Review audits onsite assessment and reports

What is a review audit?
A review audit is an on site assessment of the quality of care and services provided to residents by a 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 home’s systems against all of the Accreditation Standards.

We will provide a poster to be displayed in a prominent place at the home to inform the residents about the visit. If the visit is announced, this will be sent to the home in advance; if it is unannounced the assessment team will provide the poster at the entry meeting.

How does a review 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 team arrives.

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 when relevant staff and others will be available to be interviewed.

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

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 home’s quality management system which demonstrate 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
  • looking at records and other documents such as care plans and education records
  • considering other information provided to the team or observed while on site.

 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 home performs is made available to the assessment team, as a failure to do so could lead to an incorrect finding that the home fails to meet the Accreditation Standards.

The team also meets with the approved provider or their delegate 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 home’s systems and care to residents.

The assessment team may identify issues indicating failure to meet several of the expected outcomes, or potential serious risk to residents’ health, safety and wellbeing (‘serious risk’). The team immediately informs the approved provider or key personnel at the home, and contacts a manager at our local office for a decision on what action is required. If there is serious risk we immediately inform the Department of Health and Ageing, which may decide that sanctions should be imposed.

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 and is not published.

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 gathering information about a home. Residents and their representatives are often eager to participate.

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

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

The home should ensure that 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 home’s managers 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 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 home meets 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 findings.

The report is submitted to the Accreditation Agency, for a decision to be made.

The team is then disbanded.