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 Manage Aged Care Assessment Contacts Part 3: What Evidence Are Assessors Looking For?

Part 1 of our “How to Manage Aged Care Assessment Contacts” series provided practical tips on how to manage the entry meeting for an Assessment Contact. Part 2 looked at how to make the most of your human resources.

This week, with the help of our partner, Critical Success Solutions (CSS), ACE has gathered on-the-ground information from Aged Care Providers on their first-hand experiences with Aged Care Quality and Safety Commission (ACQSC) Assessment Contacts.

We’ve compiled this information into the table below. It shows some of the key evidence gaps identified by ACQSC Assessors that led to real life findings of “Not Met”. In other words, these are some of the things that aged care providers should have had in place but did not. That makes it a handy tool that you can use to determine your own readiness for Assessment and perhaps reflect on what areas you should be tackling to demonstrate improvements.

Aged Care Quality Standard

Evidence Gaps That Led to Findings of “Not Met”

Standard 1: Consumer Dignity and Choice

• No diversity plan or demonstrated commitment to diversity.

• No conversation with the consumer in the pre-admission process regarding the Quality Standards or key concepts of the Quality Standards, such as rights, capacity, choice, decision making, partnering with the consumer and minimising restraints.

• Care staff not understanding the consumers’ likes/dislikes/who they are and their preferences.

• Team members not informing/explaining daily tasks and events to consumers.

Standard 2: Ongoing Assessment and Planning with Consumers

• Poor care and service planning documentation that is not “consumer goal” orientated and readily accessible to consumers or their representatives.

• Consumers having limited input into their care plans including not approving or signing off initial care plans or subsequent reviewed plans.

Standard 3: Personal Care and Clinical Care

• Home unable to demonstrate that care and services are tailored to resident needs and choices.

• Management unable to describe best practice at the home and how this is provided through policies, procedures and assessment tools.

• Insufficient systems for identifying consumer risks and deterioration.

• Consumers not being reassessed by the speech pathologist/dietitian in line with identified needs; staff with no knowledge of the international dietary dysphasia standardisation initiative levels and consumers not reassessed under the new system.

• Management of significant weight loss – not following policy and not acting in a timely manner.

• Management of pressure injuries – gaps in wound care regimes; lack of timely referrals to external consultants.

• Management of high-risk respite consumers – unclear how they are identified by staff and supported and provided with referral to key agencies as required, including on discharge.

• The Psychotropic Self-Assessment Record - poor documentation and management of this document. Homes need to ensure they have systems in place to ensure the currency of this document including regular review and updating (June 2019 to present).

• No evidence of risk assessments for restraints; alternatives not being documented as per legislation; inappropriate use of emergency restraint processes; RNs not aware of restraint legislation; GPs not reviewing restraint documentation; consumer not monitored when restraint or restrictive practice is being used e.g. bed rails in place.

• Behaviour Management – poor use of external agencies to assist in the management of behaviours, including not referring to DSA.

• Infection control management – no vaccination listing for both consumers and staff; no information provided to consumers and staff for informed consent or no evidence of consent.

• No systems to support the comprehensive review of consumers returning from hospital and actioning of their changed needs. This includes lack of clear documentation for demonstrating information provided to the medical practitioner, review of assessments and care plans; and follow up of discharge requirements and referrals, as required.

• Antimicrobial stewardship – limited examples of goal setting and training of workforce, in particular RNs, as well as limited communication to consumers and representatives.

• Progress notes not adequately:

o documenting other stakeholders involved in care, including their role in care planning and assessment
o defining risk issues and alternative management strategies.

Standard 4: Services and Supports for Daily Living

• For consumers unable to verbally express their meal preferences, the service could not demonstrate consultation strategies regarding choice and preference.

• Lifestyle programs not focused on consumers’ needs and preferences.

Standard 5: Organisation’s Service Environment

• Fire emergency management and activation of the Business Continuity Plan (BCP) – poor documentation regarding fire drills; no fire drills; fire drills not including all stakeholders; BCP not tested annually and not reviewed annually.

• Unable to demonstrate how noise, ventilation and heating and cooling is monitored for effectiveness.

• Poor documentation or no documentation demonstrating actions taken when testing or measures are out of range, e.g. legionella samples, thermostatic mixing valve checks; broken call bell or equipment.

• Poor governance of the maintenance systems and slow turnaround time in completing responsive maintenance tasks.

• Not all areas are safe, clean, well-maintained or comfortable. Audit processes not identifying deficiencies in cleaning and maintenance, as well as environmental hazards and risks.

• Not all consumers able to move freely indoors and outdoors.

• Equipment and furniture not always suitable for consumers and their individual needs.

Standard 6: Feedback and Complaints

• Small day to day complaints not being registered or followed-up.

• No evidence that open disclosure has been used where a complaint involved a health or safety incident.

• No trending or analysis of complaints including identified the themes from complaints.

• Unable to demonstrate complaint process followed, including acknowledgment with consumer, investigation and resolution for effectiveness and consumer satisfaction.

Standard 7: Human Resources

• Staff not knowing about the Aged Care Quality and Safety Commission, how was it formed and its role (including Management not understanding recent changes in Jan 2020).

• Education not reflective of best practice processes.

• Orientation not occurring and not recorded consistently to demonstrate the skills, knowledge and competency of new employees.

• Poor contractor management systems including for monitoring of non-compliance and knowledge of the new Quality Standards.

Standard 8: Organisational Governance

• Strategic plan not in place or unable to demonstrate the Board’s commitment to safety, quality and inclusion.

• No evidence of Board education, including induction training, or plan for completion of education. No evidence of skills matrix of the Board.

• National mandatory indicators –data not available and not clear what actions had been taken to rectify issues or minimise risks identified.

• No clinical governance framework that minimises the use of restraint.

• Poor responses when Assessors asked for examples of clinical issues and how the clinical governance process was commenced and escalated from home level to Board/Executive level.

• Insufficient organisational wide governance systems for regulatory compliance. This included insufficient systems for:

o minimising the use of restraint

o reviewing systems for notifying the Aged Care Quality and Safety Commissioner of any change of circumstance that materially affects their suitability to be a provider of aged care (Section 9-1 of the Aged Care Act 1997)

o reviewing compulsory reporting systems (Section 63 1AA, Aged Care Act 1997)

• Risk management systems – risk management plan not reflective of the clinical risks in aged care.

• Financial governance – no policies and procedures in place; no access to annual budget; asset register, monthly reporting or evidence of consulting with consumers regarding budgets.

• Incident management – in sufficient follow-up processes in relation to critical incidents; lack of evidence ongoing actions implemented.

• Unable to describe or demonstrate process for open disclosure including being able to provide examples of how the open disclosure process was implemented and escalated to Board/Executive level.

• Audit system not including review and evaluation of consumer choice and risk.


Does the information in this table match your experience of dealing with Assessments? What was it like for you?

If you've experienced an ACQSC Assessment under the new Quality Standards, ACE is keen to hear all about it. Your insights could help other aged care homes manage their assessments and could help us provide better guidance to all our subscribers.

So please let us know your thoughts via the link below. We will keep all your information anonymous.

Take Anonymous Survey


Critical Success Solutions

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Critical Success Solutions is a wholly owned Australian company that was established in July 2002. Critical Success Solutions was developed in response to an identified need for businesses to be able to access fresh and innovative approaches to business quality and system solutions.

Mark Bryan

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Mark is a Legal Research Consultant at CompliSpace. Mark has worked as a Legal Policy Officer for the Commonwealth Attorney-General’s Department and the NSW Department of Justice. He also spent three years as lead editor for the private sessions narratives team at the Royal Commission into Institutional Responses to Child Sexual Abuse. Mark holds a bachelor’s degree in Arts/Law from the Australian National University with First Class Honours in Law, a Graduate Diploma in Writing from UTS and a Graduate Certificate in Film Directing from the Australian Film Television and Radio School.

ACE Editorial Team
ACE is published by CompliSpace and Critical Success Solutions. CompliSpace is an Australian company that specialises in helping organisations manage their legal and regulatory obligations. Critical Success Solutions is an Australian company that specialises in helping Aged Care and Disability Services manage their regulatory and legal requirements.

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