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Quality Reporting

General Frequently Asked Questions

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1. Where can I find more detailed information on the Community Care Common Standards?

Details on the Community Care Common Standards may be found at http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-commcare-qualrep-standards.htm

2. Which community care programs are the Community Care Common Standards applicable to?

The Community Care Common Standards are applicable to the Home and Community Care Program (HACC), Community Aged Care Packages (CACP), Extended Aged Care at Home (EACH) and Extended Aged Care at Home Dementia (EACHD) and the National Respite for Carers programs.

(Community Care Common Standards Guide Section 1.4 / p 2)

3. When did the Community Care Common Standards commence?

The Community Care Common Standards came into effect on 1 March 2011.

4. How many Standards and expected outcomes are there in the Community Care Common Standards?

There are three Standards: Effective Management, Appropriate Access and Service Delivery and Service User Rights and Responsibilities. There are 18 expected outcomes: eight management outcomes, five service delivery outcomes and five service user rights outcomes.

(Community Care Common Standards Guide Section 3.1 / p 20)

5. Do we still need to comply with State and Territory Government funding requirements and program guidelines?

Yes. Funding requirements and program guidelines/policies specific to the programs your organisation is funded for still need to be complied with. Information on the resources that may be helpful is included in the Community Care Common Standards Guide.

6. How often are quality reviews conducted?

Quality reviews are usually conducted at least once in a three year cycle; however, if follow-up is required as part of your quality review or on-site follow-up forms part of your local jurisdiction’s process, you may have more than one visit in the three year cycle.

7. How do we know what information the quality reviewers will want to look at for each expected outcome?

The Community Care Common Standards Guide outlines information to assist service providers in preparing documentation for the quality reviewers to look at. This is included under each Expected Outcome in Section 3 of the Community Care Common Standards Guide. These are guidelines only and are not prescriptive requirements. They are examples of documentation, records and information that may assist in demonstrating that you meet an Expected Outcome.

(Community Care Common Standards Guide Section 3 / pp 22-58)
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8. Who will be conducting the quality reviews?

Quality reviews will be conducted by quality reviewers from the Department of Health and Ageing and the relevant State and Territory government department or their representatives.

9. Who conducts the quality review if we are funded for both packaged care and HACC?

If your organisation is funded for both packaged care and HACC these will be, where possible, assessed together in a combined review with quality reviewers from each department/delegates. The government departments/delegates will coordinate and plan the visits and contact you about the requirements.

10. How many quality reviewers will review our service?

Generally two quality reviewers will review services. If your service is very small or very large this may be varied but the government departments/delegates will advise you when planning your visit. One of the quality reviewers will be designated as the Principal Quality Reviewer and will be your main point of contact during the review process.

11. Will the quality reviews be very different from previous reviews?

The process of the quality reviews (talking to staff from your organisation, reviewing policies and procedures and records) will be the same and will continue to be based on a continuous quality improvement approach. There may be some changes depending on your State/Territory and programs delivered, including:

Quality reviewers may work independently of each other and review different elements of your organisation so that all expected outcomes can be reviewed in the allocated timeframe. The quality reviewers will want to talk with some of your service delivery staff and your service users (and/or their representatives) either face-to-face or by telephone to determine that the services delivered are meeting service user needs. These interviews will be planned with you prior to your quality review visit.

You will be rated as having ‘met’ or ‘not met’ each expected outcome. If you are rated as ‘not met’ in an expected outcome, you will be required to implement required improvement/s to rectify the identified issue/s. The quality reviewers may also identify improvement opportunities and include these in your quality review report. Required improvements, improvement opportunities and any other improvements your organisation has identified are included in the Improvement Plan that you will complete after your quality review visit.

Your Improvement Plan needs to be updated on an ongoing basis and submitted annually (or as requested) to demonstrate that you are implementing the improvements in the plan.

12. What is included in the quality review process?

The quality review process is generally a 20 week process and includes:

• notification of the quality review;
• a self assessment completed by the funded organisation;
• an on-site visit;
• provision of a quality review report;
• development of your improvement plan; and
• annual submission or review of your improvement plan.

(Community Care Common Standards Guide Section 2.1.2 / p 6)
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13. What is the purpose of the self assessment?

The self assessment provides an opportunity to service providers to review their organisation’s practices and identify areas for improvement. Quality reviewers use the self assessment to:

• gain an insight into the service provider’s operations;
• understand the current practices and processes the service provider uses to meet the Community Care Common Standards;
• review the information contained in the self-assessment to identify issues that need to be discussed during the on-site visit; and
• assist in the planning of the on-site visit including organising interpreters and service user interviews.

(Community Care Common Standards Guide Section 2.3 / p 7 and Section 2.3.6 / p 11)

14. What is included in the self assessment?

Service providers complete the following sections of the self assessment tool:

• information about the organisation, its service users, funding received, services provided and quality processes used;
• practices and processes, results and plans for improvement against each expected outcome; and
• a service provider’s rating of whether the organisation has met or not met the expected outcome.

(Community Care Common Standards Guide Section 2.2.3 / p 8)

15. The self assessment asks for our organisation to describe results; what do you mean by results?

Results can be sourced from a range of activities that your organisation already completes. For example, survey results, feedback, compliments and complaints information, audit results, hours of service, staff retention rates, training record information, waitlist information, referrals etc.

Some suggestions and examples of results and performance measures are included in the Community Care Common Standards Guide.

(Community Care Common Standards Guide Section 2.3.3 /pp 8-10;
Community Care Common Standards Guide Section 4 pp 59-63)

16. How long are the site visits?

Site visits will usually be of one day duration. If your service is very small or very large this may be varied but the government departments/delegates will advise you when planning your visit.

(Community Care Common Standards Guide Section 2.4.1 / p 11)

17. How do I prepare for the on-site visit?

Preparing for the on-site visit includes:

• liaising with the Principal Quality Reviewer of the Quality Review Team regarding the schedule of the visit;
• advising staff and service users/representatives (who may wish to meet with the quality reviewers) of the quality review visit (and interpreters if required);
• preparing records and documents to show the quality reviewers. Examples of these are included in the Community Care Common Standards Guide;
• organising some staff and service users (and/or their representatives) to be available to talk with the quality reviewers; and
• preparing an area for the quality reviewers to work from.

(Community Care Common Standards Guide Section 2.4.1 / pp 11-12)
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18. What is the format for the quality review visit?

The draft agenda for quality review visits is set out in Appendix 7 of the Community Care Common Standards Guide and includes:

• an entry meeting;
• documentation review and discussion with management personnel;
• a focus group with service users/representatives (or telephone interviews);
• meeting with support staff and other personnel;
• review of records and documents relevant to the Standards; and
• an exit meeting.

Each service and organisation is different. The Quality Review Team will work with each organisation to plan the quality review including giving consideration to the service providers’ operations and service user group.

(Community Care Common Standards Guide Appendix 1: Section 2 Part 3 Sub-section 3.2 / pp 19-21; Community Care Common Standards Guide Appendix 7)

19. Why do the quality reviewers want to talk with staff/volunteers and service users and/or representatives?

Talking to a range of stakeholders provides the quality reviewers with the opportunity to validate information from other sources and to assess whether the services delivered are meeting service user needs.

(Community Care Common Standards Guide Section 2.4.3 / p 13)

20. Will the quality reviewers talk to us during the visit about met or not met expected outcomes?

The quality reviewers will advise you if it appears that you have met or not met an expected outcome. They will explain the reasons why and will provide you with an opportunity to demonstrate the systems and processes you have in place for that expected outcome.

(Community Care Common Standards Guide Section 2.4.4 / pp 15 - 16)

21. What is the purpose of the quality review report?

The quality review report has two main purposes:

• to provide service providers with information regarding the findings of the on-site assessment against the Expected Outcomes; and
• to provide a record of the on-site assessment for the funding body.

The quality review report includes:

• a summary of ratings against the 18 expected outcomes;
• a general overview of the service performance against the standards, highlighting the strengths of the service; and
• a summary of required improvements and improvement opportunities against each expected outcome as relevant. If any expected outcomes are rated as not met, required improvements are identified and evidence to support the not met outcomes is detailed in the quality review report.

The quality review report is used to assist you to develop an Improvement Plan.

(Community Care Common Standards Guide Section 2.5 / p 16)
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22. What is the purpose of the improvement plan?

The purpose of the improvement plan is to:

• provide you with a tool to assist with implementing and monitoring ongoing improvements;
• document required improvements and opportunities for improvement;
• document other identified improvements;
• document the agreed strategies to implement the improvements and the timeline; and
• demonstrate the actions taken to implement the improvements to the Quality Reviewers (and funding bodies).

(Community Care Common Standards Guide Section 2.6 / p 17)

23. What happens once the quality review visit is over?

The quality reviewers will provide you with a quality review report outlining your performance against the Community Care Common Standards and each expected outcome. You have 10 days after receiving your quality review report to submit your improvement plan to the Principal Quality Reviewer.

(Community Care Common Standards Guide Section 2.6 / p 16)

24. What if our organisation does not agree with the information contained in the quality review report?

If you do not agree with the information contained in the quality review report you are able to provide additional information to the Principal Quality Reviewer for consideration within 10 days of receiving the Quality Review Report. Additional information may result in a review of the quality review findings.

(Community Care Common Standards Guide Section 2.5.1 / p 16)

25. What if our organisation does not agree with the outcome of our quality review?

If you do not agree with the quality review outcome decision, you may seek a reconsideration of the decision. To do this, you will need to write to the supervisory jurisdictional manager of the quality review program within the relevant department within 10 days of receiving notification of the outcome of your review. The appropriate authority within the relevant department will undertake a review of the quality review and notify the service provider of the outcome as soon as practicable.

(Community Care Common Standards Guide Section 2.5.1 / p 16)

26. What if our organisation has a complaint about the quality review process?

You are able to make a complaint about any aspect of the quality review process at any stage. To do this, you will need to write to the supervisory jurisdictional manager of the quality review program within the relevant department, who will look into your concerns.

Community Care Common Standards Guide Section 2.5.1 / p 16)

27. What happens when we submit our annual improvement plan?

The Quality Review Team will review your improvement plan and may contact you to discuss any further actions that may be necessary. You will receive a letter to acknowledge the receipt of the annual improvement plan.

(Community Care Common Standards Guide Section 2.7 / pp 18 - 19)
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28. Are quality reviewers qualified to conduct reviews?

Quality reviewers are experienced in conducting quality reviews and bring a wealth of experience in the community care sector. Quality reviewers have undergone specific training in the revised quality review process and Standards.

(Community Care Common Standards Guide Appendix 1 Section 2.4 / p 7)

29. Who makes up the quality reviewer team?

The quality review team is generally made up of a Principal Quality Reviewer and a Quality Reviewer who work together to conduct the quality review. If a joint quality review is being conducted, a representative from each government department/delegate will make up the team. The name and contact details of the Principal Quality Reviewer will be provided to you when you are notified of the quality review visit as this is the person you will liaise with regarding your visit.

(Community Care Common Standards Guide Appendix 1 / Section 2.4.1 / p 7)

30. How applicable are the Community Care Common Standards to National Respite for Carers (NRCP) funded services?

The Community Care Common Standards apply to NRCP funded service delivery. The expected outcomes relating to management apply to all organisations in the context of their individual arrangements. The service delivery and service user rights and responsibilities expected outcomes are applicable to all service users, including carers.

31. Why are Expected Outcomes only rated as ‘met’ or ‘not met’?

The aim of the Community Care Common Standards is to provide a range of minimum standards that guide the delivery of high quality community care. Rating the Expected Outcomes as ‘met’ or ‘not met’ provides clarity for funding bodies and service providers regarding whether further improvements are required in specific areas. In some previous standards frameworks a ‘partly met’ or ‘working towards’ rating was applied; however, when this rating was applied, improvements were still required. If an Expected Outcome is rated as ‘met’, improvement opportunities may be identified. If an Expected Outcome is rated as ‘not met’, required improvements will be identified and the service provider and funding body will be clear on the actions (and timeframes) that are necessary to meet the Expected Outcome.

(Community Care Common Standards Guide 2.4.4 / p 15)

32. What happens if an Expected Outcome is rated as ‘met’ for one program, say packaged care and ‘not met’ in another, say HACC?

If an Expected Outcome is rated as ‘not met’ for one program and the same Expected Outcome is rated as ‘met’ for another program, the Quality Review Report will reflect this and the required improvement will only relate to the program that was rated ‘not met’. Follow up and monitoring of improvements (if a joint quality reporting visit has been conducted) will generally be conducted by the government department responsible for the program in which the ‘not met’ outcome or outcomes are identified.

(Community Care Common Standards Guide 2.4.4 / p 15)

33. Will my ongoing funding be affected if our service is rated as ‘not met’ in some Expected Outcomes?

Funding for service providers will not be directly affected by the quality review process itself. The Community Care Common Standards utilise a continuous quality improvement approach to resolving issues of concern identified through quality reviews. In the main, service providers are required to submit improvement plans to the quality review team setting out how required improvements and improvement opportunities will be implemented. However, as with the existing quality reporting processes, where there are significant concerns necessitating referral for compliance and program management action, subsequent measures may have an effect on the ongoing funding of the service provider.

(Community Care Common Standards Guide Section 1.5/p 4;
Community Care Common Standards Guide Appendix 1 2.3/p 6 and 3.3.5/p 26)
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34. Is information regarding the outcome of quality review visits shared with funding managers or other government departments?

Information from the quality reporting process may be shared with other areas of the Department for a variety of reasons. Under the Community Care Common Standards framework, information may be shared between the Commonwealth and State and Territory governments during the planning and undertaking of a joint review. This would be done in consultation with the service provider.

Additionally, where joint reviews of service providers receiving both Commonwealth-only and HACC program funding are not possible, information prepared by service providers for quality reviews can be shared between the Commonwealth and State and Territory governments with the agreement of the service provider under review.

35. Is information regarding each organisation’s quality review visit outcome made publicly available?

Aggregated information is published but information in relation to individual organisations is not made public at present. However, it is possible information of this nature may be requested through the Freedom of Information legislation. Additionally, if a sanction or Notice of Non-Compliance is applied to a service provider through the compliance process (CACP, EACH, EACHD only), this information is publicly available through the Department of Health and Ageing internet site and the Aged Care Australia website.

36. If we address all of our ‘not met’ outcomes in the required timeframes are our ratings then changed to ‘met’ on the records?

No, the records will show that you have taken appropriate action to address the not met outcomes in the required timeframe. At the next quality review you will be assessed against the expected outcomes again.

37. Will a nurse or health professional be assessing the delivery of nursing services or high care service delivery, such as EACH and EACHD?

Some jurisdictions have nurses and health professionals in the Quality Review Team and all jurisdictions provide the Quality Review Team access to advice from nurses or allied health professionals if a technical care issue requires discussion during a quality review.

38. What is our responsibility in meeting the Community Care Common Standards when we broker some or all of our services?

As the organisation who receives funding to deliver services you are responsible for ensuring that those services meet the requirements of the Community Care Common Standards, even if you are not directly delivering services. Organisations use a range of mechanisms for ensuring that requirements are met by the organisation delivering services including: developing brokerage agreements; conducting meetings and communication strategies; instituting structured ongoing monitoring processes; being notified of service user feedback and complaints; and third party reviews.

Third party reviews can involve the funded organisation going to the organisation that is responsible for service delivery and reviewing their operations and records to determine that services are being delivered as required.

If you broker services, the quality reviewers will be interested in understanding what practices and processes you have in place to ensure that the brokered services are meeting service user needs and the requirements of the Community Care Common Standards.

39. If we receive both HACC and packaged care funding, will we always have a joint quality review visit?

Joint quality reviews are planned for organisations that receive both HACC and packaged care funding; however, due to local jurisdictional arrangements, this may not always be possible. The arrangements for joint quality review visits will be discussed with you when your quality review is due.
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40. Are the Community Care Common Standards appropriate to counselling services?

Yes. The pilot of the demonstrated that the Community Care Common Standards is appropriate to counselling services as the service delivery Expected Outcomes are based on ensuring access, assessment, care/service plan development, reassessment and referral, if required. Counselling services may use other terminology for their care/service plan, but they do develop a plan of care/support for each service user based on the service user’s needs. Counselling services are required to have in place appropriate management practices and support service user rights in the delivery of their services.

41. Are the Community Care Common Standards appropriate to organisations providing services to people with special needs including Aboriginal and Torres Strait Islander people and, people from culturally and linguistically diverse backgrounds?

Yes. The pilot of the Community Care Common Standards demonstrated that the Community Care Common Standards are appropriate to organisations that provide services to Aboriginal and Torres Strait Islander people and people from culturally and linguistically diverse backgrounds. The ‘practices and processes’ section of each of the service delivery and service user rights and responsibilities Expected Outcomes make reference to meeting the needs of people with special needs.

As with all organisations delivering community care services, organisations who provide services to people with special needs are required to have in place appropriate management practices to support the delivery of their services.

42. How do we ensure that we have gained consent for the Quality Review Team to view service user and staff records?

The Quality Review Team will need to access a random selection of service user and staff records to validate that Expected Outcomes are being met. Organisations are required to ensure the privacy and confidentiality of this information. The Commonwealth and State and Territory governments have different arrangements for authorising access to records (including, for the Commonwealth, authorised officers under the Aged Care Act 1997, with specific powers in relation to CACP, EACH and EACHD).

For this reason, if your services are funded by both the Commonwealth Government (through CACP, EACH, EACHD and the NRCP) and State or Territory government (through the HACC program), it is advisable that you include access to records by quality reviewers in your generic consent forms for service users and staff. The principal quality reviewer will check that you have consent from your service users and staff to review records (where appropriate) when they contact you to plan the on-site visit.

The Quality Review Team members are bound to keep information they review confidential.

(Community Care Common Standards Guide 2.4.1 / pp 11-12 and EO 3.2: Privacy and Confidentiality / pp 52-53)

43. What is a ‘service outlet’ and how will quality reviews be conducted when an organisation has multiple service outlets within a region?

A service outlet is defined as ‘the base from which services are coordinated, and where hard copies of service users’ files are located. A service provider may have several outlets or just one.’

(Community Care Common Standards Guide Tab 2: Acronyms and Glossary)

Service providers delivering Commonwealth funded services (CACP, EACH, EACHD and NRCP) will undertake a quality review at each service outlet.

Arrangements for HACC services vary between jurisdictions. Services will be advised of how the quality review will be conducted at the time it commences.

44. How do the Community Care Common Standards apply to services funded under the National Aboriginal and Torres Strait Islander Flexible Aged Care Program.

Where an Aboriginal and Torres Strait Islander Flexible Aged Care service is funded separately to provide Home and Community Care Services, the service provider will also participate in reviews under the Community Care Common Standards and may report on some of the same information required under this Quality Framework (or visa versa).

In this event, the quality reviewers and the service provider will liaise to identify any relevant information common to both processes that can potentially be shared between reviewers, to avoid a duplication of effort. It will however, be important for the quality reviewers to determine that the information is current and relevant to the expected outcome of the particular standard.

This will need to be on a case-by-case basis in consultation with the service provider and the relevant areas of the Department.
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