Audit process

We do an audit against the strengthened Aged Care Quality Standards (strengthened Quality Standards) when an organisation, person or registered provider applies in categories 4, 5 or 6 to:

be registered as a provider
renew their registration
vary their registration.

Audit initiation

We start an audit:

when we’re assessing an application for registration or variation (adding category 4, 5 or 6)
when a provider advises us that they plan to renew their registration.

To start the audit process, we send you an audit initiation email that explains the audit type and asks you for information. The email will:

ask you to complete and submit the Audit Evidence Collection Tool (AECT) with key documentation
ask you to provide details about the governing body and senior management representatives who’ll attend meetings and their availability
includes resources to help you prepare for the audit
reminds you to send updated policies and procedures to us, as they’re available.

After we send the email, we’ll call you to:

confirm you received the email
discuss the audit process
arrange an audit initiation meeting (online or in person).

We’ll follow up with an email that:

confirms the date and time of the meeting
includes a meeting invitation link
includes the meeting agenda.

We’ll contact you if we don’t receive a completed AECT. We can’t do the audit without it. If you don’t complete and submit it by the deadline, we can withdraw your application.

Audit delivery

Provider audit

A provider audit is where we collect and assess evidence of your governance arrangements, systems and processes. We use this information to understand how your organisation operates and drive the next steps in the audit process.

When we do a provider audit, we:

review and analyse the AECT you completed in the audit initiation stage
meet with your governing body and senior management representatives to understand your systems and processes for governance, clinical and care quality and staffing
decide where to do the audit if you offer category 4 or 5 services
prepare an audit plan and tell you how and where they’ll do the audits with you.

For all registration types (categories 4, 5 and 6), the audit will include a review of provider evidence such as your organisational policies and procedures applicable to the strengthened Quality Standards and meetings with your governing body and senior management. We’ll only collect this evidence from the provider once. We’ll let you know in advance when we will visit you.

For registration and variation of registration audits, we’ll meet with your governing body and senior management representatives. We’ll let you know if we need to visit a site to see where you’ll deliver services.

For renewal of registration audits, in addition to collecting the provider evidence from you, we’ll also do audits at all Category 6 residential care homes and at a sample of your category 4 and 5 service locations. The number of site audits will depend on the size and type of your organisation:

Providers applying to be registered in Category 6 will have an audit at each residential care home.
Providers applying to be registered in categories 4 or 5 will have one provider audit that assesses a sample of locations.

Care delivery or residential care home audit

A care delivery or residential care home audit is where we test that the provider’s systems and processes have been embedded and are effective in ensuring safe and quality care and services. The care delivery or residential care home audit relates to renewal audits only.

Before each care delivery location or residential care home audit, we send you an email that:

explains the purpose and type of audit
asks you to complete a Care Delivery Evidence Collection Tool (CDECT).

We’ll contact you to confirm that you received the email and offer support if you need it. Once we receive your completed CDECT, we will review and analyse the information you provided.

A care delivery location or residential care home audit starts with an online opening meeting for the location we’re auditing. For categories 4 and 5 care delivery locations, there will be one opening meeting for all sampled locations. For Category 6, there will be an opening meeting before each residential care home audit. This opening meeting helps us to understand more about how you deliver care and services to older people and provides advice about when we will be onsite, and will contact older people. We will also hold a brief entry meeting when we arrive at your site.

These audits include:

interviews with older people and their representatives
interviews with staff
observations
file reviews.

We will have regular, open and honest feedback meetings throughout the audit.

You can find our audit meeting agendas on audit guidance and resources.

We will use a digital audit tool to collect information and evidence. We regularly share feedback on the audit’s progress and findings.

At the end of the audit, there’s a closing meeting. For categories 4 and 5 care delivery locations there will be one closing meeting for all sampled locations audited. For Category 6, there will be a closing meeting at the end of the onsite activity for each residential care home audit.

We will give a preliminary conformance rating for each Outcome for the strengthened Quality Standards assessed.

Audit reporting

After the audit delivery stage, we will prepare a preliminary report that:

includes initial findings from the audit
includes conformance ratings against each Outcome for the relevant strengthened Quality Standards
includes detailed findings to support a rating of minor non-conformance or major non-conformance
considers the experiences of older people and their supporters
considers the experiences of workers
considers feedback (positive and negative) received during the audit
doesn’t include the names or identifying information of older people and their supporters or workers.

We email the preliminary report to you and call to confirm that you’ve received it. You can provide feedback about the preliminary report, including submitting supporting evidence. You must submit this to us by the deadline, using the secure link we provide.

Where we find that a provider is conformant with all 7 strengthened Quality Standards, we will invite them to submit evidence to support the exceeding rating. To find out more visit graded assessment and audit ratings.

If you respond to the preliminary report, we review your response and any supporting evidence you provide. We then prepare a final report that considers your response and gives our reasons for the final audit ratings, including where they may differ from the preliminary report.

We share the final report with you and with our provider registration team. Audit reports inform our decision to register you as a provider and to apply any conditions to your registration.

For renewal of registration, when we complete the audit program, we send a final audit report to you and our provider registration team. The report summarises the ratings given throughout the audit program.

You can learn more about provider registration on Provider registration.