Infection Control Spot Checks in Residential Aged Care: What Providers Need to Know

The Aged Care Quality and Safety Commission (ACQSC) is stepping up its program of infection control spot checks of residential aged care homes.

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How to Demonstrate that you Understand, Apply, Monitor and Continuously Improve ACQS Requirements

From 1 July 2019 approved providers applying for accreditation or re-accreditation will be assessed against the new Aged Care Quality Standards (Quality Standards). The new Standards consolidate four separate sets of standards which, in theory, should simplify regulation. But with over 40 overlapping requirements across eight Standards, the rules may be even more convoluted, making compliance more complex.  

The one thing that’s clear is that demonstrating the Standards have been met requires more than just “ticking boxes”. The Standards are framed as outcomes rather than directives. Organisations must show they not only have systems in place that meet the requirements, but that these systems are actually being implemented and actioned and producing tangible consumer outcomes.

As explicitly outlined in the Quality Standards preamble, for each of the Quality Standards requirements, Quality Assessors from the Aged Care Quality and Safety Commission (Commission) will be expecting organisations to demonstrate that they:

  • understand the requirement
  • apply the requirement, and this is clear in the way they provide care and services
  • monitor how they are applying the requirement and the outcomes they achieve
  • review outcomes and adjust practices based on these reviews to keep improving

These four metrics reflect the stated purpose of the new Quality Standards. That is, to “focus on outcomes for consumers and reflect the level of care and services the community can expect from organisations that provide Commonwealth subsidised aged care services”.


How do organisations “demonstrate” these metrics?

In short, to truly demonstrate your organisation understands the requirement, applies it, monitors how they’re applying it and reviews the outcomes and adjusts practice accordingly, you need to develop and maintain a culture of compliance.

Having a strong compliance culture starts with having documented policies. Policies are the foundation for building any organisational culture – in fact, a key reason they are developed is to try and establish desired behavioural outcomes. Policies must have clear structures that clearly state the who, how, when, what and why of obligations under the Standards.

But the reality is that policies don’t change culture – people do. Compliance requires an organisation and all its members to bring the policies to life – they need to become part of a shared vision that directs staff practice, and the expectations of consumers and other key stakeholders. Without more, policies themselves won’t make aged care providers compliant.

Ensuring that your organisation and its workforce understand and apply requirements comes down to the location and ease of access to organisational policies, and educating the workforce. A central, web-based repository of policies and procedures is superior in many ways to a paper-based or H Drive policy framework. Additionally, staff education including the development and implementation of work instructions can ensure that your policies and procedures are effectively and accurately applied by the workforce.

Organisations then need to monitor and review the effectiveness of their policies and learning programs. Monitoring the application and implementation of an organisation’s requirements can occur through the use of a number of audit tools, such as process and practice audits, and staff competency assessments are essential. Effective tools should work in tandem to allow the collection of accurate data on outcomes and performance, and the analysis and identification of systemic issues. Reviewing these audit outcomes, as well as incident, injury, near miss and feedback and complaint data trends can provide an accurate understanding of the effectiveness and outcomes of current practice, and identify key corrective actions that should be taken to improve  existing practice.


The CompliSpace P-LAR Methodology

Aged Care Essentials publisher, CompliSpace, uses a proven and award-winning framework designed to achieve a culture of compliance by transforming policy to culture. Interestingly, this framework maps directly to the four metrics from the Quality Standards outlined above. P-LAR is an acronym that stands for Policy, Learning, Assurance and Reporting – the policy to culture lifecycle.

It was originally created to help our non-government school clients manage outcomes from the Royal Commission into Institutional Responses to Child Sexual Abuse. It was designed to fix gaps in staff understanding of obligations, inconsistency in executing the associated actions required and the lack of visibility for school leadership on these gaps.

Aged care providers face these same systemic issues, as evident from the findings of the Royal Commission into Aged Care Quality and Safety to date. Our P-LAR methodology is a proven method of instigating real change and that is why the Commission’s four metrics so closely resemble our framework. Interestingly, our P-LAR methodology also matches up very well with the desired outcomes of the Quality Standards four metrics: Understand, Apply, Monitor and Review.

Each element of the P-LAR methodology helps our clients’ journey from policy to culture.

(P) Policy

Our framework begins with having a strong foundation of policies that we tailor to an organisation’s circumstances to support their compliance obligations. They cover the who, how, when, what and why of each policy.

(L) Learning

Our learning tools are designed to help members of the workforce understand the policies so that they can apply them in their everyday practice.

(A) Assurance

Our assurance workflow management and audit tools allow you to implement policies and monitor the outcomes being achieved. They ensure that key elements of an organisation’s policies ‘come to life’.

(R) Reporting

The Standards have a strong focus on using reported outcomes and consumer feedback to continuously improve care and services. The final part of our framework is therefore providing high-quality reporting so that leadership can identify systemic issues and respond to feedback.


What Next?

Having a policy to culture system in place is more important now than ever. The Commission can conduct unannounced site audits, with non-compliance potentially resulting in a suspension or loss of accreditation. But with a culture of compliance, you will always be ready to demonstrate you are meeting the Quality Standards.

And with the Royal Commission into Aged Care Quality and Safety still underway, regulation is likely to be in flux over the new few years. There is even the possibility of more stringent regulations. Our P-LAR methodology creates a dynamic system that is responsive to change – it is set up to allow seamless improvements to your organisational structure so that organisations are not left with uncertainty every time there is a legislative change. While aged care providers are burdened with over 40 requirements under the new Quality Standards, compliance becomes achievable and sustainable when organisations have a robust and dynamic system that firmly embeds compliance in its organisational culture.


To learn more, visit

Jennifer Ma
Jennifer Ma is a Content Development Assistant at CompliSpace. She recently completed the Juris Doctor at the University of Sydney, and is currently completing her PLT to be admitted as a legal practitioner. She also has an undergraduate degree in Medical Science from the University of Sydney.

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