When auditors come knocking and the outcome is less than ideal, it can feel like the roof just caved in. But take a breath. You are not the first to face non-compliance—and you certainly will not be the last.
Whether it is paperwork gaps, outdated procedures, or unclear roles, the key is in how you respond. So let us walk through the steps to get your aged care service back on the rails with a plan that works—not just for ticking boxes, but for improving care where it matters.
What Is Non-Compliance in Aged Care?
In plain terms, non-compliance means your service did not meet one or more expected outcomes under the Aged Care Quality Standards. These findings come from audits or reviews conducted by the Aged Care Quality and Safety Commission.
Sometimes the issue is minor—an unclear policy or a missing signature. Other times, it is more serious, such as failures in medication management, resident safety, or dignity in care.
Whatever the case, the response needs to be swift, clear, and thorough.
Why a Fast, Thoughtful Response Matters
Think of non-compliance like a warning light on your car’s dashboard. You could ignore it, but you would be risking a full breakdown.
Responding quickly and carefully shows your commitment to accountability and improvement. It helps you rebuild trust with your residents, your staff, and the Commission. More importantly, it can prevent small issues from snowballing into major sanctions—or worse, putting people at risk.
Step 1: Acknowledge the Findings Honestly
When you receive a notice of non-compliance, your first instinct might be to defend or explain it away. Resist that urge. Instead, take the findings seriously and acknowledge them in writing.
Do not sugar-coat. Auditors do not want spin—they want facts. Acknowledge what was found, and accept responsibility where needed.
“Yes, the medication fridge logs were incomplete for three weeks. We did not have a backup system, and that was our mistake.”
This kind of clarity sets the tone for everything that follows.
Step 2: Review the Details Carefully
Now it is time to roll up your sleeves.
Gather your documentation. Talk to the staff involved. Understand exactly what went wrong, how it happened, and why it was not picked up sooner. This part can be uncomfortable, but it is necessary.
Look at:
- What policy or process was not followed?
- Was the policy itself unclear or out of date?
- Were staff unaware of their roles?
- Was training missing or incomplete?
- Was there a failure in communication?
This is where having strong aged care policy templates can really help. If your documentation is consistent and clear, it is much easier to pinpoint gaps.
Browse our aged care policy templates if you need a stronger foundation going forward.
Step 3: Start the Audit Fail Response Plan
An audit fail response should cover three things:
- Immediate Actions Taken – What you did straight away to fix or reduce the risk.
- Short-Term Corrective Actions – How you will prevent the issue in the next few days or weeks.
- Long-Term Improvements – What changes you are putting in place to avoid it happening again.
Use clear language. Include timeframes and names of responsible staff. For example:
"As of 12 May, all staff on night shift received refresher training on pressure injury reporting. From 1 June, a new handover checklist will be mandatory."
This shows you are not just patching a hole, but building a better wall.
Step 4: Create a Policy Improvement Plan
This is not just about rewriting documents—it is about fixing the root cause.
A strong policy improvement plan will help you:
- Review and update the relevant policy
- Check that it lines up with current legislation and standards
- Add more specific instructions or responsibilities
- Include better monitoring systems
Sometimes, policies are technically correct but practically useless. For example, if your manual says “clean common areas regularly” but does not say who does it, how often, or how it is recorded, then it is not much help during an audit.
Make your policies clear, practical, and easy for staff to follow. Again, if you need help rebuilding, start with professionally written aged care policy templates.
Step 5: Communicate Changes to Your Team
Policies are only useful if people follow them. And people only follow them if they understand them.
Schedule team meetings. Keep the language simple. Explain:
- What went wrong
- What has changed
- What they need to do differently
- Why it matters
You might even say something like:
“Look, the Commission picked up that our medication checks were not being recorded properly. We all know that is not how we want to run things. So we are tightening the process, and we are going to do this better—together.”
This helps your team feel part of the solution—not the problem.
Step 6: Document Everything
The Commission wants proof that you are making real changes. So write everything down.
That includes:
- Meeting minutes
- Policy updates
- Training attendance
- Risk assessments
- Daily or weekly checklists
- Photographs or logs if needed
Keep records well organised, signed, and dated. Use consistent document control formats, and label everything clearly. This makes it easier for future audits and internal reviews.
Step 7: Submit Your Response
When submitting your written response, keep it professional, specific, and structured.
Include:
- A cover letter addressing the findings
- A summary of immediate and long-term actions
- Updated policy documents or evidence logs
- Contact details for follow-up
Avoid fluff. You are not writing a marketing brochure. You are showing the Commission that your service is safe, organised, and improving.
Step 8: Follow Up and Check Progress
Change does not stop when you submit your paperwork.
Set a regular follow-up schedule. Check that your team is sticking to the new procedures. Do random audits or spot checks. Ask residents and families if they have noticed improvements.
If something is not working, do not wait. Adjust the plan, retrain staff, and update your records.
This is about building trust—and that only happens with consistency over time.
Common Pitfalls to Avoid
Even experienced providers trip over these from time to time:
- Ignoring low-risk issues – These can grow fast if left unaddressed.
- Changing documents without changing practice – If staff keep doing things the old way, nothing has really improved.
- Overcomplicating policies – More words do not always mean more clarity. Keep it simple and practical.
- Failing to consult staff – If the people doing the job are not involved in the fix, your solution might not work on the floor.
What Governa AI Can Do For You
Writing policies from scratch is time-consuming. So is reviewing them line by line. Governa AI provides clear, easy-to-follow aged care policy templates designed for Australian providers. They align with legislation, follow current best practices, and are ready for audit reviews.
If your documents are due for an upgrade—or you just want to stop patching up old policies—start here.
Responding Well Builds Confidence
Non-compliance is never fun. But it is not the end of the road. It is a sign that something needs attention. And when you respond well, it shows that your organisation takes care, safety, and accountability seriously.
So do not panic. Take stock. Get the right people involved. Put your plan in writing. And show the Commission—and your residents—that you mean business.
Need Help With Your Policies?
Governa AI has policy templates that meet Australian standards, are written in plain language, and help you respond to audits with confidence.
👉 Browse Governa AI's Aged Care Policy Templates and take the next step toward stronger compliance today.
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