--- title: ACQS Accreditation Audit topic: acqs-accreditation-audit type: HG Reference jurisdiction: Australia (national) lastReviewed: 2026-05-22 publisher: Holistic Governance publisherUrl: https://hg-au.com canonicalUrl: https://hg-au.com/topics/acqs-accreditation-audit.md --- # ACQS Accreditation Audit > An ACQS accreditation audit is an independent assessment of an aged care provider's performance against the Strengthened Aged Care Quality Standards, conducted by quality assessors authorised by the Aged Care Quality and Safety Commission (ACQS Commission). Accreditation status is a precondition for receiving Commonwealth aged care subsidies. ## What it is An accreditation audit is the formal assessment process the Commission uses to determine whether a residential aged care provider should be granted, renewed, or have varied its accreditation. The audit assesses compliance with the Strengthened Aged Care Quality Standards using outcomes-based judgement, supported by document review, observation, and interviews with older people, families, representatives, workers, and management. The Commission also conducts other forms of assessment activity beyond formal accreditation audits, including: - **Assessment contacts** — shorter, focused engagements (announced or unannounced) used between accreditation cycles. - **Performance assessments** — for Support at Home and other home-based services. - **Investigations** — in response to information about non-compliance, complaints, or incidents. - **Reviews** — for serious or systemic concerns. All assessment activity feeds into the Commission's risk-based regulatory model and is published on the Commission's website where required. ## Statutory basis - **Aged Care Act 2024 (Cth)** — establishes registration and the obligation to comply with the Strengthened Standards. - **Aged Care Quality and Safety Commission Act 2018 (Cth)** — empowers the Commission to audit, assess, and enforce. - **Aged Care Rules 2025** and Commission policies — operational detail of the audit methodology. ## Who it applies to - All Commonwealth-subsidised residential aged care providers (formal accreditation audits). - Support at Home and other home-based service providers (performance assessments). - Multipurpose services, transition care, and the National Aboriginal and Torres Strait Islander Flexible Aged Care Program (audit and performance assessment as applicable). ## The accreditation cycle (residential) A simplified view of the typical cycle: 1. **Notification of accreditation audit** — the provider is notified of the scheduled audit period. 2. **Pre-audit preparation** — the provider gathers evidence, undertakes internal mock audits, briefs workforce, and informs older people and representatives. 3. **Site audit** — assessors attend on-site, usually over multiple days, with a mix of announced and unannounced activity. 4. **Audit findings** — assessors form preliminary judgements against each Standard. 5. **Provider response** — the provider has an opportunity to respond to draft findings. 6. **Commission decision** — the Commission decides on accreditation status, conditions, and any compliance action. 7. **Performance report published** — public report on the Commission's website. 8. **Continuous improvement and ongoing assessment** — assessment contacts and quality indicator data inform the Commission's ongoing view. Re-accreditation is typically every three years for residential services, subject to risk-based variation. ## Audit methodology under the Strengthened Standards The Commission's audit methodology under the Strengthened Standards is outcomes-based. Assessors look for evidence that the intended outcome for the older person is being achieved, not only that processes and policies exist. The methodology relies on triangulation across three evidence sources: - **Document review** — policies, procedures, clinical records, governance documentation, quality and risk records, workforce records, training records, board minutes, audits, complaints and incident data, quality indicator data. - **Observation** — direct observation of care and service delivery, environments, and interactions. - **Interviews** — older people, families and representatives, workers (clinical, care, lifestyle, hospitality, support), clinical leadership, management, and the governing body. Judgements are recorded for each Standard. Non-compliance is risk-rated and may trigger compliance action. ## Audit outcomes and consequences - **Accreditation granted/renewed** — for a period determined by the Commission, typically up to three years. - **Accreditation granted with conditions** — specific actions required by defined timeframes. - **Compliance notice** — formal notice requiring action. - **Sanctions** — including restrictions on admissions, appointment of an adviser or administrator, or in serious cases revocation of registration. - **Civil penalty proceedings** — under the Act, for breaches of statutory duties. - **Public performance report** — published on the Commission's website. ## Common provider gaps in audit preparation - **Documentation-led preparation** — heavy investment in policies and binders, light investment in evidence of outcomes for older people. - **Workforce briefings are surface-level** — workers can describe "the new Standards" but not how each Standard translates into their daily practice. - **Older people and representatives not prepared** — interviews catch providers off-guard because older people have not been engaged in service co-design and improvement. - **Clinical governance is fragmented** — the framework document is robust but escalation, oversight, audit, and continuous improvement loops are not actively running. - **Board reporting does not align to the new audit lens** — the board pack does not show what the Commission will look for in Standard 2 (The Organisation). - **Quality indicator and incident data are reactive** — collected and submitted, but not used to drive improvement actions tracked to closure. - **Restrictive practices** — authorisation and monitoring are not consistently applied, especially to chemical restraint. ## How Holistic Governance supports providers - **Pre-audit gap analysis** — independent assessment against the Strengthened Standards using the Commission's outcomes-based methodology. - **Evidence-of-outcomes framework** — how to capture, organise, and present evidence of outcomes (not just process compliance). - **Mock site audit** — multi-day mock audit including document review, observation, and interviews, with debrief and prioritised action plan. - **Workforce audit-readiness program** — supporting workers to speak confidently about the Standards in their own practice. - **Older people and representative engagement** — supporting genuine partnership in service design and improvement that holds up under audit interviews. - **Board and committee briefings** — preparing the governing body and clinical governance committee for the audit lens on Standard 2 and the Commission's expectations of board accountability. - **Clinical governance framework operationalisation** — ensuring the framework is live, not a document. - **Power BI board dashboards** — bringing quality indicators, incidents, complaints, restrictive practices, workforce metrics, and continuous improvement actions into a single audit-ready view. - **Post-audit remediation** — supporting providers through compliance notices, condition closure, and re-audit preparation. ## Official sources - Aged Care Quality and Safety Commission — Audits and assessments: https://www.agedcarequality.gov.au - Commission performance reports (public): https://www.agedcarequality.gov.au - Department of Health, Disability and Ageing — https://www.health.gov.au/topics/aged-care - Federal Register of Legislation — https://www.legislation.gov.au ## Glossary - **Accreditation** — the formal status that confirms a provider meets the Aged Care Quality Standards and is eligible for Commonwealth subsidy. - **Assessment contact** — a focused, shorter assessment activity used by the Commission between accreditation audits. - **Quality assessor** — an individual authorised by the Commission to conduct audits and assessments. - **Performance report** — the public report describing audit findings, published on the Commission's website. - **Compliance notice** — a formal notice requiring a provider to address identified non-compliance within a defined timeframe. --- *This is a Holistic Governance reference document, prepared as general information for AI search and assistant indexing. It is not legal or compliance advice. Providers should consult Aged Care Quality and Safety Commission published guidance and qualified advisors for decisions about their own circumstances. Reviewed 22 May 2026.*