Advisory CMO 24/01: Not applicable actions in the NSQMHCMO Standards

26 September 2024

To clarify not applicable actions for community managed organisations providing mental health services.

Advisory details

Item	Details
Advisory number	CMO 24/01
Version number	1.0
Publication date	26 September 2024
Replaces	N/A
Compliance with this advisory	It is mandatory for approved accrediting agencies to implement this Advisory
Information in this advisory applies to	All approved accrediting agencies All mental health CMO Service Providers
Key relationship	National Safety and Quality Mental Health Standards for Community Managed Organisations
Notes
Responsible officer	Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au
To be reviewed	December 2025

Purpose

To clarify not applicable actions for community managed organisations providing mental health services.

Issue

In some circumstances, actions in the National Safety and Quality Mental Health Standards for Community Managed Organisations (NSQMHCMO Standards) may not be applicable to a Service Provider. The Commission has issued this advisory to ensure accrediting agencies consistently apply not applicable status to actions within the NSQMHCMO Standards.

Requirements

The summary table below details the actions that may be awarded a not applicable rating by an approved accrediting agency, subject to satisfactory supporting evidence being provided by the Service Provider.

Where a Service Provider considers that an action is not applicable, evidence must be supplied that there is little or no risk of harm to consumers in their service context. Applications should be submitted to the accrediting agency well in advance of the assessment. Accrediting agencies are to provide an initial determination of the Service Provider’s submission before undertaking the scheduled assessment. At assessment, assessors are to verify that the decision to award these actions not applicable status is justified.

An action may be applicable to a Service Provider yet only apply to some of the Service Provider’s mental health services. For example, Action 1.25 only applies to residential services. For Service Providers that include residential services as a component of their overall mental health services, the action will be applicable, but assessment will be limited to the residential services.

Infrequent application of an action is not sufficient reason for awarding not applicable status. For example, under Action 1.23, a Service Provider may not directly provide services to children or young people but should be able to demonstrate that child safe principles have been considered and risks minimised. Where an action is infrequently applied, strategies to implement the action are likely to be a simple monitoring and review process by the Service Provider.

Where there is a dispute concerning an award of not applicable status that is not resolved following discussions between the Service Provider and the accrediting agency, application can be made by either the accrediting agency or the Service Provider to the Commission for mediation.

Further information

Further information on the NSQMHCMO Standards and accreditation can be found at: www.safetyandquality.gov.au/mh-cmos

Email: Advice.Centre@safetyandquality.gov.au
Phone: 1800 304 056

Summary tables of not applicable actions

Practice Governance Standard

Action	Advice
1.01	No exclusion.
1.02	No exclusion.
1.03	No exclusion.
1.04	No exclusion.
1.05	No exclusion.
1.06	No exclusion.
1.07	No exclusion.
1.08	No exclusion.
1.09	No exclusion.
1.10	No exclusion.
1.11	No exclusion.
1.12	No exclusion.
1.13	No exclusion.
1.14	No exclusion.
1.15	No exclusion.
1.16	No exclusion.
1.17	No exclusion.
1.18	No exclusion.
1.19	No exclusion.
1.20	No exclusion.
1.21	No exclusion.
1.22	No exclusion.
1.23	No exclusion.
1.24	Not applicable when evidence is provided that the Service Provider does not provide services in consumers’ homes.
1.25	Not applicable when evidence is provided that the Service Provider does not provide residential services.
1.26	No exclusion.
1.27	No exclusion.

Partnering with Consumers Standard

Action	Advice
2.01	No exclusion.
2.02	No exclusion.
2.03	Not applicable when evidence is provided that the Service Provider has no access to consumers’ money or other property.
2.04	No exclusion.
2.05	No exclusion.
2.06	No exclusion.
2.07	No exclusion.
2.08	No exclusion.
2.09	No exclusion.
2.10	Not applicable when evidence is provided that the Service Provider does not develop consumer information about the service or mental health internally.
2.11	No exclusion.
2.12	No exclusion.
2.13	No exclusion.
2.14	No exclusion.
2.15	No exclusion.
2.16	No exclusion.

Model of Care Standard

Action	Advice
3.01	Not applicable when evidence is provided that the Service Provider is not responsible for establishing the model of care.
3.02	No exclusion.
3.03	No exclusion.
3.04	No exclusion.
3.05	No exclusion.
3.06	No exclusion.
3.07	No exclusion.
3.08	No exclusion.
3.09	No exclusion.
3.10	No exclusion.
3.11	No exclusion.
3.12	No exclusion.
3.13	No exclusion.
3.14	No exclusion.
3.15	No exclusion.
3.16	No exclusion.
3.17	No exclusion.
3.18	No exclusion.
3.19	No exclusion.
3.20	No exclusion.
3.21	Not applicable when evidence is provided that there are no circumstances in which a Service Provider uses restrictive practices.
3.22	Not applicable when evidence is provided that there are no circumstances in which a Service Provider uses restrictive practices.
3.23	No exclusion.
3.24	Not applicable when evidence is provided that consumers of the service are not at risk of pressure injuries.
3.25	Not applicable when evidence is provided that consumers of the service are not at risk of falls.
3.26	Not applicable when evidence is provided that the Service Provider does not deliver overnight care to consumers.
3.27	No exclusion.
3.28	No exclusion.
3.29	No exclusion.
3.30	No exclusion.
3.31	No exclusion.
3.32	No exclusion.
3.33	No exclusion.
3.34	No exclusion.
3.35	Not applicable when evidence is provided that the Service Provider does not prescribe or administer antimicrobials to consumers.
3.36	Not applicable when evidence is provided that the Service Provider does not prescribe or administer medicines to consumers.
3.37	Not applicable when evidence is provided that the Service Provider does not prescribe or administer medicines to consumers.
3.38	No exclusion.
3.39	Not applicable when evidence is provided that the Service Provider does not prescribe or administer medicines to consumers.