Making a Plan and Checking it Twice: Aged Care COVID-19 Advice from the ACQSC

A second wave of COVID-19 is currently being experienced by several of our communities, particularly within Victoria and NSW, and a large percentage of cases are older people within our aged care homes. While previously only a few facilities were impacted by COVID-19, we have never experienced the number of infectious outbreaks impacting such a large number of Aged Care Homes at one time as are currently being reported across Melbourne.

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Managing COVID-19 in a Residential Aged Care Facility: The First 24 Hours Checklist

The spike in Victorian cases reminds us that COVID-19 is still a serious and immediate threat to aged care facilities. To help aged care providers cope, the Department of Health has released a new Fact Sheet on how to manage an outbreak in the first 24 hours.

Providers should refer to the full Fact Sheet here for details, but if you’re pressed for time or need a quick overview for reference or staff communication, here are the key points set out in an easy to use checklist.

If a COVID-19 positive case is identified at your residential aged care facility, follow these steps in order:

First 30 minutes
Step  Details Person/Role Responsible Comments Done 
1 Isolate and inform the COVID-19 positive case(s)

Use PPE for any interactions with positive cases.
1A If the COVID-19 positive person is a staff member they must immediately leave the facility and isolate at home as directed by the public health unit (PHU).      
1B If the COVID-19 positive case is a resident they should be immediately isolated in a single room with an ensuite, if possible.


May be transferred to hospital or other accommodation if clinically required.
1C Outside affected residents’ rooms place the following:
  • Contact and droplet precaution signs
  • Alcohol-based hand rub
  • Appropriate PPE and hands-free bins for used PPE.
1D Inform the resident and their family of their diagnosis with sensitivity and support as needed.      
2 Contact your local Public Health Unit (PHU)      
3 Contact the Commonwealth Department of Health      
4 Lockdown the residential aged care facility      
Minutes 30-60
Step  Details Person/Role Responsible Comments Done 
5 Convene your outbreak management team      
6 Activate your outbreak management plan      
7 Establish screening protocols.

This includes placing appropriate and clear signage across the facility.
8 Release an initial communication.

This should include residents, staff, families, and key stakeholders.

Providers with multiple services should consider communications for other sites.



Hours 2-3
Step  Details Person/Role Responsible Comments Done 
9 Contact tracing.

Identify anyone who spent 15 minutes within 1.5 m of the COVID-19 positive person.
Led by PHU    
9B Increase monitoring of all residents for any symptoms of COVID-19. Take clinical observations two to three times a day.      
10 Identify key documents for PHU and Commonwealth.

  • detailed floor plan
  • current resident list
  • staff employed by the facility
  • specimen records including results.
11 PPE stocktake      
12 Communication

Expect and prepare to manage a very high volume of calls.
Hours 4-6
Step  Details Person/Role Responsible Comments Done 
13 First meeting of the Outbreak Management Team      
14 Bolster your staff and plan your roster.

You should allocate separate staff for COVID-19 positive, COVID-19 suspected and non-COVID-19 residents.
Plan what you would do if key staff or the CEO became unwell.
15 Conduct testing

Urgently test all residents and staff for COVID-19 to understand the status of the outbreak.
  Clinical management of COVID-positive cases      
Hours 6-12
Step  Details Person/Role Responsible Comments Done 
17 Cohorting and relocation      
18 Move to a command-based governance structure

  • Clearly communicate the command and governance structure for every shift.
  • Ensure handovers for all staff occur at the start of a new shift and cover clinical and care needs.
19 Rapid PPE supply      
20 Infection control

  • Appoint an infection control lead for the service. Ensure that:
  • staff refresh their infection control training
  • enhanced environmental cleaning occurs twice daily at a minimum
  • residents’ rooms are well-cleaned daily
  • frequently touched surfaces (including bedrails, bedside tables, light switches, handrails) are cleaned more often
  • the rooms of ill residents should are cleaned and disinfected.
Hours 12-24
Step  Details Person/Role Responsible Comments Done 
21 Nurse First Responder from Aspen to commence      
22 Review advance care directives      
23 Establish strong induction and control processes

The responsible person must ensure:
  • robust induction for all new agency and surge workforce staff coming onsite, and
  • that all staff working are competent using PPE.
Consider having workforce competency reviews for all staff.
24 Maintaining social contact – residents and their families/ representatives.

You will need extra staff to assist residents with communications/use of technology.
25 Follow up communications

Establish a clear and consistent pattern of daily follow-up outbound communications.
26 Continue primary health care      
27 Support your staff – they are your most import asset.      
28 Continue to monitor state / territory guidelines      


Other Useful Resources

Protocol to support joint management of a COVID-19 outbreak in a residential aged care facility (RACF) in NSW

The purpose of this protocol is to formalise the coordination of government support to an aged care approved provider (provider) in their management of a COVID-19 outbreak in a Commonwealth funded residential aged care facility (RACF) in NSW. The protocol outlines the roles and responsibilities of relevant parties, governance structures, escalation procedures and expectations around information sharing and timeframes. You can access the protocol here.


Webinar Recording and 2 Audit Tools:   Understanding the Gaps in Infection Control Plans that can put Residential Aged Care Facilities at Risks

This free CompliSpace webinar covers:

  • How your COVID-19 infection prevention control systems – and outbreak management plan – relate to other key areas of operational risk and compliance
  • Which of these interrelated areas are most often missed by residential aged care facilities, and what are the potential risks and consequences?
  • The role of active surveillance and risk management in identifying gaps and areas to improve
  • How to stay on top of change and adapt quickly to best practice updates and new legislative requirements.
  • How to efficiently and cost-effectively keep up with continual change so that your systems and processes produce the outcomes needed now and in the future.

Click here to watch the recording:

CompliSpace also shared two audit tools mentioned in the webinar:

Click here to download the Outbreak COVID-19 Preparedness Audit Tool

Click here to download the Outbreak Management COVID-19 Audit Tool 


Demo: How CompliSpace Helps Residential Aged Care Facilities of all Sizes Manage Infection Control

CompliSpace presented a webinar to demonstrate CompliCare, which uses a proven framework that combines policies, staff learning, assurance tools and reporting to help residential aged care facilities (of any size) sustain compliance – in this ever-changing legislative environment – in areas such as: 

  • Infection prevention and control
  • Risk Management
  • Clinical and Personal Care
  • Services and supports
  • Incident management
  • Quality Standards Compliance
  • Complaints Handling
  • Privacy
  • Work Health & Safety
  • Organisation service environment
  • Human Resources and workforce management
  • Board Governance Practices

Click here to watch the webinar demonstration.

Click here to access the Q&A document from the webinar.


One Facility’s Experience

In June a small Residential Aged Care facility in Victoria, Edith Bendall Lodge, had an unannounced Monitoring Assessment with the Commission. Three assessors arrived at around 9:30am to review the Home’s systems in line with COVID 19 and infection prevention and control. Related systems were also explored at this time including stock supplies, non-clinical areas (laundry, cleaning and food services), and management and Governance systems.


The assessors completed the visit in 3 hours. The result: all areas reviewed were found to have met the relevant requirements of the Quality Standards.


CompliSpace have been working with the Home in a consulting capacity, as well as implementing the CompliCare system with the management team.


The Director of Nursing, Martha Weson, was able to demonstrate:

  • the system to the assessors
  • the ease of review in relation to publishing of documents and
  • how policies and procedures are updated to ensure current / best practice content.

“It was definitely a surprise to receive a phone call from the ACQASC to be informed following a phone screening that we were about to have an unannounced visit focusing on our preparedness for COVID-19.  However, the assessors were great and due to the hard work attended over the last few months with Ruth Greene from CompliSpace using the CompliCare system, we were able to obtain a great result!” Martha Weston, Director of Nursing

This great outcome demonstrates the success of the CompliCare Infection Control Program and Outbreak Management Plan.


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To request a conversation about CompliCare, click here.


Mark Bryan
Mark is a Legal Research Consultant at CompliSpace and the editor for ACE. 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.

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