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Aged Care Quality and Safety Commission - Glossary

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AAT – See Administrative Appeals Tribunal

Accommodation bond – A lump sum payment for accommodation in an aged care home paid by a resident who first entered permanent residential care before 1 July 2014.

Accreditation decision – A decision about a residential service’s accreditation or re-accreditation by the Commissioner (or delegate) (not part of the Assessment Team). Residential services must be accredited to continue receiving residential care subsidies from the Commonwealth Government.

Accredited service – A service which has been approved by the Commission to provide care and services to aged care consumers.

As defined in the Rules:

(a) a residential care service, or a flexible care service, that has been accredited or re accredited under Part 3 for a particular period and that period has not ended; or
(b) a residential care service for which a determination under section 42 5 of the Aged Care Act in force; or
(c) a flexible care service that is a deemed accredited service.

Administrative Appeals Tribuna (AAT) – Entity which conducts independent merits review of administrative decisions made under Commonwealth laws. The AAT reviews decisions made by Australian Government ministers, departments and agencies and, in limited circumstances, decisions made by state government and non-government bodies.

Advance care directive – A document completed and signed by a competent consumer who still has decision-making capacity regarding their future care and preferences for end-of-life care.

In Australia, advance care directives are recognised by specific legislation or common law. Advance care directives can record the person’s preferences for future care and/or appoint a substitute decision-maker to make decisions about the person’s health care.

Advance care planning – The process of planning for future health and personal care, whereby the person’s values, beliefs and preferences are made known so they guide decision-making at a future time when that person cannot make or communicate their decisions.

Adviser – An individual selected and contracted directly by the approved provider to assist the provider to return to compliance in relation to care and services/governance and business operations.

The Commission expects that the adviser appointed have the skills, qualifications and experience to address the areas of non-compliance identified at the service, including; experience in senior positions in managing or providing professional advice and support to an aged care service.

Advisers must not be a disqualified individual, or a Commonwealth officer or employee.

Advocate – A person who:

  • publicly supports or recommends a particular cause or policy
  • puts forth a case on someone else’s behalf.

Aged Care Act 1997 (the) – The overarching legislation which outlines the obligations and responsibilities that aged care providers must follow to received subsidies from the Australian Government. Aged Care Act 1997

Aged Care Assessment Team (ACAT) – A team of health professionals which can approve residential care, Home Care Packages and transition care. An ACAT assessor may include a doctor, nurse, social worker or other health professionals.

Aged care consumer (Consumer) – As defined in the Commission Act means:

(a) a care recipient; or
(b) a person who is a recipient of a Commonwealth funded aged care service.

Aged Care Funding Instrument (ACFI) – The instrument used by residential aged care providers to determine the residential care subsidy for each resident who permanently enters their care. This calculation may determine how much an aged care consumer may pay in fees to the residential service provider.

Aged Care Learning Information System (Alis) – The Commission’s online learning system which provides access to Commission educational programs for providers and external stakeholders, with modules focusing on the Quality Standards. Alis can be accessed at

Aged Care Quality and Safety Commission (the Commission) – The national end to end regulator of aged care services, and the primary point of contact for consumers and providers in relation to quality and safety in aged care in Australia.

The Commission’s primary purpose is to protect and enhance the safety, health, well-being and quality of life of aged care consumers; to promote aged care consumers’ confidence and trust in the provision of aged care services; and to promote engagement with aged care consumers about the quality of their care and services.

Aged Care Quality and Safety Commission Act 2018 (the Commission Act– The Commission Act sets out the functions related to the Commission.

Aged Care Quality and Safety Commission Rules 2018 (the Rules) – The Rules set out the process for how the Commission performs its functions as defined in the Commission Act.

Aged Care Quality Standards (Quality Standards) – The Quality Standards with which the Commission requires organisations providing aged care services in Australia to comply. Refer to the Commission’s website for Quality Standards guidance and resources.

Annual Prudential Compliance Statement (APCS) – A statement by the approved provider on how it has met/not met the prudential requirements set in the Aged Care Act and the Fees and Payments Principles 2014 (No. 2).

An approved provider that held one or more entry contributions, accommodation bonds or refundable accommodation deposits at any time during a financial year must submit an APCS. The approved provider must also submit an independent audit of the APCS.

Antimicrobial – A medicine that kills microorganisms, like bacteria, or stops them from growing. Antibiotics and antifungals are antimicrobials.

Antimicrobial resistance – When microorganisms such as bacteria become resistant to antimicrobial medicines such as antibiotics. This results in medications becoming less effective and infections persist in the body, increasing the risk of spread to others.

Antimicrobial stewardship – Efforts by an organisation to reduce the risks related to increasing antimicrobial resistance and to extend the effectiveness of antimicrobial treatments. It can include a broad range of strategies, such as monitoring and reviewing how antimicrobials are used.

Approval, Compliance and Investigations Group – The group within the Commission responsible for the:

  • assessment and determination of applicants suitable to become an approved provider of home, flexible or residential care.
  • management of material change notifications by approved providers
  • revocation on request by approved providers
  • monitoring and management of non-compliance action with a provider
  • review of prudential requirements of residential and financial operations of home care providers
  • management of compulsory reporting intake and escalation of cases for regulatory response.

Approved Provider (AP) – As defined in the Commission Act, a person or body is an approved provider if:

(a) the person or body:
 (i) has been approved as a provider of aged care under section 63D of the Commission Act; or
 (ii) is taken, under paragraph 63F(2)(a), to be an approved provider; and
(b) the approval of the person or body is in effect.
Approved providers may also be referred to as service providers or providers or aged care providers.

Assessment – Regulatory activities undertaken by the Commission, including:

  • provider approval assessment processes
  • assessment of provider compliance with the Quality Standards (including site audits, assessment contacts (performance assessment), quality audits and review audits)
  • assessment of compliance with the Prudential Standards
  • assessment of compliance with the Aged Care Act

Assessment contact – Any form of contact (other than a site audit, a review audit or a quality review) between a Commission regulatory official and the approved provider of an accredited service or a previously accredited service, or the home service providers of a home service, for either or both of the following purposes:

a) to assess the provider’s performance, in relation to the service, against the Quality Standards;
b) to monitor the quality of care and services provided by the provider through the service.

Assessment contact (performance assessment) – means an assessment contact for the purpose of assessing the provider’s performance against the Quality Standards.

Assessment contact (monitoring) – means an assessment contact for the purpose of monitoring the quality of care and services provided by the provider.

Assessment contact (targeted) – means an assessment contact targeted at a specific issue or area of care which has come to the attention of the Commission. These assessment contacts may be for either performance assessment or monitoring purposes.

May be either a site or non-site activity, or a combination of both.

Assessment methodology – An internal Commission resource that provides a framework for, and systematic approach to, consistent assessment of provider performance against the Quality Standards.

Assessment Team – The team formed to conduct a performance assessment (site audit, review audit, quality review or assessment contact (performance assessment)); consists of one or more quality assessors.

Assistance with Care and Housing for the Aged (ACHA) – The program which assists eligible financially disadvantaged older people who are homeless or have insecure accommodation and are at risk of becoming homeless remain in the community.

Authorised complaints officer – An employee of the Australian Government who has been appointed in writing by a delegate of the Commissioner to be an authorised complaints officer for the purposes of Part 8 of the Commission Act.

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Best practice (for clinical care) – Diagnosis, treatment and care are timely and based on the best available evidence, which is used to achieve the best possible outcomes for consumers.

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Campaign – A coordinated plan focused on a specific issue or issues which is organised to promote understanding of key regulatory matters, and to encourage change.

Carer – A person who provides personal care, support and help to a consumer. This does not include members of the organisation’s workforce, or people the organisation contracts or pays to provide those services, or people who provide the services as a volunteer. This definition is in line with the Carer Recognition Act 2010.

Care recipient – A person approved under Part 2.3 of the Aged Care Act as a recipient of aged care.

Case management – The term used by the Commission to describe its monitoring of a provider following a finding of non-compliance with the Quality Standards.

Charter of Aged Care Rights – Describes the rights of consumers of Australian Government funded aged care services to be consulted and respected. Provides the same rights to all consumers, regardless of the type of subsidised care and services they receive. The Charter is made under the Aged Care Act 1997.

Chemical restraint – Refer to restrictive practices.

Clinical care – Health care that encompasses the prevention, treatment and management of illness or injury, as well as the maintenance of psychosocial, mental and physical well-being. It includes care provided by doctors, nurses, pharmacists, allied health professionals and other regulated health practitioners. Organisations providing clinical care are expected to make sure it is best practice, meets the consumer’s needs, and optimises the consumer’s health and well-being.

Clinical governance – An integrated set of leadership behaviours, policies, procedures, responsibilities, relationships, planning, monitoring and improvement mechanisms that are implemented to support safe, quality clinical care and good clinical outcomes for each consumer.

The purpose of clinical governance in aged care is to support the workforce and visiting practitioners in a service to provide safe, quality clinical care as part of a holistic approach to aged care that is based on the needs, goals and preferences of consumers.

Clinical governance framework – Describes the organisational approach for ensuring the quality and safety of clinical care for consumers. organisational approach

Cognitive function or ability – Brain based skills and abilities which relate to carrying out tasks, memory and thinking processes, such as attention, language, decision making and learning.

Cognitive impairment – A description of someone’s condition which may include loss of some memory or thinking abilities. A person with cognitive impairment can find it difficult to learn new things, to concentrate, or make decisions.

Commencing service – A residential service is a commencing service if:

  • an approved provider has been allocated places for the service
  • residential care has not been provided for those places through the service
  • the service is not an accredited or previously accredited service.

A Short Term Restorative Care (STRC) service is a commencing service if:

  • the STRC is provided in a facility where residential care is provided through a residential service
  • that residential service is a commencing service.

A service is not a commencing service if there is a change in the approved provider, a change in the location of the service, or where the service has been closed for a period due to renovations or rebuild.

Commission – The Aged Care Quality and Safety Commission.

Commissioner – The Aged Care Quality and Safety Commissioner.

Commission Act – Legislation which establishes the Commission and enables the Minister to make Rules prescribing matters for carrying out or giving effect to the Commission Act.

Commission Rules – The Rules which give operational effect to the processes of the Commission under the Commission Act.

(CHSP) Programme Manual – An Australian Government consolidated program that provides entry-level home support for older people who need assistance to keep living independently at home and in their community.

Commonwealth Home Support Programme (CHSP) Programme Manual – Sets out the operational and administrative requirements supporting the delivery and management of CHSP.

Provides an overview of CHSP including the types of services it funds and requirements for delivering those services.

Complainant – A person who contacts the Commission and provides information or raises a concern about the care or services being provided to a person receiving Australian Government funded aged care services.

Complaint – An expression of dissatisfaction with any aspect of a provider’s responsibilities that requires the Commission to facilitate the resolution of the complaint.

Complaints management principles – A set of principles which encompass the Commission’s objectives, enablers and operational expectations.

Complaint notices (Notice of intention to Give Directions and Directions) – Explains the preliminary findings on any issues of concern identified through a resolution process and gives the provider the opportunity to respond to the concerns by identifying how it has, or will, address the issues.

Complaints manager – A complaints officer who has a supervisory role.

Complaints officer – A Commission staff member employed to resolve complaints about Australian Government funded aged care services (residential care, flexible care and care in the home). Includes a complaints manager.

Complaints Resolution Group (CRG) – The group within the Commission responsible for the resolution of complaints related to Australian Government funded aged care.

Comprehensive Grant Agreement – Terms and conditions which provide Government with maximum level of control over any grant.

Compulsory reporting – The responsibility of approved providers under the Aged Care Act for reporting suspicions or allegations of reportable assaults occurring at their services to the local police and the Commission within 24 hours.

The law also requires service providers to report that a resident is absent without explanation (also known as a missing resident).

Computer Assisted Auditing Tool (CAAT) – A Commission records management system used to collate and store performance assessment information.

Computer Assisted Telephone Interviewing (CATI) – A telephone survey technique in which the person interviewing follows a script generated by computer software. The software enables the questions to be customised, depending on the responses provided and supports timely data collection and editing.

Conciliation – A process where a complaints officer assists the complainant and provider to reach mutually agreeable outcomes to resolve the issues in complaint.

Conflict of Interest – A serious incompatibility between two or more opinions, principles, or interests.

The Australian Public Service Commission defines two types of conflict of interest – real or actual, and apparent or perceived:

  • A real or actual conflict of interest occurs where there is a direct conflict between the public duty and personal interests of an employee that improperly influences the employee in the performance of his or her duties.
  • An apparent or perceived conflict of interest occurs where it appears that an employee’s personal interests could improperly influence the performance of his or her duties, but this is not in fact the case.

Consumer – A person approved under the Aged Care Act to receive aged care who has been assessed by an Aged Care Assessment Team to receive Australian Government funded aged care services.

Also known as aged care consumer or care recipient.

Consumer-centred care – Care and services designed around an individual’s needs, preferences and background. It includes a partnership between consumers and providers.

Consumer Directed Care (CDC) – Gives people control when making choices about the types of care and services they wish to receive at home. All Home Care Packages are offered on a CDC basis.

Consumer Experience Interview – Interviews with random samples of consumers where a core set of consumer interview questions are used to collect data on the experiences of the quality of care and services from those living in the service.

The findings are reported in a Consumer Experience Report.

Consumer Experience Report – Provides information about consumers’ experiences regarding the quality of care and services they receive in each service, gathered through Consumer Experience Interviews.

Consumer representative – A nominated person given consent by an aged care consumer to speak and act on their behalf. Includes:

  • a person appointed under relevant legislation to act or make decisions on behalf of a consumer; and
  • a person the consumer nominates to be told about matters affecting the consumer.

Continuity of care – Processes that ensure that everyone who cares for a consumer knows, and has information about their care and service needs, choices and preferences.

Helps to ensure that there are no gaps when the responsibility for the delivery of care and services is transferred between individuals within an organisation or different organisations.

Continuous improvement – A systematic, ongoing effort to raise an organisation’s performance in achieving outcomes for consumers under the Quality Standards. Continuous improvement:

  • responds to the needs and feedback of consumers,
  • supports the workforce to improve and innovate in providing safe and quality care and services, and
  • can address practices, process or outputs to achieve a desired outcome.

Contractor and subcontractor – Any person who carries out care and services, or administration or maintenance for an organisation under contract.

Corroboration – Secondary evidence which confirms or supports an initial statement, theory or finding.

Cultural respect – When systems provide a safe environment and where cultural differences are respected and reflected in programs and policies.

Cultural safety – An environment, determined by a consumer or their family, which is spiritually, socially, emotionally and physically safe and respectful, and is a key principle in improving health outcomes.

Culturally safe care – Care and services that are planned and delivered in a way that is spiritually, socially, emotionally and physically safe and respectful for consumers. Culturally safe care and services also ensure that a person’s identity is respected so that who they are and what they need is not questioned or denied.

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Day Therapy Centres (DTC) – Centres which offer allied health and other therapy services and activities to older people living in a community setting, retirement village or low care need facilities. Often funded under grants and administered according to a contract with the Australian Government.

Decision maker – An employee of the Commission who is delegated to make decisions and exercise regulatory functions and powers under the Aged Care Act, the Commission Act and the Rules.

Decision making (supported) – The process of enabling a person who requires support to make, and/or communicate, decisions about their own life. The decision making is supported, but the decision is theirs.

Deemed accredited service – A flexible care service providing short-term restorative care in a residential setting may be a ‘deemed accredited service’ in circumstances where the provider of a flexible care service is allocated flexible care places under Div 14 of the Aged Care Act, and the flexible care places are being provided in an accredited service.

Refer also to the definition of deemed accredited service provided in Section 7 of the Rules.

Delegate – An officer who holds a position to which the Commissioner has delegated powers under the Commission Act or Rules

A delegate should exercise discretion according to their own judgment, consider any factors listed in the legislation and any other factors relevant to a decision, follow steps of legislation and take into account policy guidelines.

Department (the) – The Australian Government Department of Health.

Detailed Resolution Report (DRR) – A record of the issues of a case, a summary of the resolution process adopted, the outcome recommended in relation to each issue and the rationale for recommending the proposed outcome in relation to each of the issues.

Dignity of risk – The concept that all adults have the right to make decisions that affect their lives and to have those decisions respected, even if there is some risk, perceived or actual, to themselves.

A balance between respect for an individual’s autonomy and the protection of their other rights (such as safety, shelter), unless it is unlawful or unreasonably impinges on the rights of others.

Direction – May be issued to a provider where the Commissioner is satisfied that the provider is not meeting its responsibilities.

Will describe the actions to be taken by the provider (and the timeframes within which those actions must be taken) in order to comply with the Aged Care Act and the Rules or the Comprehensive Grant Agreement.

If the provider fails to comply with this direction, compliance action may be taken against the provider.

Disclosure Standard – Describes the disclosure obligations that an approved provider has to residents and potential residents and is set out in the Fees and Payments Principles 2014 (no 2).

Diversity – The varied needs, characteristics and life experiences, which may be social, cultural, linguistic, religious, spiritual, psychological, medical, or care needs of consumers.

Also refers to diverse gender and sexuality identities, experiences and relationships, including lesbian, gay, bisexual, transgender or intersex.

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Early resolution of complaints – The complainant is supported to resolve their concerns quickly and directly with the provider without the Commission’s ongoing formal involvement. The assistance may include providing routine information and discussing the complainant’s concerns with the provider.

End of life care – The care provided to a consumer in the period when they are nearing the end of their life. It can include physical, spiritual, emotional and psychological support.

Entry contribution – Any payment, of money or other valuable contribution, made before 1 October 1997, as defined in the Aged Care Act 1997.

Evidence domain – Combination of related Quality Standards for the purpose of collecting evidence during a performance assessment with a residential service.

The four evidence domains will guide the way an assessment is conducted, who is selected for interview, the questions asked, the observations made, the documents reviewed, which types of evidence are pursued and lines of enquiry. Different pieces of evidence will answer different questions under each domain.

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Flexible care – The type of care provided in a residential or community setting through an aged care service that addresses the needs of people receiving care in alternative ways to the care provided through residential care services and home care services, as defined in section 49-3 of the Aged Care Act 1997.

This includes services provided through Short-Term Restorative Care, Transition Care, Innovative Care or Multi-purpose services.

Freedom of Information (FOI) – Requires that Government Agencies publish a broad range of information under the Freedom of Information Act 1982 (FOI Act). The aim is for the Commission to provide clarity and transparency to its approach to regulation.

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General Purpose Financial Report – A report for a financial year for an approved provider, prepared by the provider as required by section 35A of the Accountability Principles 2014.

Governance – The rules, practices, processes and systems an organisation uses to direct and manage that organisation and its services

Governance Standard – The requirement for an approved provider that holds refundable deposit balances or accommodation bond balances to implement and maintain a governance system that ensures that the balances are only used for permitted uses and can be refunded as and when they fall due. Set out in the Fees and Payments Principles 2014 (No. 2).

Governing body – The individual or group of people with overall responsibility and ultimate accountability for the organisation. This includes responsibility for the strategic and operational decisions that affect the safety and quality of care and services.

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High-impact – A risk that can have a significant effect on a person’s safety, health or well-being.

High-prevalence – A large number of people in a particular group that are affected by the same condition or risk.

Home care – Care consisting of a package of care and services provided in a non-residential care setting.

Home service – means:

(a) a home care service; or
(b) a flexible care service through which short term restorative care is provided in a home care setting; or
(c) a home support service.

Home Care Packages Program – means:

An Australian Government funded co-ordinated package of services tailored to meet the person's specific care needs, with eligibility determined by an Aged Care Assessment Team.

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Immediate and severe risk – When non-compliance is identified the Commission considers whether there is an immediate and severe risk to the safety, health, well-being and quality of life of consumers.

In these cases, 'immediate' means risk that has occurred recently or is likely to occur, or will continue into the future without actions to resolve, or indicates an ongoing risk that a provider has failed to resolve. 'Severe' means risk that has or may result in death, permanent loss of function, is life threatening or other significant adverse outcomes.

Findings of immediate and severe risk result in the Commission imposing sanctions and/or Notice to Agree.

Incident – An event or set of circumstances that resulted or could have resulted in unintended or unnecessary harm, loss or damage to a person

Infection prevention and control program – The plan and processes which an organisation uses to prevent and manage the spread of infection. The scope and complexity of a program will depend on the nature of the care the organisation provides, the context and risk.

The plan and processes that an organisation has in place to manage influenza infections. If an organisation provides residential aged care, their program includes workforce influenza vaccinations, Influenza infection control program as outlined in the Quality of Care Principles 2014.

Interested person – A person whose interests are affected by a decision.

Interested persons are specified under Section 98 of the Rules.

Investigation – A resolution approach in which the Commission may gather evidence from different relevant sources including:

  • the complainant
  • the provider
  • anyone else who can provide relevant information, and
  • by conducting site visits.

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Key Personnel – Defined under the Aged Care Act, relating to an entity, as:

  • a member of the group of persons who are responsible for the executive decisions of the entity at that time
  • any other person who has authority or responsibility for (or significant influence over) planning, directing or controlling the activities of the entity at that time

if, at that time, the entity conducts an aged care service:

  • any person who is responsible for the nursing services provided by the service (must hold a recognised qualification in nursing), and
  • any person who is responsible for the day to day operations of the service
  • whether or not the person is employed by the entity

if, at that time, the entity proposes to conduct an aged care service:

  • any person who is likely to be responsible for the nursing services to be provided by the service (must hold a recognised qualification in nursing), and
  • any person who is likely to be responsible for the day to day operations of the service
  • whether or not the person is employed by the entity.

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Liquidity Standard – Requires an approved provider that holds one or more refundable deposit balances, accommodation bond balances or entry contribution balances to develop, implement and maintain a Liquidity Management Strategy and maintain, in the form specified in the strategy, the minimum level of liquidity required to refund any balances that can be expected to fall due in the next 12 months. Set out in the Fees and Payments Principles 2014 (No. 2).

Long pathway to sanctions – Commences (usually) with the issue of a Non-Compliance Notice and ends in the issuing of a Notice of Decision to Impose Sanction. The intention is to apply an increasing force of regulatory action until the provider returns to compliance; a Sanction may or may not be activated.

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Material change – A change that is substantial or considerable in nature and materially affects the suitability of an approved provider to provide aged care, notified to the Commission within 28 days of that change occurring.

Mediation – A process where an independent mediator assists the complainant and provider to resolve the issues in a complaint.

Medication – A substance or combination of substances that is used to treat, prevent or cure disease, or relieve symptoms of a disease. Many medications are prescribed by a doctor; some can be accessed over the counter.

Medication contraindication – A situation when a medication should not be used because it may be harmful to the person.

Multi-purpose Service (MPS) – A joint initiative of the Australian Government and state and territory governments which aims to deliver flexible and integrated health and aged care facilities for small rural and remote communities.

Is generally established when the local population is not large enough to support separate services, such as a hospital and a residential aged care facility and where there is poor access to essential health and aged care facilities.

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National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP) – A program to provide quality, flexible and culturally appropriate aged care to older Aboriginal and Torres Strait Islander people close to their home and community.

National Disability Insurance Agency – An independent statutory agency which implements the National Disability Insurance Scheme.

National Disability Insurance Scheme (NDIS) – Supports people with permanent and significant disability which may affect their ability to participate in everyday activities. The scheme provides funding directly to individuals.

National Disability Insurance Scheme Quality and Safeguards Commission – An independent agency established to improve the quality and safety of NDIS supports and services.

National Respite for Carers Program (NRCP) – Provides funding to assist carers with information, respite care and other support.

Natural justice – A common law doctrine that provides procedural rights in administrative decision-making to support people being treated fairly and without bias.

Those who are affected by a decision that is made by the Commission have access to natural justice provisions through review processes such as reconsiderations. Or, may receive a notice of intent that sets out a decision that may be made in the absence of any response from the recipient.

The bias rule in administrative law requires that a decision-maker must approach a matter with an open mind that is free of prejudgment and prejudice.

No Further Action (NFA) (letter) – A notification to a provider, in writing, when the non compliance has been remedied and that no further action will be taken in respect of that non-compliance.

Non-Compliance Notice (NCN) – A formal regulatory notice from the Commissioner to a provider stating that the provider has been found non-compliant with the Quality Standards or Prudential Standards.

The Notice identifies the problems that need to be addressed by the provider to ensure that the Quality Standards or Prudential Standards are complied with, including a timeframe that they must be addressed by.

Failure to respond to the Notice, or take action to address non-compliance may lead to sanctions being imposed under the Commission Act.

Notice of Decision to Impose Sanctions (NDIS) – A notification to a provider, in writing, of the Delegate’s decision to impose one or more sanctions on the provider.

The Commissioner may impose one or more sanctions of a kind mentioned in section 63R of the Commission Act on an approved provider if: 

a) the Commissioner is satisfied that the provider has not complied, or is not complying, with one or more of the aged care responsibilities of the provider; and,
b) the Commissioner is satisfied that it is appropriate to impose those sanctions on the provider.

Notice of Decision to Lift Sanctions (NDLS) – A notification to a provider, in writing, that sanctions imposed on the provider have been lifted.

A provider may apply to the Delegate for a sanction to be lifted at any time. The request may be to have one sanction lifted, or to have all sanctions that have been applied lifted.

If the Commissioner decides, under section 63X of the Commission Act, to lift a sanction imposed on an approved provider, the Commissioner must, within 14 days after making the decision, give written notice of the following to the provider:
a) the decision;
b) the day on which the sanction will cease to be in effect;
c) any other matters specified in the rules.

Notice of Decision Not to Lift Sanctions (NDNLS)

If the Commissioner decides, under section 63X of the Commission Act, not to lift a sanction imposed on an approved provider, the Commissioner must, within 14 days after making the decision, give written notice of the following to the provider:

a) the decision;
b) the reasons for the decision;
c) how the provider may apply for reconsideration of the decision.

Notice of intention to give directions (NIID) – A notice to a provider where the Commission sets out preliminary findings on any issues of concern identified through a resolution process. The notice gives the provider the opportunity to respond to the concerns by identifying how the provider has, or will, address the issues identified.

Notice of Reconsideration of Decision to Impose Sanctions (NRDIS) – Notice sent to an approved provider when the Commission decides to lift a sanction imposed after identified non-compliance, specifying a day on which the sanction is to cease to have effect.

Notice of Requirement to Agree to Certain Matters (NTA) – Notice sent to an approved provider when the Commission is considering revocation of its approval to deliver aged care, after identified non-compliance.

The notice requires the approved provider to agree to certain requirements, including time frames. If the provider fails to agree to the requirements set out in the notice, the Commissioner may revoke approval to provide aged care services.

Notice to Remedy (NTR) – Issued by the Commission delegate if they are satisfied with a provider’s response to a Non-compliance notice, a requiring the provider to remedy non-compliance within a certain period.

In response to a Notice to Remedy, the provider gives an Undertaking to Remedy committing to undertake the required actions within the specified timeframes.

Notifiable – Events, things or incidents, such as serious infectious diseases, that must be reported.

Notification of material changes for approved providers – Refer to material change.

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Open disclosure – Open discussions with consumers, their family, carers and other support people of incidents that have caused harm or had the potential to cause harm to the consumer.

It involves an expression of regret and a factual explanation of what happened, the potential consequences and what steps are being taken to manage this and prevent it happening again.

Organisation – The provider of care and services.

Currently, aged care legislation uses the term ‘approved provider’; this term does not include providers that deliver Commonwealth Home Support Programme (CHSP) and certain grant funded National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP) services.

Other parties – People and organisations who the Commission consults with and keeps informed about a complaint process, but who are not the complainant or the service provider. Examples may include:

  • the person receiving aged care
  • an advocate nominated by the person receiving aged care
  • a legally appointed representative of the person receiving aged care
  • a person with a significant relationship to the person receiving aged care (such as a partner or close relative)
  • organisations such as police and hospitals.

Outcomes – Describes the effect or result of a service or support, such as an improvement in an individual’s well-being. Can be short-term (such as a consumer being involved in service planning) through to long-term (such as a consumer being able to manage daily activities on their own after support and reablement).

Outputs – Describes the amount of something produced, or the delivery of services and supports, such as training.

Own initiative concern – A resolution process commenced by the Commission based on information received from a source other than a complainant.

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Partnership – A working relationship between two or more people or groups. Refers to organisations finding ways to work with consumers and listening to their needs, goals and preferences, to plan their care and services.

Performance assessment – An assessment under the Rules of performance against the Quality Standards. Includes:

  • site audits of residential services other than recommencing services as part of the re-accreditation process (Part 3, Division 3, Subdivision D)
  • quality reviews of home services or National Aboriginal and Torres Strait Islander Flexible Aged Care Program services (Part 4, Division 3)
  • assessment contacts for the purpose of assessing the provider’s performance, in relation to the service, against the Quality Standards (Part 5, Division 5)
  • review audits of accredited services (Part 5, Division 6).

Performance Assessment Methodology – Refer to Assessment Methodology.

Performance report – Prepared following a performance assessment.

Outlines assessment of performance against the Quality Standards and is given to the Commissioner and provider.

Will outline the delegate’s decisions regarding compliance against the Quality Standards (compliant/non-compliant at the Standard and requirement level). May also include areas for improvement.

Personal care – Services such as bathing, showering, dressing, feeding and toileting.

Personal information – Information or an opinion (including information or an opinion forming part of a database), whether true or not, and whether recorded in a material form or not, about an individual whose identity is apparent, or can reasonably be ascertained, from the information or opinion.

Physical restraints – Refer to restrictive practices.

Plan for Continuous Improvement (PCI) – A written plan for a service, required under Part 5, Division 4 of the Rules, that sets out:

a) how the provider of the service will:
i. assess the quality of care and services provided through the service against the Quality Standards; and
ii. monitor and improve the quality of care and services as measured against those Standards; and

b) if there are any areas in which improvements in relation to the service are needed to ensure that the Quality Standardss are complied with – how the provider of the service will make those improvements.

The continuous improvement cycle and development of PCIs.

Police report – A report about a person’s criminal conviction record that is issued by either the Australian Federal Police or a State or Territory police force or service.

Previously accredited service – Services that were, but are no longer, an accredited service. Examples include:

  • a service where accreditation expired as the service was closed for a period of time due to renovations or re-build;
  • following revocation of accreditation, a service was sold to a new approved provider. That approved provider is applying for re-accreditation of a previously accredited service.

Pro re nata (PRN) – In relation to medications; taken as needed.

Procedural fairness – The process followed by decision-makers to ensure decisions are fair by providing all interested parties to a complaint or a decision:

  • the right to be heard
  • the right to be treated without bias
  • the right to be informed of and respond to allegations, and
  • the right to information regarding the status of the complaint.

Provider – An entity which has been approved to provide residential care, home and/or flexible care. Approved providers receive government subsidies for the delivery of care to consumers.

A provider might also be referred to as:

  • an approved provider;
  • a service provider; or
  • an organisation.

Provider approval – The process by which an organisation applies in writing to the Commissioner in order to be approved to provide residential care, home care or flexible care and receive Government subsidies for that care.

The Commission Act specifies who can apply, how applications are to be submitted and what matters are considered during the assessment process.

The matters provided for under the Commission Act are underpinned by the Aged Care Act and Quality of Care Principles.

Provider resolution – A process where the Commission refers a complaint to a provider to resolve. The Commission requires the provider to provide a report about what action it has taken to resolve the complaint.

Provider responsibilities – Responsibilities approved providers have in relation to the aged care they provide through their services to aged care consumers/care recipients.

These responsibilities, under the Aged Care Act relate to:

  • the quality of care they provide;
  • user rights for the people to whom the care is provided;
  • accountability for the care that is provided, and the basic suitability of their key personnel.

Provider returned to compliance – Provider (or service) which had been found non-compliant with their responsibilities under the relevant Standards (Prudential, Quality) and that non-compliance was resolved.

Prudential Compliance – Compliance with prudential requirements set out in the Aged Care Act, where a provider providing residential aged care holds accommodations deposits and entry contributions, in accordance with the Fees and Payments Principles 2014 (No. 2).

Prudential Review – On-site activities conducted with the approved providers consent intended to educate the provider on its prudential responsibilities under the Aged Care Act, and the Fees and Payments Principles 2014 (No. 2).

Prudential Standards – A set of four standards set out in the Fees and Payments Principles 2014 (No. 2) and made under Section 96-1 of the Aged Care Act,, which outline how providers must manage the refundable accommodation payments of their consumers.

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Quality Assessment and Monitoring Group (QAMG) – The group within the Commission responsible for the accreditation and monitoring of residential aged care services, quality review of services provided in the home and community and assessment of National Aboriginal and Torres Strait Islander Flexible Aged Care Program services.

Quality assessor – A person registered by the Commissioner under Part 6 of the Rules to undertake a performance assessment against the Quality Standards or to monitor the quality of care and services.

Quality audit – The terminology used to describe the process for assessing the performance of a home service during a quality review (changed from ‘site visit’ to ‘quality audit’ from 1 January 2020).

Quality Bulletin – The Commission's regular newsletter for Australian aged care providers, sharing the latest information to support our vision of a world-class aged care service.

Quality management – The systems and processes an organisation has in place to monitor, review, plan, control and make sure it delivers quality services, supports or products.

Quality review – A comprehensive assessment of a home service provider, or a National Aboriginal and Torres Strait Islander Flexible Aged Care Program service’s performance against the Quality Standards, conducted under Part 4 of the Rules (or for National Aboriginal and Torres Strait Islander Flexible Aged Care Program services, conducted in accordance with the Quality Review Guidelines).

Quality Review Guidelines (in the context of the National Aboriginal and Torres Strait Islander Flexible Aged Care Program) describes how quality reviews and monitoring of services under the National Aboriginal and Torres Strait Islander Flexible Aged Care Program are undertaken.

Quality Standards – The Aged Care Quality Standards

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Reablement – A consumer-directed process to support restoration of function or adapt to some loss of day-to-day function and regain confidence and capacity for daily activities. It may promote consumer independence, capacity or social and community connections. Supports could include training in a new skill, modification to a consumer’s home environment or having access to equipment or assistive technology.

Recommencing service – Previously accredited services where care and services are not being provided for the allocated places at the time the re-accreditation application is made.

A previously accredited service is a recommencing service if:

a) the approved provider of the service has made an application for re-accreditation as a previously accredited service; and
b) the approved provider of the service has been allocated places for the services under Part 2.2 of the Aged Care Act; and
c) at the time the application was made, residential care was not being provided for those allocated places through the service.

An example is a service which has closed for several years for renovations, is recommencing operations but has not yet commenced providing care and services to consumers.

A recommencing service does not include services that have had their accreditation revoked; and are in the process of applying for re-accreditation.

Reconsideration of regulatory or complaints reviewable decision – Review, or reconsideration, of certain decisions (as reviewable decisions) made by the Commissioner or delegate, as provided for under the Commission Act and Rules, as requested by an interested person.

Reconsideration period – The time period (14 days) in which a person affected by a decision can request reconsideration of a reviewable decision. Allowable under Part 8B of the Commission Act and Part 7, Div 1 of the Rules.

Records Standard – Part of the Prudential Standards, as set out in Division 3, Part 5 of the Fees and Payment Principles 2014 (No. 2).

Referral – A process where specific issues raised in a complaint or during a performance assessment are referred to another organisation or agency for consideration or action.

Refundable Accommodation Deposit (RAD) – A lump sum paid for accommodation in an aged care home by a consumer who entered permanent residential care on or after 1 July 2014. The payment does not accrue daily.

Refundable Deposit Register – A register, required under Division 3, part 5 of the Fees and Payment Principles 2014 (No. 2), which a provider must maintain, and includes the information about refundable deposits, accommodation bonds and entry contributions.

Regulatory action – Any and all administrative or regulatory action and formal or informal enforcement action undertaken by the Commission in response to non-compliance with responsibilities under the Aged Care Act, the Commission Act, the Rules or the Quality Standards.

Including but not limited to Directions, Non-compliance Notices, Undertaking to Remedy, sanctions.

Regulatory Bulletin – A targeted communication to assist providers in understanding how specific requirements and processes fit into the overarching aged care regulatory framework. It articulates expectations and underlying reasons for the Commission's approach.

Regulatory decision – A decision required to be made under the Commission Act or the Rules which relates to the performance of the Commissioner’s regulatory functions.

Regulatory engagement – A risk-based approach to making an objective and informed judgement when engaging with organisations, providers or individuals regarding complaints or compliance actions.

In cases where the Initial Risk Assessment indicates that the risk to consumers is more than minor in nature or where a provider has failed to remedy non-compliance through an administrative action, it may be necessary for the Commission to respond with regulatory action.

Regulatory official – A Commission staff member whose position is linked to delegations which include regulatory powers. Officials include the Commissioner, their delegate or a quality assessor. Quality assessors are included for the purposes of assessment activities and consequent exercise of powers, such as entry and search, which are separate to complaints officers powers under the Commission Act.

Regulatory Strategy – The Commission's strategy to delivering regulatory functions under the Commission Act, in accordance with the Rules.

Reportable assault – Unlawful sexual contact, unreasonable use of force, or assault specified in the Accountability Principles 2014 and constituting an offence against a law of the Commonwealth or a State or Territory, that is inflicted on a person when:

a) the person is receiving residential care in respect of which the provider is approved; and

(i) *subsidy is payable for provision of the care to the person; or

(ii) the person is approved under Part 2.3 as the recipient of that type of residential care.

Representative – Defined in the Section 5 of the Records Principles 2014 as:

(a) a person nominated by the care recipient as a person to be told about matters affecting the care recipient; or

(b) a person:

(i) who nominates himself or herself as a person to be told about matters affecting a care recipient; and

(ii) who the relevant approved provider is satisfied has a connection with the care recipient, and is concerned for the safety, health and wellbeing of the care recipient.

(2) Without limiting subparagraph (1)(b)(ii), a person has a connection with a care recipient if:

(a) the person is a partner, close relation or other relative of the care recipient; or

(b) the person holds an enduring power of attorney given by the care recipient; or

(c) the person has been appointed by a State or Territory guardianship board (however described) to deal with the care recipient’s affairs; or

(d) the person represents the care recipient in dealings with the approved provider.

Requirement – Legislated elements of the Quality Standards against which approved provider compliance is assessed.

Residential care – Defined under section 41-3 of the Aged Care Act as personal or nursing care, or both personal and nursing care, that:

  • is provided to a person in a residential care facility in which the person is also provided with accommodation that includes:
    • appropriate staffing to meet the nursing and personal care needs of the person
    • meals and cleaning services, and
    • furnishings, furniture and equipment for the provision of that care and accommodation, and
  • meets any other requirements specified in the Residential Care Subsidy Principles 2014.

Residential service – An accredited service, or a previously accredited service, for which an application to the Commission for accreditation or re-accreditation is made, and which supports older Australians who can no longer live independently at home.

Respectful – Understanding a person’s culture, acknowledging differences, and being actively aware of these differences. It is about understanding that each consumer is unique and has a right to be treated in an inclusive and respectful way.

Respite care – Residential care or flexible care (as the case requires) provided as an alternative care arrangement with the primary purpose of giving a carer or a consumer a short term break from their usual care arrangement.

Does not include residential care provided through a residential care service while the care recipient in question is on leave under section 42 2 of the Aged Care Act from another residential care service.

Restraint – Refer to restrictive practices.

Restrictive practices – The use of interventions and practices that have the effect of restricting the rights or freedom of movement of a person. These primarily include restraint and seclusion.

Chemical restraint means a restraint that is, or that involves, the use of medication or a chemical substance for the purpose of influencing a person’s behaviour, other than medication prescribed for the treatment of, or to enable treatment of, a diagnosed mental disorder, a physical illness or a physical condition.

Physical restraint means any restraint other than:

a) a chemical restraint; or
b) the use of medication prescribed for the treatment of, or to enable treatment of, a diagnosed mental disorder, a physical illness or a physical condition.

The Commission’s Quality Standards guidance adopts the general principle that restrictive practices:

  • are only implemented as a last resort;
  • are implemented for the least amount of time possible;
  • are recorded, monitored and reviewed;
  • have tight safeguards in place that are focused on minimising risk to consumers, staff, and others; and
  • are undertaken with a focus on ensuring decency, humanity and respect at all stages.

Review audit – A comprehensive on-site assessment of a residential service provider’s performance against the Quality Standards and are most commonly used when the Commissioner considers the service may not be complying with the Quality Standards.

Results in a decision whether to revoke a service’s accreditation, and if accreditation is not revoked, whether to vary the period of accreditation.

Review delegate – The delegate responsible for undertaking a reconsideration following a request for review of a complaints or regulatory reviewable decision.

Reviewable decision – A decision made under the Commission Act or the Commission Rules which can be reconsidered.

Refer to Section 74J of the Commission Act and Section 98 of the Rules for a list of regulatory and complaints reviewable decisions.

Revocation of Approved Provider Status – A decision to remove approval of aged care provider status under section 63H or 63J of the Commission Act.

The Commissioner may make a decision to revoke the approval of an aged care provider (person or organisation) if:

  • they have ceased to be a corporation,
  • they have ceased to be suitable for approval
  • the application for approval contained information that was false or misleading in a material particular
  • the approved provider writes to the Commissioner requesting the revocation of its approval

Once revoked, the provider no longer remains an approved provider under the Commission Act and ceases providing care as a Commonwealth-funded provider of aged care.

Risk – The chance of something happening that will have a negative impact. It is measured by the consequences and likelihood.

In terms of the Commission’s regulatory functions, risk means the current or future risk of a provider’s non-compliance with their responsibilities, including the provision of quality care and services; and associated risks of harm to an aged care consumer or group of consumers.

The risk rating informs the regulatory treatment selected, including the timing, mode and frequency of the Commission's response.

More information can be found in the Regulatory Strategy.

Risk-based questions – A set of standard risk based questions that will be asked on commencement of a performance assessment.

Risk escalation – The identification and escalation of information regarding non-compliance with the Quality Standards or a provider’s responsibilities under the Aged Care Act for risk assessment for the purpose of determining the appropriate regulatory response.

Rules – The Aged Care Quality and Safety Commission Rules 2018.

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Sanction or sanctions in place – A penalty imposed by the Commission on operators of aged care services in cases of serious non-compliance with their responsibilities. The decision to impose sanctions includes consideration of issues such as:

  • whether non-compliance is minor or serious
  • whether it has occurred before, and
  • whether it threatens the health, welfare or interests of the consumer.

Different sanctions may be imposed depending on the circumstances of the non-compliance, which include revocation of approved provider status, loss of Australian Government subsidies for new persons receiving care or revocation of allocated places.

Secretary (the) – Secretary of the Department of Health.

Self-assessment –  The act or process of a provider analysing and evaluating its own performance and outcomes against the Quality Standards.

Serious offence –  An offence under a law of the Commonwealth, or a State offence that has a federal aspect, punishable by a maximum penalty of imprisonment for life or five or more years. This includes murder or sexual assault.

Serious offence conviction –  A conviction for a serious offence, as described in the Rules; relating to a conviction for murder or sexual assault, any other form of assault.

Service (in relation to approved provider) –  The business run by an approved provider through which Commonwealth funded aged care services and supports are provided. An approved provider may have multiple services.

An approved provider can exist without a service however a service must be linked to an approved provider.

Services and supports for daily living – Services other than clinical and personal care that include but are not limited to: food services, domestic assistance, home maintenance, transport and recreational and social activities. Services and supports for daily living may also be services that support consumer emotional, spiritual and psychological well-being.

Service culture – The culture of an organisation which is characterised by how people behave, what is prioritised and how processes are owned and improved by the workforce. A culture of safety and quality will be consumer-centred, driven by information, and organised for quality and safety.

Service environment – The physical environment where care and services are delivered. Overall surroundings where aged care services are being delivered are included, such as the building, fixtures, fittings and factors such as lighting, air temperature and water supply.

It does not include a consumer’s private home where in-home services are provided.

Short notice visit – A visit to the premises of an aged care provider undertaken at short notice.

Short Pathway to Sanction – The immediate imposition of sanctions due to an Immediate and Severe risk to the safety, health, or well-being of consumers.

A Notice of Decision to Impose Sanction is issued at the outset. The process omits the escalating action that begins with an administrative approach or a Non-compliance Notice.

This represents one of the strongest actions the Commission can take.

Can only be used in quality compliance matters, as the Commission does not consider a financial or prudential risk presenting an immediate risk to consumers.

Short term restorative care (STRC) – A form of flexible care, as defined in the Subsidy Principles 2014, that:

  • a) is aimed at reversing or slowing functional decline in older people through the provision of a package of care and services designed for, and approved by, the care recipient who is to receive the care and services; and
  • b) depending on the needs of the care recipient, is provided in either or both of the following settings:
    • a. a residential care setting;
    • b. a home care setting; and
    • c. can be characterised as:
      • (i) goal oriented; and
      • (ii) multidisciplinary; and
      • (iii) time limited.

Site audit – An unannounced comprehensive performance assessment against the Quality Standards undertaken for the purpose of informing a decision whether to re-accredit a residential service. Results in a decision of whether to re-accredit a service, and if re-accredited, the further period of accreditation.

Site audits are also defined in the Rules as being an audit of the service conducted under Subdivision D of Division 3, Part 3.

Site visit – A visit to a service or a consumer’s residence by regulatory officials or authorised complaints officers.

In the context of a complaint, will include complaints officers meeting at any place with complainants, providers and any party to a complaint.

Special needs groups – The groups of people defined in the Aged Care Act for whom there is additional consideration in the planning and delivery of appropriate aged care services. These are:

  • people from Aboriginal and/or Torres Strait Islander communities
  • people from culturally and linguistically diverse backgrounds
  • people who live in rural or remote areas
  • people who are financially or socially disadvantaged
  • people who are veterans of the Australian Defence Force or an allied defence force including the spouse, widow or widower of a veteran
  • people who are homeless, or at risk of becoming homeless
  • people who are care leavers (which includes Forgotten Australians, Former Child Migrants and Stolen Generations)
  • parents separated from their children by forced adoption or removal
  • people from lesbian, gay, bisexual, trans/transgender and intersex communities.
  • People of a kind specified in the Allocation Principles.

Staff – People working in an organisation who are responsible for the care, administration and support of, or involvement with, consumers.

Subcontracting – Entering into an arrangement with a third party for delivery of care and/or services.

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Targeted campaigns – Prudential and HCCI sections - Sector education campaigns conducted on a biannual basis by the Prudential and Home Care Compliance and Investigations sections. Intended to educate the sector on a specific requirement, which is determined by undertaking a review of existing information such as trend analysis of section intelligence and other Commission intelligence.

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Undertaking to Remedy (UTR) – A written undertaking given to, and accepted by, the Commission in response to a Notice to Remedy following a breach of a provider’s responsibilities under the Aged Care Act, the Commission Act and/or non-compliance with the Quality Standards.

Where a breach/finding of non-compliance is assessed as being high or severe risk, the Commission may require a provider to give a UTR committing to take the required actions within a certain period to address specific breaches/areas for improvement.

UTRs are enforceable in a court.

User Rights Principles 1997 – The principles which set out the responsibilities of approved providers in providing residential or home care services, and deal with security of tenure for consumers, access for persons acting for consumers, and the information the provider must give consumers in particular situations.

Also describes the rights and responsibilities of consumers of both residential care and home care.

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Workforce – People working in an organisation who are responsible for its maintenance or administration, or the care and services, support of, or involvement with, consumers.

A member of the workforce is anyone the organisation employs, hires, retains or contracts (directly or through an employment or recruitment agency) to provide maintenance or administration, or care and services under the control of the organisation. It also includes volunteers who provide care and services for the organisation.

For clarity, people in an organisation’s workforce include:

  • employees and contractors (including all staff employed, hired, retained or contracted to provide services under the control of the organisation)
  • allied health professionals the organisation contracts
  • kitchen, cleaning, laundry, garden and office staff the organisation employs either directly or under contract.

People who are not part of an organisation’s workforce include:

  • visiting medical practitioners, pharmacists and other allied health professionals and services a consumer has asked for, but the organisation doesn’t contract
  • trades people who don’t work under the control of the organisation (such as independent contractors), for example, plumbers, electricians or delivery people who work on an as needs basis.

Writing, in writing – All references to writing to someone, or notifying someone in writing, including email.

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Young people in residential aged care – People younger than 65 years who receive care in residential aged care services.

Monday, 21 June 2021 - 2:21pm