Accreditation site audit onsite assessment and reports

What is an accreditation site audit?
An accreditation site audit is a process whereby an assessment team appointed by the Agency assesses the quality of care provided by the applicant against the Accreditation Standards.

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

The approved provider must, within three days of being notified of a site audit, inform residents and representatives about the site audit. We provide a notice which may be displayed in the residential aged care home, and a letter which may be sent to residents and their representatives. The letter advises that a site audit will be carried out, when that site audit will occur and advises residents and their representatives they will have an opportunity to talk to the assessors in private.

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

The visit begins with a brief entry meeting. This includes an overview of the site 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 team uses a standard audit methodology which is outlined in the Audit handbook. 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 residential aged care home’s application and assesses compliance with the Accreditation Standards by:

• verifying information provided in the self-assessment concerning compliance with the Accreditation Standards
• reviewing aspects of the residential aged care home’s quality management system which demonstrate compliance and continuous improvement for residents
• observing the environment and what occurs at the residential aged care 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 residential aged care home complies with the Accreditation Standards. Providing false or misleading information is a serious offence under the Criminal Codes Act 1995.

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

Issues indicating major non-compliance or potential serious risk to residents’ health, safety and wellbeing may be identified by an assessment team during an accreditation site audit. Any issues of serious risk are discussed with the approved provider. They are then reported to the Agency immediately, and we consider information provided by the team and decide whether any action is required. If there is serious risk to the health, safety or wellbeing of residents, we immediately recommend to the Department of Health and Ageing that sanctions be imposed.

The team also meets with the approved provider or key personnel at least once each day during the site 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 residential aged care home’s systems and care to residents.

What happens at the end of an accreditation site audit?
At the end of the site audit the team holds an exit meeting with the approved provider or key personnel, and provides a statement of major findings. This is for the approved provider, is not published and contains information on the team’s recommendations regarding compliance.

The exit meeting is intended to give a summary of the assessment team’s major findings. Major issues are discussed during the audit so there are no surprises at the exit meeting. In depth discussion of the issues is not necessary as they have been discussed earlier in the visit. Further opportunity to respond to the major findings is provided after the assessment information has been received.

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

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

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

The residential aged care home should ensure those 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 an accreditation site audit?
The assessment team needs a private work area where the team members can consider the information they have gathered and prepare the statement of major findings.

The residential aged care home’s management 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. These may include key personnel, care staff and ancillary staff. The residential aged care 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 team to verify the residential aged care home is compliant with the Accreditation Standards and is therefore providing good care and services to residents. This information is generally identified in the residential aged care home’s self-assessment which forms part of the application for accreditation.

What happens after an accreditation site audit?
After the visit, the assessment team prepares the ‘major findings – assessment information’. This contains specific information on each of the expected outcomes, including details of any non-compliance, other issues which, if not dealt with, may lead to non-compliance, and suggestions for improving the care and services provided to residents. This document is sent to the approved provider from the Agency and the approved provider has up to 14 days to submit a response to this information.

The team also prepares a site audit report which contains more information on the team’s recommendations. The report includes recommendations about:

• whether the residential aged care home should be accredited; and
• if the residential aged care home should be accredited, for what period; and
• the type and frequency of support contacts.

This report is then submitted to the Agency, for a decision to be made. The team is then disbanded.

This report is published after a decision about accreditation is made.