What Happens During a HealthCERT Audit — A Guide for Aged Care Staff

HealthCERT audits can feel stressful, but they follow a predictable structure. Knowing what to expect — and what auditors are actually looking for — means your team can walk through one confidently rather than anxiously.

This guide covers what happens before the audit, what auditors look for on the floor, what questions they commonly ask frontline staff, and what good documentation looks like.

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What is HealthCERT and why does it audit rest homes?

HealthCERT is the team within the Ministry of Health that administers certification of rest homes, hospitals, and other residential care providers under the Health and Disability Services (Safety) Act 2001. All rest homes providing care for three or more residents must be certified and audited to confirm they meet the Ngā Paerewa Health and Disability Services Standard (NZS 8134:2021).

Certification periods run from one to four years. A longer period means better performance. An unannounced audit typically occurs midway through the certification period. When a rest home is sold, a new certification audit is required before the new provider can operate.

The audit team

Audits are carried out by a Designated Auditing Agency (DAA) — a private firm approved by the Ministry of Health. The audit team typically includes:

Lead Auditor — coordinates the visit, has deep knowledge of Ngā Paerewa
Clinical Auditor — a registered nurse or allied health professional focused on care standards
Technical Expert — sometimes present for specialist services (memory care, hospice, etc.)

Auditors are not inspectors in the punitive sense — their job is to assess whether the system is working, not to catch individual staff in mistakes.

Before the audit: what to prepare

For certification audits, your facility receives notice in advance. The audit team reviews documentation before arriving on site, so the following need to be current and accessible:

All policies and procedures (especially falls, medication, restraint, and incident reporting)
Staff qualification and training records
Care plans — current, individualised, and linked to interRAI assessments
Complaints register with resolution records
Incident and adverse event logs
Maintenance and facility compliance records

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The most common audit finding

Generic care plans that don't reflect the individual resident — not updated after condition changes, not linked to interRAI findings, no evidence of resident involvement. Auditors look at a sample of care plans first. Make sure yours are personalised and current.

What happens on audit day

The typical audit structure follows this sequence:

Opening meeting — Auditors introduce themselves, outline the schedule, and answer management questions
Document review on site — Clinical records, care plans, staff files, incident reports
Observations — Watching care delivery, medication administration, interactions between staff and residents
Conversations with staff — Informal, unscripted questions to frontline workers
Conversations with residents and whānau — Confidential, about their experience of care
Closing meeting — Summary of preliminary findings

What auditors ask frontline staff

Auditors talk to HCAs, nurses, and support workers directly — not just management. These conversations are confidential and you're encouraged to speak honestly. Common questions include:

"Can you tell me about the falls protocol — what do you do when a resident falls?"
"How do you know what care this resident needs?"
"If you had a concern about a resident's safety, what would you do?"
"Can you show me where the [medication / incident / restraint] policy is kept?"
"What training have you had in the last 12 months?"

Staff get asked these questions at 11pm, not just during audits.

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How auditors rate your service

Each criterion in the Ngā Paerewa Standard is rated on a five-point scale:

Rating	What it means
Continuous Improvement	Performance above required levels — commendable
Fully Attained	Meets the standard — no issues
Partial Attainment	Partially meets the standard — corrective action plan required
Unattained	Does not meet the standard — corrective action plan required, may shorten certification period
Not Applicable	The criterion doesn't apply to this service

If criteria are rated as Partial or Unattained, your facility must submit a corrective action plan. Your DHB monitors progress against this plan.

Section 31 notifications

Outside of scheduled audits, the Health and Disability Services (Safety) Act 2001 requires providers to notify HealthCERT in writing (under Section 31) when:

Serious incidents occur that put resident health or safety at risk
Significant changes to services are planned (new services, change in bed numbers)
Ownership of the facility changes

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Audit-ready by design

If an auditor asks "how does your staff know the falls protocol?" the strongest answer is a documented system — not "we trained them." An audit log showing every staff member's queries and the cited responses is stronger evidence than a laminated A4 sheet.

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This article is for general information only. HealthCERT requirements change periodically. Always refer to the current Ngā Paerewa Standard (NZS 8134:2021) and the Ministry of Health's HealthCERT guidance for definitive requirements applicable to your service.