National standards for mental health services 2010

Standard 10. Delivery of care

Page last updated: 2010

10.1 Supporting recovery
10.2 Access
10.3 Entry
10.4 Assessment and review
10.5 Treatment and support
10.6 Exit and re-entry

10.1 Supporting recovery

The MHS incorporates recovery principles into service delivery, culture and practice providing consumers with access and referral to a range of programs that will support sustainable recovery.


The MHS actively supports and promotes recovery oriented values and principles in its policies and practices.
The MHS treats consumers and carers with respect and dignity.
The MHS recognises the lived experience of consumers and carers and supports their personal resourcefulness, individuality, strengths and abilities.
The MHS encourages and supports the self determination and autonomy of consumers and carers.
The MHS promotes the social inclusion of consumers and advocates for their rights of citizenship and freedom from discrimination.
The MHS provides education that supports consumer and carer participation in goal setting, treatment, care and recovery planning, including the development of advance directives.
The MHS supports and promotes opportunities to enhance consumers' positive social connections with family, children, friends and their valued community.
The MHS demonstrates systems and processes for consumer and carer participation in the development, delivery and evaluation of the services.
The MHS has a comprehensive knowledge of community services and resources and collaborates with consumers and carers to assist them to identify and access relevant services.
The MHS provides access for consumers and their carer(s) to a range of carer-inclusive approaches to service delivery and support. Top of page

10.2 Access

The MHS is accessible to the individual and meets the needs of its community in a timely manner.


Access to available services meets the identified needs of its community in a timely manner.
The MHS informs its community about the availability, range of services and methods for establishing contact with its service.
The MHS makes provision for consumers to access acute services 24 hours per day by either providing the service itself or information about how to access such care from a 24/7 public mental health service or alternate mental health service.
The MHS, wherever possible, is located to provide ease of physical access with special attention being given to those people with physical disabilities and/or reliance on public transport. Top of page

10.3 entry

The entry process to the MHS meets the needs of its community and facilitates timeliness of entry and ongoing assessment.


The MHS has a written description of its entry process, inclusion and exclusion criteria and means of facilitating access to alternative care for people not accepted by the service.
The MHS makes known its entry process, inclusion and exclusion criteria to consumers, carers, other service providers, and relevant stakeholders including police, ambulance services and emergency departments.
The MHS has a documented system for prioritising referrals according to risk, urgency, distress, dysfunction and disability with timely advice and / or response to all those referred, at the time of assessment.
The entry process to the MHS is a defined pathway with service specific entry points that meet the needs of the consumer, their carer(s) and its community that are complementary to any existing generic health or welfare intake systems.
Entry to the MHS minimises delay and the need for duplication in assessment, treatment, care and recovery planning and care delivery.
Where admission to an inpatient psychiatric service is required, the MHS makes every attempt to facilitate voluntary admission for the consumer and continue voluntary status for the duration of their stay.
When the consumer requires involuntary admission to the MHS the transport occurs in the safest and most respectful manner possible and complies with relevant Commonwealth and state / territory policies and guidelines, including the National Safe Transportation Principles.
The MHS ensures that a consumer and their carer(s) are able to identify a nominated person responsible for coordinating their care and informing them about any changes in the care management. Top of page

10.4 Assessment and review

Consumers receive a comprehensive, timely and accurate assessment and a regular review of progress is provided to the consumer and their carer(s).


Assessments conducted and diagnoses made are evidence-based and use accepted methods and tools, as well as internationally accepted disease classification systems.
Assessments are conducted during the consumer's first contact with the MHS by appropriately qualified staff experienced and trained in assessing mental health problems, and where possible in a consumer's preferred setting with consideration of safety for all involved.
The MHS, with the consumer's informed consent includes carers, other service providers and others nominated by the consumer in assessment.
The MHS actively plans as early as possible in the course of psychiatric inpatient admission, for the discharge of the consumer from inpatient care.
The MHS conducts a review of a consumer's treatment, care and recovery plan when the consumer:
  • requests a review
  • declines treatment and support
  • is at significant risk of injury to themself or another person
  • receives involuntary treatment or is removed from an involuntary order
  • is transferred between service sites
  • is going to exit the MHS
  • is observed through monitoring of their outcomes (satisfaction with service, measure of quality of life, measure of functioning) to be in decline.
    The MHS conducts assessment and review of the consumer's treatment, care and recovery plan, whether involuntary or voluntary, at least every three months (if not previously required for reasons stated in criteria 10.4.5 above).
    The MHS has a procedure for appropriate follow-up of those who decline to participate in an assessment.
    There is a current individual interdisciplinary treatment, care and recovery plan, which is developed in consultation with and regularly reviewed with the consumer and with the consumer's informed consent, their carer(s) and the treatment, care and recovery plan is available to both of them. Top of page

    10.5 Treatment and support

    The MHS provides access to a range of evidence based treatments and facilitates access to rehabilitation and support programs which address the specific needs of consumers and promotes their recovery.


    Treatment and support provided by the MHS reflects best available evidence and emphasises early intervention and positive outcomes for consumers and their carer(s).
    Treatment and services provided by the MHS are responsive to the changing needs of consumers during their episodes of care that address acute needs, promote rehabilitation and support recovery.
    The MHS is responsible for providing the consumer and their carer(s) with information on the range and implications of available therapies.
    Any participation of the consumer in clinical trials and experimental treatments is subject to the informed consent of the consumer.
    The MHS provides the least restrictive and most appropriate treatment and support possible. Consideration is given to the consumer's needs and preferences, the demands on carers, and the availability of support and safety of those involved.
    Medications are prescribed, stored, transported, administered and reviewed by authorised persons in a manner consistent with Commonwealth, state/ territory legislation and related acts, regulations and professional guidelines.
    The MHS actively promotes adherence to evidenced based treatments through negotiation and the provision of understandable information to the consumer.
    The views of the consumer and their carer(s), and the history of previous treatment is considered and documented prior to administration of new medication and/or other technologies.
    The MHS ensures that there is continuity of care or appropriate referral and transfer between inpatient, outpatient, day patient, community settings and other health/ support services.
    The MHS ensures that medication and/or other therapies when required, are only used as part of a documented continuum of treatment strategies.
    The treatment and support provided by the MHS is developed and evaluated collaboratively with the consumer and their carer(s). This is documented in the current individual treatment, care and recovery plan.
    The MHS facilitates access to an appropriate range of agencies, programs, and/or interventions to meet the consumer's needs for leisure, relationships, recreation, education, training, work, accommodation and employment in settings appropriate to the individual consumer.
    The MHS supports and/or provides information regarding self care programs that can enable the consumer to develop or re-develop the competence to meet their everyday living needs.
    The setting for the learning or the re-learning of self care activities is the most familiar and/or the most appropriate for the skills acquired.
    Information on self care programs or interventions is provided to consumers and their carer(s) in a way that is understandable to them.
    The MHS endeavours to provide access to a range of accommodation and support options that meet the needs of the consumer and gives the consumer the opportunity to choose between these options.
    The MHS promotes access to vocational support systems, education and employment programs. Top of page

    10.6 Exit and re-entry

    The MHS assists consumers to exit the service and ensures re-entry according to the consumer's needs.


    The MHS ensures that on exiting the service the consumer has access to services that promote recovery and aim to minimise psychiatric disability and prevent relapse.
    The consumer and their carer(s) are provided with understandable information on the range of relevant services and support available in the community.
    The MHS has a process to commence development of an exit plan at the time the consumer enters the service.
    The consumer and their carer(s) and other service providers are involved in developing the exit plan. Copies of the exit plan are made available to the consumer and with the consumers' informed consent, their carer(s).
    The MHS provides consumers, their carers and other service providers involved in follow-up with information on the process for re-entering the MHS if required.
    The MHS ensures ease of access for consumers re-entering the MHS.
    Staff review the outcomes of treatment and support as well as ongoing follow-up arrangements for each consumer prior to their exit from the MHS.
    The MHS, in conjunction with the treating clinician, has a procedure for appropriate follow-up of all consumers within 7 days after discharge from inpatient care wherever possible, and has a follow-up procedure for those consumers who do not keep the planned follow-up arrangements.