Monitoring and Compliance Arrangements Supporting Quality of Care in Residential Aged Care Homes
The audit objective was to assess the effectiveness of monitoring arrangements (by the Accreditation Agency) and compliance activities (by DoHA) put in place to achieve residential aged care homes’ compliance with the Accreditation Standards and their other, related, responsibilities under the Act and its associated instruments.
The ANAO’s assessment considered whether:
— a sector-wide compliance strategy was in place and aligned with effective monitoring and compliance activities at the operational level;
— there was a clear articulation of the separat but complementary roles and responsibilities of DoHA and the Accreditation Agency; and
— performance information gathered by both agencies to support public reporting and business improvements was useful and enabled comparison of performance over time.
The aged care sector
1. Australia’s aged care sector currently provides care to over one million older Australians—over a third of all older people and about 4.6 per cent of the Australian population. Care is provided through either residential aged care services or through services to older Australians in their homes (community care).
2. Public and private expenditure on aged care in 2008–09, at an estimated $12.9 billion, accounted for 1.0 per cent of GDP, with the Australian Government’s $8.6 billion contribution to that expenditure accounting for some 3.1 per cent of its revenues. In 2009–10 the Australian Government provided just over $6 billion in residential aged care subsidies to Approved Providers of residential aged care homes for the purposes of providing care and services to residents.
3. The Australian Government’s Intergenerational Report 2010 reported that over the next 40 years the number of aged care recipients is projected to increase by approximately 150 per cent. On these projections, by 2049–50 over 2.5 million older people (around 8 per cent of Australia’s population) would be utilising aged care services (both residential aged care and community care). Public and private expenditure on aged care is projected to account for about 1.8 per cent of GDP, with the Commonwealth’s contribution accounting for about 7.4 per cent of its revenues, on current policy settings. It is estimated that by 2049–50, about 4.9 per cent of the Australian workforce will be employed in the delivery of aged care.
4. An ageing population, increased longevity and greater diversity in the care expectations and preferences of residents (including an increasing demand for culturally, linguistically and gender relevant care) are placing pressure on the sector. Its capacity to respond is being limited by current business models, homes operating at full or near full capacity and a general shortage in the residential aged care workforce. 
The quality, regulatory and accreditation framework under the Act
5. The Commonwealth Aged Care Act 1997 (the Act) establishes the legal framework for the funding, regulation and accreditation of aged care services. The framework is informed by ten objects specified in the Act, which include the promotion of high quality of care and accommodation that meets the needs of individuals, and the protection of the health and wellbeing of the recipients of aged care services. The Act provides for a national quality assurance framework for residential aged care, encompassing building certification, accommodation bonds, accreditation of homes, continuous improvement in service delivery, complaints handling and the support of users’ rights.
6. The Act also establishes a link between quality and expenditure by the Australian Government on residential aged care. To be entitled to receive Australian Government subsidies for providing residential aged care services, an organisation must be approved by the Australian Government as an ‘Approved Provider’ and have ‘places’ allocated at its homes providing those services. To receive subsidies for the services provided by a particular home, the home must be accredited.
7. As at June 2010, 2773 residential aged care homes across Australia were accredited, with the capacity to provide about 178 000 residential aged care places.
8. DoHA and the accreditation body appointed under the Act, have key roles in the legal framework established under the Act. Their respective roles as regulator and accreditation assessor are separate but complementary.
9. DoHA’s regulatory and compliance role is undertaken by the Office of Aged Care Quality and Compliance (OACQC), which is responsible for:
- responding to individual complaints regarding the quality of care provided and, where DoHA suspects that the subject of a complaint applies to more than one resident, transferring this information to the accreditation body for further investigation;
- monitoring Approved Providers’ compliance with prudential responsibilities and matters that affect suitability to provide aged care; and
- taking action under the Act in response to non-compliance.
10. Since 1998 the accreditation role has been performed by the Aged Care Standards and Accreditation Agency Ltd (the Accreditation Agency), a Commonwealth company limited by guarantee and subject to the Corporations Act 2001 and the Commonwealth Authorities and Companies Act 1997.
11. The Accreditation Grant Principles made under the Act provide that the functions of the Accreditation Agency include:
- managing the accreditation process using the Accreditation Standards;
- promoting high quality care, and helping industry to improve service quality, by identifying best practices and providing information, education and training to industry;
- assessing and strategically managing services working towards accreditation; and
- liaising with DoHA about services that do not comply with the standards applicable to them.
12. Accreditation is a process of assessing the performance of an organisation against generally accepted standards of performance. The Accreditation Standards for the residential aged care sector established by the Australian Government outline the standards for the quality of care and services to be provided to residents and the quality of life that residents can expect to experience.
13. Under the Accreditation Grant Principles, the Accreditation Agency is required to liaise with DoHA about homes that do not comply with the Accreditation Standards. DoHA is then responsible for determining the appropriate compliance action. The sharing of information and the action each party is required to take when non-compliance is identified, is formalised through the Department – Agency Compliance Protocol of July 2002. The Protocol is currently being renegotiated to better reflect current practice.
14. The legal framework provides for a graduated response to identified non-compliance, by Approved Providers, with the Accreditation Standards and their other responsibilities under the Act. If Approved Providers breach their responsibilities, such as by failing to implement improvements required by the Accreditation Agency or the department, DoHA is responsible for taking compliance action commensurate with the degree of non-compliance, which may include imposing sanctions.
15. The audit objective was to assess the effectiveness of monitoring arrangements (by the Accreditation Agency) and compliance activities (by DoHA) put in place to achieve residential aged care homes’ compliance with the Accreditation Standards and their other, related, responsibilities under the Act and its associated instruments.
16. The ANAO’s assessment considered whether:
- a sector-wide compliance strategy was in place and aligned with effective monitoring and compliance activities at the operational level;
- there was a clear articulation of the separate but complementary roles and responsibilities of DoHA and the Accreditation Agency; and
- performance information gathered by both agencies to support public reporting and business improvements was useful and enabled comparison of performance over time.
17. ANAO Audit Report No. 42 2002–2003, Managing Residential Aged Care Accreditation, recommended that an evaluation of the impact of accreditation on the quality of care in the residential aged care sector be undertaken. A subsequent Parliamentary Joint Committee of Public Accounts and Audit (JCPAA) hearing into the ANAO report recommended that this be extended to incorporate quality of life considerations. In response, DoHA commissioned research in 2004 to evaluate the impact of accreditation on quality (broadly) in subsidised residential aged care homes. The research report, commonly known as the Campbell Report, was released in October 2007. A key finding of the Campbell Report was that accreditation has had a positive impact on the quality of care and quality of life for residents in Australian Government-subsidised aged care homes and is part of a robust regulatory framework.
18. The accredited residential aged care sector currently attracts over $6 billion in Australian Government subsidies for 2 773 homes nationally, which between them have the capacity to provide 178 000 places. Spending on aged care is projected to grow from 0.8 per cent of GDP in 2009–10 to 1.8 per cent of GDP in 2049–50, with growth in spending on residential aged care projected to be the main contributor to the increase. Australia’s ageing population is the primary driver of aged care spending over the next 40 years, and will continue to place pressures on the system while also creating opportunities for new service providers.
19. Australians expect high standards of care in aged care services. An effective monitoring and compliance framework, focused on improving the quality of aged care services through compliance with minimum standards, is an important means for maintaining confidence in the capacity of the sector to provide quality care and services to residents, many of whom are among the most frail and elderly in the community.
20. Within this context, DoHA and the Accreditation Agency have key roles. DOHA administers the Act, advises the Australian Government on aged care policy and manages a suite of aged care programs. It also has a regulatory role, monitoring compliance by Approved Providers with all their responsibilities under the Act and taking compliance action (including sanctions) if Approved Providers breach their responsibilities. The Accreditation Agency has a more defined role, with responsibility for promoting high quality care through its management of the accreditation process, the provision of information and education to industry, and monitoring homes’ compliance with the Accreditation Standards. The sharing of information and the action each organisation is required to take when non-compliance is identified, is formalised through a Protocol.
21. The framework places a strong emphasis on Approved Providers accepting responsibility for providing, maintaining and improving service, and the framework’s regulatory processes are designed to give Approved Providers every opportunity to address non-compliance. Consistent with this approach, the Accreditation Agency and DoHA have adopted a range of strategies to educate Approved Providers about their obligations, monitor compliance with the framework at the level of individual homes, enable them to work with Approved Providers to address non-compliance, and share information to inform their decision-making.
22. In 2009–10 the Accreditation Agency conducted an average of 2.2 visits to each accredited home, or a total of 6 119 visits. These visits are undertaken to assess and monitor homes against the Accreditation Standards, and take the form of accreditation site audits, review audits and Support Contacts. Support Contacts are conducted to give assurance to the Government, community and residents that homes are providing quality care. As required by the Australian Government, all homes received at least one unannounced Support Contact during 2009–10. The Accreditation Agency adopts a case management approach, involving risk-based decision-making on the timing of Support Contacts and the details of the Accreditation Standards to be assessed during Support Contacts. However, the current operational policy does not enable assessors to alter the scope of assessment for a Support Contact, even where concerns arise about the performance of the home in areas outside the assigned scope of a Support Contact. Where this occurs, assessors are required to contact their state office Assessment Manager for direction if they consider their concerns warrant further assessment, or include an outline of their concerns in the Support Contact record. While recognising the benefits in maintaining a focus on the pre-identified issues, there are also potential benefits in terms of both efficiency and effectiveness in allowing assessors some latitude to examine other risks to service delivery that they identify during visits.
23. Information from Support Contacts, especially where serious risk to the health, safety and wellbeing of residents is identified, is provided to DoHA to inform its compliance action, as required under the framework. Accreditation Agency staff communicate regularly with DoHA, including at the regional office level, and the Agency has adopted a structured education program to inform and support industry.
24. DOHA has also established a network of regional compliance officers, with responsibility for monitoring compliance, issuing Notices of Non-Compliance to Approved Providers, and, where the non-compliance is not addressed, imposing sanctions. DoHA undertakes compliance action commensurate with the level of non-compliance identified, and its compliance response is informed by information and intelligence received from the Accreditation Agency, the Complaints Investigation Scheme (CIS), Approved Providers and state and territory health departments.
25. While the specific strategies adopted by DoHA and the Accreditation Agency are generally effective and appropriate, the ultimate test of the regulatory framework is its ability to respond to issues in a timely and appropriately calibrated manner. Past incidents in the sector serve as a reminder of the potential impact of non-compliance on frail and elderly residents, and the importance of adopting a proactive and flexible approach to the administration of the framework, including the timely reporting and assessment of information collected by DoHA and Agency staff.
26. The framework’s design and administration are informed by the size of the residential aged care sector, its home-based structure, and the primary responsibility placed on Approved Providers for quality care. Accordingly, both the framework and the majority of strategies adopted by DoHA and the Accreditation Agency are focused on promoting quality in individual accredited homes, with a lesser focus on sector-wide risks to quality and compliance. Notwithstanding this, non-compliance can arise from the actions or inactions of management and staff within a single home, through to non-compliance relating to an individual home’s capacity to deal adequately with risks arising from sector-wide developments or pressures. A variety of sector-wide risks has been identified by stakeholders and DoHA in recent times, which may influence the ability of homes to comply with the framework. In this context, further developing the existing home-focused monitoring and compliance strategy to take account of sector-wide risks would be beneficial.
27. In the course of performing their respective functions, DoHA and the Accreditation Agency collect information which could be leveraged to provide additional assurance on the full range of compliance risks. DoHA has recently developed a Service Providers of Concern (SPoC) list, which contains up-to-date information on a range of risk indicators, typically for about 30 Approved Providers. The Accreditation Agency has developed a separate Homes of Interest (HoI) list, which also uses risk indicator information, typically for about the same number of homes found to be non-compliant with the Accreditation Standards. At present, only a small proportion (about five per cent) of homes is covered by the two lists, meaning that risk indicators are not compiled for the great majority of homes. The development of a common risk profile, to be completed for each accredited home, and the analysis of information from such risk profiles at an aggregate level would contribute to an improved understanding of trends in both compliance and non-compliance across the sector. The consolidation and expansion of the existing SPoC and HoI lists would provide a starting point for such an approach.
28. The compliance framework places a strong emphasis on the responsibilities of Approved Providers and could be further strengthened by improving Approved Providers’ understanding of DoHA’s role and expectations under the framework. The Accreditation Agency has a Charter of Commitment to Service Quality which outlines its commitment to providing quality monitoring and education services, and there would be value in DoHA also developing a Service Charter. Reporting against these charters would also assist stakeholders to better understand the separate but complementary roles of DoHA and the Accreditation Agency.
29. The accountability and performance framework could also be strengthened further by developing a more complete reporting framework to assist stakeholders to assess the respective contributions of the Accreditation Agency’s compliance monitoring role and DoHA’s regulatory role to quality improvement in residential aged care. Currently, the Accreditation Agency and DoHA largely report performance on an activity basis, such as the number of homes visited as part of the accreditation process and the numbers of Approved Providers on whom sanctions were imposed. By its nature, and in isolation, activity-based reporting limits the extent to which stakeholders can develop an appreciation of regulatory performance and its contribution to improvements in the quality of outcomes.
30. The Campbell Report (2007) acknowledged the challenges, in a sector as complex as residential aged care, for developing meaningful, appropriate and measurable quality indicators. Nevertheless, the report concluded that there was a need to provide a more rigorous mechanism for the monitoring of quality, so that improvements could be measured over time and progress reported. The report set out a range of options for measuring quality improvement, and DoHA is considering the most appropriate approach. Within the context of this work, DoHA could consider how best to assess and report on the contribution made by accreditation to the overall goal of quality improvement sought by the Australian Government.
31. The ANAO made three recommendations to support DoHA and the Accreditation Agency to further strengthen the compliance framework and to enhance the monitoring and reporting of quality and performance.
Communicating roles and responsibilities
32. DoHA is a regulator and the Accreditation Agency assesses compliance against the Accreditation Standards. While their roles are separate but complementary, confusion can arise in the minds of stakeholders in some circumstances, such as when the two organisations are working within the same home simultaneously.
33. Government policy requires Australian Government agencies to develop a Service Charter in consultation with the community they serve. DoHA has not developed a Service Charter with its regulated community—Approved Providers. The Accreditation Agency has a Charter of Commitment to Service Quality, but does not report its performance against the commitments in the Charter. The industry’s understanding of DoHA’s and the Accreditation Agency’s separate but complementary roles would be improved by the introduction of a DoHA Service Charter which outlined the roles, commitments and obligations of the parties concerned. In particular, a Service Charter would enable DoHA to communicate, in an accessible format, its goal of assisting Approved Providers to achieve and maintain compliance and could outline to them the graduated actions DoHA will take where non-compliance is not remedied, and the rationale for sanctions and timeframes for decision-making. The accountability and performance framework would also be strengthened if both organisations reported annually against their Charters.
34. DoHA consults formally with stakeholders through a national Ageing Consultative Committee. However, communication with stakeholder groups at the state level is less structured, and this may have affected stakeholders’ level of understanding about the respective roles of DoHA and the Accreditation Agency. More structured communication may contribute to improved stakeholder understanding.
35. The Accreditation Agency has implemented a communication strategy comprising a number of practical elements: industry training, formal liaison meetings and the appointment of Relationship Managers. A number of stakeholders interviewed by the ANAO, particularly advocacy groups and specialised professional groups such as a nursing organisation, saw opportunities for improved communication with the Agency. In the light of this feedback, the Accreditation Agency may wish to consider how best to structure a deeper engagement with advocacy and professional groups.
36. DoHA and the Accreditation Agency have in place a Communication and Referral Protocol which could be revised to improve consistency in the exchange of information. Communication at the operational level, including at the regional level, is regular.
37. The legislative framework places a strong emphasis on Approved Providers accepting responsibility for providing, maintaining and improving service, and the framework’s regulatory processes are designed to give Approved Providers every opportunity to address non-compliance. DoHA and the Accreditation Agency have formal arrangements in place to monitor and address non-compliance at the level of individual homes.
38. The Accreditation Agency uses a range of risk-based indicators, aligned with the Accreditation Standards, to inform its operational level planning and monitoring strategies. DoHA uses a broader range of indicators, drawing on additional information available to it as a regulator, to inform its planning and compliance strategies. There are also established procedures in place to facilitate the ongoing exchange of information between DoHA and the Agency, including information obtained from their monitoring and compliance activities, residents or their representatives and other stakeholders.
39. The framework is focused on promoting compliance and quality in the 2773 individual accredited homes, with a lesser focus on sector-wide risks to quality and compliance. While the risk of non-compliance by a particular Provider requires attention at the level of the individual home, DoHA and stakeholders have identified a range of sector-wide risks which may affect an individual Provider’s capacity to comply with the Accreditation Standards and other related responsibilities under the Act.
40. The development of a common risk profile, to be completed for each accredited home, and the analysis of information from such risk profiles at an aggregate level, would contribute to an improved understanding of trends in non-compliance across the sector. The consolidation and expansion of DoHA’s SPoC list and the Accreditation Agency’s separate HoI list would provide a starting point for such an approach.
Monitoring and managing compliance
41. The Department – Agency Compliance Protocol, July 2002, (the Protocol) sets out the referral process between DoHA and the Accreditation Agency and details how compliance monitoring and action will be undertaken consistent with the legislation. There are four types of referral, reflecting a graduated response. Referral categories provide additional guidance to the Accreditation Agency to focus its visits, with approximately 1550 referrals to the Agency in 2009–10.
42. The ANAO identified variability in the referral process. Staff training would support the consistent application of the Protocol.
43. Case management is undertaken separately by DoHA’s state and territory offices and the Accreditation Agency’s state offices; jointly by DoHA and the Agency at the state level; and by each state-based office with its corresponding national office. These arrangements enable case-by-case risk information to flow in multiple directions to inform the compliance and monitoring activities of DoHA and the Accreditation Agency respectively.
44. The Accreditation Agency uses case management to determine whether a problem already exists, or is likely to emerge, and accordingly tailors its schedule of visits and the Accreditation Standards/expected outcomes to be considered. Where there is significant change in a home’s level of compliance, the Accreditation Agency conducts a review to ascertain why such a change occurred.
45. Support Contacts are conducted to give assurance to the Government, community and residents that homes are providing quality care. Under the Accreditation Agency’s current operational policy, additional matters identified by assessors can be logged for future visits and are used to inform the case management of the home and the development of the scope of subsequent visits. However, the policy does not enable assessors to alter the scope of assessment for a Support Contact without reference to a decision-maker in the relevant state office, even where concerns arise about the performance of the home in areas outside the assigned scope of a Support Contact. There are potential benefits in allowing assessors in the field some latitude to examine other risks to service delivery that they identify during visits. The extent of this latitude could be specified to avoid significant scope variation.
46. One of the risk factors guiding the actions of the Accreditation Agency is a change to a home’s key personnel, including senior nursing staff or change in an Approved Provider. The timely transfer and accuracy of data on DoHA’s National Approved Providers System (NAPS) directly affects the Accreditation Agency’s ability to monitor this risk indicator.
47. NAPS does not have a direct interface to the Accreditation Agency’s Better Business Program (BBP) system. Key personnel changes are entered manually into NAPS from DoHA records, and are updated as data is received from Approved Providers, increasing the risk of out-of-date information remaining on the system. The management of NAPS data could be enhanced to ensure that the Accreditation Agency receives the information in a timely manner.
48. At the operational level, DoHA and the Accreditation Agency have arrangements in place to monitor and address possible non-compliance. If the Accreditation Agency identifies serious risk to the health, safety and wellbeing of residents of an aged care home, this information is transferred to the relevant DoHA state office. Appropriate compliance responses, which may include sanctions, are determined by DoHA, informed by information from accreditation activities, CIS activities, and other sources.
49. Sanctions, as the ultimate deterrent, are the final response to non-compliance. The regulatory process gives Approved Providers every opportunity to address identified non-compliance before sanctions are contemplated. Sanctions have been imposed by DoHA for significant non-compliance issues including: non-compliance with clinical care standards; staff failing to monitor or respond to distressed residents; health risks arising from the presence of rodents in a home; risks to the safety and security of residents arising from delays in maintaining equipment, fencing and the grounds surrounding a home; and for long term or ongoing non-compliance. Sanctions have taken the form of: a suspension of Australian Government funding for new care recipients, the appointment of specialist advisers, and a requirement for an Approved Provider to provide, at its expense, training for its officers, employees and agents.
Monitoring and reporting performance
50. DoHA and the Accreditation Agency largely report performance on an activity basis, such as the number of homes visited as part of the accreditation process and the numbers of Approved Providers on whom sanctions were imposed. A more complete reporting framework would assist stakeholders to assess the contribution of the separate but complementary roles performed by DoHA and the Accreditation Agency to quality improvement in residential aged care. Improvements in the reporting framework could be considered in the context of DoHA’s response to the 2007 Campbell Report.
51. A copy of the proposed report was provided to DoHA. DoHA provided the following response:
The monitoring and compliance arrangements undertaken by the Aged Care Standards and Accreditation Agency (accreditation and monitoring) and the Department of Health and Ageing (regulation and monitoring) are an important component of the regulatory framework for residential aged care homes to ensure quality care is provided to residents.
The recommendations in the report will support the work of the Department to further enhance the residential aged care monitoring and compliance framework, and the performance reporting and assessment of quality care in residential aged care homes. The outcomes of the ANAO report will also be relevant in the context of the significant reform agenda currently underway in aged care.
52. A copy of the proposed report was provided to the Accreditation Agency. The Accreditation Agency provided the following response:
The Accreditation Agency agrees with the Report. The Report is a useful and informative analysis of the company’s approach to our responsibility to promote high quality care in the aged care sector. We note that the Report reflects the extensive changes we have made in our approach since the tabling of ANAO Report No. 42, 2002–03 in May 2003, particularly the introduction of risk based case management in accreditation and the growing industry education program.
The audit also provides a good outline of the regulatory environment within which aged care providers, the Department of Health and Ageing and the Aged Care Standards and Accreditation Agency Ltd operate. It clearly articulates the role of the Department as the regulator and the Accreditation Agency as the company responsible for the promotion of quality through accreditation, education and the provision of information to the sector.
 Department of Health and Ageing, Annual Report 2009–10, p. 185. The Budget Estimate is over $6.6 billion for 2010–11 and $7 billion for 2011–12.
 The Australian Nursing Federation notes that: ‘More and more older Australians are remaining in their own homes for longer, and are entering nursing homes only when their care needs are too complex to be managed in the community’, available at: <http://www.anf.org.au/html/publications_factsheets.html>, [accessed March 2011].
 The Accreditation Agency Better Practice Melbourne Conference, August 2010, Melbourne, and also referenced on the Centre for Cultural Diversity in Ageing website: <http://www.culturaldiversity.com.au/>, [accessed March 2011].
 The Productivity Commission’s draft report, 2011, ‘Caring for Older Australians’ notes that the supply of workers is problematic. The formal aged care system faces difficulties in attracting and retaining workers. These difficulties are expected to intensify due to increasing competition for workers as the overall labour market tightens in response to population ageing.
 In its 2010 incoming government brief, DoHA advised the Australian Government that ‘it will be a challenge for the current structures of the (aged care) system to respond to the increased demand for aged care services arising from the ageing population’, and ‘it will also be a challenge for the current business models to meet the changing expectations of aged care recipients, including greater levels of self determination and choice in the type of aged care they receive. ’Incoming Government Briefing: Volume 1’, Ageing and Aged Care System, p. 3, available at <http://www.health.gov.au/internet/main/publishing.nsf/Content/min-briefs>, [accessed March 2011].
 The Act, Division 2, Section 2-1(1) (b).
 In 2009–10, not-for-profit Approved Providers (religious, charitable and community-based providers) were responsible for almost 59 per cent of residential aged care places while private for-profit Approved Providers increased their share of residential aged care places by a further one per cent to 35 per cent. The remaining six per cent of places were operated by state and local governments.
 State, territory and local governments also have regulatory roles in particular areas of residential aged care, such as the determination of staffing and industrial awards, and monitoring compliance with building and fire safety regulations.
 In 2009–10, the department issued 134 Notices of Non-Compliance in relation to quality of care. DoHA issued seven Notices of Decision to Impose Sanctions to seven Approved Providers, and at the end of 2010 three of these sanctions remained in place.
 Under Part 5.4 of the Act, the Secretary of DoHA may, on behalf of the Commonwealth, enter into a written agreement with a body corporate under which the Commonwealth makes one or more grants of money to the body for: accreditation of residential care services in accordance with the Accreditation Grant Principles; and any other purposes specified in the Accreditation Grant Principles. The sole member of the company is the Australian Government, represented by the Minister with responsibility for the Aged Care Act 1997.
 The Accreditation Grant Principles 1999 have been revoked and replaced with the Accreditation Grant Principles 2011 which commenced on 20 May 2011. The functions of the Accreditation Agency remain the same.
 While accreditation as a process contributes to quality, it cannot guarantee that all residential aged care homes will, at all times, provide the quality of care and services to residents envisaged under the Act. In addition a range of other variables, such as workforce issues and revenue streams, may influence care outcomes for residents.
 Commonwealth of Australia, Evaluation of the impact of accreditation on the delivery of quality of care and quality of life to residents in Australian Government-subsidised residential aged care homes, 2007, p. ix.
 Commonwealth of Australia, The 2010 Intergenerational Report, Chapter 4.3.
 While the majority of Approved Providers continue to be not-for-profit, there is a large and growing proportion of for-profit providers.
 DoHA, Report on the Operation of the Aged Care Act 1997, 1 July 2009 - 30 June 2010, 2010, p. 78.
 The performance of a home is assessed against the 44 Expected Outcomes (EOs) of the four Accreditation Standards, relating to management systems, staffing and organisational development; health and personal care; residential lifestyle; and physical environment and safe systems. A complete assessment is carried out during site audits and review audits, with more targeted assessment against a smaller number of EOs during Support Contacts.
 The term ‘Assessment Contact’ was introduced in place of ‘Support Contact’ following the revocation of the Accreditation Grant Principles 1999 and their replacement by the Accreditation Grant Principles 2011 on 20 May 2011. The term ‘Support Contact’ is used in the audit report as it was in effect during the conduct of the audit.
 Aged Care Standards and Accreditation Agency Ltd, ‘Support Contact Arrangements’, AS_PL_00456, version 2.2, 30 October 2009, p. 1.
 ibid, p. 6.
 In the course of a CIS investigation, where a DoHA officer considers that the subject matter of an individual complaint may apply to more than one resident, there are formal channels for the referral of this information to the Accreditation Agency for further consideration.
 The most prominent was the disclosure in early 2000 that some residents at a private nursing home had been bathed in a kerosene solution as a cure for scabies.
 The initial focus of the list was on identifying prudential risks, but there is now an increasing focus on incorporating quality of care risks, whether or not these were initially caused by a home’s financial status. For example, the list now includes homes which have a history of non-compliance with the Accreditation Standards, a questionable track record of addressing non-compliance, current or recent complaints activity and key changes in governance arrangements.
 The number of homes on the HoI list is not constant and varies over the accreditation cycle. For example, the Accreditation Agency advised that in 2009–10 its National Case Management Committee reviewed approximately 180 homes.
 Commonwealth of Australia, Guide to the Government’s small business statement—More Time for Business, March 1997, Canberra, p. 11.
 The Accreditation Agency has undertaken to report performance against the Charter in the 2010–11 Annual Report.
 Type 1, referred for the information of the Accreditation Agency. Type 2, referred for the Accreditation Agency to consider during its next scheduled contact. Type 3 suggests the Accreditation Agency conducts a Support Contact within 4 weeks. Type 4 requires the Accreditation Agency to arrange for a Review Audit immediately.