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., Serious 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)
Audit Completion:
100% execution of the annual internal clinical audit schedule on time.
PCI Upkeep:
Actionable, documented, and regularly updated Plan for Continuous Improvement reflecting real-time facility changes.
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:
Robust communication and coaching skills, with the ability to bring care teams along on quality initiatives without overwhelming daily operations.

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