Aged Care Governance Compliance Audits – a Preparation Roadmap to Success

Ensuring compliance with the strengthened governance requirements that were effective for existing aged care providers from 1 December 2023, is essential to oversighting the delivery of high-quality care to our elderly. Now the Commission is looking at governance with a closer eye in recent audits as these strengthened governance arrangements should now be cemented in place. Aged care approved providers, therefore in anticipation of upcoming audits, should proactively prepare and strengthen governance frameworks, documentation and check this through audits.

In this article, we provide insights on getting started, conducting thorough risk assessments, utilising the Commission’s recently released pre-audit tool and leveraging preparation strategies to navigate compliance audits successfully.

Begin by understanding the Aged Care Quality Standards, relevant legislative requirements and reforms. Establish a dedicated team responsible for overseeing compliance efforts and ensuring alignment with organisational goals and values.

Conduct comprehensive risk assessments to identify potential areas of non-compliance and vulnerabilities within your organisation. Assess risks related to clinical care, workforce skills and knowledge, governance structures and environmental factors to develop targeted mitigation strategies.

Providers should:

  • Utilise preparation techniques to streamline audit processes and enhance compliance outcomes.
  • Develop robust policies and procedures.
  • Implement regular workforce training programs.
  • Maintain accurate documentation and evidence to demonstrate adherence to quality standards.

Providers should already be utilising the Self-assessment Tool (published 2019) for the current Aged Care Quality Standards to assess their compliance with each of the Standards requirements. In addition, providers should be reviewing their operations and governance against the draft Pre-audit Preparation Tool, recently released by the Aged Care Quality and Safety Commission. This Pre-audit Preparation Tool (Tool), serves as a comprehensive guide for providers to assess their compliance with the new strengthened Aged Care Quality Standards.

Note that we have provided feedback to the Aged Care Quality and Safety Commission, that the draft Pre-audit Preparation Tool (released 6 February 2024) is based on the Strengthened Standards Quality Pilot Project Pre-Audit Preparation Tool Template v2 080623 and there are some small discrepancies between the draft Strengthened Aged Care Quality Standards (released November 2023), for example:

SAQCS final draft: Outcome statement 1.1

The provider understands that the safety, health, wellbeing and quality of life of older people is the primary consideration in the delivery of care and services. The provider understands and values the older person, including their identity, culture, ability, diversity, beliefs and life experiences. Care and services are developed with, and tailored to, the older person, taking into account their needs, goals and preferences.  

Pre audit tool: Outcome statement 1.1

The provider understands and values the older person, including their identity, culture, ability, diversity, beliefs and life experiences. Care and services are developed with, and tailored to, the older person. Care and services are provided in a way that upholds the rights of older people and cultivates their relationships and social connections.

However, even with these discrepancies, the Tool assists providers in the review of each Outcome for each Standard, where providers can document how they can demonstrate their conformance and commitment to delivering high-quality care. From the guidance tab within the Excel draft Tool:

‘The purpose of the Tool is to help providers prepare for upcoming audits. The Tool can also support providers to identify opportunities for continuous improvement at any time. Providers must complete the Tool prior to the audit and must review each Outcome for each Standard (where relevant) and provide a response on how it demonstrates conformance to the Outcome. This will assist auditors to determine that the Provider:

  • Understands what is required to achieve the outcome and actions for each relevant standard.
  • Has applied or is working towards applying the action into their services.
  • Is reviewing and monitoring outcomes and progress.

At Critical Success Solutions (CSS) we believe whether you use the Pre-audit Preparation Tool or have consultants such as CSS conduct a structured external Audit Review has the following benefits:

  • Guided Assessment: The Tool/external Audit Review guides providers through a structured assessment of each Outcome for each Standard, ensuring a thorough review of compliance requirements.
  • Actionable Insights: Providers can identify specific actions required to achieve compliance and track progress towards implementation, enabling proactive risk management and continuous improvement. CSS can provide in addition to a detailed Audit Review Report, an Action Plan (with a comprehensive listing of actions) that can be used as a Continuous Improvement Plan.
  • Auditor Alignment: Completing the Tool/conducting an external Audit Review enhances communication and alignment with auditors, facilitating a smoother audit process and mitigating potential compliance issues. Having all documents/evidence readily available is also advantageous as it shows you are organised.

At CSS, we are committed to supporting aged care providers in elevating their compliance standards to meet the Aged Care Quality Standards. Our tailored solutions address key governance challenges effectively, streamline operational processes and enhance care outcomes.

  • Comprehensive Governance and/or Audit Reviews: Our experienced consultants conduct thorough reviews of governance frameworks, policies, and procedures and compliance to Standards to identify areas for improvement and ensure alignment with regulatory requirements.
  • Training and Education Programs: We offer specialised training and education programs tailored to the unique needs of aged care providers. Our interactive workshops empower the workforce with the knowledge and skills required to maintain compliance and deliver person-centered care.

Contact: Fleur Hannen, Managing Director


Mobile: 0414 588 795

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