Weekly Wrap: 24 May 2020

Aged care news highlights from the week ending 24 May 2020.

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The New Aged Care Quality Standards: How Will Compliance Be Assessed?

The website for the Aged Care Quality and Safety Commission (the Commission) provides a huge amount of information on how the Commission will assess a residential care service’s compliance with the new Aged Care Quality Standards (the Standards). But much of that information is scattered across multiple pages, so it’s not always easy to find what you need. That’s why we’ve done the searching for you and summarised the key points in this simple guide.


Why Does Assessment Happen?

Assessment can happen:

  • as part of the accreditation or re-accreditation process
  • as part of a process to help a service comply or improve
  • for the purpose of assessing whether a service has met a Timeline for Improvement (TFI)
  • if a service has requested reconsideration of a decision made against them
  • if the Commission suspects that a service is not complying with the Standards.


When Does Assessment Happen?

 Assessment for the purposes of re-accreditation will happen “as soon as practicable” after a service has lodged its application for re-accreditation.

Other forms of assessment can happen at any time. Assessors from the Commission may turn up at a service’s premises on weekdays or weekends inside or outside business hours. They may turn up with or without notice.


What Are the Different Kinds of Assessment?

The Commission uses many different terms when it comes to assessment.


Site Audit

A Site Audit is an essential part of the re-accreditation process. It involves an assessment team visiting a service’s premises to make a comprehensive assessment of the service’s compliance with the Standards to determine if the service should be re-accredited.


Review Audit

“Review Audit” is the Commission’s term for “a Site Audit that is not part of the re-accreditation process.” A Review Audit might occur if the Commission suspects a service is not complying with the Standards or if a service has requested reconsideration of a decision made against them.


Quality Review

This is the Commission’s term for a review of home services. It does not apply to residential care services.


Assessment Contact

This is a “catch all” term. It covers any kind of assessment except Site Audit, Review Audit and Quality Review. It includes contact by phone and writing, and any visit to the service’s premises that is not comprehensive enough to qualify as a Site Audit or Review Audit.



As part of the re-accreditation process a service must submit a Self-Assessment that demonstrates their performance, measured against the Standards.


What Does a Site Audit/Review Audit Involve?

Site Audits and Review Audits involve assessors visiting a service’s premises to make a comprehensive assessment. Here’s how it happens:


Before the Day

A Review Audit may be conducted with or without notice, but a Site Audit must be conducted “unannounced”. The Commission will tell a service that a Site Audit is going to happen at some point within a period of a few weeks or months, but they will not tell them the exact date on which it will occur. The service can request that the assessors not turn up on certain dates, but the Commission does not have to comply with this request.

When the Commission notifies a service that a Site Audit will be happening, they also provide posters and a form of words that the service must use to alert consumers about the upcoming Site Audit. The service must put up the posters and alert consumers “as soon as practicable” after receiving the notice from the Commission.

Copies of the Commission’s posters and notices can be found on the Commission’s website.


On the Day

When the assessors arrive, they will request the occupier’s consent to enter the premises and conduct the assessment. The assessors are not permitted to enter the premises without consent.

As soon as the assessors enter the premises and begin the assessment, the person in charge at the premises is expected to take reasonable steps to inform consumers that the assessment is underway. This includes displaying the posters that the assessors will provide ahead of time or on the day.

The assessors will then collect information to assess the service’s performance against the Standards. Information will be drawn from three potential sources of evidence:

  • interviews with consumers, visitors, staff and anyone else who is involved with the service
  • observation of the environment and staff interactions with consumers
  • review of documents and records.

The key documents and records that assessors will want to see on the day are the Self-Assessment, Plan for Continuous Improvement and Self-Assessment Tool for Recording Consumers Receiving Psychotropic Medications. Providers should ensure that relevant staff have easy access to the most recent versions of these documents in case assessors turn up for an unannounced visit.

The audit can last several days. Assessors will meet with the person in charge at the premises each day to discuss the progress of the assessment.



After the visit, the assessors will write a report and submit it to the Commissioner. For Site Audits, the assessors must do this within seven days. For Review Audits they have 14 days. A copy of the report will be sent to the service provider “as soon as practicable.”

If the Site Audit Report or Review Audit Report includes a finding of non-compliance, the provider will be given 14 days to provide a written response. This response will be one of the things the Commissioner considers when making their decision. In the case of a Site Audit this decision will be whether or not to re-accredit the service. In the case of a Review Audit this decision may be whether or not to revoke accreditation, impose sanctions, provide assistance or seek further information.

For more information on what happens during site visits, see our previous article on Themes from Assessor Visits.


The Focus and Primary Purpose of Assessment

The Commission’s website says that when making an assessment, assessors will focus on:

  • areas of risk identified for the service
  • areas previously notified for improvement and subject to a timetable for improvement
  • requirements of Quality Standards that have high prevalence of non-compliance across the sector
  • current sector-wide strategies of the Commission such as a focus on infection control, and
  • other relevant information provided to the Commission.

The site also notes that for the period of 1 July 2019 to 1 September 2019, assessment contacts (unless determined by matters as above) will focus on:

  • Standard 1 – Consumer dignity and choice and/or
  • Standard 6 – Feedback and complaints.

But underpinning these particular areas of focus is the same primary purpose. Whether it’s a three-day site audit or a quick chat over the phone, the primary purpose of an assessment is to measure the service’s performance against the Standards. This involves assessing how well the service understands, applies, monitors and reviews some or all of the 42 requirements across the eight Standards.

To find out more about how to meet the requirements in the Standards, see our series of Mapping Matrix tools for each of the new Standards.

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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