Re-accreditation of residential services

This section outlines the re-accreditation process for accredited or previously accredited services. It includes how to apply, conducting an unannounced site audit, the decision-making process, and possible outcomes.

Accredited services include residential aged care services as well as flexible care services through which short-term restorative care is provided in a residential care setting.

Previously accredited services are 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 rebuild
  • 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.

A previously accredited service is a Recommencing service if:

  1. the approved provider of the service has made an application for re-accreditation as a previously accredited service; and
  2. the approved provider of the service has been allocated places for the services under Part 2.2 of the Aged Care Act 1997; and
  3. at the time the application was made, residential care was not being provided for those allocated places through the service.

The re-accreditation application form for accredited services and previously accredited services (including recommencing services) is below.

See Accreditation fees information.

If your service is not accredited or has not previously been accredited see our accreditation of commencing services page.

From 1 July 2018, the arrangements for notified site audits were replaced with site audits made without notice to providers. This is to help ensure quality and safe care standards are maintained at all services at all times across residential services (not recommencing services).

Frequently asked questions about unannounced site audits are available.

Accreditation is further supported by monitoring the quality of care and services delivered by accredited services. This may occur through assessment contacts and review audits.

Applying for re-accreditation

An approved provider of an accredited service or previously accredited service can apply to the Aged Care Quality and Safety Commissioner (Commissioner) for re-accreditation.

The Commissioner will give the approved provider of an accredited service a reminder notice before the end of the service's period of accreditation.

Applications for re-accreditation require self-assessment information against the Quality Standards to be submitted.

For further information on the self-assessment process and to download the self -assessment tool visit our Self-assessment page.

Re-accreditation application form

The re-accreditation application form is below. This form is also used for recommencing services:

For accreditation fees information, see the Accreditation fees page.

The re-accreditation process

Recommencing services

The process for the re-accreditation of recommencing services is the same as the process for the accreditation of commencing services. Refer to the accreditation of commencing services page for more information.

Exclusion of specific dates for unannounced visits

Residential aged care approved providers can request that specific dates are excluded from unannounced activities (excluded dates). Although this does not guarantee visits will not occur on those days, the Commissioner will consider these dates when scheduling activities such as unannounced site audits.

Refer to the Regulatory Bulletin for more details on the exclusion of specific dates for unannounced visits.

Notifying consumers and their representatives before the audit

A notice specifying the form of words to be used to tell aged care consumers (consumers) and their nominated representatives about the site audit. A poster about the site audit to be displayed at the service will be sent to the approved provider with the reminder notice or after the Commissioner has received an application for re-accreditation.

Approved providers must take reasonable steps to ensure that each consumer of the service and their nominated representative is made aware of the site audit; the period in which the site audit may occur; and that they will have an opportunity to talk to members of the Assessment Team or give information to the Commission.

You can also download and print our English and translated letters and posters for site audits.

Notifying consumers and their representatives on the day of the audit

Approved providers must take reasonable steps to inform consumers and their nominated representatives that the site audit has commenced. This will need to occur as soon as practicable after the site audit starts.

Reasonable steps will be relative to the capacity of the service.

Reasonable steps must include displaying the poster that the Assessment Team gives the approved provider. This poster will inform consumers and their nominated representatives that the audit has commenced.

Reasonable steps may also include:

  • informing consumers while attending to their care;
  • sending consumer representatives an email or text message to tell them that the audit has commenced; or
  • in some instances, contacting individual consumer representatives by phone, (particularly, if they have advised that they wish to meet with the assessment team and cannot be contacted by other means).

Providers must enable consumers and their nominated representatives who wish to meet with the Assessment Team to do so privately. This includes providing the Assessment Team with details of consumers and their nominated representatives who have asked to meet with them.

Unannounced site audits

Conducting an unannounced site audit

The Commissioner will appoint an Assessment Team to conduct an unannounced site audit of a service following an application for re-accreditation. Site audits aim to look at the approved provider’s everyday performance against the Quality Standards.

Upon arrival at the premises the Assessment Team will request consent to enter the premises and exercise search powers for regulatory purposes.

The quality assessors interview the person in charge of the service. This will include asking a set of risk-based questions developed by the Commission. These questions change based on identified industry risks and trends.

While on site, the Assessment Team collects information to assess the service’s performance against the Quality Standards. Information is drawn from three potential sources of evidence:

  • interviews: the team interviews consumers, their nominated representatives, staff, management, allied health personnel, volunteers, suppliers and contractors;
  • observation: the team observes staff practices and interactions with consumers, as well as the general living or physical environment; and
  • document and records review: the team reviews documents to assess what the service says it does, what the service actually does and the results it achieves. Documentation can be paper based or electronic.

The Assessment Team must sample sufficient relevant information to support their assessment. This is referred to as our assessment methodology.

Human resource management

On the first day of the site audit, the Assessment Team will provide the person in charge of the service a Numbers of personnel in the service form to be completed. A completed form is one of the initial documents requested on entry to the service.

This information will help the Assessment Team to assess the service’s performance against Quality Standard 7 Human resources.

Meetings with the approved provider during the audit

On each day of the site audit, a member of the Assessment Team will meet with the person at the premises who is in charge of the service to discuss the progress of the audit.

Exit meeting

On the last day of the site audit a member of the Assessment Team will meet with the person at the premises who is in charge of the service to discuss the key issues that the team identified during the audit.

After the site audit

Site audit report

Within 7 days of the end of the site audit, the Assessment Team will provide a site audit report to the Commissioner.

The site audit report is a written document that contains an assessment of the approved provider's performance against the Quality Standards and any other matters the Assessment Team considers relevant. A delegate of the Commissioner will consider the information in the site audit report in preparing a performance report and making a decision to re-accredit or not to re-accredit the service.

A copy of the performance report will be given to the approved provider.

Responding to the site audit report

If the approved provider wishes, they have 14 days after receiving the site audit report to provide a written response to its contents. The response should present factual information about how the service meets the Quality Standards, and what actions have been taken or are planned to meet the Quality Standards to ensure adequate and sustainable services for consumers.

Approved providers should consider all information provided in reports when preparing a response or in planning continuous improvement to the care and services to consumers.

The decision process

The Commissioner will prepare a performance report and decide whether to re-accredit or not to re-accredit the service within 28 days of receiving the site audit report from the Assessment Team. In making a decision, the Commissioner must take into account:

  • the performance report
  • the site audit report
  • the approved provider’s response to the site audit report
  • any relevant information given to the Commission or the Assessment Team by a consumer or former consumer or by their nominated representative
  • any relevant information about the approved provider of the service given to the Commission by the Department of Health
  • whether the Commission is satisfied that the approved provider of the service will undertake continuous improvement in relation to the service, measured against the Quality Standards if the service is re-accredited
  • any other relevant matter.

Decision to re-accredit a service

If the Commission decides to re-accredit a service, the approved provider is notified of the decision and:

  • the further period of accreditation and the reasons for deciding that period
  • how the provider may apply for reconsideration of the further period of accreditation
  • how the provider can apply for future re-accreditation.

A Certificate of Accreditation for the service is also provided within 28 days of the decision.

An approved provider is able to apply for reconsideration of a decision regarding the period of re-accreditation. An application for reconsideration of the decision must be submitted to the Commissioner within 14 calendar days of the approved provider being notified of the decision.

See Reconsideration and review of decisions for details on the application process.

The decision and the report is published on the Commission’s website. See find a report on a service.

Decision not to re-accredit a service

If the Commissioner decides not to re-accredit a service, the approved provider is notified of the decision and:

  • the reasons for the decision; and
  • how the approved provider can apply for reconsideration of the decision.

The approved provider is also given a copy of any information given to the Commissioner by the Department of Health that was considered in making the decision.

An application for reconsideration of the decision not to re-accredit must be submitted to the Commissioner within 14 calendar days of the approved provider being notified of the decision.

See Reconsideration and review of decisions for details on the application process.

Decision to revoke accreditation of a service

If the Commissioner decides not to re-accredit a service, the Commissioner may decide to revoke the service's accreditation. If the Commissioner decides to revoke the service's accreditation, the approved provider is notified of the decision and:

  • the reasons for the decision;
  • the day the revocation takes effect; and
  • how the approved provider can apply for reconsideration of the decision.

An application for reconsideration of the decision to revoke accreditation must be submitted to the Commissioner within 14 calendar days of the approved provider being notified of the decision.

See Reconsideration and review of decisions for details on the application process.

Monitoring accredited services

The Commissioner monitors the quality of care and services of accredited services on an ongoing basis.

For commencing services, an unannounced assessment contact is conducted before the expiry of the initial 12 months accreditation period.

More information is available in the Assessment contacts section.

Webinars

It was taken from a series of information sessions held in all states by the former Australian Aged Care Quality Agency to support the sector to prepare for the Quality Standards.

You can also download the transcript of this recording from the webinar by the former Quality Agency download transcript (PDF, 202.26 KB).

More information

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