Preparing for Your First Audit

The strengthened Aged Care Quality Standards introduce a more rigorous audit process. Unlike previous regulatory changes, there is no grace period. Providers must prepare now to meet these new requirements. Under the new Commissioner Liz Hefren-Webb’s leadership, audits will focus on assessing outcomes, requiring structured and evidence-based preparation.

One of the biggest challenges providers face is understanding what auditors will be looking for. With over 1,200 possible evidence items, an unstructured approach to preparation risks wasting time and resources without achieving conformance with the new grading system. The financial, reputational, and operational risks of being unprepared make early and strategic preparation essential.

Why This Tool Was Developed

Mark Sheldon-Stemm, a seasoned aged care leader, expert in the Consumer Directed Care model of care, and current CEO of Valley View Residence, developed this tool in partnership with Ausmed to make audit preparation practical and structured. As Mark said in a recent webinar on preparing for your first audit under the new Standards:

“The Aged Care Quality and Safety Commission has done an excellent job creating the evidence framework, but interpreting 750+ pages of material can be overwhelming.

This tool organises the evidence requirements into a user-friendly format, helping providers feel less overwhelmed and more confident in their ability to track and manage compliance“.

How the Audit Readiness Tool Helps Providers

This tool is designed to provide clarity and structure, ensuring providers can confidently navigate the complexities of audit preparation.

With the transition to the new standards, providers need a structured and comprehensive way to prepare for audits efficiently.

Ausmed’s Audit Readiness Tool:

• Simplifies 1,200+ evidence items into well-structured, easy-to-navigate themes.
• Groups evidence by category, making it easier to understand what’s required.
• Brings consistency to the audit process, reducing variations across assessments.
• Aligns with the new 3-phase audit process:
• Stage 1: Audit preparation and desktop review
• Stage 2: Audit delivery.
• Stage 3: Audit reporting.
• Introduces more certainly before graded assessments, which replace the binary ‘Met’ or ‘Not Met’ system, are introduced.
• Provides a clear framework for demonstrating that an organisation meets the required outcomes.

How to Use the Tool

Before diving in, we recommend watching Will Egan, CEO of Ausmed, demonstrate the tool and then work systematically through it.

Here are the key steps:

1. Assign Accountability

1. Review each theme and category of evidence.
2. Assign responsibility at the Provider Level (organisation-wide) and/or Service Level (individual facility).
3. Define accountability across key organisational roles:
1. Board
2. Executive Leadership (CEO, COO, Finance, HR, Compliance, Clinical/Care, etc.)
3. Facility Management Team (Managers, Clinical/Care Managers or Management Team, etc.)

2. Track Progress

1. Use the Audit Readiness Score dropdown to categorise each evidence item as:
1. Not Ready for an Audit
2. Ready with Exception
3. All Ready for an Audit

3. Organise and Store Evidence

1. Record the Source of evidence, e.g., board meeting minutes, policies, and reports.
2. Identify the Form of evidence, e.g., electronic records and paper documents.
3. Hyperlink key documents where possible to streamline retrieval during audits.

Dashboard Overview

The tool’s dashboard provides key insights:

• Overall Readiness % – Percentage of evidence items marked ‘Ready for Audit’.
• Total Evidence Items Ready vs. Outstanding – To easily identify gaps or areas to strengthen.
• Breakdown of Evidence by Responsibility Level – % of evidence at Provider vs. Service level.

Audit Readiness by Evidence Type

Quality assurance isn’t the responsibility of one person or department. It must be shared across all teams. Clear roles and collective ownership foster a culture where continuous improvement becomes the norm.

This is the basis for a key feature of Ausmed’s Audit Readiness Tool, a heat map showing which evidence categories need attention.

This is designed to help organisations prioritise areas for improvement and ensure that quality assurance and audit preparation do not fall solely on one person or one team but remain a collective effort to make measurable improvements in the quality of care.

Evidence Collection and Categorisation

To ensure comprehensive audit preparation, evidence items are grouped into 21 key themes, as per the Evidence Mapping Framework. Each theme has a sheet within the tool.

1. Person-Centred Care
2. Dignity
3. Choice
4. Agreements
5. Clinical Governance
6. Quality Systems
7. Risk Management
8. Incident Management
9. Complaints and Feedback
10. Information Systems
11. Workforce and HR
12. Emergency Preparedness
13. Assessment & Planning
14. Care and Services
15. Clinical Safety
16. Care Coordination
17. Environment
18. Infection Control
19. Medication Management
20. Food and Nutrition
21. Palliative Care

Each theme (or sheet) contains specific evidence types:

• Documents and Records
• Governing Body Feedback
• Management Feedback
• Worker Feedback
• Third-Party Feedback
• Experience of Older Persons
• Observations
• Care Outcomes

For each evidence item, the tool enables:

• Assignment of accountability (Provider or Service level).
• Designation of responsible personnel.
• Tracking of readiness status.

Example: Person-Centred Care Evidence

Evidence Type	Example Requirement	Responsibility	Accountability	Readiness Score
Documents & Records	Records of governing body discussions on person-centred care improvements	Provider Level	Board & CEO	Ready with Exception
Worker Feedback	Can you tell me about an older person that is new to the service (last 3 months)? How did you make them feel safe and welcome?	Service Level	Clinical Manager	Not Ready for an Audit
Management Feedback	What strategies and practices are in place to support older people, particular new ones to the service, to feel safe, welcome, included and understood?	Service Level	Care Coordinator	All Ready for an Audit

Get Started Now!

Thanks to the expertise and generosity of Mark Sheldon-Stemm, the Audit Readiness Tool is a free, practical, structured support designed to help you navigate the complexities of the new audit process.

By methodically using the tool, assigning accountability, and tracking progress, providers can move beyond compliance and confidently demonstrate how structures and processes lead to the desired effect of measurable improvements in the quality of care of older people.

References and Useful Resources

• Strengthened Aged Care Quality Standards - Aged Care Quality and Safety Commission
• Strengthened Quality Standards Provider Guidance - Aged Care Quality and Safety Commission
• Evidence Mapping Framework - Aged Care Quality and Safety Commission
• Guide to Preparing for Your First Audit Under the New Standards - Ausmed
• Get Audit-Ready for the Strengthened Standards - Ausmed

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