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.

Read Now
All Posts

How to Use the ACQSC Self-Assessment Process to Your Advantage

The Aged Care Quality Standards (the Standards) have been in place since July 2019. Each aged care home is expected to be meeting each of the eight Standards, as well as the linked requirements, consumer outcomes and specific organisational statements. The Aged Care Quality and Safety Commission (the Commission) provides a range of resources to support this transition, including a self-assessment tool and guiding material.

The Commission describes self-assessment as an ‘active process’, that is linked closely to the development and planning of continuous improvement. Identified issues, as well as opportunities for improvement that are recognised from the self-assessment, should be included in the plan for continuous improvement (PCI).


So, is your self-assessment current and completed through an ‘active process’

or does it require some attention?


Understanding the Self-Assessment

The self-assessment can seem like burdensome paperwork, but if it is incorporated into strategic operations it can become a useful management tool that helps you maintain continuous improvement while measuring and reporting on the care and services you provide.

Importantly, when completed correctly and seen as an active document, the self-assessment provides an honest and transparent appraisal of an organisation’s ability to demonstrate its performance against the Standards.

It is also important to note that the self-assessment is a mandatory document. You are required to provide the self-assessment to the Commission’s assessors upon request. This may happen during a site visit or assessment contact or as part of the accreditation process.


Advantages of the Self-Assessment

The self-assessment can be a powerful tool that managers can use to drive continuous improvement. If used correctly, the self-assessment can help managers to:

  • understand how care and services are delivered
  • report and evaluate outcomes that are achieved for consumers, staff and as an organisation
  • recognise opportunities for innovation and improvement at a system level, on a day-to-day basis, and improve individual consumer experiences and outcomes
  • build an organisational culture focused on improving safety and quality of care
  • communicate and report the organisation’s performance, outcomes, and risk to the governing board of the organisation
  • initiate change in accordance with the areas identified as requiring improvement.


The self-assessment should be completed as a team and contain the contributions of different staff across the care and service areas within the organisation. This encourages a shared understanding of the Standards as well as an organisation-wide commitment to continuous improvement.


Tips for writing the Self-Assessment

  • Review and understand the Standard, and the linked Requirements and what is expected.
  • Use the reflective questions detailed in the guidance documents and linked to each Requirement to assess as well as challenge this understanding further.
  • Remember the Standards are expressed in three ways and this needs to be included in the self-assessment. These are:
    1. a statement of outcome for the consumer
    2. a statement of expectation for the organisation and
    3. organisation requirements to demonstrate that the Standard has been met. 
  • Use the examples of actions and evidence detailed in the guidance documents and linked to each Requirement in writing the self-assessment document, as well as to identify opportunities for improvement.
  • Document the actions and evidence areas of the self-assessment systematically so you don’t miss any of the organisation’s achievements or opportunities for ongoing improvement. This can be accomplished through:
    • considering current policies and procedures linked to the Standard and the Requirement. Reflect on linked practices that demonstrate how care and services are provided. This may also include partnerships with other professional and community organisations
    • detailing of workforce learning as well as competency and capability systems and achieved outcomes. Consider formal and informal learning, orientation processes and management support and review across these systems
    • summarising evaluation and review processes and outcomes. Reflect on how this occurs eg. audit, performance indicators and other quality review tools, as well as the outcomes and results achieved for consumers and supporting evidence. This information is a strategic part in the identifying of areas for ongoing improvement and required actions
    • explaining reporting and communicating outcomes and review results, including who receives this information, and related responsibilities. The review of results and outcomes needs to be regarded as a measure of past performance and an opportunity for improvement.


Look again at your organisation’s self-assessment, explore the advantages and opportunities that it provides and consider making it a collaborative and active process that works for you.


Click here to access the Self-Assessment Tool - Aged Care Quality Standards.

Ruth Greene
As a Registered Nurse with over 30 years’ experience across the healthcare industry, Ruth has been employed in a range of management and clinical positions, and for several years worked as a consultant in residential aged care. Understanding organisational governance, risk and related quality standards has been a pivotal part of her work practices and has included maintaining and monitoring of legislative and regulatory requirements, as well as developing linked policy documents. Ruth is Principal Consultant – Aged Care, at CompliSpace.

Related Posts