Key Responsibilities

1. Accreditation Readiness & Audit Management

- Lead internal preparation for external accreditation audits, unannounced visits, and regulatory reviews.

- Schedule, conduct, and report on internal clinical and operational audits (e.g., medication management, clinical documentation, infection control, restraint use).

- Conduct gap assessments against mandatory Quality Standards and translate findings into clear action plans.

2. Continuous Improvement (CI) & Quality Framework

- Maintain, oversee, and dynamically update the organisation’s Plan for Continuous Improvement (PCI).

- Apply the Plan-Do-Check-Act (PDCA) methodology to systematically address clinical, operational, and service gaps.

- Track, analyze, and report on Key Quality Indicators (e.g., falls, pressure injuries, weight loss, medication errors, and skin tears).

- Utilise feedback, clinical incident reports, and complaint trends to design targeted continuous improvement projects.

3. Clinical Leadership & Practice Standards

- Provide clinical mentorship and guidance to care staff and Registered Nurses to maintain high standards of evidence-based nursing care.

- Review and update clinical policies, procedures, and care plans to ensure alignment with current legislation and best practices.

- Participate in complex case reviews, clinical risk assessments, and incident investigations (e.g., Responsible Incident Response Scheme / SIRS reporting).

- Ensure person-centred care principles are reflected in both direct care delivery and clinical documentation.

4. Education,



Training & Culture

- Identify staff learning needs resulting from audit outcomes or regulatory updates.

- Develop and deliver practical, on-the-floor education and toolbox talks on quality standards, audit expectations, and clinical skills.

- Foster a positive "audit-ready every day" continuous improvement culture among care teams, demystifying the accreditation process.

Key Performance Indicators (KPIs)

1. Audit Completion: 100% execution of the annual internal clinical audit schedule on time.

2. PCI Upkeep: Actionable, documented, and regularly updated Plan for Continuous Improvement reflecting real-time facility changes.

3. Clinical Risk Reduction: Measurable improvement or stabilization in facility Key Quality Indicators over quarterly reporting cycles.

Selection Criteria (Qualifications & Skills)

Essential:

- Nursing Registration: Current registration as a Registered Nurse (RN) with APHRA.

- Aged Care Experience: Minimum 3–5 years of clinical experience within residential aged care or a closely aligned clinical quality role.

- Standards Knowledge: Deep, working knowledge of residential aged care quality standards, accreditation frameworks, and clinical governance principles.

- Audit Expertise: Demonstrated success in developing, conducting, and analysing internal quality and compliance audits.

- Change Management: Strong communication and coaching skills, with the ability to bring care teams along on quality initiatives without overwhelming daily operations.

📌 Clinical Quality & Accreditation Nurse (Upper Orara)
🏢 Coffs Coast Legacy
📍 Upper Orara