Accreditation site audit decisions
What is an accreditation site audit decision?
The decision to accredit, or not to accredit a residential aged care home is made by the Aged Care Standards and Accreditation Agency Ltd. Each decision is made by an authorised decision-maker, on its merits and in accordance with the Accreditation Grant Principles 1999.
Information on site audit decisions is confidential until the report is published on our website.
What is considered when making a decision?
When making a decision, the following documents and information are considered:
- the residential aged care home’s compliance with the Accreditation Standards (including serious risk)
- the contents of the application (self-assessment)
- the assessment team’s statement of major findings – assessment information (includes information provided by residents and their representatives)
- the assessment team’s recommendations
- information (if any) received from the approved provider in response to the major findings – assessment information (a ‘submission’)
- information (if any) received from the Department of Health and Ageing
- the residential aged care home’s history
- whether the decision-maker is satisfied the residential aged care home will undertake continuous improvement, measured against the Accreditation Standards.
Can the decision-maker come to a different view to that of the team?
The decision-maker sometimes comes to a different conclusion to that recommended by the assessment team. Where this occurs it is usually due to changes occurring at the residential aged care home after the assessment team completes the audit. Generally, the decision-maker also has other information about the performance of the residential aged care home to consider along with the audit report provided by the assessment team which includes the residential aged care home’s history of performance and additional information from the approved provider.
How long is the accreditation period?
In general, existing residential aged care homes (that is, not commencing homes) with higher levels of non-compliance will be awarded shorter periods of accreditation and residential aged care homes will not be accredited if there is serious risk to the health, safety or wellbeing of residents or major non-compliance.
We apply some general indicators to decisions about whether to accredit a residential aged care home, and if so, for how long. These are set out below:
Three years accreditation
A residential aged care home would be likely to:
- demonstrate compliance with all or almost all 44 expected outcomes; and
- not have any non-compliance that compromises the health, safety or wellbeing of residents; and
- satisfy us that it will rectify any identified non-compliance in a short timeframe; and
- not be in breach of any other significant obligations under the Aged Care Act 1997 notified to the Agency by the Department of Health and Ageing; and
- satisfy us that it undertakes continuous improvement.
Around two years accreditation
A residential aged care home would be likely to:
- demonstrate compliance with all or almost all of the 44 expected outcomes; and
- not have any non-compliance that compromises the health, safety or wellbeing of residents; and
- satisfy us that it will rectify any identified non-compliance within an acceptable timeframe; and
- not be in breach of any other significant obligations under the Aged Care Act 1997 notified to the Agency by the Department of Health and Ageing; and
- satisfy us that it is undertaking continuous improvement and is capable of monitoring and improving its compliance with the Accreditation Standards for a long period.
Around one year accreditation
A residential aged care home would be likely to:
- be safe; and
- have a number of expected outcomes with systemic non-compliance across the Accreditation Standards; and
- satisfy us that it will rectify the non-compliance in an acceptable timeframe; and
- present no serious risk to the health, safety or wellbeing of residents; and
- satisfy us that it has the capability to, and will, undertake continuous improvement.
Refuse accreditation
A residential aged care home would be likely to:
- have extensive non-compliance across the expected outcomes of the Accreditation Standards and/or non-compliance of a serious nature; and
- present a serious risk to the health, safety and wellbeing of residents; or
- not satisfy the Agency that it will undertake continuous improvement; or
- have recurring major non-compliance with Accreditation Standards; or
- be in an unsafe building; or
- be in breach of any other significant obligations under the Aged Care Act 1997 notified to the Agency by the Department of Health and Ageing.
What happens after the decision is made?
Once the decision is made, a copy of the decision and a copy of the site audit report are sent to the approved provider.
A plan for continuous improvement must be sent to us after an accreditation site audit. The plan builds on the residential aged care home’s own plans for improvement and includes any required improvements we have identified. For more information on plans for continuous improvement, refer to the information sheet on continuous improvement.
We send a certificate of accreditation to the residential aged care home within a month of the decision.
How are residents informed of the accreditation site audit decision?
Residential aged care homes are encouraged to tell residents/representatives about outcomes of an accreditation site audit, including information on non-compliance, serious risk and sanctions.
Can the decision be appealed?
In certain cases decisions can be reconsidered (by the Agency) or reviewed/appealed (by the Administrative Appeals Tribunal). For details about reconsiderations and appeals about decisions, refer to the information sheet on Reconsiderations and appeals.
What information is publicly available?
Decisions about accreditation and the assessment team’s site audit report are available on our website under Reports on homes.
