Implementation guidelines for private office based mental health practices

Standard 2: Safety

Page last updated: October 2010

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

Suggested evidence


The intent of this Standard is to ensure that mental health services (MHS) provide a safe environment for consumers, carers, visitors and staff. This can be achieved by identification, analysis, treatment or correction, monitoring and review of risks to safety.

Promoting safety (Criterion 2.1)

The MHS must ensure the safety and wellbeing of its consumers, carers, staff and others.

Cultural beliefs form an important aspect of consumers' understanding and response to health care. Protection of consumers' cultural needs should be considered when reviewing safety issues. Care should be delivered with consumers' culture and diversity taken into account. Otherwise culturally inappropriate care may result in misunderstandings, placing the consumers at risk of events that may adversely affect their mental health and recovery. Further requirements of culture and diversity are addressed in Standard 4 Diversity responsiveness.

Culturally safe environments are those in which a consumer feels safe and that their mental health and overall health needs are understood. When a consumer's culture is viewed as an essential component of their care they feel empowered to make decisions on their care and recovery.

Legislation, regulations and guidelines (Criteria 2.6, 2.7)

Examples of relevant safety legislation, regulations and guidelines include:
  • the Australian Health Ministers' Mental health: statement of rights and responsibilities (1991)
  • national and state and territory working groups guidelines on quality and safety
  • state and territory occupational health and safety legislation
  • state and territory mental health legislation and related Acts
  • National safety priorities in mental health: a national plan for reducing harm (2005)
  • Royal Australian and New Zealand College of Psychiatrists Code of Ethics 2004.
Information on infection control should be available to staff, consumers and visitors and infection control standards should be adhered to in the MHS.

The MHS must have policy and procedures to ensure the safety of all people within the service setting, particularly those who are vulnerable.

The MHS must be conducted in an appropriately designed facility ensuring the physical environment is appropriate to deliver and facilitate safe and effective care.
Top of page
The policies and procedures to address safety issues for consumers, carers and staff in office based practice include:
  • identifying the appropriate delivery of care for the consumer
  • identifying the carers
  • managing medication and adverse medication events
  • managing clinical handover and transfer of care
  • minimising the risk of self harm and suicide
  • identifying and managing risks
  • security measures
  • controlling infection.
The MHS should have procedures to help staff, consumers, their carers and other visitors when they have been exposed to a traumatic incident within the service.

Staff safety (Criteria 2.8, 2.9, 2.10)

The MHS should employ sufficient staff to ensure their safety and the safety of consumers, carers and others. If staff are required to work alone the MHS should have written protocols that address any issues identified in a risk assessment.

The risk assessment of staff working conditions could include:
  • staff working alone and access to others at all times
  • personal security on and off site
  • violence and aggression
  • lifting and manual handling
  • hazardous substances
  • security of medications and other stores
  • evacuation in the event of a fire or other danger
  • adverse event or incident management.
Top of pageStaff should be trained in workplace health and safety in accordance with relevant legislation. There should also be evidence of staff participation in comprehensive, updated and revised training in the use of strategies to identify, prevent or de-escalate agitation, aggression and interpersonal violence.

The MHS should have a formal critical incident and emergency response plan to ensure the safety and security of staff and others within the MHS when such incidents occur.

Assessment (Criterion 2.11)

Regular assessments of the environment of the MHS should be carried out and action taken to mitigate the risk of harm.

Review and analysis of risks (Criteria 2.12, 2.13)

Office based practitioners should regularly review environmental risk and its mitigation.

Suggested evidence

Evidence that may be provided for this standard includes:
  • policies and procedures:
    • workplace health and safety
    • risk management
    • aggression and violence
    • infection control
    • staffing and resource management
    • staff safety.