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About audit reports
An audit report is created when a rest home undergoes an audit for certification under the Health and Disability Services (Safety) Act 2001. These audits assess whether the rest home meets the required standards for providing aged residential care.
Audit reports highlight how well a rest home is performing – both the strengths and areas needing improvement, helping you make informed decisions about care options.
The auditing process
When audits occur
Audits are required for certification under the Act. Rest homes are certified for a specific period – typically between one and four years – based on assessment of the audit report and other information held by the Ministry. Before the certification expires, the rest home must undergo another audit.
Additionally, at least one unannounced spot audit is conducted midway through the rest home’s certification period. This ensures that any previously identified issues are being addressed and that standards are maintained.
Audits are also required when a rest home changes ownership or introduces a new service (eg, hospital-level care).
Standards used in audits
Rest homes are audited against against Ngā paerewa Health and Disability Services Standard ('Ngā Paerewa'), which focusses on the quality of care and outcomes for residents. There are 34 subsections, each with a number of criteria within Ngā Paerewa that can be used for audits of rest homes. Ngā Paerewa ensures that services are safe, effective, and resident-focussed.
Steps involved
Audits are carried out by Designated Auditing Agencies (DAAs) approved by the Ministry of Health. After the audit:
- The report is reviewed by the rest home
- It is submitted to the Ministry of Health and Health New Zealand (HNZ) - Te Whatu Ora for review
- The Ministry determines the certification period based on the findings and feedback from HNZ.
Contracts with Health New Zealand
Rest homes operate under the Age-Related Residential Care (ARRC) Services Agreement, a national contract used between Health New Zealand and providers. This ensures consistent quality care for older individuals. These services are referred to in the audit reports as ARRC requirements. You can find out what services are covered at Aged residential care provider agreements on the Health New Zealand website.
HNZ is also responsible for monitoring and ensuring timely resolution of audit findings (where a rest home is found not to be meeting an aspect of Ngā Paerewa).
What is in an audit report
Audit reports provides information and evidence about how well a rest home is meeting the requirements of Ngā Paerewa.
While the format is consistent, the length and detail vary depending on:
- the number of subsections audited (spot audits don't audit as many standards as full certification audits)
- the amount of evidence gathered
- the number of corrective actions and/or continuous improvement ratings.
How data is collected
Auditors gather data through:
- observing the rest home in action
- interviews with rest home staff, residents and family members
- review of systems, policies, procedures and records.
This data is analysed to determine compliance with each subsection and criterion.
Key outcome areas
- Our Rights
- Workforce and Structure
- Pathways to Wellbeing
- Person-Centred and Safe Environment
- Infection Prevention and Antimicrobial Stewardship
- Restraint and Seclusion
Each section has several subsections, and each subsection has criteria. For example, section 1: Our Rights has 10 subsections and each subsection has a number of criteria.
Attainment levels and risk ratings
You can tell how well the requirements of a subsection or criteria have been achieved by the ratings of ‘attainment’ and level of risk.
| Abbreviation | Full word/s | Achievement of standard or criteria |
|---|---|---|
| CI | Continued improvement | Achievement beyond the full attainment |
| FA | Fully attained | Full attainment and meets the requirements |
| PA | Partial attainment | Partial attainment and improvement required |
| UA | Unattained | Not met |
| NA | Not applicable | Standard or criterion not audited as it does not apply |
Risk ratings
If a subsection is partially attained (PA) or unattained (UA), it is assigned a risk rating: negligible, low, moderate, high, or critical. These ratings reflect the potential impact on residents.
Partial attainment is common and does not indicate failure – it highlights areas for improvement.
Corrective actions
When improvement is required, the audit report includes or will include a Corrective Action Request (CAR). This outlines: the action required and a time frame for correcting the issue(s).
Navigating the audit report
Front section
Includes:
- rest home details
- type of audit
- the kinds of services the rest home is certified to provide
- bed occupancy on the day of audit.
Executive Summary
Summarises findings across the 6 sections (see above), often supported by indicators to highlight performance.
Summary of Attainment
This table summarises the number of subsections and criteria audited, along with their ratings.
Attainment against the Health and Disability Services Standards
This table presents the results of all the subsections assessed during the audit. Not all subsections or criteria apply to every provider, and some may not be assessed at every audit, depending on the services offered or audit type.
Criteria requiring corrective actions
When a subsection is rated partially attained (PA) or unattained (UA), specific corrective actions are recorded. This table lists the criteria where such actions have been recorded.
Criteria recorded for continuous improvement
In addition to the subsection, individual criterion within a subsection may be rated as demonstrating continuous improvement. This rating indicates that the provider has exceeded the level required for full attainment. This table highlights the criteria where continuous improvement has been acknowledged.
