A site audit is conducted at a residential aged care service once an approved provider has submitted an application for re-accreditation.
Approved aged care providers must apply for re-accreditation regularly. Reminder notices are sent seven months before the expiry of the current accreditation. A decision on the new application will happen before the current approval expires.
As part of the approval process, we carry out unannounced site audits.
The site audit is used to gather information, assess performance against the Aged Care Quality Standards, and determine whether the service should be reaccredited for a further period.
All eight standards are assessed during the audit. The audit usually takes a few days, and the Assessment Team of registered Quality Assessors are likely to be on-site for more than a day, sometimes up to a whole week.
Unannounced site audits can happen anytime between an application submission for re-accreditation and when the service’s accreditation period runs out.
Site audits can also happen any time during the week, outside business hours or on weekends.
Assessment Teams carry out the site audits.
Consent to enter
When the Assessment Team arrives, they will request consent to enter the premises for the audit. They will show their credentials and give the person in charge a letter confirming the visit.
The Assessment Team must only enter the premises of a service if consent has been granted.
If consent is withdrawn during a site visit, the Assessment Team must immediately leave the premises.
When the Assessment Team receives consent to enter, they will hold an entry meeting with staff. They will say how many days they expect to be on-site. These timings may change once the audit starts.
During the entry meeting, the Assessment Team will explain:
- how the site audit will be carried out
- the process for the regular review of the site audit progress
- arrangements for information gathering, such as the availability of documents and records and how to access them
- arrangements for interviews with staff and consumers.
Occasionally, the Assessment Team may change its original approach. Usually to accommodate the needs of the service, the availability of staff, or to minimise disruption to consumers.
Providers should ensure that the usual quality care and services continue as planned during a site audit.
Responsibilities of the person in charge
During the entry meeting, the person in charge of the aged care service on that day or shift can ask the Assessment Team questions about the site audit. The person in charge can change during the duration of the audit. Where there is a change in the person in charge, this should be advised to the Assessment Team.
The person in charge will be the contact for the Assessment Team. This person should have access to the application and self-assessment information. They may be asked to provide policies and staffing information or any other evidence requested by the Assessment Team to measure the service’s performance against the Quality Standards.
Site audit meetings with consumers
During a site audit, the Assessment Team must meet with at least 10 per cent of people using the service or their nominated representatives.
They may contact a consumer’s guardian to seek their views on the quality of care and services delivered to the person in care.
The Assessment Team will ask for information about how approved providers monitor and ensure the quality of their outsourced services.
The Assessment Team may identify a line of enquiry relating to an external contractor in the site audit. If so, the team can arrange to contact them directly by phone or Skype. This may be done after hours if necessary. Contact details for the external contractor must be provided to the Assessment Team.
The Assessment Team must meet with the person in charge on the last day of the site audit. They will communicate critical issues that they’ve identified.
Exit meeting process
- The person in charge can have other people or consumer representatives attend the exit meeting.
- We take an open and transparent audit approach. There should be no surprises at the exit meeting.
- The Assessment Team will ask the person in charge for more information during the site audit if any key issues are identified.
- The person in charge can provide further information about any matters the Assessment Team raises. They can also ask for clarification on any issue.
Site audit findings
The Assessment Team will make their findings based on evidence gathered during the site audit.
- The Assessment Team will prepare a site audit report for the Commissioner within 7 days.
- A copy of the audit report will be given to the approved provider.
- An approved provider then has 14 days to respond to the findings and recommendations of the site audit.
- The response will present factual information and evidence about how the service meets the Quality Standards. It will include what actions have been taken or are planned to meet the Quality Standards.
- Approved providers should consider all information in reports when preparing a response.
- The audit report, the approved provider’s response to the report, and other relevant information will then be considered. They will be used to develop a performance report and make the accreditation decision.
Additional information after a site audit
Sometimes, required information can’t be found on the day(s) of the site audit. When that happens, an approved provider may be allowed to submit the information to the Assessment Team after they’ve left the site.
If it’s information that the approved provider should have been able to find and give to the Assessment Team while on site and when requested, it’s unlikely the Assessment Team will accept that information after the exit meeting.
The Assessment Team will consider each circumstance before deciding whether to accept information after leaving the site. The provider will be notified of the reasons to accept or not accept this information.
- Before the site audit, all relevant feedback from the Commission from consumers, former consumers or their representatives will be provided to the Assessment Team. They must consider this information in conducting the site audit and then in preparing the site audit report.
- The Assessment Team must take all reasonable steps to meet privately with any consumer or their representative who asks to meet during the site audit. Even if they have already provided feedback before the site audit.
- Consumers and their representatives can provide feedback anonymously or confidentially at any time. If feedback is provided anonymously, no identifying details are provided. If feedback is provided confidentially, a name and contact details are provided. These are not disclosed to the relevant provider unless there is a risk of harm to a consumer.
- Callers will be requested to provide the aged care service details so that information can be delivered to an Assessment Team to inform a site audit.
Notifying consumers and their representatives of a site audit
When a provider puts in an application for re-approval, they need to let people know about the audit process, including:
- each consumer in their care
- their nominated representative
- appointed advocates or guardians of consumers.
When the Assessment Team arrives to do the site audit, the same people must be told the audit is happening.
How to communicate the site audit is happening.
The provider can display the poster the Assessment Team gives them. This lets consumers and their representatives know the site audit has started.
They can also explain the site audit by:
- telling consumers while they give them care
- sending consumer representatives an email or text message telling them that the audit has begun
- contacting individual consumer representatives by phone. Particularly if they have asked to meet with the assessment team and can’t be contacted by other means.
Providers should help consumers and their nominated representatives meet privately with the Assessment Team. This includes giving the Assessment Team details of consumers and representatives who have asked to meet with them.
Posters and letters for site audits
Posters about site audits should be put up in one or more prominent locations at the service.
The following notices and posters are to be used by approved providers for a site audit:
- English - Site audit notice (unannounced) and Site audit poster (unannounced)
- Community language Site audit (unannounced) and Site audit poster (unannounced
Assessment contact poster
Use these posters to advise of an upcoming assessment contact visit.
Review audit poster
Use these posters to advise of an upcoming review audit.
Quality review (quality audit) notice
Use this letter to advise of an upcoming quality audit.
Assessment contact notice
Use this notice to inform about an assessment contact visit.
Conflict of interest
Quality assessors must be objective and impartial. We have a clear policy on managing any real or apparent conflicts concerning quality assessors.
The Conflict of Interest Policy:
- provides clear guidelines on what is a conflict
- requires quality assessors to notify us of any conflicts of interest
- outlines how we will manage conflicts, including possible actions following a breach.
Where a quality assessor identifies a real or apparent conflict of interest before or during a site audit, this must be immediately brought to our attention.
The disclosed conflict of interest will be managed on a case-by-case basis by us based on:
- the nature and seriousness of the conflict
- the significance of any relationship or interest.
If we believe there’s a conflict of interest, appropriate management action will be taken. This is done to maintain the integrity of the audit process. We have various options for managing disputes, including contacting the provider to disclose the conflict.
When an application for re-accreditation is made late, we’re not required to complete the re-accreditation process before the period of accreditation ends. Applications must be lodged by the date specified in the reminder notice to avoid a gap in accreditation status.
Section 47 of the Rules outlines the consequences of an application being made late.
The Aged Care Quality and Safety Commission Act 2018 (Commission Act) provides legal authority for us to charge fees for services provided in performing our functions. We publish fees for accreditation through the annual Cost Recovery Implementation Statement (CRIS).
Providers are to submit self-assessment information when submitting their application for re-accreditation. The specified date is included in their reminder notice. It’s usually about 28 days from the date of the reminder notice.
Ongoing monitoring and improvement
Self-assessment is an active process to support quality improvement. It should be updated on an ongoing basis rather than seen as a task to be completed only for re-accreditation. It’s a framework for providers to evaluate and review the performance of their service against the Quality Standards. This will also assist with updating the plan for continuous service improvement.
Providers aren’t required to use the template we provide. They’re encouraged to use whatever template best supports their business needs. However, self-assessment information must demonstrate the provider’s service performance against the Quality Standards, so we recommend reviewing ours for guidance.
There’s no standalone evaluation of the adequacy of the self-assessment. However, we’ll provide the self-assessment to the site audit’s assessment team. The self-assessment is part of the overall assessment during the site audit. We may also consider it in developing a performance report.