Re-accreditation audit assessment and reports

What is a re-accreditation audit?
A re-accreditation audit is a process whereby an assessment team appointed by the Accreditation Agency visits a home to assess the quality of care and services provided to residents against the Accreditation Standards.

The audit generally takes two days, although in the case of large or complex homes, it may require more time.

The approved provider must inform residents and representatives about the re-accreditation audit. We provide a notice which may be displayed in the home, and a letter which may be sent to residents and their representatives. The letter advises that a re-accreditation audit will be carried out and when it will occur, and advises residents and their representatives they will have an opportunity to talk to the assessors in private.

How does a re-accreditation audit begin?
Assessors carry photographic identification, a request for access to the home and a letter confirming their appointment to the assessment team. These are shown to the approved provider or person in charge when the assessment team requests access.

The visit begins with a brief entry meeting. This includes an overview of the audit process, confirmation of the schedule for the audit and the availability of relevant staff and others to be interviewed.

What happens during the assessment phase of the visit?
The assessment team uses a standard audit methodology which is outlined in the Assessor handbook. (1.7Mb) This includes a strong resident focus, corroboration of information through a variety of sources (interviews, observation and documentation), and sampling techniques.

The assessment team follows-up on information supplied in the home’s self assessment and assesses the home’s performance against the Accreditation Standards by:

  • reviewing the home’s self-assessment of its performance against the Accreditation Standards
  • reviewing aspects of the home’s quality management system which demonstrate performance against the Accreditation Standards and continuous improvement for residents
  • observing the environment and what occurs at the home including staff–resident interactions and general care to residents
  • interviewing residents and their representatives, management, staff and other relevant people such as visiting doctors and pharmacists
  • reviewing records and other documents such as care plans and education records
  • considering other information provided to the team or observed while on site.

It is the responsibility of the approved provider to demonstrate the home meets the Accreditation Standards.

As issues are identified, assessors may speak with key personnel to seek clarification or ask them to provide more information. It is important that all information which shows how well the home performs is made available to the assessment team, as it is the home’s responsibility to demonstrate its performance against  the Accreditation Standards.

Issues indicating failure to meet the standards or potential serious risk to residents’ health, safety and wellbeing may be identified by an assessment team during a re-accreditation audit. Any issues of serious risk are discussed with the approved provider. They are then reported to the Accreditation Agency immediately, and we consider information provided by the team to decide whether any action is required. If there is serious risk to the health, safety or wellbeing of residents, we immediately advise the Secretary of the Department of Health and Ageing.

The team also meets with the approved provider or key personnel at least once each day during the audit to discuss the process and to ensure management is kept informed of progress against the audit schedule. This also allows the team to discuss any possible deficiencies in the home’s systems and care to residents.

What happens at the end of a re-accreditation audit?
At the end of the audit the assessment team holds an exit meeting with the approved provider or key personnel, and provides the 'Audit Major Findings’. This is for the approved provider, is not published and contains the assessment team’s findings about the home’s performance against the Accreditation Standards.

The exit meeting is intended to present the assessment team’s major findings. Major issues will have been discussed during the audit so there are no surprises at the exit meeting and in depth discussion is not necessary. The approved provider will have the opportunity to respond to the major findings after we send the ‘Audit assessment information’.

How are residents included in a re-accreditation audit?
Interviewing residents and their representatives is an important part of gathering information about a home. Residents and their representatives are often eager to participate.

The assessment team interviews at least 10 per cent of residents or their representatives. Residents and their representatives may also provide written information to the assessment team if they wish.

If the home has a number of residents who do not speak English, the assessment team may organise an interpreter.

The home should ensure that any residents or their representatives who wish to speak to the assessment team can do so in private and are assured of confidentiality.

How can management and staff assist during a re-accreditation audit?
The assessment team needs a private work area where team members can consider the information they have gathered and prepare the major findings.

The managers of the home should assist the assessment team to identify the most appropriate people with whom to discuss particular systems and processes. This will generally be confirmed at the entry meeting. They may include key personnel, care staff and ancillary staff. The home may also wish to involve other stakeholders such as volunteers, doctors or allied health professionals.

Information and documentation should be available to enable the assessment team to verify the home’s performance against the Accreditation Standards and show that it is providing good care and services to residents. This information is generally identified in the home’s self-assessment which will be one of the first documents that the assessment team will ask to see.

What happens after a re-accreditation audit?
After the visit, the assessment team prepares the ‘Audit assessment information’. This contains specific information on each of the expected outcomes, including details of expected outcomes that are not being met; other issues which – if not dealt with – may lead to failure to meet the Accreditation Standards; and suggestions for improving the care and services provided to residents. This report is submitted to the Accreditation Agency and sent to the approved provider, who has up to 14 days to submit a response before the decision is made.

The assessment team’s final ‘Audit report’ is based on the ‘Audit assessment information’. Because the report will be published, it includes the assessment team’s rationale for their findings but not the supporting and additional information that could contain private information about residents or identify staff.

The assessment team is then disbanded.