition of institutions includes:
A basic social arrangement in modern society is that the individual tends to sleep, play and work in different places, with different co-participants, under different authorities, and without an overall rational plan. The central feature of total institutions can be described as a breakdown of the barriers ordinarily separating these three spheres of life.
2.2 Evidence to the inquiry described the atmosphere in many homes as emotionally and physically punitive, and where children were subjected to criminal assaults and had no emotional relationships with any adults or personal interaction with significant people in their lives. Apart from specific acts of emotional, mental, physical, psychological, and sexual abuse, institutional life itself is inherently abusive:
It was abusive to be kept in an institution separate from your family. It was abusive to be denied rights as a human being, such as affection and relationships. It was abusive to be required to get up at five o'clock in the morning and milk the cows or have a cold shower.
2.3 Many Australian institutional settings for children and young people such as orphanages, group cottage homes, foster care, homes for children with disabilities and juvenile detention centres, have fitted the above negative descriptions. Of significance is that while children and young people need care, protection and safe environments, over time, many children were placed in institutions which not only did not meet these needs, but meted out cruel treatment and abuse.
Framework of children's institutional care - Australia
Introduction
2.4 The following discussion outlines the development of institutional care in Australia from the earliest times to the 1970s. The Committee was not in a position to conduct in-depth historical research into changes in child welfare practices in each jurisdiction. Much of the information provided below relates to New South Wales and Victoria, however indications are that these examples would be similar in other States.
2.5 Certainly the difficulties in gaining a clear picture of the development of policies affecting children in institutional care are worth noting and illustrated by an examination of the situation relating to child welfare departments. No comprehensive histories about the States' establishment of separate social welfare departments are available, presumably because such issues have always been a state responsibility, with myriad arrangements to accommodate them. It seems too that the administrative structures within which child welfare issues rest have been largely ignored by historians and governments alike. Further, any attention which they have received has usually been for reasons unrelated to the needs of child welfare issues.
2.6 However, the information below should assist with understanding care arrangements for children, including the elements that have combined to influence the formation and evolution of policies and practices affecting children in institutions. While these issues have been described under a number of headings, they have an obvious nexus in terms of their relationship and interaction with each other.
Overview
2.7 The early period of Australian settlement was beset with problems in every aspect of life. From 1788, colonial New South Wales needed care for children who were orphaned or whose parents were in jail, destitute or experiencing some misfortune.[32] Given Australia's British heritage, notions from England about child welfare and juvenile justice practices prevailed, and well into the 1890s, benevolent ideas of usurping poor parents and placing children in more 'morally suitable environments', prospered.
2.8 The youth of this newly formed class were the targets of new systems of dealing with young people. Further the systems of control which were introduced to colonies like Australia were imposed in a society which was also in the process of dispossessing the indigenous community.
2.9 Practices in Australia for children in institutions emanated from factors including the extent of government involvement which ebbed and flowed over many eras. Of significance was the power of organisations such as churches and 'child-saving'[35] lobbyists, overlaid by the non-uniformity of standards, laws and government policies among the colonies, which continued after Federation in 1901, and became a hallmark of Australia's federal system. Further, colonial governments' involvement in policy decisions about the fate of children who needed some form of out-of-home care, may have been determined by what was politically and economically feasible, which in turn was subject to the influences of the media and public opinion.
2.10 A reflection on the patterns of the development of children's institutions in Australia is a reminder of the power of groups such as the churches, and the powerlessness of women, children and young people and poor families.
Policies of governments placing children in care
The role of governments, churches, and other groups
2.11 Beginning in the 1800s, notions about ways to care for children requiring welfare assistance tended to move between those favouring institutions, or, family-based care such as foster care.[36] Initially, the new colony chose foster care but the shortage of stable families and the survival needs of the times rendered this strategy doubtful. Fashions existed at various times both within and among the colonies about institutional care or boarding-out (out-of-home care or foster care). Such fluctuations continued until the 1960s when governments became more involved in child welfare and moves began to close large institutions for children.
2.12 From the early times, churches were important given that before 1890 most of the children's institutions had been established by churches. The Catholic Church favoured institutional care for it was a way of imbuing the children with religion. According to evangelical reformers such as George Ardill and other church people, the key to helping children was via a proper Christian education, 'best achieved in a church institution’. Catholic orphanages were used extensively for the many Catholic children needing care in 1881-1905 and it is perhaps significant that most Catholic families were too poor to provide foster care to needy children.
2.13 Other groups with influence over government child welfare policies, such as the New South Wales 1873-1874 Public Charities Commission, were scathing of institutional life for children, basing their criticisms on the appalling conditions they gleaned on their visits to State children's homes. The Commission noted the violence meted out to girls at the Biloela Asylum, many of whom had black eyes, bruises and bloody noses. The Randwick Destitute Children's Asylum, set up in the 1850s, also came under the Commission's critical eye, for many reasons including because it was said to be a barracks-like environment which bred barrack children. Other groups such as leading child saving experts also opposed institutional life for children.
Developments - institutions versus boarding-out (foster care)
2.14 In the period 1850-1890, institutions continued as the prime response for housing welfare children, and this coincided with the development of child neglect legislation and the establishment of reformatories and training schools and marked the beginning of greater government acceptance of responsibility in the child welfare sector.
2.15 Among the colonies however, variations existed about ways to deal with child welfare issues, at times determined by economic imperatives and, as mentioned, the churches' views. Financial difficulties in Tasmania meant that many children were boarded out until 1846, when the government again funded the orphanages. In Victoria, while pressures to deal with its child welfare problems initially focused on institutions, the earliest responses, in the late 1840s, had centred on boarding-out schemes. The 1850s saw the establishment of a number of institutions commencing in 1851 with the Melbourne Orphan Asylum, and further boarding out schemes were established in the 1850s. During the 1920s the shortage of foster parents in Victoria, attributable to economic pressures, resulted in the growing use of children's homes.
2.16 In Queensland, after the 1866 economic collapse, the Diamantina Orphanage was bursting at the seams and the government partly funded the Catholic St Vincent’s. Generally, throughout 1890-1935 there was a push towards institutional care because it was seen as cost effective. However, by 1930 in Queensland, only 10 per cent of State children were in institutions. This led to problems in securing inspectors to supervise the over 8 000 boarded-out children and hence Queensland State children were returned to institutions. The first boarding-out experiments began in South Australia in 1872 with 200 children taken into cottage homes. Boarding-out was still in its infancy in 1900 in Western Australia, because government officials considered that there were insufficient suitable homes in the colony.
2.17 The drift of State children back to institutions increased in the 1930s and 1940s because of a lack of foster families. By the 1940s, most young children needing residential care were placed in institutions. Another shift started and occurred at different rates in different states. In Queensland the percentage of State children in institutions doubled during 1930-1950 but declined slowly in the 1960s. By contrast, in Victoria, by the early 1950s, around half the state wards were in institutions, increasing to 85 per cent in the early 1960s and only starting to decline late in the decade.
2.18 In 1881, there were just over 3 000 orphaned, neglected, and delinquent children in government industrial schools and reformatories. By 1911 there were 17 731 such children in Australia receiving State care, three-quarters of whom were fostered while the remaining one-quarter were in institutions.
Moves from institutions to other forms of care
2.19 A number of factors influenced policymakers' decisions about moving children from institutions to smaller homes. Issues about the cost of maintaining orphanages were significant and by the mid-1970s served as an incentive for governments to find alternatives. No real thought seems to have gone into the effects on children of institutional life and until the early 1960s, little attention was paid to children's emotional needs and the effects of harsh treatment on children in later life. Child protection services began to move from homes in the late 1950s-early 1960s, influenced by child development theories on the importance of maternal love and family life, but principally because of Bowlby’s 1951 work about the link between maternal deprivation, emotional adjustment and mental health and childhood care.
2.20 Government and non-government child welfare agencies considered that if children could not be in their own homes, they would be better off with family members or foster carers. The 1960s saw the end of the orphanage system and in the 1970s and 1980s many large children's homes were closed down.
If regimentation, isolation from the community, lack of independence, dignity and privacy, poor quality of care, and control by others were seen as the essence of an institution, then there is little wonder that social reformers and health and welfare advocates of the 1960s and 1970s argued for deinstitutionalisation.
Trends in types of care, including move towards foster care
2.21 In the 1960s and 1970s increased emphasis on adoption resulted in fewer children requiring residential care. For out-of-home children, the initial emphasis was on foster homes, and later, placements with relatives/friends and support for children in their own family home.
2.22 In the late 1950s, 'family group homes' comprised of children in a house with 'cottage/house' parents had started to take over from institutions. In 1950s Western Australia after the Hicks Report into child welfare, institutionalisation was regarded as a 'last resort' and the department recruited foster parents to deal with children's placements. By 1959, the State's Welfare Reception Home was the only State out-of-care facility and the Government started to provide direct out-of-home care. During the 1950s some Victorian non-government groups began to close large homes in favour of family group homes and there was an increase in foster care services among organisations and the department itself.
2.23 While views and attitudes towards social welfare and what form of care best addresses the needs of a child have developed and changed over the decades, the one fundamental was simply described by a 70 year old lady:
I feel though things may get tough, a mother or father should never be forced to give up their children to any institution or home if it is at all possible to stay together, because after all a child only needs to know they are truly loved and wanted.
2.24 Nowadays, very few large institutions remain and most residential care for children is provided in family group homes or smaller residential establishments. More information about the trend towards the use of foster care and contemporary foster issues will be discussed in a second volume of this report.
Government responsibility and initiatives for children in institutions
2.25 Aligned to early debates and practices about institutional or boarding-out options, was the ambivalence of governments to take full responsibility for child welfare. In colonial New South Wales, government-subsidised committees ran the voluntary institutions. In 1824 the responsibility for orphan schools was transferred to the Anglican Archdeacon and in 1836 funds were provided to Catholic institutions. This pattern of government and private joint control remained for over a century.
2.26 Over the years, the use of charities for children's institutions was attractive for governments for various reasons including the churches' preparedness to take children at short notice.[65] As well, non-government organisations provided cheaper options; in Queensland, the licensing of St Vincent's Orphanage in 1867 resulted largely from financial expediency on the part of the government during an economic downturn.
2.27 Governments were at times influenced by non-government groups in decisions about types of care for welfare children. This was demonstrated in 1881 by the success of child savers (who favoured boarding-out systems) in persuading the New South Wales Government to establish the State Children's Relief Board, which then implemented a policy to pay subsidies to families with boarded-out children.
2.28 However, the late 19th century saw moves for more government control over child welfare issues. For example, in the 1880s and 1890s, colonial governments appointed inspectors or superintendents to inspect and report on all charitable institutions which received government subsidies.
2.29 Government bodies dealing with children in care seemed to adapt their roles in line with trends about ways to house children. In New South Wales the anti-institutionalisation stance fell into disrepute. After the enactment of the Child Welfare Act 1923, the State Children's Welfare Relief Board was abolished and replaced by a Child Welfare Department, responsible to the Minister of Education. This move marked a rethink about ways to house children and a return to the use of institutions. However, orphanages' operations essentially remained the same until the 1950s.
2.30 After World War II another push emerged for family-based care. In 1956, the New South Wales Child Welfare Department became the Department of Social Welfare with its own ministerial head.[70] By the 1960s, despite that State government children's receiving depots were grossly overcrowded, the government did not opt to use non-government institutions because it favoured the boarding-out system.
2.31 In Victoria, from the 1870s the State ceased operating government establishments except for the children's reception centre 'The Depot' at Royal Park, and for many years relied heavily on charitable and church-based agencies. However, from 1954 the government increased its involvement in direct services, coupled with the tighter government standards for non-government homes. The Victorian department's increased participation reflected the growing recognition of the importance of retaining the parents in their children's lives. Under the Victorian Children's Welfare Act 1954, the government established its own institutions for children and young offenders. However, the Victorian Government continued to rely on the non-government sector until the 1960s and 1970s.
2.32 Evidence to the Committee showed the dependence of various State governments on the non-government sector in the provision of care to State children:
Without the voluntary children's homes it would have been impossible for the Victorian government to carry out its residential child care function in the 1950s and 1960s.
Some key points about...[WA out-of-home care] are: it has historically been one of a state sponsored system, with more facilities run by the private than the public sector. The role of charitable, mainly religious, bodies in the provision of out-of-home care has been paramount.
2.33 Later developments in Victoria included the introduction of the Social Welfare Act 1960, when the Social Welfare Branch of the Chief Secretary's Department replaced the Children's Welfare Department. This coincided with moves towards foster care. The Social Welfare Act 1970 in Victoria saw the establishment of a separate Social Welfare Department and various processes commenced including moves to keep children in care closer to their families.
2.34 The Queensland Government set standards for children's institutional care including under the State Children Act 1911. However, the orphanage system was very poorly funded and the government sought to reduce spending on children's institutions. Until the reforms of the Report of the Committee on Child Welfare Legislation (1963) and a Public Service Commission (1962), the department was massively under resourced and standards for the care of State children were poor.
2.35 Across Australia, increases in government responsibility in child welfare in the 1960s saw the establishment of separate State welfare departments. Generally, prior to that, child welfare departments, however styled, had been part of other government departments. With the exception of Western Australia which set up its first child welfare department in 1934, most other states did not establish separate child welfare departments until the 1960s-1970s.
Attitudes of government officials who placed children in care
2.36 The Committee received many submissions that were critical of government departments and the officers responsible for placing children in care. The point was made often that welfare departments seemed to be obsessed with regulating adolescent sexual behaviour, particularly that of girls. While such notions dated back to very early eras, they pervaded institutions up to the 1980s.
2.37 This care leaver explained how the ineffectiveness of government systems had negative repercussions for her:
I was made a state ward at 15, in the early 1980s, after years of ineffectual intervention by a number of welfare organisations - government and non-government - as well as the police...I had to cope with sexual assaults from my stepfather and an uncle. By my 12th birthday, I had been to 20 different primary schools and had lived, variously, in Salvation Army hostels, foster care, orphanages, Housing Commission accommodation, motels, and an endless series of ad hoc, low-quality rentals. I had been repeatedly removed from my family and placed in care. (Sub 138)
2.38 Overall, many care leavers do not consider that child welfare officers took proper care of the children in their charge:
I believe the people employed by the Child Welfare Department should be made accountable for the emotional, physical and mental abuse they bestowed on the young people who went through the system. Many of them are still living and their actions should be investigated. Some of the officers were very good and decent people, others were vicious and child abusers...Shame on the Department of Child Welfare, shame, shame, shame!!! (Sub 238)
Government financial contributions to non-government children's homes
2.39 While non-government organisations have played a key role in providing children's institutional care, the following information illustrates the intricacies at times between governments and the voluntary sector, particularly regarding funding for the homes and factors that increased their financial pressures. Significantly, when legislative definitions of children who could be made state wards were broadened, the numbers coming into homes increased as did the need for more institutions.[80] Further, often governments only made payments to homes for children who were designated as state wards or whose parents could not afford to pay.
2.40 The Western Australian Department for Community Development advised the Committee that its payments policy did not cover all children in homes:
It was not true for all children in institutions. We were paying for wards and we were paying for some proportion of privately placed children whose parents could not afford to pay for them.
2.41 In New South Wales, government policies for the State care of children had developed in conjunction with voluntary organisations which were heavily subsidised by government. However, the relationship between the State and agencies altered after the 1873 Public Charities Commission. The government ceased its funding to the homes which continued, but became dependant on private funds.[82] Similarly in other States, orphanages relied on businesses for finances and services and fund-raising activities.
2.42 Ms Sarlos from Wesley Dalmar confirmed the importance of government funding for the homes for children whose parents were unable to pay:
If say a year has gone by and the agreed payments from the parents have not been coming in, it may well be at that point that the government supported the children. It was really driven by the finances in terms of trying to make sure that there was some income...to support each child.
2.43 In 1958, the New South Wales Association of Child Caring Agencies started lobbying for State subsidies for Catholic homes, many of which ran without government funding. The New South Wales Government favoured its boarding-out policies but in 1961 amended the 1939 Child Welfare Act to provide an allowance for children in homes, payable only where the parents permitted their children to become state wards. This practice became an administrative nightmare and in 1965 the Act was amended again to eliminate the requirement for wardship.
2.44 Victorian non-government homes were funded on a per head basis for state wards and the government reimbursed institutions for children's expenses. It seems that relations between the government and non-government sectors were difficult at times. In evidence to the Committee, Ms Gaffney said that the government might, with no warning, decide not to reimburse organisations for children's expenses:
I am not saying that that is a standard feature of the relationship, but you have little things like that, where the non-government organisations have maybe done everything, they can and the government plays games or tightens its belt without necessarily telling them.
It is my impression, in some respects, that non-government organisations or institutions were sometimes put over a barrel. They became dependent upon state funding. They became dependent upon receiving state wards because of the per head funding. When they complained they were receiving unsuitable wards...and said, 'Will you stop sending us these wards', the government's response, on more than one occasion, was, 'We will stop sending you wards, and you will not get any money'. I have read file notes that said: 'This institution needs our money so we can threaten them with stopping sending them wards. They will accept any ward we want because they need our money.'
2.45 According to Ms Gaffney, the government at times had the upper hand even to the point of playing non-government organisations off against each other:
That marks Victorian welfare very much. It is an assumption that non-governments will provide these services-we can change the legislation and throw the number of children at them that we want; they will still pick up the children and provide the services. Here is the assumption that the government plays non-governments off against each other-the idea that if you will not take that ward because you think he is difficult, too bad; we will just remove all the wards and remove all your money. So there is competition between non-governments for government funding.
2.46 The pressures among institutions about government payments to house state wards in Victoria came to a head in the early 1970s when the charitable institutions ceased to take voluntary placements and became, in effect, part of the residential arm of the Social Welfare Department.[88]
2.47 As mentioned, by the mid-1970s institutions' costs served as incentives to find other ways to house state welfare children. Parents' ability to pay for their children's upkeep particularly in relation to any government financial help was also influential in decisions about children being placed in institutions. This issue is discussed below.
Government financial assistance to parents
2.48 Mr Scott from the Association of Children's Welfare Agencies told the Committee that for many years after WWII moves were made to obtain financial recompense from parents of children in homes:
When a child was made a ward, if the father was able to make a financial contribution he would be approached to make such a contribution. It did not necessarily make a great impact on the budget for the state care of children; it was seen more as reminding him of his responsibilities and, to some extent, keeping a link between them. It was abandoned because it was seen as punitive. It was expensive to collect...For various reasons at that time it was seen as desirable that parents maintain a financial contribution.
2.49 In various eras in Australia, schemes had been introduced to help mothers to keep their children at home. During the 1880s, Brisbane's St Vincent's Orphanage trialled paying the same allowances to mothers as were paid to foster mothers but the scheme stopped because it was seen to be creating a class of permanent pensioners. In Victoria, New South Wales, Queensland and South Australia in the late 1800s, financial assistance was introduced for mothers to keep their own children. However, the early forms of such government assistance were limited for various reasons.
2.50 By the late 1920s, many State children or those on benefits were cared for in their own homes though some parents could not afford to keep their children despite boarding-out payments. During 1900-1945, some States assisted parents with cash or goods to help them maintain their children, and, the federal government introduced the maternity allowance (1912) and the child endowment allowance (1941).
2.51 Given the pivotal role of finances in determining a family's ability to maintain their children, the social security benefits that characterised the Whitlam Government era (1972-1975) had obvious effects for people who might otherwise need to place their children in a home. The introduction of the Supporting Mothers Benefit in 1973 and other government assistance, particularly to women, made it much less likely that parents would relinquish their children to the state, for financial reasons.
2.52 The increased Commonwealth Government financial support of the 1970s to parents fundamentally shifted the role of the state regarding parental responsibilities. In earlier times it had been accepted that some parents would be unwilling or unable to care for their children and could place their children in a home and pay for the child's care (or perhaps not), with the state playing no role. However, from the 1970s the state had an increasing role in supporting families and protecting children.
2.53 A discussion of the correlation between parents' finances and the economic pressures that have contributed to children's placement in homes, appears in chapter 3.
Number of children in institutional care
2.54 It is likely that more than 500 000 Australians have experienced life in an orphanage, home or other form of out-of-home care during the last century in Australia.
2.55 Evidence to the Committee has shown the difficulties encountered when assessing such numbers. Often data on children in institutions is not comprehensive, covers different time periods and has gaps and inconsistencies. As CLAN noted, often data is not broken down into categories such as numbers already in care, new admissions or departures from care, and because of recording practices, children may be counted more than once. Significantly, not all children in institutions were taken through the official legal processes of state wardship and therefore would not necessarily have been included in official records. Further, different ways of collecting and maintaining data have existed within and among States according to counting requirements of various times. A discussion of how the 500 000 figure has been arrived at, is in Appendix 5.
Conclusion
2.56 The above outline demonstrates the ad hoc and disparate nature of the workings of governments and other groups and their agendas, which over the years, have had responsibility for children. Perhaps it is not surprising that many problems occurred for children in institutions. For instance given that State governments contributed nothing or very little to non-government children's homes, they effectively relinquished their chances to oversee the activities or standards of the homes.
2.57 As an academic, Dr Penglase noted, the New South Wales Government washed its hands of funding for the homes, clearly demonstrating its disapproval of the use of institutions. Dr Penglase also noted the lack of cooperation between the government and non-government sectors.[96] Mr McIntosh, a Victorian child welfare researcher advised the Committee that by the 1960s, any original reform ideas of the homes had diminished and the government's involvement had become merely administrative so that any planning and research activities came from the voluntary sector. As such, departmental officials were unable to suggest or require changes in care methods and voluntary institutions were limited in any efforts to introduce changes, because they did not have the funds to do so.
2.58 More than anything, one would consider it reasonable to expect that there would be cooperation and openness between the sectors, given that the non-government sector was essentially doing the government's work.
2.59 Most telling perhaps is that the majority of State governments did not have separate child welfare departments until well into the 1960s and 1970s, a demonstration that child welfare issues were not a high agenda item for governments. In other words, it is likely that the core business of the large departments dealing with child welfare issues would have overshadowed the needs of children in institutions. This is also pertinent given that the managerial styles of large bureaucracies are not at all conducive to meeting the best interests of children, particularly those children who are society's most vulnerable.
NSW Communities & Justice. (2018). A Mandatory Reporter's Guide To Selecting A Decision Tree. https://reporter.childstory.nsw.gov.au/s/article/Guide-To-Selecting-A-Decision-Tree
Content
When using the MRG, you select the main decision tree that most closely matches the concern(s) you have. If you have more than one concern, start with your most serious. After selecting the applicable decision tree, you will be asked a series of questions. It is important to read the accompanying definitions to complete a ‘yes’ or ‘no’ answer until a final decision is reached. At the end, a decision report will be issued with an explanation of the outcome based on your completed decision tree.
If your concern does not fit any of the decision trees, it is probably not reportable, but you may consult your Child Wellbeing Unit (CWU), if you have access to one, and/or other professionals and/or your supervisor as appropriate.
The examples in the following tables aim to help you make an informed decision about the most appropriate decision tree to use. Please note that in some situations more than one tree may be applicable.
| Decision Tree | Use this when |
|---|---|
| Physical Abuse |
|
| Neglect |
|
| Sexual Abuse |
|
| Psychological Harm |
|
| Child/Young Person is a Danger to Self and/or Others |
|
| Relinquishing Care |
|
| Carer Concern |
|
| Unborn Child |
NOTE: Reports related to an unborn child are not mandatory but mandatory reporters should consider the benefits for the parent/s and unborn child in making a report. A report can enable FACS and other agencies to work collaboratively with the parent/s to access support services. Furthermore, a report can enable FACS to prepare for statutory intervention when the child is born. Where FACS has received a ROSH report about an unborn child, a parent responsibility contract can be used to support expectant parents to address issues, so the child is safe when born. NOTE: Where you are concerned about a child who has just been born and due to lack of information none of the other decision trees apply, use this tree to identify your concerns such as inadequate preparation for the birth. |
| Decision Tree | Use this when |
|---|---|
| Supervision |
|
| Shelter/environment |
|
| Food |
|
| Hygiene/clothing |
|
| Medical care |
|
| Mental health care |
|
| Education- not enrolled/habitual absence |
|
Carer concern
| Decision tree | Use this when |
|---|---|
| Substance abuse |
|
| Mental health |
|
| Domestic violence |
|
Sexual abuse
| Decision tree | Use this when |
|---|---|
| Child |
|
| Young person |
|
| Problematic sexual behaviour towards others |
|
Australian Government. (2023). Work Health and Safety. https://business.gov.au/Risk-management/Health-and-safety/Work-health-and-safety
Work health and safety (WHS) involves managing risks to the health and safety of everyone in your workplace, including your:
- workers
- customers
- visitors
- suppliers.
It is sometimes known as occupational health and safety (OH&S). Managing WHS may initially cost money and time to implement safe practices and install safety equipment. However, not taking action can result in prosecution, fines and loss of your skilled staff.
Workers’ compensation laws also require you to have a workers’ compensation insurance policy for your employees.
Benefits of WHS in your business
Creating a safe work environment is a legal requirement. It’s also critical to the long-term success of your business and can:
- help you keep your staff
- improve staff productivity
- reduce injury and illness in the workplace
- reduce the costs of injury and workers' compensation.
Your WHS obligations
You must put health and safety practices in place as soon as you start your business. Under Australian WHS laws your business must:
- ensure the health and safety of your workers
- not put the health and safety of other people at risk.
To do this you must:
- provide a safe work environment
- provide and maintain safe machinery and structures
- provide safe ways of working
- ensure safe use, handling and storage of machinery, structures and substances
- provide and maintain adequate facilities
- provide any information, training, instruction or supervision needed for safety
- monitor the health of workers and conditions at the workplace.
Your workers' WHS obligations
People working in your business also have WHS obligations. They must:
- take care of their own health and safety
- take care not to do anything that could hurt others
- follow WHS instructions
- follow the workplace’s WHS policies and procedures.
WHS requirements in your state or territory
Each state has its own WHS laws and a regulator to enforce them. The WHS framework for each state includes the:
- Act – outlines your broad responsibilities.
- Regulations – set out specific requirements for particular hazards and risks, such as noise, machinery, and manual handling.
- Codes of practice – provide practical information on how you can meet the requirements in the Act and Regulations.
- Regulating agency (regulator) – administers WHS laws, inspects workplaces, provides advice and enforces the laws. Check their website for WHS information and resources.
In some states there is a different regulator for workers' compensation.
WHS requirements for your industry
Your business’s WHS requirements depend on the risks in your workplace. Check our industry information pages to find the requirements for your industry.
It may be worth getting independent advice on the WHS requirements for your business.
Emergency plans and first aid
Part of WHS is being ready to respond if an accident or emergency happens. To help minimise workplace risks and be better prepared for emergencies, check:
- Do you have an emergency plan?
- Have you done a first aid assessment of your business?
- Do you have enough trained first aiders to cover unplanned staff absences?
- Is the first aid equipment in your workplace easy to find and access?
- Does your workplace run emergency drills?
- Have you evaluated your business activities to identify areas of increased risk?
Work in extreme weather
Extreme weather, including extreme heat, cold, hail or strong winds may affect your business. It's important you understand your obligations to workers when these events happen. Under WHS laws you must provide a safe working environment and keep your workers safe in extreme weather. You should make sure you’re aware of the signs of heat-related illness and how to manage the risks. Not all employers have to provide leave if their employees can’t work because of extreme weather, but some do. Check whether your employees have entitlements to leave under your award or agreement. If you’re not clear on your rights and responsibilities as an employer:
- visit the Fair Work Ombudsman website, or
- contact the Fair Work Infoline on 13 13 94.
Work functions and WHS
Work functions are a great way to celebrate and thank your staff for their hard work. However, while your staff may be 'off the clock' at the event, you're still responsible for their health and safety. Here are some suggestions to help celebrate safely.
Before the event make sure your internal policies and procedures are up to date. These include the policies for acceptable behaviour, and bullying and harassment in the workplace
You can send a friendly email to staff, reminding them that:
- while the party is a time to relax, it's still a work function
- the usual rules still apply, including those around sexual harassment
- they should be careful if consuming alcohol.
At the event:
- if you serve alcohol, make sure it's served legally and responsibly
- there should be enough food and non-alcoholic drinks available
- make arrangements for staff to get home safely afterwards. For example, organising a bus, pre-ordering taxis or arranging designated drivers.
Working with remote team members
Your WHS obligations as an employer still applies when your staff are working remotely or from home.
If you have staff working remotely, make sure your policies and procedures accommodate it. For example, you may have to update them to account for your employees' remote work environments. When considering WHS implications for remote working, think about how to:
- report incidents or injuries while working at home
- provide guidance on what a safe home office environment is
- allow workers to borrow equipment from an office if available
- provide information supporting mental health and wellbeing.
Australian Government (n.d.). Restraint scenarios. https://www.agedcarequality.gov.au/sites/default/files/media/restraint_scenarios_v1.pdf
Introduction
These scenarios are intended to be illustrative only, and should not be relied upon as authority. Providers should be mindful of their obligations under the Quality-of-Care Principles 2014, and pay careful attention to the legislative requirements underpinning the use of restraint when applying those obligations to real-life situations. The legal requirements on approved providers about the use of restraint under the Aged Care Act 1997 are set out in the Quality-of-Care Principles 2014 (the principles) and include obligations on approved providers to ensure that restraint is only used in response to proper clinical assessment and (for chemical restraint) prescribing by health professionals. Section 15F of the Principles covers use of physical restraint, and section 15G covers chemical restraint.
It is important to note that State and Territory (S and T) laws continue to apply. This is relevant to consent for both physical restraint and chemical restraint. Different States and Territories have differing legislation relating to who can legally give substitute consent and in which specific situations. It is important that prescribers and other health professionals performing a role in relation to restraint are aware of the legislation specific to their own jurisdiction.
Ronald, 67-year-old male
Ronald has a background of chronic schizophrenia, managed by his GP and with regular reviews by his long-standing psychiatrist. His medication is risperidone. He is happy in the residential aged care service (RACF) and says he enjoys the staff interactions and social opportunities provided. Ronald understands why he is on the medication, and his doctors have assessed that he is able to give his own consent.
This IS NOT chemical restraint. The medication is to treat a diagnosed mental condition (schizophrenia) and Ronald is consenting.
Maria, 78-year-old
Female Maria was diagnosed with dementia four years ago and is taking donepezil (Aricept). She recently transitioned to a secure RACF due to wandering from her home at night, becoming lost and becoming aggressive with family members. Maria was very agitated and upset when she arrived at the RACF, and repeatedly tried to leave. Staff are very vigilant about preventing her from leaving as there is a risk that she will get lost or wander to nearby busy roads and the river. This IS physical (environmental) restraint. The locked environment is preventing Maria from going where she wants to. This requires assessment, documentation, and consent according to the principles and the relevant S & T legislation.
Because Maria is distressed and constantly exit-seeking, the RACF staff request the assistance of available behaviour support resources and assistance from the family, to reassure her and give staff strategies to help her settle in. Maria’s GP is also asked to help, assesses her and suggests that a low dose of risperidone in the short-term might help with the behaviour and distress. Maria’s husband (who is her authorised representative) agrees and gives his informed consent. Maria is calmer. She is monitored for side effects such as drowsiness and there is a clear plan to document her behaviour and to review the need for the risperidone in the following weeks as she settles in. This IS chemical restraint. Although Maria has a diagnosed mental disorder (dementia), risperidone is not a drug to treat dementia. The donepezil she is taking is a drug to treat dementia, the risperidone is not; rather, it is being used to manage associated behaviour. This requires assessment, documentation and consent according to the principles and the relevant S & T legislation.
Geoffrey, 92 year old male
Geoffrey has been in the RACF for many years with vascular dementia. He is in a locked secure facility because he was placed in the residential service against his will by a guardian with the appropriate authority, due to extreme risks living at home that he was unable to understand. When Geoffrey was expressing his wish to leave and had the ability to leave, the locked facility constituted physical restraint. Geoffrey’s health has gradually declined, and his dementia is now advanced. Geoffrey is now bed-bound, doubly incontinent, eating and drinking little and does not talk. He is no longer capable of wishing to leave or trying to leave and is dependent on staff for all care and comfort. While Geoffrey no longer requires a locked facility, there is no practical alternative, and the RACF considers it would be inhumane and contrary to his best interests to move him given he is approaching the end of his life. He is in a familiar environment with staff who know his individual care needs and preferences, and he is no longer on any medications. This is NOT physical restraint. Geoffrey’s overall health status, and not his environment, restricts his free movement. Nothing else is interfering with his freedom of movement. His position would be the same whether or not he is in a locked facility.
Geoffrey’s roommate, Donald an 88-year-old male with mild dementia, is wheel-chair dependent. He likes to go into the courtyard and sit in the sun and would like to go out of the facility for a change of scenery and to do some shopping. The staff often do not have time to facilitate this. Donald IS being physically restrained because his locked environment, as well as his impaired mobility, are interfering with his free movement to do what he wants to do.
Ann, 84-year-old female
Ann has dementia and has lived in the RACF for a few years. She has begun to wander around a lot more and has been getting into other people’s beds. She calls out frequently and is awake for many hours at night. The nursing staff ask the GP to provide something to help her sleep. The GP suggests some management strategies and a referral to a behaviour advisory service. The GP prescribes both regular diazepam (Valium) and risperidone PRN (as required) in case she is having a particularly bad night. Both of these drugs ARE being used as chemical restraint, even though in the case of risperidone it is PRN and not regular. Both require assessment, documentation, and consent according to the principles and the relevant S & T legislation.
Christina, 96-year-old female
Christina is deaf and has trouble communicating, however she has no dementia and is not cognitively impaired. She asked her GP for something to help her nausea that is limiting her appetite and her enjoyment of food. She does not want any investigations. The GP outlines the options and the potential side-effects, and they decide to try prochlorperazine (Stemetil) and assess for effectiveness and side-effects such as drowsiness. This is NOT chemical restraint. The medication is technically categorised as a psychotropic, and it may have side effects such as drowsiness that require monitoring. However, it is not being used to influence her behaviour; rather, it is being used as an antinausea agent.
Charles, 68-year-old male
Charles is an indigenous man with chronic renal disease, diabetes and he is blind. He does not have any cognitive impairment. He is in a secure RACF which is the only one available near his community and family. He wants to access the community at times and is assisted on outings by staff. At other times he goes out with family members. He cannot see to use the numbered keypad to unlock the door and cannot leave without assistance, but he is able to ask. He does not wish to move to an open (unlocked) RACF that has been offered to him as in his view this will be more restrictive as he will be away from his community, his family will be much less able to take him out, and he will not be on his country. Charles has been assessed by his GP and this is documented appropriately. He has considered alternatives and is able to provide his own informed consent. Additionally, the provider regularly monitors Charles for signs of distress or harm. The provider also reviewed the necessity of the restraint and determined there was no practical alternative. This IS physical (environmental) restraint as the provider is restricting Charles’ free movement with a locked environment; Charles is not able to leave without assistance. However, the provider is compliant with its responsibilities under the principles and the relevant S & T legislation.
Pam, 82-year-old female
Pam has dementia and has come into the RACF after a bad fall at home which resulted in a hip fracture that involved a long hospital admission with complications. She is frail, very weak and unsteady, and is meant to be using a frame to walk. Pam forgets about the frame and whenever she wants to go to the bathroom, she gets up impulsively and tries to rush unaided. She has had two near-miss falls in the facility. The staff decide to put her in a recliner chair to prevent her walking unaided and falling. The chair is very comfortable, but she is unable to get out of it without assistance. This IS physical restraint as Pam is being prevented from moving freely, even though the motivation is safety. It requires assessment, documentation and consent according to the principles and the relevant S & T legislation. When Pam was noted to be incontinent in the recliner, the staff put in a regime of regular toileting which was successful in eliminating incontinence and also stopped the impulsive rushing behaviour.
George, 79-year-old male
George is normally able to come and go freely from his RACF using the numbers on the keypad at the door. One day he is very confused, incontinent, and behaving inappropriately, abusing other residents and refusing to eat, get out of his wet clothes or to shower. Staff consider the options of: securing him in a chair with a lap-sash; or calling the GP for a phone order of risperidone to settle him down and to prevent him from harming himself or others. BOTH of these options ARE restraint. However, the staff realise that a sudden change in behaviour like this represents a clinical deterioration and there may be a serious underlying medical condition causing it. George may have a delirium and the cause needs to be investigated. The decision is made to transfer him to hospital and his family are notified. George developed pneumonia, is successfully treated, and returns to the facility. George is back to his old self and does not require any restraint measures.
Australian Government. (2021). Overview of restrictive practices. https://www.agedcarequality.gov.au/sites/default/files/media/overview-of-restrictive-practices_0.pdf
Restrictive practices must only be used as a last resort and in the least restrictive form
The Aged Care Act 1997 and the Quality-of-Care Principles 2014 have been updated to clarify and strengthen approved provider requirements in relation to the use of restrictive practices in aged care. These changes protect senior Australians receiving aged care and services and ensure that providers understand and meet their obligations in this regard. The revised legislation, taking effect from 1 July 2021:
- replaces the term ‘restraints’ with ‘restrictive practices’
- defines restrictive practices
- details the requirements for the use of restrictive practices, including strengthening those in relation to consent, documentation, and monitoring
- emphasises person-centred care and reinforces the rights of aged care consumers, by ensuring that restrictive practices are only used as a last resort to prevent harm after best practice behaviour supports have been considered, applied and documented
- require the provider to have a behaviour support plan in place for each consumer who has restrictive practices considered, implemented or used as part of their care
- introduces restrictive practices compliance notices and the potential for civil penalties if providers do not meet the requirements
What is a restrictive practice?
A restrictive practice is any practice or intervention that has the effect of restricting the rights or freedom of movement of an aged care consumer. Under the legislation, there are five types of restrictive practices:
- Chemical restraint
- Environmental restraint
- Mechanical restraint
- Physical restraint
- Seclusion.
The definitions of restrictive practice and the five types of restrictive practices were implemented to provide clarity to providers on what constitutes a restrictive practice and the circumstances for the use of a restrictive practice. These definitions are aligned with those applied under the National Disability Insurance Scheme.
Chemical restraint
Chemical restraint is a practice or intervention that is, or that involves, the use of medication or a chemical substance for the primary purpose of influencing a consumer’s behaviour, but does not include the use of medication prescribed for:
- the treatment of, or to enable treatment of, the consumer for a diagnosed mental disorder, a physical illness or a physical condition; or
- end of life care for the consumer.
Examples of chemical restraint are administration of any medication, including prescribed, Pro Re Nata (PRN or as required) and over the counter medication, to a consumer, which influences, moderates or controls their behaviour. Where medication is prescribed for the medical treatment of a diagnosed mental disorder, a physical illness or physical condition, or end of life care, as allowed for under the legislation, providers need to ensure they are using the medication as prescribed and with appropriate monitoring and consent.
Environmental restraint
Environmental restraint is a practice or intervention that restricts, or that involves restricting, a consumer’s free access to all parts of the consumer’s environment, including items and activities, for the primary purpose of influencing the consumer’s behaviour. The consumer’s environment includes their room, any common areas within the service, and the common grounds outside of the service. It does not include another consumer’s room. Further it does not include areas within the service where a consumer would not ordinarily be allowed to access, or only access with support from care staff. This may include the kitchen, laundry, clinical spaces or areas where medication may be stored, or maintenance sheds for example. Examples of environmental restraint are restricting a consumer’s access to an outside space, removing or restricting access to an activity or to the outside environment, or limiting or removing access to a wanted or needed item, such as a walking frame, by putting it out of reach.
Mechanical restraint
Mechanical restraint is a practice or intervention that is, or that involves, the use of a device to prevent, restrict or subdue a consumer’s movement for the primary purpose of influencing the consumer’s behaviour. It does not include the use of a device for therapeutic or non behavioural purposes in relation to the consumer. Examples of mechanical restraint include use of a lap belt or princess chair, bed rails, low beds or use of clothing which limits movement and is unable to be removed by the consumer. Devices used for therapeutic purposes or non behavioural purposes are not considered to be mechanical restraints, such as use of a wheelchair for someone who needs mobility support, however if the service leaves a person in the wheelchair, applies the brakes so they remain in one position and they are unable to move themselves, this is mechanical restraint. Devices in place for safety purposes or to prevent harm, even if consented to by the consumer, are considered to be a mechanical restraint if not used for therapeutic or non-behavioural purposes. Use of bed rails is the most common example here. Bed rails are mechanical restraint and require discussion of the risks and proposed benefits, and a behaviour support plan to be in place, unless the person is able to operate the rails themselves or if the rail is partial and the person can still get in and out of the bed.
Physical restraint
Physical restraint is a practice or intervention that is or involves the use of physical force to prevent, restrict or subdue movement of a consumer’s body, or part of a consumer’s body, for the primary purpose of influencing the consumer’s behaviour. This does not include the use of a hands-on technique in a reflexive way to guide or redirect the consumer away from potential harm or injury if it is consistent with what could reasonably be considered the exercise of care towards the consumer.
Examples of physical restraint are physically holding a consumer in a specific position to force personal care issues such as showering to be attended to or for administration of medication, pinning a consumer down, or physically moving a consumer to stop them moving into a specified area where they may wish to go.
Assisting a consumer with activities of daily living where this has been requested and the consumer is unable to assist themselves, guiding them away from danger or catching a consumer if they are about to fall are not considered physical restraint.
Seclusion
Seclusion is a practice or intervention that is, or that involves, the solitary confinement of a consumer in a room or a physical space at any hour of the day or night for the primary purpose of influencing the consumer’s behaviour where:
- voluntary exit is prevented or not facilitated; or
- it is implied that voluntary exit is not permitted.
Examples of seclusion are placing a consumer alone in a space or room from which they cannot exit, including in a space by themselves where their access to a call bell or walker is limited, or imposing a ‘time out’. Seclusion significantly affects a consumer’s dignity and rights and should only be used after all other forms of behaviour management or appropriate alternative restrictive practices have been exhausted. Seclusion is an extreme form of restrictive practice and should never be used as a punishment. A consumer who decides to close and lock a door behind them, such as in their own room or bathroom is not considered seclusion, as they are able to enter and leave the area of their own free will. Where consumers are required to isolate for the purpose of complying with state and territory public health directives, this is not considered to be seclusion, as the primary purpose of such an action is not to influence the consumer’s behaviour but to comply with the health order.
Requirements for the use of any restrictive practice
The following requirements must be met for the use of any restrictive practice in relation to a residential aged care consumer:
- Restrictive practices must only be used as a last resort to prevent harm to the consumer or other persons, and after consideration of the likely effect on the consumer.
- An approved health practitioner who has day to day knowledge of the consumer, has assessed the consumer as posing a risk of harm to themselves or another person, and has assessed the restrictive practice as necessary, and these assessments have been documented.
- In the case of a restrictive practice that is chemical restraint, the above assessments must be conducted by a medical practitioner or nurse practitioner who has subsequently prescribed the medication; and the assessments, the consumer’s behaviours relevant to the need for the chemical restraint, the practitioner’s decision to use the chemical restraint, the reasons the chemical restraint is necessary, and the information that informed the practitioner’s decision, must be recorded in the consumer’s care and services plan in accordance with the Aged Care Quality Standards (Quality Standards).
- Best practice alternative behaviour support strategies have been used, and the consideration and/or use of these strategies and their effect has been documented.
- Restrictive practices must only be used in proportion to the risk of harm, in the least restrictive form, and for the shortest period possible.
- The need for, use of, and effectiveness of restrictive practices must be continually monitored, reviewed and documented. As part of this, providers must consider whether an individually appropriate alternative strategy can be used and the restrictive practice can be reduced or stopped. In the case of a restrictive practice that is chemical restraint, providers must also give information about the effects and use of the chemical restraint to the prescribing practitioner.
- Informed consent for the use of a restrictive practice must be obtained from the consumer. If the consumer does not have the capacity to give that consent, it must be obtained from their restrictive practice substitute decision-maker. Providers must ensure that consent has been obtained in accordance with state and territory requirements and subsequently recorded.
- The use of the restrictive practice must comply with the Charter of Aged Care Rights and Quality Standards, the requirements (if any) of the law of the State or Territory in which the restrictive practice is used, as well as any relevant provisions of the consumer’s care and services plan, or behaviour support plan from 1 September 2021.
Emergency use of restrictive practices
An emergency is a serious or dangerous situation that is unanticipated or unforeseen and that requires immediate action. It is expected that providers will be actively engaged in a consumer’s day to day care and support needs, including behaviour support planning, and that this understanding and engagement will reduce the incidence of emergencies. Situations where restrictive practices are required in residential aged care in the event of an emergency should therefore be rare. Some requirements, such as the requirement for consent, are exempt when the use of the restrictive practice is in an emergency. These exemptions are intended to ensure that a provider can appropriately and rapidly respond to an emergency to protect a consumer or other person from immediate harm. An emergency situation is not expected to last for an extended period of time and an emergency situation will be considered to have ended when there is no immediate risk of harm or injury for the consumer or others. If a provider uses a restrictive practice in an emergency, the provider must, as soon as practicable after the restrictive practice starts to be used, inform the restrictive practices substitute decision-maker about the use of the restrictive practice, and ensure that the following is documented in the consumer’s care and services plan:
- The consumer’s behaviours that were relevant to the need for the restrictive practice
- The alternatives to the restrictive practice that were considered or used (if any) • the reasons the restrictive practice was necessary
- The care to be provided to the consumer in relation to their behaviour
- A record of having informed the restrictive practices substitute decision-maker about the use of the restrictive practice
- All assessments, information, and decisions relevant to the use of the restrictive practice
- Any additional advice or support to be sought. Once the emergency is over, the provider should revert to the usual policies and procedures regarding the use of any restrictive practice for the consumer. During an emergency, providers must still seek to ensure the least restrictive form of a restrictive practice is being applied and that it is for the shortest period possible. Additionally, providers must monitor the use of the restrictive practice to determine whether an alternative strategy can be used and whether the restrictive practice can be reduced or stopped.
Requirements for care and services plans in relation to the use of restrictive practices
From 1 September 2021, providers are required to have a behaviour support plan in place for every consumer who exhibits behaviours of concern or changed behaviours, or who has restrictive practices considered, applied or used as part of their care. The behaviour support plan forms part of the individual care and services plan, and does not replace it. The behaviour support plan must set out information about the consumer that helps the provider to understand the individual’s background and changed behaviours, including but not limited to:
- Any assessments which have been carried out regarding those behaviours,
- Known triggers which may precede those behaviours,
- Alternative strategies which are known to be successful, or unsuccessful, in managing those behaviours, and
- Any restrictive practices which are used or applied once alternative strategies have been tried. It must also include evidence of consent from the consumer or their restrictive practices substitute decision-maker. It must be in a form and place that makes it available to staff to inform ongoing care.
Serious Incident Response Scheme
The Serious Incident Response Scheme (SIRS) is an initiative to help prevent and reduce incidents of abuse and neglect in residential aged care services subsidised by the Australian Government. The SIRS sets new arrangements for approved providers of residential aged care and flexible care delivered in a residential setting to manage and take reasonable action to prevent incidents with a focus on the safety, health, well-being and quality of life of aged care consumers. The SIRS requires every residential aged care service to have in place an effective incident management system — a set of protocols, processes, and standard operating procedures that staff are trained to use.
Inappropriate use of restrictive practices may be reportable under SIRS. Providers should familiarise themselves with their responsibilities under SIRS. Information on SIRS for providers can be found at https://www.agedcarequality. gov.au/sirs Information on SIRS for consumers can be found at https://www.agedcarequality. gov.au/consumers/serious-incident-responsescheme
How can I get more information?
Department of Health
General information about the use of restrictive practices in aged care can be found on the Department of Health website at can be found on the Department of Health’s website at https://www.health. gov.au/health-topics/aged-care/providingaged-care-services/working-in-aged-care/ minimising-restrictive-practices-in-aged-care
Aged Care Quality and Safety Commission
Information about the use of restrictive practices in aged care including education and regulatory requirements can be found on the Aged Care Quality and Safety Commission website at https://www.agedcarequality.gov
Dementia Support Australia
Information about supports for people with dementia who are experiencing changes in behaviour that affect their care or their carer, including access to the Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Teams (SBRT) can be found at https://dementia.com.au/
Dementia Training Australia
Supports including free on-line dementia training, practical resources and training packages, including guidance on behaviour support planning can be found at https://dta.com.au/
Queensland Government. (2023). Identifying abuse, neglect and exploitation. https://www.dcssds.qld.gov.au/our-work/disability-connect-queensland/preventing-responding-abuse-neglect-exploitation/identifying-abuse-neglect-exploitation/indicators-signs
Indicators and signs
Abuse, neglect, and exploitation can take many forms. Being aware of common indicators may improve your ability to recognise and respond to them. Although no single behaviour is an absolute indicator of abuse, neglect and exploitation, some examples are included below.
Physical abuse
Physical indicators:
- unexplained cuts, abrasions, bruising or swelling
- unexplained burns or scalds, cigarette burns
- rope burns or marks on arms, legs, neck, torso
- unexplained fractures, strains or sprains; dislocation of limbs
- bite marks
- dental injuries
- ear or eye injuries.
Behavioural signs:
- avoidance of particular staff, fear of a particular person
- sleep disturbances
- changes in behaviour (e.g. unusual mood swings, uncharacteristic aggression)
- changes in daily routine, changes in appetite
- unusual passivity, withdrawal
- self-harm, suicide attempts
- inappropriate explanations of how injuries occurred
- excessive compliance to staff.
Sexual abuse
Physical indicators:
- direct or indirect disclosure of abuse or assault
- trauma to the breasts, buttocks, lower abdomen or thighs
- difficulty walking or sitting
- pain or itching in genital and/or anal area; bruising, bleeding or discharge
- self-harm, abuse, suicide attempts
- torn, stained or blood-stained underwear or bedclothes
- sexually transmitted diseases, pregnancy
- unexplained money or gifts.
Behavioural signs:
- sleep disturbances
- changes in eating patterns
- inappropriate or unusual sexual behaviour or knowledge
- changes in social patterns
- sudden or marked changes in behaviour or temperament
- anxiety attacks, panic attacks, clinical depression
- refusal to attend usual places (e.g. work, school, respite)
- going to bed fully clothed
- excessive compliance to staff.
Psychological/emotional abuse
Physical indicators:
- speech disorders
- in the case of a child, lags in physical development, failure to thrive
- injuries sustained from self-harm or abuse
- suicide attempts
- anxiety attacks.
Behavioural signs:
- self-harm or self-abusive behaviours
- challenging/extreme behaviours
- excessive compliance to staff
- very low self-esteem, feelings of worthlessness
- clinical depression
- marked decrease in interpersonal skills
- extreme attention-seeking behaviour.
Chemical abuse
Physical indicators:
- withholding of prescribed medication
- abuse of prescribing rights by staff/over-administration of medication.
Behavioural signs:
- persistent over-activity
- unusual levels of confusion/disorientation.
Financial abuse
Physical indicators:
- no access to, or unwarranted restrictions on, personal funds or bank accounts
- no records, or incomplete records kept of expenditure and purchases
- no inventory kept of significant purchases
- person controlling the finances does not have legal authority
- misappropriation of money, valuables or property
- forced changes to a person’s will
- persistent failure to produce receipts
- receipts indicating unusual or inappropriate purchases.
Behavioural signs:
- person has insufficient money to meet normal expenses
- person is persistently denied outings and activities due to a lack of funds.
Denial of access to legal system/remedies
Physical indicator:
- consistent denial of telephone or Internet access.
Behavioural signs:
- person does not seek privacy to undertake activities normally undertaken in private
- person indicates they have no-one to speak to about things they are unhappy about.
Systemic abuse
Physical indicators:
- no program or inadequate/inappropriate program developed for client
- not endeavouring to use staff of the same gender to perform personal duties for clients
- providing staff with insufficient training on duty of care and policies and practices related to preventing abuse.
Behavioural signs:
- person is persistently provided support that does not meet the requirements of their service package
- person refuses part of their service support due to feeling uncomfortable with particular staff members.
Neglect
Physical indicators:
- physical wasting, unhealthy weight levels
- poor dental health
- food from meals left on face and/or clothes throughout the day
- dirty, unwashed body and/or face, body odour
- person always wearing the same clothes
- ill-fitting and/or unwashed clothes
- person is always over- or underdressed for the weather conditions
- food is consistently poor quality, insufficient, inedible and/or unappetising.
Behavioural signs:
- constant tiredness
- persistent hunger
- unexpectedly poor social/interpersonal skills
- signs of loss of communication and other skills
- staff member, service provider, carer or support person consistently fails to bring the person to appointments, events, activities
- person is persistently denied opportunities to socialise with others in the community.
Risk factors
Below are a number of characteristics that should be considered in assessing a person’s exposure to risk of abuse, neglect and exploitation. An assessment of circumstances might then help disability services staff to develop strategies to reduce risk.
Service characteristics
- Segregated service environments (e.g. residential care facilities, sheltered employment)
- Overcrowding
- Incompatibility between residents and/or co-workers or other service users
- Clients not valued and respected
- Tolerance of violence
- Lacking quality management systems
- High staff turnover
Family characteristics
- Low levels of attachment between family members (parent–child, sibling relationships)
- Past or current substance abuse
- Perceived caregiver stress
- Social isolation
- Power and control issues
- Poor health and wellbeing, including social determinants such as low income, inadequate housing etc.
- Negative attitudes towards people with disability demonstrated by family members
- High levels of dependency (either on or by the person with a disability)
- Lack of awareness and use of formal supports
- History of family violence and attitudes suggesting a tolerance of family violence
Individual characteristics
- Social isolation and lack of close relationships
- Communication difficulties
- Challenging, disruptive, reckless and/or risky behaviour
- Inappropriate sexual behaviour
- Learnt over-compliance or complete dependence on caregivers
- Limited physical mobility
- Limited sense of personal power, low self-esteem
- Low income or restricted access to resources
- Limited sex education or age-appropriate sexual experiences
- High tolerance of violence
- Lack of self-protection skills
- Limited life experiences
- Lack of knowledge of rights
This list of characteristics is not exhaustive and other factors may also contribute to or increase a person’s risk. A number of people with disability have significant communication and sensory issues, and as a result may have difficulty raising concerns about incidences of abuse, neglect and exploitation. It is essential that people with communication and sensory issues are provided with appropriate communication tools.
Australian Health. (2017). Principles for goal setting. https://www.health.gov.au/sites/default/files/documents/2021/01/principles-for-goal-setting.pdf
Developing person-centred goals
Meaningful and achievable goals are critical to the success of wellness and reablement. Without goals, clients can feel overwhelmed and unsure of how to get where they want to go. While there is no universal tool for setting meaningful and achievable goals, there are certain principles that should underpin the goal setting process with your clients.
Developing using SMARTA
Each client is different, there is no one-size-fits all to developing a care plan and delivering support. Due to this, the support-based goals you and your client develop together should be person-centred and suited to their aspirations and needs. Using the SMARTA approach can help you create clear, concise, and measurable goals with your clients which are based on their individual needs and preferences. In addition, using this approach will help to motivate and empower your client to achieve their goals
Specific
Be as specific as possible, because the more precisely you can describe the goal, the clearer the client will be on what they are striving for, and what their role is in achieving it. When setting a specific goal, consider the following:
- Who is involved?
- Is the goal in the client’s voice? E.g., using the client’s language
- What does the client want to accomplish?
- Where, when will this happen? E.g., location and timeframe
- Why are we setting this goal? E.g., what are the benefits, specific reasons for this goal?
Example: general goal versus specific
General: I want to be healthy
Specific: I will walk 15 min/day, 3 days/wk
Measurable
Always include a measurable way to monitor and track progress for each goal you set. When a client is able to see and follow their progress, they are more likely to stay on track and be motivated to achieve their goal.
Example: to determine if your goal is measurable
Using the example above, the specific goal of 'I will walk 15 minutes a day, 3 days a week' - shows you how the goal will be tracked and when the client knows they have achieved it. For example, if they walk for 10 minutes on day 1, 12 minutes on day 2, then they know they are making progress. The goal is measurable because it specifies how many, how much and when it will be achieved.
Achievable
Assess and discuss with the client whether the goal is achievable. For a goal to be achievable it must be about something of interest to the client, realistic to achieve and also challenging. Discussing what needs to be done to achieve the goal often indicates whether the client is motivated and willing to do it.
Example: there needs to be a balance between setting achievable and challenging goals. If a goal is not sufficiently challenging, it will fail to motivate the client. However, if the client perceives the goal as being too hard, they will lose hope of achieving it.
Relevant
Goals need to be relevant to the client. This means they have to be meaningful and align with client’s needs and wants. The deeper the connection between the client and the goal, the higher the chances are of them staying motivated and on track to achieving it.
Example: say a client wants to improe their aerobic fitness but does not enjoy walking, do not suggest walking for 15 minutes a day, 3 days a week as one of their SMARTA goals. Rather, discuss with the client a goal that is aligned to their interests and that improves their aerobic fitness. For example gardening, regular shopping or aqua aerobics.
Time-limited
A goal should be grounded in a timeframe. This is easier to do when services are within a time-limited period. However, a general rule in goal setting is that all goals require a timeframe or else there is no urgency or motivation to achieve them. Deadlines are what make most people switch to action. However, it is important to not be overly stringent; goal timeframes need to be tied to a client’s ability and capacity to achieve it.
Example:
Generic goal: I want to be able to dress myself:
Specific goal: I want to be able to dress myself independently with no assistance in six weeks.
Agreed
For goals to be actively pursued and progressed by the client, they must be co-designed and include shared participation and agreement. This will help the client to personally commit to reaching the goals. It will also increase their motivation and attachment to reaching their outcomes.
Example: make sure you seek verbal confirmation from a client that the goal is appropriate, achievable and aligned with where they want to go.
Goal-setting checklist
| Specific |
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| Measurable |
|
| Achievable |
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| Relevant |
|
| Timely |
|
| Agreed |
|
