Responding to an assessment team's report

What is a response to an assessment team’s report?
A response to a team’s report is a submission to the Accreditation Agency by an approved provider after it has received the assessment team’s findings in writing and before a decision is made. It may present:

  • reasons why information in the report is inaccurate or incomplete
  • actions conducted since the team’s visit to remedy deficiencies
  • actions planned to remedy deficiencies.

After a re-accreditation audit or review audit the approved provider is invited to submit a response to the Audit assessment information report.

After an assessment contact, the Accreditation Agency may choose to invite the approved provider to respond to the assessment contact report.

The deadline for the approved provider to submit a response before a decision is made is always specified in reports and correspondence from us.

A submission gives the decision-maker increased confidence that the issues have been, or are being managed, and therefore contributes positively to the decision.

If you have any concerns about the submission, you should contact the State Manager in your local Accreditation Agency office. If you have concerns you will receive retribution, you should raise your concerns with us as soon as possible.

Will submitting a response really make a difference?
Submitting a response gives the decision-maker information that deficiencies are being managed to ensure continuing care for residents. It also provides confidence that any failure to meet the Accreditation Standards will be rectified quickly and in a planned manner to prevent recurrence.

Responses from approved providers form a major reason why a decision-maker may disagree with a team’s findings regarding failure to meet the Accreditation Standards. They may also affect the period of accreditation granted, and the form and frequency of assessment contacts.

What should be included in a response?
The response should present a logical argument about how the home meets the Accreditation Standards, or what actions are occurring to meet the standards in the quickest possible time to ensure adequate and sustainable care for residents.

While each issue identified in the report should be addressed, the submission should also include information on:

  • how the overall system has been remedied or works to ensure adequate and sustainable care and services to residents
  • how the home has communicated any necessary changes to staff and residents
  • what systems have been put in place to monitor expected outcomes that the team identified as ‘not met’, and prevent recurrence of the issue.

The decision-maker is most interested in receiving information on how the system is now working to provide adequate care and services to residents. Such information should therefore include a description of the system and any changes (including dates), and supporting information – such as copies of calendars, tools, memoranda.

Some improvements require extensive planning. For this reason, where the home has not yet put all actions in place, including evaluation processes, the approved provider should provide information on progress made and an improvement plan for future actions. Such a plan should be broken down into smaller actions to remedy an overall issue and contain:

  • details on each action
  • intended result of each action
  • person responsible (to reflect adequate resourcing)
  • clear dates for each individual action
  • any additional relevant comments.

The dates for planned actions should be reasonable. This means prioritising improvements, and ensuring prompt action will be taken to remedy areas of poor care and services to residents as soon as possible. The goals should be achievable.

Please be aware that providing false or misleading information is a serious offence under the Criminal Codes Act 1995.

Should responses only include information on expected outcomes that were reported not met?
Because the assessment team only presents findings about performance against the Accreditation Standards, a decision-maker may consider other information in a report, and decide on additional failures to meet the Accreditation Standards. Other issues may also give further weight to failure to meet the Accreditation Standards.

Approved providers should therefore consider all information provided in reports. This also reflects the approved provider’s approach to using all available information about the home to pursue continuous improvement of care for residents.

How do I make a response?
Detailed instructions about how to make a response is provided to approved providers either in the reports (‘assessment information’) or in correspondence from a decision-maker.

Where can I get more information?
Information on some of the considerations for ensuring performance against  the Accreditation Standards is found in our Results and processes guide.

For more information on plans for continuous improvement, refer to continuous improvement.