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Accreditation, Compliance and Quality

Timboon and District Healthcare Service (TDHS) is committed to providing safe, high-quality, person-centred care across all of our services. We maintain comprehensive governance, compliance and quality systems to ensure we meet legislative requirements, industry standards and community expectations.

Our commitment to compliance and continuous improvement helps ensure patients, residents, clients and visitors can have confidence in the care and services we provide.


Accreditation and Quality Standards

TDHS participates in a range of external accreditation and quality assurance programs that independently assess our performance against nationally recognised standards.

These accreditation programs assure that our systems, processes and services are focused on safety, quality, continuous improvement and positive consumer outcomes.

Timboon and District Healthcare Service (TDHS) is accredited against the National Safety and Quality Health Service (NSQHS) Standards, Australia’s nationally recognised framework for ensuring safe and high-quality healthcare.

These standards help ensure that consumers and their families receive care that is safe, effective and centred around their individual needs. Independent assessors regularly review our services to ensure we continue to meet these standards and identify opportunities for improvement.

The NSQHS Standards focus on nine key areas:

  • Standard 1 – Clinical Governance
    Making sure TDHS has strong leadership, systems and processes in place to support safe, high-quality care and continuous improvement.
  • Standard 2 – Partnering with Consumers
    Working together with consumers, families and carers to make informed care decisions and improve our services.
  • Standard 3 – Preventing and Controlling Infections
    Reducing the risk of infections through effective hygiene practices, infection-prevention measures, and staff education.
  • Standard 4 – Medication Safety
    Ensuring medicines are prescribed, supplied and administered safely to reduce the risk of medication-related harm.
  • Standard 5 – Comprehensive Care
    Providing care that considers a person’s physical, emotional, mental, cultural and social needs, while supporting their individual goals and preferences.
  • Standard 6 – Communicating for Safety
    Supporting clear and effective communication between healthcare professionals, consumers and their families to improve care and reduce risk.
  • Standard 7 – Blood Management
    Ensuring blood and blood products are used safely, appropriately and only when needed.
  • Standard 8 – Recognising and Responding to Acute Deterioration
    Having systems in place to quickly identify and respond when a consumer’s condition changes or worsens.
  • Integrated Health and Aged Care Services Module
    Ensuring residential aged care services are delivered safely and of a high quality with a person-centred care approach.

Our Commitment to Quality Care

Meeting the NSQHS Standards is part of our ongoing commitment to delivering safe, high-quality healthcare for our community. We continually review our services, listen to feedback, and work to improve the care and experience of everyone who accesses TDHS services.

If you would like more information about the NSQHS Standards, please speak with a member of our team.

At Timboon and District Healthcare Service (TDHS), we are committed to providing safe, respectful and high-quality aged care services that support older people to live with dignity, independence and choice.

Our community aged care services are delivered in line with the Strengthened Aged Care Quality Standards, which set clear expectations for the quality of care and services older Australians should receive.

These standards place older people at the centre of care and help ensure that consumers are treated with respect, have a voice in decisions that affect them, and receive care that reflects their individual needs, preferences and goals.

  • Standard 1: The Individual
    We respect each person’s rights, identity, culture, beliefs and life experiences. We support consumers in making their own choices, maintaining their independence, and having a say in the care and services they receive.
  • Standard 2: The Organisation
    We are committed to strong leadership, good governance and a culture of safety and quality. This means having the right systems, processes and workforce in place to provide high-quality care and continually improve our services.
  • Standard 3: The Care and Services
    We work closely with consumers, families and carers to understand individual needs and goals. Care and services are tailored to each consumer and regularly reviewed to ensure they continue to meet changing needs and preferences.
  • Standard 4: The Environment
    We provide a safe, comfortable and welcoming environment where consumers feel secure, respected and at home. This includes maintaining safe facilities, equipment and infection prevention practices that support health and wellbeing.
  • Standard 5: Clinical Care
    We provide safe and effective clinical care that is delivered by qualified and experienced healthcare professionals. Clinical care is planned in partnership with residents and focuses on supporting health, wellbeing and quality of life.
  • Standard 6: Food and Nutrition
    We understand the important role food plays in health, wellbeing and enjoyment. Consumers are provided with nutritious meals, snacks and drinks that reflect their dietary requirements, preferences and cultural needs wherever possible.
  • Standard 7: The Residential Community
    We support consumers to stay connected with family, friends and the broader community. We aim to create an inclusive and welcoming environment where people can participate in activities, build relationships and continue to live meaningful lives.

Our Commitment

Meeting the Aged Care Quality Standards is part of our commitment to providing compassionate, person-centred care for older people in our community.

We regularly seek feedback from consumers, families and carers, and use this feedback to continually improve the care and services we provide.

Timboon and District Healthcare Service (TDHS) is a registered provider under the National Disability Insurance Scheme (NDIS).

As a registered NDIS provider, we are independently assessed against the NDIS Practice Standards to ensure the services and supports we provide are safe, high-quality and focused on the needs and goals of each consumer.

The NDIS Practice Standards are designed to protect the rights of people with disability and promote choice, independence, inclusion and wellbeing.

The standards focus on:

  • Rights and Responsibilities
    We respect and uphold the rights of people with disability, including the right to be treated with dignity and respect, make informed decisions, exercise choice and control, and participate fully in their community.
  • Governance and Operational Management
    We maintain strong leadership, systems and processes to ensure our services are safe, effective and accountable.
  • Provision of Supports
    We work closely with consumers, families and carers to deliver services that are tailored to individual needs, goals and preferences.
  • Safe Environment
    We are committed to providing safe and welcoming environments that support the health, wellbeing and independence of consumers.
  • Feedback and Complaints
    We encourage feedback and provide clear, accessible ways for consumers, families and carers to raise concerns or make complaints. Feedback helps us improve the services we provide.
  • Incident Management and Risk Management
    We have systems in place to identify, manage and learn from incidents, while supporting consumers to make informed choices and manage risks safely.
  • Workforce Capability
    Our staff receive appropriate training, education and support to ensure they have the skills and knowledge required to provide high-quality services.
    Continuous Improvement
    We regularly review our services, seek feedback from consumers and monitor our performance to ensure we continue to improve and meet the needs of our community.

Our Commitment

At TDHS, we are committed to providing disability services that are safe, respectful and person-centred. We work in partnership with consumers to support their independence, wellbeing and goals, while ensuring our services meet the requirements of the NDIS Practice Standards and the expectations of the people we support.

The Timboon Medical Clinic is accredited through Australian General Practice Accreditation Limited (AGPAL), demonstrating our commitment to providing safe, high-quality healthcare to our consumers and community.

AGPAL accreditation involves an independent assessment against the Royal Australian College of General Practitioners (RACGP) Standards for General Practices, which are recognised nationally as the benchmark for quality and safety in general practice.

Accreditation helps ensure that our clinic has the systems, processes and facilities in place to provide safe, effective and patient-centred care.

The RACGP Standards focus on areas including:

  • Patient Safety and Quality Care
    Providing healthcare that is safe, effective and focused on the needs of consumers and their families.
  • Infection Prevention and Control
    Maintaining high standards of hygiene and infection prevention to protect consumers, visitors and staff.
  • Clinical Governance
    Supporting continuous improvement through strong leadership, quality systems and regular review of clinical practice.
  • Practice Operations and Administration
    Ensuring the clinic operates efficiently and provides a welcoming, accessible and well-organised environment for consumers.
  • Medical Records and Information Management
    Maintaining accurate, secure and confidential consumer records while protecting privacy and supporting continuity of care.
  • Risk Management and Emergency Preparedness
    Having systems in place to identify and manage risks, respond to emergencies and maintain consumer safety.
  • Continuous Quality Improvement
    Regularly reviewing our services, seeking consumer feedback and implementing improvements to enhance the care and experience we provide.

Our Commitment

AGPAL accreditation provides independent assurance that the Timboon Medical Clinic meets nationally recognised standards for quality and safety.

Our team is committed to delivering professional, compassionate and patient-centred healthcare; while continually improving the services we provide to support the health and wellbeing of our community.


Privacy and Information Management

Timboon and District Healthcare Service (TDHS) is committed to protecting the privacy and confidentiality of our consumer, families, carers, staff and visitors.

We understand that personal and health information is sensitive and important. We collect, use, store and share information only when it is necessary to provide care, deliver services, meet legal requirements or support the safe and effective operation of our organisation.

TDHS manages personal and health information in accordance with relevant Victorian and Commonwealth privacy legislation, including the Privacy and Data Protection Act 2014 (Vic) and the Health Records Act 2001 (Vic).

We are committed to:

  • Protecting Your Information
    We take reasonable steps to protect personal and health information from loss, misuse, unauthorised access, disclosure or alteration.
  • Maintaining Secure Records
    Information is stored securely, whether in electronic systems or paper records, and access is restricted to authorised staff who require the information to perform their duties.
  • Respecting Confidentiality
    Your personal information will only be accessed, used or shared where it is necessary for your care, required by law, or where you have provided consent.
  • Supporting Access to Information
    You have the right to request access to your personal and health information, and to request corrections if you believe information held about you is inaccurate or incomplete.
  • Managing Information Responsibly
    We are committed to being transparent about how information is collected, used and managed, and to ensuring our practices meet legal and ethical requirements.

Your Privacy Matters

Protecting your privacy is an important part of providing safe, respectful and person-centred care. If you have questions about how your information is managed, or would like to access your records, please contact our Privacy Officer.

For more detailed information, please refer to our Privacy Policy.

Timboon and District Healthcare Service (TDHS) is committed to openness, transparency and supporting individuals to access information about their care.

Under the Freedom of Information Act 1982 (Vic), you have the right to request access to documents held by TDHS, including your medical records. This may include obtaining a copy of your records or arranging to view the original record.

What Information Can I Access?

You may request access to:

  • Your personal information
  • Medical and health records
  • Administrative documents
  • Other documents held by TDHS, subject to legislative requirements and exemptions

In some circumstances, you may also request that personal information be amended if you believe it is inaccurate, incomplete, out of date or misleading.

How Do I Apply?

To make a valid Freedom of Information request, you must:

  1. Submit a Written Application
    Complete and sign a Freedom of Information Request Form and provide a clear description of the documents you are seeking. The more information you can provide, the easier it will be for us to locate the records.
  2. Provide Proof of Identity
    Applications must include photo identification that shows your signature, such as a driver’s licence or passport. If you are applying on behalf of another person, you must also provide written authority from that person or appropriate legal documentation.
  3. Pay the Application Fee
    A statutory application fee applies to Freedom of Information requests. Additional charges may apply depending on the volume of information requested and the time required to process the application.

Financial Hardship

If paying the application fee would cause financial hardship, you may request that the fee be waived. TDHS can consider requests for fee relief where appropriate.

Processing Your Request

Once a valid application has been received, TDHS will process your request in accordance with the Freedom of Information Act.

We will generally provide a decision within 30 days, although this timeframe may be extended in some circumstances as permitted under the legislation.

If access to information cannot be granted, either in full or in part, we will explain the reasons and advise you of any review rights available to you.

Accessing Your Medical Records

Many requests received by TDHS relate to medical records. If you would like to access your health information, our team can help determine the most appropriate process and guide you through the application requirements.

Contact Us

For further information or assistance with a Freedom of Information request, please contact:

Freedom of Information Officer
Timboon and District Healthcare Service
21 Hospital Road, Timboon VIC 3268
Email: timboon.tdhs@swarh.vic.gov.au
Phone: (03) 5558 6000

You can also find additional information about Freedom of Information rights and processes through the Office of the Victorian Information Commissioner (OVIC).


Clinical Governance and Risk Management

At Timboon and District Healthcare Service (TDHS), providing safe, high-quality care is at the heart of everything we do.

Clinical governance is the system we use to make sure our consumers receive care that is safe, effective and focused on their individual needs. It also helps us continually improve the services we provide.

Our approach is guided by the National Model Clinical Governance Framework and Safer Care Victoria’s Clinical Governance Framework, which set the standards for safe and high-quality healthcare across Australia and Victoria.

  • Working Together with Consumers
    We believe people receiving care should be actively involved in decisions that affect them. We work closely with consumers, families and carers to understand what matters most to them, seek feedback and use their experiences to improve our services.
  • Supporting Our Staff
    Providing high-quality care starts with a skilled and supported workforce. We invest in ongoing training, education and professional development to ensure our staff have the knowledge, skills and resources they need to provide safe and effective care.
  • Monitoring Quality and Safety
    We regularly review how our services are performing and look for ways to improve. This includes monitoring patient outcomes, reviewing feedback, conducting audits and implementing improvements when needed to ensure we continue to deliver high-quality care.
  • Creating a Safe Environment
    We have systems in place to help keep patients, residents, visitors and staff safe, including:

    • Managing risks and safety concerns
    • Preventing and controlling infections
    • Supporting medication safety
    • Responding to incidents and learning from them
    • Maintaining safe facilities and equipment
    • Preparing for emergencies

    These systems help us identify issues early, respond appropriately and continually improve the care we provide.

  • A Culture of Continuous Improvement
    We are committed to learning, improving and delivering the best possible care for our community. By listening to feedback, reviewing our performance and adopting best practice, we continue to strengthen the safety and quality of our services.

Our Commitment

When you receive care at TDHS, you can be confident that we are committed to providing care that is safe, respectful, person-centred and focused on achieving the best possible outcomes for you and your family.


Occupational Health and Safety

Timboon and District Healthcare Service (TDHS) is committed to providing a safe, healthy and respectful environment for everyone who visits, lives, works or receives care at our service.

The safety and wellbeing of our consumers, visitors, volunteers and staff is an important part of delivering high-quality care.

We work to create safe environments by:

  • Identifying and managing risks
  • Maintaining safe buildings, equipment and facilities
  • Providing education and training for staff
  • Preparing for emergencies and unexpected events
  • Preventing workplace injuries and incidents
  • Supporting the health, safety and wellbeing of our workforce

Creating a Safe Environment for Care

Everyone has a role to play in maintaining a safe environment.

We ask consumers, residents, visitors and staff to:

  • Follow safety signs and instructions
  • Report hazards or safety concerns
  • Practise good hand hygiene and infection prevention measures
  • Treat others with courtesy and respect
  • Follow emergency instructions if required

Respectful and Safe Behaviours

TDHS is committed to providing an environment where everyone feels safe and respected.

We do not tolerate behaviour that places the safety or wellbeing of others at risk, including violence, aggression, bullying, harassment or discrimination.

Our Commitment

We continually review our safety practices and work to improve the environments in which care is delivered.

By maintaining strong health and safety systems, we help ensure that everyone who accesses TDHS services can feel safe, supported and respected.


Whistleblower Protections and Public Interest Disclosures

Timboon and District Healthcare Service (TDHS) is committed to maintaining the highest standards of integrity, accountability and ethical conduct.

We encourage staff, volunteers, contractors, consumers and members of the community to report concerns about suspected wrongdoing, corruption, misconduct or other inappropriate behaviour that may affect the organisation, its people or the community we serve.

Under Victorian legislation, individuals who make a report in good faith may be protected through the Public Interest Disclosure (Whistleblower) framework.

Speaking Up Safely

TDHS is committed to creating an environment where people feel safe and supported to raise concerns without fear of intimidation, discrimination, victimisation or reprisal.

Anyone who reports suspected wrongdoing in good faith will be treated with respect, and their concerns will be managed appropriately and confidentially, in accordance with legislative requirements.

What Can Be Reported?

Examples of conduct that may be reported include:

  • Corruption or fraudulent activity
  • Misuse of public funds or resources
  • Serious misconduct or unethical behaviour
  • Breaches of laws, regulations or policies
  • Conduct that creates a substantial risk to public health, safety or the environment
  • Actions that undermine public trust in the organisation

Our Commitment

TDHS is committed to:

  • Providing safe and confidential reporting pathways
  • Taking concerns seriously and responding appropriately
  • Assessing reports fairly and impartially
  • Protecting the identity of whistleblowers where required by law
  • Preventing victimisation, harassment or retaliation against those who raise concerns in good faith
  • Meeting all obligations under Victorian Public Interest Disclosure legislation

Making a Report

If you have concerns about suspected wrongdoing within TDHS, you are encouraged to raise them through the appropriate reporting channels.

Reports will be managed confidentially and in accordance with TDHS policies and Victorian legislation.

Building a Culture of Integrity

Whistleblower protections play an important role in promoting transparency, accountability and ethical behaviour. By supporting people to speak up when something is not right, we help create a safer, stronger and more trustworthy organisation for our community.


Continuous Improvement

At Timboon and District Healthcare Service (TDHS), we are committed to continually improving the care and services we provide to our community.

We believe that quality healthcare is built on listening, learning and adapting. By regularly reviewing our performance and seeking feedback from consumers, families, carers, staff and community members, we can identify opportunities to improve and ensure our services continue to meet the needs of our community.

How We Improve

We use a range of activities to monitor and improve the quality and safety of our services, including:

  • Consumer feedback and satisfaction surveys
  • Clinical audits and service reviews
  • Accreditation assessments
  • Incident reporting and learning
  • Quality improvement projects
  • Staff education and professional development
  • Community and consumer engagement
  • Monitoring performance against key quality and safety indicators

Listening to Our Community

The experiences and feedback of those who use our services are invaluable. We encourage consumers, families and carers to share their feedback, suggestions and ideas.

Whether it’s a compliment, suggestion or concern, your feedback helps us understand what we are doing well and where we can do better.

Our Commitment

Continuous improvement is part of our culture and our commitment to providing safe, high-quality and person-centred care.

By learning from experience, embracing innovation and working in partnership with our community, we strive to ensure our services remain safe, effective, accessible and responsive to the needs of the people we serve.

Page last updated: 16 June 2026