Your 90‑Day Aged Care Compliance Sprint

With strengthened Aged Care Quality Standards and a new regulatory model arriving in 2025, safety obligations are tightening. Here’s a practical story of how a small provider turned audit anxiety into a repeatable 90‑day readiness program—without blowing the budget.

1) Introduction: The Compliance Wake‑Up Call

“If we were audited today, could we prove every essential safety measure is up to date?” Mia, owner of a 38‑bed residential service, wasn’t sure. The regulator’s new model clarifies that registration requirements depend on the services you deliver, and the strengthened Standards lift expectations for a clean, safe, comfortable environment. Closer scrutiny is coming for asset registers, essential safety measures (ESMs), water and air quality, and contractor management under the Environment Standard. The risk? Inability to evidence planned preventive maintenance—AS 1851 fire systems, emergency lighting, lifts, water temperature and Legionella controls—and timely rectification can trigger non‑compliance findings. Detailed reports on maintenance schedules, safety checks, and upgrades are now required. Time to act.

2) Challenge: Asset Registers Under the Microscope

Mia’s “asset register” lived in three spreadsheets, two email threads, and a wall of paper certificates. Auditors, however, expect a single source of truth that shows what you own, where it is, when it was last tested, the Standard that governs it, and who is responsible.

What auditors expect

Each plant/system mapped to its governing Standard and test interval.
Asset IDs, locations, serials, and risk ratings complete and consistent.
Verification/calibration certificates and service dockets attached to each asset record.
Overdue work orders closed or risk‑assessed with documented mitigations.

Without this, even good work can look invisible.

3) Challenge: Essential Safety Measures and AS 1851

The Australian Fire Safety Reform changes are mandatory from 13 February 2025. Under AS 1851, Mia needed to demonstrate that ESMs were tested at the right intervals—and that defects were rectified fast.

High‑visibility ESMs

Fire detection and alarm systems
Emergency lighting and exit signs
Fire doors and hydrants
Sprinklers and pumps

“If it isn’t documented, it didn’t happen.” — Fire inspector, during a pre‑audit clinic

Beyond fire, similar scrutiny applies to lifts, emergency power, and evacuation chairs across common spaces—stairways, corridors, mail rooms, and garbage areas.

4) Challenge: Water and Air Quality Controls

Resident wellbeing hinges on water temperature, Legionella risk management, and air handling hygiene. The infection prevention and control (IPC) guidance supporting the strengthened Standards sets clear expectations: sampling plans, temperature checks, and evidence of HVAC filtration and coil cleaning.

Evidence that stands up

Logged water temperature checks and Legionella test results with corrective actions.
HVAC filter changes, coil cleaning records, and IAQ assessments.
Certificates and lab reports linked to affected assets and dates.

No loose PDFs—everything must trace back to the asset.

5) Challenge: Contractor Management Under the Environment Standard

Contractors kept Mia’s facility running, but the paperwork was scattered. The Environment Standard expects safe services delivered by competent people, which means verified insurances, inductions, permits to work, and clear scope of works—especially for remote and after‑hours technicians.

Common gaps

Expired insurance or licenses not flagged in time.
Service reports not attached to the asset they relate to.
No record of who attended, when, and what rectification occurred.

Great contractors still need clear, documented systems to follow.

6) Solution: The 90‑Day Readiness Check

Mia set a 90‑day sprint with one rule: single source of truth or bust.

Six practical moves

Map each plant/system to its Standard (AS 1851, lifts, water temp/Legionella, HVAC), required test interval, and responsible person.
Migrate assets into one register; standardize IDs, locations, and risk ratings.
Close or risk‑assess overdue work orders; create corrective actions with due dates and owners.
Attach calibration/verification certificates, service dockets, photos, and lab reports to each asset record.
Schedule forward maintenance for the next 12 months; enable reminders and escalations.
Build a compliance dashboard: on‑time PM %, overdue defects, certificates expiring, and contractor compliance status.

This turned scattered effort into auditable evidence.

7) Systemise: “Document Your Business or Get Out”

Mia codified how work gets done so anyone—onsite or remote—could follow instructions without guesswork.

Make it easy to do the right thing

Write SOPs with photos and checklists for ESM tests, water checks, and HVAC tasks.
Use mobile forms so technicians capture readings, attach proof, and sign off on site.
Role‑based approvals: nurse unit manager signs water temps; facility manager signs ESM defects.
Contractor portal: upload insurances, inductions, and task reports—auto‑remind before expiry.

“Document your business or get out.” The moment your systems live outside people’s heads, remote workers can safely execute, and audits become repeatable—not personal.

By week 10, overdue work orders were cleared, certificates were attached, and the dashboard showed trend lines improving. Audit rehearsal took hours, not days.

8) Outcome and Next Steps: From Anxiety to Audit‑Ready

When the regulator arrived, Mia’s team didn’t scramble—they clicked. Every question had a trail: asset → Standard → test interval → last result → certificate → rectification. The facility could demonstrate a clean, safe, and comfortable environment that optimises residents’ sense of security. Your turn:

Pick a start date and run a 90‑day readiness check.
Name a responsible person for each plant/system and test.
Centralise your asset register and attach evidence to the asset, not the inbox.
Rehearse your audit: “Show me emergency lighting evidence for Wing B.”

If you can’t evidence it, you don’t own it. Start now.

Your 90‑Day Aged Care Compliance Sprint