Unannounced re-accreditation audits – Information for providers

Page last updated: 24 July 2018

Unannounced re-accreditation audits aim to look at the provider’s everyday performance against the standards.

The new arrangements will apply to all residential care services:

  • applying for re-accreditation from 1 July 2018
  • with an accreditation expiry date on, or after, 1 January 2019

Key changes

Implementing unannounced re-accreditation audits requires some changes to the current re-accreditation process. The following information summarises the key changes.

Reminder notice

  • The reminder notice will include a date by which the provider needs to make the application for re-accreditation.

Application process

  • A compliant application is in the form approved by the Quality Agency and must include:
    • the provider’s self-assessment on the service’s performance against the standards
    • consent for the surveyors to access the service to undertake the audit (the provider can withdraw this consent at any time)
    • a commitment to undertaking continuous improvement in relation to the relevant service
    • the application fee.
  • The provider may request that the unannounced re-accreditation audit not be undertaken on specific days (for example, cultural and religious reasons). Reasons will need to be given.

Notice of the site audit and assessment team

  • The provider will no longer receive advance notice of the date of the audit and the members of the assessment team. Details of the assessment team will be provided at the start of the audit.

Notifying residents and their representatives before the audit

  • A notice and a poster to inform residents and their representatives of the upcoming re-accreditation audit will be sent to the provider with the reminder notice.
  • The notice will tell residents and their representatives how to give information to the Quality Agency before and during the audit.
  • At the time of applying for re-accreditation, providers will need to inform residents and their representatives of the upcoming re-accreditation audit (rather than the specific date of the audit).

Notifying residents and their representatives on the day of the audit

  • Providers must take reasonable steps to inform residents and their representatives that the re-accreditation audit has commenced. This will need to occur as soon as practicable after the start of the audit.
  • Reasonable steps will be relative to the capacity of the service.
  • Reasonable steps include displaying the poster that the assessment team gives the provider. This poster will inform care recipients and representatives that the audit has commenced.
  • Reasonable steps may also include:
    • informing care recipients while attending to their care
    • sending care recipient representatives an email or text message to tell them that the audit has commenced
    • providing the assessment team with details of care recipients and representatives who have asked to meet with them
    • in some instances, contacting individual care recipient representatives by phone, (particularly, if they have advised that they wish to meet with the assessment team and cannot be contacted by other means).
  • Providers will need to enable care recipients and representatives who wish to meet with assessment team to do so.

Meetings with the provider during the audit

  • The assessment team will meet with the person at the service’s premises who is in charge of the service at the time of the audit.

Providing feedback to the service provider on the audit

  • An exit meeting will be held with the person in charge at the service on the last day of the re-accreditation audit to communicate issues arising from the audit.
  • A report of major findings will no longer be provided on the last day of the audit. The full audit report will be given to the provider within 7 days of the audit.
  • If the provider wishes to respond to the audit report they will have 14 days to do so after they receive the report.
  • The audit report and the provider’s response to the report will be taken into account in the accreditation decision by the Quality Agency.

Further information

For further information refer to the Quality Agency website.