Better health and ageing for all Australians

Quality Framework for the National Aboriginal and Torres Strait Islander Flexible Aged Care Program

Appendix 5: On-site Review Tools and Templates

Up to Office of Aged Care Quality and Compliance (OACQC)

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Purpose:

The following tools and template are to support Quality Reviewers to un-dertake the On-Site Review and develop a Review Report. At the conclusion of the review, the draft Review Report will be provided to the Service Provider.

Template 1: Reviewer Audit Tool – Staff Files

Template 2: Reviewer Audit Tool – Service User Files

Template 3: On-Site Review Report Template

National Aboriginal and Torres Strait Islander Flexible Aged Care Program

Reviewer Audit Tool: Staff files
Service Provider
Service ID
Site Address
Contact Name
Position
Completed by
Date

National Aboriginal and Torres Strait Islander Flexible Aged Care Program

Reviewer Audit Tool: Staff files
Service Provider
File ContentsIn Staff file or Other Record (3, 7 or NA)
12345678910
Job description (2.3)
Application/resume/interview record shows suitable experience for the role and responsibilities (2.4)
Copies of qualifications, where applicable (2.4)
Reference checks (2.4)
Police record checks (2.4)
Employment contract/agreement (2.4)
Induction record:
  • Occupational Health & Safety
  • Emergency procedures (2.3)
Training/professional development recorcds (2.4)
Performance appraisals (2.4)
Comments
1
2
3
4
5
6
7
8
9
10
Note to reviewers: The bracketed reference following each item relates to the corresponding Expected Outcome/Guide to requirements. No identifying in-formation is to be recorded by reviewers. The file number (1-10) should be used if recording information in the comments section.

National Aboriginal and Torres Strait Islander Flexible Aged Care Program

Reviewer Audit Tool: Service User Files
Service Provider
Service ID
Site Address
Contact Name
Position
Completed by
Date

National Aboriginal and Torres Strait Islander Flexible Aged Care Program Quality Framework On-site Review

Reviewer Audit Tool: Service User Files
Service Provider
File ContentsIn Staff file or Other Record (3, 7 or NA)
12345678910
Evidence of eligibility (1.1)
Process to establish priority of access (1.1)
Completed assessment which considers:
  • independence
  • physical needs
  • social needs
  • emotional needs
  • cultural needs
  • clinical care needs, where applicable (1.1)
Evidence of service user and/or their representatives participation in assessement (1.1)
Completed care plan which:
  • addresses all assessed needs/preferences
  • documents the action to be taken
  • documents who is responsible for what care
  • documents where and when care is to be received
  • includes a cultural support plan that:
  • includes strategies to maintain privacy and dignity
  • individual interests
  • customs and beliefs
  • independence
  • family connectedness (1.2)
Evidence of service user and/or their representatives participation in care planning (1.2)
Evidence that the service user and/or their representative has received a copy of the care plan (1.2)

National Aboriginal and Torres Strait Islander Flexible Aged Care Program Quality Framework On-site Review

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Reviewer Audit Tool: Service User Files
Service Provider
File ContentsIn Staff file or Other Record (3, 7 or NA)
12345678910
Care plan review:
  • occurs at least six monthly and where needs change
  • identifies progress against planned goals/actions
  • results in any changes in needs and preferences being documented in the care plan. (1.3)
Clinical care needs are documented as applicable:
  • special care needs
safe and effective management and administration of medication
  • effective assessment, treatmen and management of pain
  • access to specialised palliative care services
  • access to other specialist health care/allied health services
  • functional care
  • cognitive care
  • sensory care
  • nutritional care
  • personal care (1.4)

Note: The requirements within this outcome may have limited applicability or not be applicable to some organisations, depend-ing upon the services provided to service users.
Evidence that the service user and/or their representative has received information about available services and eligibility to receive services in a manner that is appropriate in format and culturally acceptable. (1.5)
Evidence that consent to share information has been obtained (1.5)

National Aboriginal and Torres Strait Islander Flexible Aged Care Program On-site Review

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Reviewer Audit Tool: Service User Files
Service Provider:
Date:
File ContentsIn Staff file or Other Record (3, 7 or NA)
12345678910
Evidence that:
  • the service user has been offered a service agreement1
  • the service agreement sets out the terms and conditions of the service/s to be received and the service user’s rights and responsibilities
  • the content of the service agreement has been fully explained to each service user (and/or their representative) in a culturally acceptable way prior to entering into the agreement
  • a process is in place to enable service users to be repre-sented by an advocate of their choice (1.5)
Comments
1
2
3
4
5
6
7
8
9
10
Note to reviewers: The bracketed reference following each item relates to the corresponding Expected Outcome/Guide to requirements. No identifying in-formation is to be recorded by reviewers. The file number (1-10) should be used if recording information in the comments section.
On-site Review Report
Service Name
Service Provider
Service ID
Site Address
Contact Name
Reviewer Names
Reviewer Date/s
Date of report

Executive Summary

The Review Team inserts information about the following:
  • background/history of the organisation
  • size, location/s, structure of the organisation
  • services provided
  • service user group/s and the community
  • a summary of the organisation’s strengths, weaknesses and opportunities for im-provement identified by the reviewers with reference to the overall Review Result and number of expected outcomes that have been Met, Part Met or Not Met
  • other relevant information impacting on the review.
    Assessment Matrix
    Expected OutcomesPlace a tick (3) in the appropriate box:MetPart MetNot MetNot Applicable
    Standard 1: Care Delivery and Information
    1.1 Assessment
    1.2 Care Planning
    1.3 Review
    1.4 Clinical Care
    1.5 Information
    Standard 2: Management and Accountability
    2.1 Governance
    2.2 Management Systems
    2.3 Risk Management
    2.4 Human Resources
    Assessment
    result:
The Assessment Matrix is a summary of the findings of the on-site review and repre-sents the organisation’s overall performance against the Standards. The Review Team has rated your organisations performance against each expected outcome, by applying the following ratings:
  • Met: written and verbal evidence clearly demonstrates that the service provider meets all the requirements of the expected outcome
  • Part Met: written and verbal evidence clearly demonstrates that the service pro-vider only meets part of the requirements of the expected outcome
  • Not Met: written and verbal evidence clearly demonstrates that the service pro-vider does not meet the requirements of the expected outcome
  • Not Applicable: a not applicable rating may apply, for example, where a service does not provide clinical care to service users (refer to expected outcome 1.4).
  • Once each expected outcome has been rated, the overall Review Result can be de-termined
  • The Review Result has been determined by applying the following:
  • Met: all the requirements of each expected outcome have been met
  • Part Met: the requirements of one or more expected outcomes have not been fully met
  • Not Met: the requirements of no expected outcomes have been met.
    Standard 1: Care Delivery and Information
    Expected Outcome 1.1: Assessment
    Evidence Examples
    Reviewer Findings
    Reviewer Rating:
    Quality Improvement Actions
    Action required to meet the Expected Outcome:
    Optional action to support Continuous Quality Improvement:
Standard 1: Care Delivery and Information
Expected Outcome 1.2: Care Planning
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
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Standard 1: Care Delivery and Information
Expected Outcome 1.3: Review
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
Standard 1: Care Delivery and Information
Expected Outcome 1.4: Clinical Care
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
Standard 1: Care Delivery and Information
Expected Outcome 1.5: Information
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
Standard 2: Management and Accountability
Expected Outcome 2.1: Governance
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
Standard 2: Management and Accountability
Expected Outcome 2.2: Management Systems
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
Standard 2: Management and Accountability
Expected Outcome 2.3: Risk Management
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:
Standard 2: Management and Accountability
Expected Outcome 2.4: Human Resources
Evidence Examples
Reviewer Findings
Reviewer Rating:
Quality Improvement Actions
Action required to meet the Expected Outcome:
Optional action to support Continuous Quality Improvement:

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