Aged Care Quality and Safety Commission audits: what providers must have ready

How the Commission conducts audits under the new Act

The Aged Care Quality and Safety Commission operates under a risk-based regulatory model. Scheduled performance assessments occur at minimum every three years for residential aged care providers and home service providers, but the Commission can conduct unannounced audits at any time — and the Aged Care Act 2024 has significantly strengthened the Commission's powers to do so. Under the new Act, the Commission can issue compliance notices, accept enforceable undertakings, impose civil penalties, and suspend or revoke approved provider status. The regulatory stakes for documentation gaps are higher than they were under the previous framework.

The Commission's audit approach has also shifted in character. Under the strengthened Quality Standards, auditors assess whether care outcomes are actually being achieved for each individual person receiving care — not just whether systems and processes exist. In documentation terms, this means auditors look for evidence that each person's care plan is being followed, their goals are being supported, their preferences are being respected, and their health and wellbeing are being monitored over time. A folder of blank compliant templates does not satisfy this standard — the records must show what actually happened.

Unannounced audits are most commonly triggered by complaints received by the Commission, SIRS reports indicating serious harm, notifications of significant incidents, referrals from the Department of Health and Aged Care, or indicators from provider performance data. Providers have no guaranteed notice period before an unannounced inspection, which means audit-ready documentation is not something providers can create in response to a scheduled assessment — it must exist every day.

What the Commission typically requests in aged care audits

Commission auditors request records based on the audit scope, but certain categories appear in almost every performance assessment. Understanding what auditors look for helps providers prioritise their documentation systems around the records most likely to be reviewed.

Individual care plans and care plan review records

Auditors verify that each person has an up-to-date care plan that reflects their current needs, preferences, and goals, and that the care plan has been reviewed at the prescribed frequency. They look for records showing that the person (and, where relevant, their representative) participated in the care planning process. Outdated care plans or plans that have not been reviewed within the required period are a common finding under Standard 2 (The Person) and Standard 5 (Clinical Care).

Shift notes and daily care records

Shift notes are the most frequently reviewed category of record in Commission audits. Auditors sample notes across the review period to assess whether care observations are specific and person-centred, whether changes in condition are identified and escalated, whether goals are being actively supported, and whether the care being documented matches the care plan. Vague or template-style notes — "participant was calm and cooperative, shift uneventful" — consistently fail to satisfy auditors that adequate care is being delivered and monitored.

Incident records and SIRS documentation

Auditors review the incident register and cross-check incident records against SIRS notifications submitted to the Commission. They look for completeness of incident documentation, timeliness of reporting, and adequacy of the provider's response. Auditors also check whether incidents that were not reported to the Commission should have been classified as Priority 1 or Priority 2 SIRS events.

Medication management records

Medication administration records, PRN medication records, and medication review documentation are reviewed against clinical care standards. Auditors look for evidence of medication reconciliation, oversight of PRN use, and documentation of refused medications and the clinical response. Gaps in medication records are a common source of findings under Standard 5.

How providers build documentation that survives Commission scrutiny

Providers that perform well in Commission audits share a common characteristic: their documentation is specific, timely, and person-centred by default — not retrofitted before an assessment. The practices that support audit-ready documentation are operational habits, not pre-audit rituals.

Specificity at the point of care

The most consequential documentation quality gap auditors identify is vagueness. A shift note that records specific observations — the person's mood, their engagement with the activity, whether they ate, a reported pain level, the action taken when a concern arose — creates an evidentiary record that survives scrutiny. A note that records "good shift, no concerns" does not. Providers that invest in documentation systems which prompt specific observations at the point of care — rather than allowing narrative drift toward templated language — consistently produce records that auditors find credible.

Continuity of record across shifts

Auditors assess records longitudinally, not just shift-by-shift. A concern identified on a Monday note must appear in subsequent notes — as an active issue being monitored, as an escalation that occurred, or as a resolution with supporting evidence. Providers whose documentation systems enable continuity — where workers completing a note can see what was flagged in the previous shift — create records that tell a coherent story of care. Providers whose notes are disconnected from each other create records that appear to show neglect of identified concerns, even when care was actually delivered.

Alignment between care plans and care records

One of the clearest audit failure patterns is a care plan that describes a person's needs and preferences but daily records that make no reference to those needs or preferences. Auditors look for alignment — they compare what the care plan says should happen with what the shift notes say did happen. Providers that build this alignment into their documentation systems, so that workers see the person's goals and care plan during note completion, produce records that consistently evidence delivery of planned care.