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About Re-applying for Accreditation

What about homes re-applying for accreditation?
How does a home apply?
What is a valid application?
What is a desk audit?
What is a site audit?
What happens at a site audit?
How are residents included in the site audit?
How can management and staff assist during the site audit?
What happens after the site audit?
What accreditation decisions can be made?
What happens when the decision is to accredit?
How long is the accreditation period?
What if the decision is not to accredit?
Can the decision be appealed?
What is published?

What about homes re-applying for accreditation?

A provider of an existing home must re-apply for accreditation and then be accredited for a further period in order to continue to receive Commonwealth subsidies. Being an accredited home is recognition of the level of compliance with the Accreditation Standards, and the continuous improvement results which the home has achieved for the benefit of residents.

A major component of the application process is self-assessment against the 44 expected outcomes that make up the four Accreditation Standards. Self-assessment is a valuable management tool that enables the provider and the home’s management to evaluate the home’s performance and identify strengths and opportunities for improvement.

The results of self-assessment will form the basis of the application which must demonstrate what the home achieves in relation to each expected outcome and that it is compliant with the Accreditation Standards. It is the responsibility of the provider to demonstrate that the home complies with the Accreditation Standards.

How does a home apply?

The Agency will advise the provider of the date by which an application is required when the provider is informed about the accreditation decision. The due date will usually be 25 weeks before the accreditation period expires.

Download the Application for accreditation from the Agency’s website. If this is difficult or not possible, contact the local Agency office and ask for either a compact disk (CD) or paper copy. If you have a dial-up connection with a 56 K modem you may have difficulty and we suggest you request a CD version of the application by contacting the local state office of the Agency. Click here to download the application for accreditation.

The Agency encourages the use of the electronic form of the application and submission by e-mail. By choosing the electronic option for both the self-assessment report and for supporting documents, the home will save paper and time spent photocopying. However, if you intend to complete a hardcopy application click here to download a PDF version of the paper application and the Accreditation application self-assessment prompts.

What is a valid application?

To be considered valid, an application must:

be made by the provider
use the approved Agency application form
have all parts completed
include an agreement by the provider to undertake continuous improvement
include payment of the correct accreditation fee.

Only valid applications can be accepted and processed by the Agency. Once the Agency decides that the application is valid, an assessment team will assess the application at desk audit and verify what is in the application at the site audit. This will lead to a decision about accreditation. Following accreditation the Agency will monitor compliance with the Accreditation Standards and the home’s continuous improvement activities.

Note: Providers intending to open a commencing service should read the fact sheet about new homes for information on how to apply for accreditation.

What is a desk audit?

After the Agency decides the application for accreditation is valid, a team of aged care quality assessors will be appointed. The first task of the assessment team will be to conduct a desk audit.

A desk audit is a review of the results of the self-assessment and supporting documents, and any information provided to the Agency by the Department of Health and Ageing such as certification status, prudential arrangements, concessional resident ratios or information about complaints matters.

During the desk audit the assessment team identifies issues requiring follow up at site audit, and plans how to verify and corroborate the information in the application. The team also identifies if there are any special needs groups for which arrangements need to be made, eg provision of an interpreter.

The assessment team may find that the application does not contain enough information and evidence of results achieved for residents to demonstrate that the home complies with the Accreditation Standards. The Agency will take this into account in its decision about whether to proceed to site audit. The assessment team may request further information be sent to the Agency or to be available on site.

After the desk audit, the assessment team will prepare a Desk audit report which includes advice about whether or not the information in the application indicates that the home complies with the Accreditation Standards. The Agency will decide whether to proceed with the application for accreditation. The provider will be advised in writing by the Agency of the decision to proceed or not to proceed to site audit. If the audit is to proceed the letter will include the dates of the audit, a proposed audit schedule to assist the home plan for the audit and, if it will assist the home demonstrate its compliance with the Accreditation Standards, a request to provide specific information during the site audit. If there is a need to clarify or discuss the schedule, the management of the home may contact the person whose name appears on the letter or the Assessment Manager at the local state office of the Agency.

If the Agency decides not to proceed to site audit, the provider will be given in writing:

reasons for the decision, including any matters for improvement which would allow the assessment team to recommend that the application continue
information about arrangements for support contacts
information about how to apply for reconsideration or review of the decision, and
a copy of the Desk audit report.

The home may then make the suggested improvements and re-apply for accreditation or apply for reconsideration of the Agency’s decision.

What is a site audit?

A site audit is an on-site assessment of the home by an assessment team appointed by the Agency. During the site audit there will be opportunities for the management of the home to clarify any questions about the accreditation process and the home’s performance.

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

The provider must inform residents and relatives about the site audit. The Agency will provide a notice which may be displayed in the home, and a form 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 that they will have an opportunity to talk to members of the assessment team in private.

What happens at a site audit?

On arrival at the home, there will be a brief entry meeting. At the entry meeting the assessment team will present an overview of the site audit process, confirm the schedule for the audit and the availability of relevant staff and others to be interviewed.

The assessment team will meet with the provider or key personnel at least once each day during the site audit to discuss the process, to ensure that the management is kept informed of progress against the audit schedule, and informed of any findings of concern.

Assessors carry photographic ID and a letter confirming their appointment to the assessment team. These must be shown to the provider if requested.

The assessment team will follow up on information supplied in the application and assess compliance with the Accreditation Standards by:

verifying information provided in the self-assessment concerning compliance with the Accreditation Standards
reviewing aspects of the home’s quality management system which demonstrate compliance and continuous improvement
observing the environment and what occurs at the home
interviewing residents and their representatives, management, staff and other relevant people (eg visiting doctors, pharmacists)
reviewing records and other documents (eg care plans, policies)
considering other information provided to the team or observed while on site.

The assessment team will consider each piece of information (whether it be from observation, an interview or documentation) to reach its findings about the performance of the home against the Accreditation Standards.

The assessment team will test the home’s systems for achieving each expected outcome through a sampling process – not every resident will be interviewed and not all records will be examined.

Team members may need to follow up on specific issues with the provider or key personnel to clarify issues affecting their findings. It is important that all information which shows how well the home performs is made available to the assessment team – the key is to provide clear information to demonstrate compliance.

At the end of the site audit the team will hold an exit meeting with the provider or key personnel, and provide a Statement of major findings which is a report of the assessment team’s major findings from the audit.

The exit meeting is designed to give a summary of the assessment team’s major findings. Major issues will already have been discussed during the audit so there will be no surprises at the exit meeting.

The provider will be given an opportunity to respond to the Statement of major findings by making a submission to the Agency, including supporting evidence, within 14 days of the exit meeting.

How are residents included in the site audit?

Interviewing residents and their representatives is an important part of information gathering about a home. Residents and their representatives are often eager to participate.

The team will interview at least 10 per cent of residents or their representatives; however a significantly higher number may be interviewed. Residents and their representatives may also provide written information to the team if they wish.

How can management and staff assist during the site audit?

The assessment team will need a private work area where the team members can consider the information they have gathered and prepare the Statement of major findings.

The home should ensure that those residents or their representatives who wish to speak to the assessment team can do so in private and are assured of confidentiality.

Information and documentation should be available to enable the team to verify that the home is compliant with the Accreditation Standards and the Act. This information will have been identified as part of the self-assessment undertaken for the application for accreditation. It might include reports, audits, surveys, education and training records, minutes of staff meetings, documents used to guide staff and results of any reviews of the care and services provided to residents. In addition, the assessment team may have informed the provider of information needed at the site audit when arrangements for the audit were confirmed.

The home’s management should also assist the assessment team to identify the most appropriate people with whom to discuss particular systems and processes. These may include the provider or key personnel, members of the Board or Management Committee, managers within the home, care staff and ancillary staff. The home may also wish to involve other stakeholders such as volunteers, doctors or allied health professionals.

It may be helpful to use the schedule provided by the assessment team before the audit to assist in organising the availability of particular people.

What happens after the site audit?

After the site audit, the assessment team will prepare a Site audit report based on all of the information the assessors have seen, heard or read in relation to the home and provide it to the Agency. The report will include a recommendation about whether to accredit the home, and if so for what period and the type and frequency of support contacts. If any findings of the Site audit report are significantly different from those provided in the Statement of major findings, the provider will be given a copy of the Site audit report and invited to make written comment

Any comments submitted by the provider about the Statement of major findings or the Site audit report will be considered by the Agency when making the accreditation decision.

Issues indicating significant non-compliance or potential serious risk to residents’ health, safety and wellbeing may be identified by an assessment team during a site audit. These will be reported to the Agency immediately, and the Agency will 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, the Agency will immediately recommend to the Department of Health and Ageing that sanctions be imposed.

It is important to note that while the assessment team conducts audits, it is the Agency that makes accreditation decisions.

After the Agency makes a decision about accreditation, the provider will be informed of the decision and the Agency will publish the decision, the Site audit report and the Executive summary on its website.

What accreditation decisions can be made?

The decision to accredit, or not to accredit, an 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. It is possible for a decision maker to make a decision different from a team’s recommendation because the decision maker must take into account all relevant facts and may have more information than the Site audit report.

The two essential elements taken into account when making the decision are:

the home’s compliance with the Accreditation Standards
whether the Agency is satisfied the home will undertake continuous improvement, measured against the Accreditation Standards, if it is accredited.

In deciding whether or not to accredit and, if so, for how long, the Agency decision maker must consider:

the Desk audit report from the assessment team
the Site audit report from the assessment team
information (if any) provided by the home in response to the Statement of major findings
information (if any) received from the Department of Health and Ageing including about certification.

The Agency may also take into consideration any other information that it holds about the home’s performance.

What happens when the decision is to accredit?

When the decision is to accredit the home, the Agency will send the provider a copy of the Site audit report and notice of the decision, including:

that the home is accredited
the period of accreditation including the date of effect and the last day of accreditation
any matters for improvement concerning the Accreditation Standards
the number and type of planned support contacts
requirements concerning the Plan for continuous improvement
the circumstances in which the accreditation may be reviewed
arrangements for a further period of accreditation
the date by which an application should be made for a further period of accreditation
information about reconsideration mechanisms, if appropriate.

A certificate of accreditation will be sent within a month of the decision, after which the provider must submit a Plan for continuous improvement to the Agency. The plan should build on the home’s own plans for improvement and include any required improvements identified by the Agency.

How long is the accreditation period?

Accreditation decisions take into account the overall level of compliance and the extent to which any non-compliance compromises the health, safety or wellbeing of residents. There is no direct link between numbers of compliant outcomes and the period of accreditation.

In general, homes with lower levels of overall compliance will be awarded shorter periods of accreditation and homes will not be accredited if there are any findings of serious risk to the health, safety or wellbeing of residents or findings of extensive non-compliance.

The Agency does, however, apply some general indicators to decisions about whether to accredit a service, and if so, for how long. These are set out below.

Three years accreditation

Such a service would be likely to:

demonstrate compliance with all or almost all 44 expected outcomes; and/or
not have any non-compliance that compromises the health, safety or wellbeing of residents; and
satisfy the Agency 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 the Agency that it undertakes continuous improvement.

Around two years accreditation

Such a service would be likely to:

demonstrate compliance with all or almost all of the 44 expected outcomes; and/or
not have any non-compliance that compromises the health, safety or wellbeing of residents; and
satisfy the Agency 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 notified to the Agency by the Department of Health and Ageing; and
satisfy the Agency 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

Such a service would be likely to:

be safe; and
have a number of expected outcomes with systemic non-compliance across the Accreditation Standards; and
satisfy the Agency 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 the Agency that it has the capability to, and will, undertake continuous improvement.

Refuse accreditation

Such a service may:

have extensive non-compliance across the expected outcomes of the Accreditation Standards and/or non-compliance of a serious nature; and/or
present a serious risk to the health, safety and wellbeing of residents; and/or
not satisfy the Agency that it will undertake continuous improvement; and/or
have recurring major non-compliance with Accreditation Standards; and/or
be in an unsafe building; and/or
be in breach of any other significant obligations under the Aged Care Act notified to the Agency by the Department of Health and Ageing.

What if the decision is not to accredit?

If the decision is not to accredit, the Agency will send the provider a copy of the Site audit report and notice of the decision which includes:

reasons for the decision including a recommendation about improvements which are necessary to demonstrate compliance with the Accreditation Standards
information about support contacts
information about how to submit an improvement outline and when this must be done
information about how to apply for reconsideration of the decision
an explanation of the date of effect of the decision.

Can the decision be appealed?

For details about reconsiderations and appeals about decisions, refer to Reconsiderations and appeals.

What is published?

The Agency publishes the accreditation decision, an executive summary and the Site audit report on its website. Click here to view current reports

The most recent report for a home is published under “current reports” and old reports are available in the archive section of the website.

If the home receives a Better Practice in Aged Care Award, it will be acknowledged on the website.