Review audits onsite assessment and reports
What is a review audit?
A review audit is an onsite assessment of the quality of care provided to residents by a residential aged care home measured against the Accreditation Standards. Review audits are conducted by an assessment team of at least two assessors.
Review audits may be announced or unannounced. They involve a complete review of the residential aged care home’s systems against all of the Accreditation Standards.
Although there is no requirement for the approved provider to inform residents and representatives about the review audit once the team is onsite, we encourage residential aged care homes to notify residents that a visit is occurring so they can request an interview if they wish.
How does a review 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 at the beginning of the visit, when the team requests access.
The visit begins with a brief entry meeting. This includes an overview of the review audit process, confirmation of the plan 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 sound sampling techniques.
The assessment team conducts a full assessment of the care and services provided to residents, as measured against the Accreditation Standards. This includes:
- 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. Please be aware that 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 and a failure to do so may lead to an incorrect recommendation of non-compliance.
Issues indicating major non-compliance or potential serious risk to residents’ health, safety and wellbeing may be identified by an assessment team during a review audit. These are reported to the Agency immediately, and the Agency considers information provided by the team and decides whether any action is required. If there is serious risk to the health, safety or wellbeing of residents, the Agency immediately recommends 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 review audit to discuss the process and to ensure management is kept informed of progress of the visit. 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 a review audit?
At the end of the review audit the team holds an exit meeting with the approved provider or key personnel, and provides a statement of major findings of the visit. This is for the approved provider, is not published and includes recommendations concerning compliance and the period of accreditation.
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. The approved provider then has seven days to submit a response to the major findings.
How are residents included in a review 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 a review audit?
The assessment team needs a private work area where the team members can consider the information they have gathered and prepare the 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.
What happens after a review audit?
The team prepares a review audit report which contains more information on the team’s recommendations. The report includes recommendations about:
- whether the residential aged care home’s accreditation should be revoked; or
- whether the residential aged care home’s accreditation should be varied; and
- the type and frequency of support contacts.
The 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 the review audit is made.
