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Case studies

Case studies

Below are real findings from published Commission performance reports and coronial findings, with the provider details removed. They are not our clients.

We use them because they show, in the regulator's own evidence, what goes wrong and what it takes to fix it. As we complete client work, we'll add our own results (with permission).

Part A · Lessons from the sector

Real, published cases.

Providers are not named. Several of these findings were made under the previous Quality Standards, so they illustrate the issue rather than the current audit framework. Each card links to its public source.

Public sector case — not a UpHealth Advisory client Case 1

Restrictive practices · Strengthened Standard 5 (Clinical care)

“We didn't know it was a chemical restraint”

What the Commission found

At a small regional residential home, four residents were prescribed regular and PRN antipsychotics without a diagnosed condition. Management did not recognise this as chemical restraint and had not obtained informed consent. The home was found non-compliant with two Standards and given 10 areas for improvement.

What fixed it

Consent was obtained for two residents. For the other two, the antipsychotics were stopped in consultation with their medical officers.

Source: The Weekly SOURCE

Public sector case — not a UpHealth Advisory client Case 2

Restrictive practices · Governance of remediation

The fix that didn't stick

What the Commission found

A residential home was found non-compliant on restrictive practices at a site audit. When assessors returned, the corrective actions had not worked. Documentation was still inaccurate, monitoring had not picked up errors, and staff did not share an understanding of what counts as a restrictive practice. This was despite the home having redesigned its psychotropic register in the care system.

Source: Commission performance report (DOCX)

Public sector case — not a UpHealth Advisory client Case 3

Restrictive practices

A remediation that held up to testing

What the Commission found

Staff and management at another home lacked knowledge of their legal obligations on restrictive practices.

What fixed it

The provider introduced a new assessment and authorisation form in its electronic care system and completed it for every affected resident. It also updated its registers, reviewed its policy against the legislation, delivered staff education and set up a monthly review of the registers. Assessors then tested the changes by sampling six residents.

Source: Commission performance report (DOCX)

Public sector case — not a UpHealth Advisory client Case 4

Medication safety · Strengthened Standard 5

Preventable medication deaths

What happened

In July 2026, the Victorian Coroner handed down findings on medication errors that led to the deaths of three aged care residents, in different homes, between August 2024 and September 2025. The Coroner found the errors could have been prevented and called for national medication safety standards. The Commission then issued a clinical alert reminding providers to follow the 6 rights of medication administration, treat medication rounds as a protected task and pack Schedule 8 medicines separately. In Victoria, from 1 July 2026, only Registered Nurses may administer prescribed and regulated medicines in aged care homes.

Source: Coroners Court of Victoria (PDF) · Commission clinical alert · The Weekly SOURCE

Public sector case — not a UpHealth Advisory client Case 5

Incident management

Incidents reported, never investigated

What the Commission found

At a residential home, medication incidents were being recorded but not investigated, and there was no process to improve investigations or reduce the risk of repeat incidents. The home had failed this requirement in two consecutive years and received a notice of non-compliance.

What fixed it

The provider appointed an experienced facility manager and put a strong leadership focus on remediation. At the next audits, most of the previously failed requirements had been turned around.

Source: The Standard (news report)

Sector snapshot

The pressure in numbers.

9,605

Reportable incidents in residential care in the first two months of the new Act (Nov–Dec 2025).1

4,659

Of those related to unreasonable use of force.1

$33.41

Maximum AN-ACC funding lost per resident, per day, by metro homes that miss care minute targets (from 1 April 2026).2

62%

Of residential aged care homes recorded an operating loss in the nine months to 31 March 2026.3

1 Australian Ageing Agenda · 2 The Weekly SOURCE · 3 StewartBrown, via Inside Ageing

Part B · How an engagement could look

Illustrative examples.

These are made-up examples to show our process. They are not real clients, and the numbers are for illustration only.

Illustrative example Example 1

Care minutes

Metro home below RN care minutes

Situation

An 80-bed metro home is meeting its total care minutes but is consistently below its RN target. The CEO wants to know the funding exposure and a realistic fix.

What we would do

Analyse 12 weeks of roster and payroll data by unit and shift. Model the sliding-scale funding impact. Identify where RN hours are lost (unfilled shifts, RNs doing non-direct tasks, skill mix on nights). Propose a revised roster, plus a weekly dashboard the DON can run.

Illustrative example Example 2

Renewal audit · Restrictive practices

Small not-for-profit with a renewal audit in 3 months

Situation

A single-home not-for-profit with no dedicated quality manager has a renewal of registration audit coming. The last monitoring visit raised concerns about psychotropic consent.

What we would do

A Registration Renewal Readiness review across all seven Standards, with a Restrictive Practices & Behaviour Support solution added.

  1. Week 1–2Gap analysis and resident sampling
  2. Week 3–6Fix with the team: registers, consent, behaviour support plans, education
  3. Week 8Mock audit and evidence pack
  4. Week 10Re-sample to confirm the fixes held
Part C · Client results

Our own results, coming soon.

No client results published yet.

We only publish client results with the client's written approval — de-identified unless they agree to be named, with measurable, verifiable outcomes. No invented quotes, numbers or logos.

What did your last audit find?

Tell us what the last audit or monitoring visit raised. We'll tell you honestly what fixing it would take.

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