In response, the St John's Village nursing home accepted the resignation of its own former acting care services manager and referred him to his professional body for potential sanction.

A federal government audit of the St John's Village home, which was ordered after the catastrophic outbreak, has found it took days after infections began in August for management to report the outbreak.

By the time they did, 16 residents and eight staff were already sick.

Three of the 10 residents who died were not referred to a doctor when they first started showing symptoms, and others had to wait five days for swabs to be taken, the report by the Aged Care Quality Agency found.

"Management were not aware of their responsibilities in relation to the reporting of the hospitalisation of care recipients with influenza or respiratory illness within 24 hours and did not comply with these requirements," the agency said.

"On occasions there was no registered nurse on duty and the nurse manager on call was not always available to come in when requested after hours."

"Except for hand hygiene training prior to the outbreak, management could not show broader infection control practices training for all staff."

The report, which was ordered by the Aged Care Minister Ken Wyatt after people started dying during this winter's flu season, found that at the time the outbreak was in full swing, 58 of the nursing home's staff were sick, including cleaning staff.

Agency and casual staff could not keep up with the workload, but, even so, managers only "attended the home for short periods of time on weekends".

"The home's infection control co-ordinator was on planned leave from August 31, 2017 until September 25, 2017".

The "environmental services supervisor," who was in charge of cleaning, also went on leave, which left the home's "leisure and lifestyle co-ordinator," who had no recent infection control training, in charge of the cleaners.

A number of cleaning staff were home sick, and "existing numbers ... were not increased to undertake infectious cleaning processes".

"A final extensive clean did not occur after the initial outbreak was declared over on September 15, 2017," the report said.

The nursing home's board ramped up its response on September 1, instituting a comprehensive review of infection control, clinical care and quality processes. It appointed a working group, hired a nurse advisor, who started work on September 4. It also employed a local infection control specialist.

Nevertheless, the government review failed the nursing home on 13 of the 44 accreditation standards - including clinical care and infection control - which homes must meet to earn federal funding.

The finding contradicts assurances given on September 1 by Victoria's acting chief health officer, Brett Sutton, who said there were "no systemic issues with this facility in terms of infection control". Mr Sutton also said staff were adequately trained.

'A number of failures'

St John's Village's chairman, Bishop John Parkes, who is also the Anglican Bishop of Wangaratta, said the nursing home, which is registered to house 165 residents, had accepted the resignation of its former acting care services manager after the audit.

As a nurse, the former manager had been referred for professional review to the Australian Health Care Practitioners' Authority, Bishop Parkes said.

"The report details a number of failures in terms of duties of that position, so we have done what we must do, this is a mandatory reporting situation and we have reported," he said.

However, Bishop Parkes praised the home's staff for doing an "incredible job under very difficult circumstances".

"We were dealing with the worst flu epidemic in living memory. 370 people died in four states, 120 people in Victoria died in nursing homes and 14,000 Victorians were diagnosed with the flu ... it hit us very hard."

Bishop Parkes said that all of the residents who died had multiple conditions and two were already in palliative care.

"It's terrible that they succumbed, but they were vulnerable people," he said.

The home was now employing more staff, as well as specialist advisers and consultants to analyse the flu response and improve its systems.

"We are very much on the front foot," Bishop Parkes said.

He was confident St John's would pass the next federal audit next month.

In response to influenza outbreaks in Victorian and Tasmanian nursing homes, Health Minister Greg Hunt made it mandatory for aged care facilities to implement flu vaccination programs for staff.

Aged care minister Ken Wyatt said all aged care providers had also been asked to review their infection control practices.

Timeline

• 7 August Two residents and two staff fall sick
• 8 August Two more residents and two more staff show onset of flu symptoms
• 9 August Two more residents and one more staff member succumb
• 10 August By now, 10 residents and seven staff showing symptoms
• 11 August Outbreak reported by management with 16 residents and eight staff sick
• 14 August First swabs for influenza taken. Ten residents and two staff test positive
• 22 August First consistent education on infection control practices given
• 24 August Management first contacts staff to check their symptoms
• 31 August Infection control co-ordinator goes on "planned" leave
• 1 September Nursing home hires a Nurse Advisor and formalises the engagement of an infection control specialist
• 4 September Nurse Advisor begins work at the home
• 15 September Outbreak declared over
• 22 September Outbreak re-opened; three staff and one resident with symptoms
• 25 September Infection control co-ordinator returns from leave; four residents experiencing respiratory illness and eight staff on sick leave