Moving towards best practice service delivery in aged care

The Aged Care Quality Standards are an important part of an organisation’s quality and compliance benchmarking. However, for providers looking to go beyond their baseline obligations, SPP hosts a number of best practice self-assessments for aged care. These guidelines and standards are designed to complement your ACQS compliance, and provide further guidance across targeted areas of service delivery and governance.

Aged Care – Clinical Governance

The Aged Care Quality and Safety Commission has developed guidance on clinical governance in aged care to assist aged care providers to develop and review their clinical governance framework.

We’ve made digesting that guidance easier for providers.  By working through our Aged Care – Clinical Governance self-assessment module, you can identify key issues that need to be addressed in a clinical governance framework, as well as identify gaps and opportunities for improvement.

Aged Care Diversity Framework

The Aged Care Diversity Framework was developed by the Australian Department of Health and Aged Care. The Aged Care Diversity Framework includes four Diversity Action Plans which are designed to help providers address barriers faced by different groups, being all diverse older people, older Aboriginal and Torres Strait Islander peoples, older CALD people, and LGBTI elders.

We have a self-assessment module for each of the Action Plans, which allows providers to work through three different levels, according to what is most relevant to their organisation: foundational actions, next steps and leading the way.

Inclusive Service Standards

The Inclusive Service Standards were developed by the Centre for Cultural Diversity in Ageing to assist aged care providers in the development and the delivery of inclusive services to all consumers. 

They provide a framework for services to adapt and improve their services and organisational practices so they are welcoming, safe and accessible.

Meeting the performance measures listed in this assessment provides evidence that an organisation has embedded an inclusive, non-discriminatory approach to its delivery of care and services.  

Dementia Australia Quality Care Recommendations

Dementia Australia’s Quality Care Recommendations have been developed by people living with dementia, their families and carers in the context of the new Aged Care Quality Standards. Each of the eight Standards has a dementia-specific recommendation on how that Standard needs to be met when providing any aged care service to a person living with dementia, their families, carers and advocates. 

This module provides organisations with further insight and direction on each of the Aged Care Quality Standards, through the lens of dementia-friendly care.

National Guidelines for Spiritual Care in Aged Care

The National Guidelines for Spiritual Care in Aged Care were developed by Meaningful Ageing Australia, who state:

Spirituality is integral to quality of life and well-being, and should be accessible to all older people in a way that is meaningful to their beliefs, culture and circumstances.

The Guidelines are designed specifically for offering spiritual care and support to older people living in residential aged care, or receiving care and support through home care packages. They are intended to support organisations to embed spirituality into key systems and processes with the goal that all older people (and their loved ones) are offered best-practice in spiritual care.

ACSA Wellness and Reablement Roadmap

The Wellness and Reablement Roadmap was developed by ACSA to help CHSP providers to self-assess their progress in integrating wellness and reablement principles into core service delivery. 

Taking a wellness and reablement approach to service design and delivery enables service providers to focus on outcomes for individuals rather than service outputs.

The Wellness and Reablement Roadmap provides a framework for discussions at all levels within an organisation to help providers identify “what they are doing well” and “what actions need to be taken to improve performance” in progressing, managing and measuring wellness and reablement.

Want to learn more?

Our modules for the standards and guidelines detailed above are available in SPP under the Aged Care – towards best practice drop-down header. They can be accessed and progressed at any time, at your own pace, as relevant to the needs of your organisation. You can automatically generate a quality improvement plan for each specific module you follow.

Access best practice
self-assessments in SPP.

The importance of a director’s work health and safety obligations

Following the death of Anne Marie Smith in 2020, two directors of a disability health service provider have recently been charged with criminal neglect and failure to comply with a health and safety duty of care. This tragic case has put a spotlight on the health and safety obligations of care providers and their directors.


Employers have a number of responsibilities regarding the duty of care they owe employees, visitors and others. SafeWork SA Executive Director, Martyn Campbell, speaking on the matter, said:

“…employers have a duty to provide a safe system of work to their workers, visitors and others who come into the workplace. This included Annie in this case. Her home became a workplace as soon as the carer entered it to do her work.”

It is important for providers to bear in mind the extent of their duty of care. Providers must ensure that where services are being delivered in homes, safe systems of work must still be followed, even though services may be out of the direct line of sight of the provider.


Directors, CEOs and governing body members of an organisation have an additional duty, known as the ‘due diligence’ requirement, to ensure that an organisation has work health and safety systems in place and that those systems are followed. In the case of Anne Marie Smith’s death, it is alleged the company directors failed in this duty.

The ‘due diligence’ requirement originates from section 27 of the model Work Health and Safety Act, which requires that officers of an organisation exercise due diligence to ensure that the organisation complies with work health and safety legislation.

Exercising due diligence involves:

  • acquiring up-to-date knowledge of WHS matters,
  • understanding the nature and risks of the operations of the organisation, and
  • ensuring the organisation uses appropriate resources to minimise WHS risks.

An officer must take an active and inquisitive role in WHS matters to satisfy their duty.

An ‘officer’ includes governing body directors and the secretary, as well as other people who make or take part in decisions which affect the whole organisation. People who sit on a governing body board or a committee on a voluntary basis are still regarded as officers.

The officer duty recognises that officers have corporate governance responsibilities and, through their decisions and behaviour, strongly influence the culture and accountability of the organisation. They can influence important decisions on the resources that will be made available for the purposes of WHS, and the policies that will be developed to support compliance by the organisation with the model Work Health and Safety Act.

How can Standards and Performance Pathways assist?

The officer duty is therefore an important responsibility of board and governing body members. We have developed a new self-assessment module in SPP to help governing body members and other officers ensure they are complying with their responsibilities under section 27 of the WHS Act.

The module guides officers through the key components of section 27(5) of the WHS Act and provides additional examples of ‘reasonable steps’ that may be taken when executing the duty. The module also details the kinds of resources, processes and procedures that officers will need to ensure their organisation has in place.

Review your obligations in SPP.

Policy development and implementation: working towards best practice

Whatever standards apply to the services your organisation delivers, they will require you to implement a core group of policies and procedures that cover both operations and service delivery. They will also require you to ensure that those policies and procedures are understood by all stakeholders, and are consistently followed across your organisation. 

These requirements are not just for the sake of compliance and ‘red tape’.  They are to help your organisation put in place procedures for the consistent delivery of safe, high-quality services for your clients, that are responsive to their individual needs.

So, how can you work towards best practice in policy development and implementation?

What drives new policy development?

The first reference point for policy development should be the regulations and standards that apply to your organisation.  You could create a list of mandatory policies and procedures based on these obligations – or if you use SPP, you will be prompted as you go through your self-assessment journey.

The next stage is identifying any gaps in your organisation’s policies and procedures. Gaps can be identified by undertaking regular detailed compliance checks against relevant standards and guidelines in SPP.

Gaps can also be identified through continuous quality improvement cycles. Feeding into CQI should be:

  • Regular reviews
  • Incidents & near misses
  • Feedback
  • Complaints

Policy development process

The process of good policy development involves:

  1. Issue identification: Awareness of a gap drives policy development – need may be identified through an incident or near-miss, feedback or regulatory requirements.
  2. Policy analysis/context: Determine the context in which a policy should be developed. Why is the policy needed? Who are the stakeholders? What is the targeted outcome?
  3. Consultation: Determine who should take responsibility; research and prepare a draft policy for wider consultation; revise the draft policy based on feedback.
  4. Decision: Present the final draft along with the implementation plan to the Board or management for approval.
  5. Implementation: Allocate appropriate resources to support broad implementation of the policy; ensure it is understood and consistently followed.
  6. Communication and promotion: Promote the policy broadly and regularly.  Make the policy available in different formats and languages (for accessibility).
  7. Review and evaluation: Review and update the policy regularly, usually annually. It is good practice to include review dates in a board governance calendar, as well as in the policy itself.

Policy contents

Organisational policies will vary depending on topic matter and purpose, but should be comprehensive, and should generally contain the following sections:

  1. Rationale or purpose statement:  Reason for issuing the policy and the desired effect or outcome.
  2. Scope or coverage statement: State who is covered and affected by the policy, and who may be exempt.
  3. Date: State when the policy comes into force.
  4. Definitions: Include clear and unambiguous definitions for terms and concepts in the
  5. Responsibilities: State who is responsible for carrying out individual policy statements.
  6. Policy statement/s: Specific regulations, requirements or modifications to organisational
  7. Procedures: Policies and procedures may be separate documents, however if you are drafting an operational policy, it should detail set procedures to be followed.
  8. Date of review:  Specify date set for review and frequency of reviews.

Organisational policy development: key considerations

Best practice approaches to developing and implementing policies include:

  • Accessibility: Ensuring policies are made widely available and in accessible formats.
  • Clarity: Ensuring policies are written in a clear, concise manner using plain English.
  • Accountability: Policies and procedures should set out who is accountable for implementing the procedures, and also accountability for updating/maintaining the currency of the policy.

Implementation: introducing policies to staff and implementing them across your organisation

Finalising a set of policies and procedures that govern how your organisation operates and delivers services is one thing – but implementation is even more important.  That is, ensuring that all workers understand and follow them consistently, and that your clients also understand them where relevant.

Boards play an important role, and should take ownership in promoting policies and ensuring that staff are aware of them.

Policies should be published somewhere accessible, e.g. staff intranet – and in a form that can be understood by the audience. Consider: do you have workers who speak English as a second language?

However, publishing is not enough. Implementation should include:

  • Onboarding and orientation for new staff, that includes briefing on organisational policies.
  • Refresher training for staff on organisational policies.
  • Keeping track of whether staff have read policies – this could be via a staff training register or a list of key documents that staff must read and sign.
  • Ensure that all current policies are centrally accessible, and updated policies are re-distributed to staff/stakeholders.
  • Hold a drill or run-through of procedures that involve staff/stakeholders.

What areas and requests are most popular?

We provide hundreds of policy templates and resources to our SPP subscribers. We develop new ones as regulatory requirements change, and also in response to popular requests. Here are some of the key areas community and health service providers are focused on currently:


  • Good governance is a cornerstone of a successful and productive organisation.
  • SPP hosts a broad suite of resources on governance and management to help organisations establish and maintain best practice leadership processes, including the Governing body meeting template and Governance and management good practice info sheet.

Easy English

  • A consistent theme throughout many standards is that information must be provided to clients in the language, mode of communication and terms that the client is most likely to understand.
  • In response to requests from providers, we’ve developed easy English policies on incidents, child rights, client rights, complaints and privacy.

Emergency and disaster management

  • We’ve recently released a selection of new and updated resources in response to an increased focus on emergency and disaster management across a number of Australian health and service standards.

Child safety

  • Any organisation providing services to, or interacting with, children should have child safe policies and procedures in place that are consistent with the National Principles for Child Safe Organisations (and state Child Safe Standards, if in NSW or VIC).

How can Standards and Performance Pathways assist?

  • Gap analysis: SPP performs an automatic gap analysis, generating ‘Action Texts’ for providers to address, where they are not meeting a requirement.
  • Linked resources and templates: Access policy templates and resources throughout the self-assessment journey, relevant to gaps in compliance.
  • Sector updates and new resource alerts: PDF updates available within the platform keep organisations informed of relevant updates.

For a summary of this blog post, click here to access our ‘Best Practice in Organisational Policy Development’ slide deck.


Seeking further guidance on policy design and implementation?

2021 – that’s a wrap!

It has certainly been a busy year for service providers and compliance professionals in our sector. Providers have been truly tested by the challenges of the pandemic and a changing regulatory landscape. We invite you to reflect with us on the key developments of this past year.

Child safety

In the child safety space, progress has been underway over the last couple of years to implement the recommendations of the Royal Commission into Institutional Responses to Child Sexual Abuse. We published a blog post on this topic in March of this year.

On 1 July 2021, the new Victorian Child Safe Standards were released, bringing these standards into alignment with the National Principles for Child Safe Organisations. Our mapped self-assessment for the Victorian Child Safe Standards is available on SPP.

NSW followed in a similar vein and in November 2021, legislation passed in NSW Parliament mandating compliance with the NSW Child Safe Standards by certain ‘child safe organisations’. The NSW Child Safe Standards, which also map to the National Principles, can be accessed in SPP.

At present, Australian Catholic Safeguarding Ltd is finalising the Second Edition of the National Catholic Safeguarding Standards, and we expect to be providing assessment modules of these standards early in the New Year.

Aged care

The Royal Commission into Aged Care Quality and Safety was the focal point for aged care this year, with some regulatory changes already implemented and others underway.

The Serious Incident Response Scheme (SIRS) brought in new compliance requirements for residential aged care providers in April. Our Incident Management Procedures (Aged Care SIRS) Policy can help get you up to speed on this. In correlation with SIRS, the Aged Care Quality Standards were updated to include a requirement on incident management, and our ACQS self-assessments have been updated accordingly.

Rules around use of restrictive practices changed, with shift in terminology from ‘restraints’ to ‘restrictive practices’, bringing aged care into alignment with disability regulation. Our updated Use of Restrictive Practices (Aged Care) Policy reflects this.

This year we released an educative version of the Aged Care Quality Standards on SPP, based on the Commission’s Guidance and Resources for Providers document, and which walks providers through their requirements in greater depth. We have also released the Board Governance Toolkit, a comprehensive suite of resources designed specifically to support board members to fulfil their responsibilities under the Aged Care Quality Standards.


In late 2021, the NDIS Practice Standards saw their biggest overhaul since their inception. The NDIS Quality and Safeguards Commission identified emergency and disaster management and mealtime management/swallowing problems as key focal areas for additional guidance and regulation, and brought in three new Practice Standards to reflect this. In addition, a number of Quality Indicators were added and amended, reflecting a focus on infection control, staff training, individualised risk assessments and insurance requirements. Our blog post will flesh this out for you.

All changes to the NDIS Practice Standards are available for completion in SPP, and you can choose from mapped or stand-alone modules, depending on your organisation’s needs.

Health care

The National Safety and Quality Healthcare Service Standards (Second edition) were updated in 2021, to include new requirements around infection control. We added two new modules to our NSQHS self-assessment on SPP to address the new Standard 3 – Preventing and Controlling Infections.

The Australian Commission on Safety and Quality in Health Care has also begun releasing a number of new standards, aiming to ensure a consistent approach to safe and high-quality health care across different service environments. In 2021, we added self-assessment modules for the National Safety and Quality Digital Mental Health Standards and the National Safety and Quality Primary and Community Healthcare Standards to SPP, and we will be closely tracking the development of the National Safety and Quality Mental Health Standards for Community Managed Organisations.

During 2021 we also released three new modules for the RACGP Standards for general practices (5th edition). We worked closely together with the RACGP to ensure that all of the standards, criteria and indicators in each module are reflected in detail in SPP’s self-assessments.


ISO standards are popular accreditations amongst our users, and this year we were pleased to add ISO 27001 Information Security Management Systems to SPP. ISO 27001 is an internationally recognised standard that requires organisations to implement an Information Security Management System (ISMS). The Australian federal government requires ISO 27001 certification for all providers of employment skills training and disability employment services, and a number of health and community service providers also choose to follow this standard.

All the best for the holiday period!

The past 12 months have definitely been jam-packed, and we expect 2022 will be just as busy.

We thank you all for your continued collaboration, and from everyone in the BNG team, we wish you a safe and happy holiday season.

See you next year!

Need to get on top of your compliance work?

Access a broad selection of Standards in SPP.

The new National Safety and Quality Primary and Community Healthcare Standards

The Australian Commission on Quality and Safety in Healthcare (the Commission) has recently published a new set of standards, the National Safety and Quality Primary and Community Healthcare Standards (the PCH Standards). These are a nationally consistent, consumer-centred set of safety and quality standards.

Who are these standards for and what do you need to know? Read on to find out more.

Who should follow the Primary and Community Healthcare Standards?

The Commission will be encouraging all Australian primary and community healthcare services that are directly involved in patient care to implement the PCH Standards.

The PCH Standards are applicable to services that deliver health care in a primary and/or community setting. These services address the prevention, treatment and management of illness and injury, and the preservation of physical and mental wellbeing. This includes health providers like dentists, physiotherapists, podiatrists, speech pathologists and other allied health providers.

What do the Primary and Community Standards require?

There are three Primary and Community Healthcare Standards that cover clinical governance, partnering with consumers and clinical safety.

  • Clinical Governance Standard, where clinical governance is the set of relationships and responsibilities established by a health service to ensure good clinical outcomes. It ensures that the community and healthcare services can be confident that systems are in place to deliver safe and high-quality health care, and continuously improve services.
  • Partnering with Consumers Standard, which describes the systems and strategies to create a person-centred healthcare service in which patients and consumers are:
    • Included in shared decision-making
    • Partners in their own health care
    • Involved in the development and design of quality healthcare services.
  • Clinical Safety Standard, which considers specific high-risk areas of health care commonly encountered that need to be addressed and mitigated.

Are the Primary and Community Healthcare Standards mandatory?

The PCH Standards are voluntary. They should only be applied where services are involved in the direct care of patients.

However, in some cases, accreditation against the Standards may be required by a funder of a healthcare service to satisfy regulatory or contractual obligations.

How do these standards fit in with other safety and quality standards developed by the Commission?

The Commission has developed a range of safety and quality standards, including:

  • National Safety and Quality Health Service Standards
  • National Safety and Quality Digital Mental Health Standards
  • National Safety and Quality Mental Health Standards for Community Managed Organisations (in development)

All safety and quality standards developed by the Commission are aligned in structure and intent, and focus on embedding clinical governance and consumer partnerships in safe, high-quality healthcare services.

If no standard is mandated, then a healthcare service may choose to implement the standard that is most applicable to their service context.

Primary and community services can be subject to multiple sets of standards.  The Commission intends that the PCH Standards “are used as the core safety and quality component of each set of standards, thus minimising the compliance burden across multiple sets of standards”.

Can I transition from NSQHS to the Primary and Community Healthcare Standards?

If a service is currently accredited to NSQHS on a voluntary basis, it can transition to the PCH Standards once accreditation becomes available, at time of reaccreditation.

If a service is accredited to NSQHS as part of regulatory or contractual requirements, for example, a Local Health Network, you will need to check with your regulator and/or funder.

How can I get accredited for the Primary and Community Healthcare Standards?

The Commission is developing an assessment model for healthcare services to become accredited under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme. It is anticipated that accreditation will become available from mid-2022.

In advance of formal accreditation, a self-assessment module for the Standards is already available on SPP. Our self-assessment module is an excellent way to familiarise yourself with, and work your way through the requirements of, the PCH Standards. The self-assessment also includes links throughout to a number of relevant resources and templates.

Further information

You can access more information from the Commission about the National Safety and Quality Primary and Community Healthcare Standards here.

Interested in the PCH Standards?

Access self-assessments for the Primary and Community Healthcare Standards on SPP.

The new NDIS Practice Standards are here! What now?

We have been waiting on the release of an update to the NDIS Practice Standards for a little while now, and as of November 2021 the NDIS Commission has provided details of key amendments. Read on to get our rundown on all the changes.

What are the key changes?

The most significant change brought in by these amendments is the introduction of the following three new NDIS Practice Standards:

In Core Module Standard 2 (Governance and Operational Management):

  • Emergency and disaster management – This standard addresses the planning required by providers to prepare, prevent, manage and respond to emergency and disaster situations whilst mitigating risks to, and ensuring continuity of, supports that are critical to the health, safety and wellbeing of participants. Note that this practice standard specifically highlights the responsibilities of a provider’s governing body in this area.

In Core Module Standard 4 (Support Provision Environment):

  • Mealtime management – This practice standard applies to providers of supports to participants who require assistance to manage their mealtimes, including those with mild dysphagia. The standard deals with the nutritional value and texture of meals, and concerns the planning, preparation and delivery of meals. The standard aims to ensure quality and safety of mealtime management. 

In Module 1: High Intensity Daily Personal Activities

  • Severe dysphagia management – This practice standard applies to providers registered to provide high intensity daily personal activities and who have severe dysphagia management set out in their certificate of registration. Providers will be required to ensure that participants with severe dysphagia receive support that is relevant and appropriate to their specific needs and circumstances.

Quite a number of other new and amended Quality Indicators

There are also a number of new and amended Quality Indicators throughout the Practice Standards. Providers should familiarise themselves with all of these changes as soon as possible.

Many of the new or amended indicators relate to emergency and disaster management, including infection outbreaks, and the associated necessary worker training and capabilities.  However, there are also other amendments in areas such as:

  • the consideration of preventative health measures in planning supports, where relevant; and
  • more prescriptive requirements in relation to participant risk assessments, and their regular review.

The new and amended Quality Indicators appear in the following Practice Standards:

Core Module

Standard 2: 
  • Risk Management
  • Human Resource Management
  • Continuity of Supports
Standard 3: 
  • Support Planning
  • Service Agreements with Participants
  • Responsive Support Provision
  • Transitions to or from a provider (Previously Transitions to or from the provider)
Standard 4:
  • Safe Environment
  • Management of Waste

Module 3: Early Childhood Supports

  • The Child

Verification Module

  • Human Resource Management
  • Risk Management

When do the changes come into effect?

  • 15 November 2021: for registered NDIS providers, the new severe dysphagia management practice standard, together with all of the new and amended quality indicators we’ve mentioned above, are applicable from this date.
  • 13 December 2021: the mealtime management practice standard is subject to a transition period and comes into effect from this date. 
  • 24 January 2022: the emergency and disaster management practice standard is subject to a transition period and comes into effect from this date. 

Updated and new SPP self-assessments will be available shortly!

We’ve been working hard to update our SPP self-assessments for the NDIS Practice Standards as soon as possible, to help you get on top of the new requirements and streamline your compliance work.

We expect to be releasing updated self-assessments within the next couple of weeks.

We will also be making available a new “educative” self-assessment for the NDIS Practice Standards, as well as a new module to help board and governing body members better understand their responsibilities under the Practice Standards, and hopefully enhance their engagement with management.

So watch this space!

Further information

An updated version of the NDIS Practice Standards has been published here.

If you would also like to read the legislative amendments in full, you can access those here and here.

Want to manage NDIS compliance simply?

Access self-assessments for the NDIS Practice Standards on the NDS Quality Portal.

Changes to child safe legislation in NSW: what you need to know

The Children’s Guardian Amendment (Child Safe Scheme) Bill 2021 has just been passed in NSW Parliament. This new Bill amends the Children’s Guardian Act to embed the NSW Child Safe Standards as the primary framework guiding child safe practices in NSW.

The requirements for specified ‘child safe organisations’ outlined in this blog post will become mandatory from 1 February 2022. 

This Bill is an amendment of an earlier Exposure Draft, released in 2020. A breakdown of the key changes from the the original Exposure Draft, can be found in the Consultation Summary.

Who is a child safe organisation?

So, who is a child safe organisation for the purposes of this legislation? Well, this new Bill features an updated definition of child safe organisation‘, which now covers the following: 

  • entities mentioned in Schedule 1 of the Children’s Guardian Act (excluding designated agencies and adoption service providers),
  • religious bodies that provide services to children, or in which adults have contact with children,
  • local government authorities, and
  • clubs or other bodies providing recreational or sporting programs or services to children, and in which workers are required to hold a working with children check clearance.
Notably, religious bodies and sport and recreation organisations are new groups on this list. The Office of the Children’s Guardian (OCG) has acknowledged that there are still some organisations who work with children who are not included in this list. While some organisations are not currently in scope, the Child Safe Standards can be implemented by all child-related organisations and will remain voluntary for organisations outside scope.

It’s important to note that designated agencies and statutory out-of-home care and/or adoption services have been specifically excluded from the Child Safe Scheme. This is because they are already subject to regulation by the OCG under the Child Safe Standards for Permanent Care (currently under review).

Special responsibilities and liabilities are held by the ‘head of a child safe organisation’. The Bill defines ‘head of a child safe organisation’ as:

  • the person or class of persons prescribed by the regulations, if the regulations prescribe such a person,


  • the chief executive officer of the organisation, however described,
  • if there is no chief executive officer—the principal officer of the organisation, however described, or
  • if there is no chief executive officer or principal officer—a person who has been nominated by the organisation and approved by the Children’s Guardian under the Children’s Guardian Act (s66).

What do child safe organisations have to do?

The ‘head of a child safe organisation’ must implement the Child Safe Standards through systems, policies and processes including the following:

  • a statement of the organisation’s commitment to child safety,
  • a child safe policy,
  • a code of conduct that applies to employees, management, contractors and volunteers,
  • a complaint management policy and procedure,
  • a human resources policy, and
  • a risk management plan.

The head of a child safe organisation must ensure the organisation implements a reportable conduct policy.

Additionally, the head of a child safe organisation is responsible for ensuring systems, policies and processes are continuously reviewed and updated to reflect any changes to the Child Safe Standards.

It is clear that organisations must be aware of who their ‘head’ is, as responsibility for implementation and monitoring of the Child Safe Standards lies with them. 

Monitoring and investigation

The Bill provides the Children’s Guardian with powers to monitor the implementation of the Child Safe Standards. The Children’s Guardian may monitor any child safe organisation through the following measures:

  • review the organisation’s systems, processes and policies,
  • review information held by the Children’s Guardian about the organisation and its employees,
  • with the consent of the head of the organisation, have an authorised person inspect the organisation’s premises, and
  • direct the head of the organisation to complete a self-assessment of the organisation’s compliance with the Child Safe Standards (a mandatory direction).

The Children’s Guardian may, at any time (by written notice) require the head of a child safe organisation to provide information about the organisation’s systems, policies and processes.

If the organisation does not provide the requested information, the Children’s Guardian may commence an investigation , and publish the organisation’s details on the Office of the Children’s Guardian’s website.

The Bill also provides the Children’s Guardian with powers for the investigation of complaints and concerns about a child safe organisation’s implementation of the Child Safe Standards. The Children’s Guardian may commence an investigation if:

  • a complaint is received about an organisation,
  • the organisation fails to respond to a recommendation made by the Children’s Guardian in a monitoring assessment report, or
  • for any other reason, the Children’s Guardian is concerned the organisation is not implementing the Child Safe Standards.

When conducting an investigation, the Children’s Guardian may follow any of the same steps as described earlier in relation to monitoring. It may also conduct an inquiry.

At the end of an investigation, the Children’s Guardian will prepare a report for the organisations, which will include recommendations for improvements, and may include enforcement measures.

How will the Child Safe Standards be enforced?

The Bill provides for enforcement measures, which allow the Children’s Guardian to issue compliance notices and to enter into enforceable undertakings with child safe organisations.

A compliance notice will be in writing and will include:

  • reasons for the belief the organisation is not implementing the Child Safe Standards,
  • risks to children that arise as result of the non-compliance,
  • the action the organisation is required to take,
  • the period of time within which action must be taken, and
  • a statement that failure to comply with the notice is an offence.

There are also provisions for organisations to request an internal review or extension of time in relation to a compliance notice.

A list of compliance notices currently in effect will be made available on the OCG’s website.

There are penalties associated with failure to comply with a compliance notice – 250 penalty units for a corporation, and 50 penalty units for others.

Instead of issuing a compliance notice, the Children’s Guardian may accept an enforceable undertaking from a child safe organisation, which is an undertaking from the organisation under which the organisation agrees to take specific action by a specific date. A list of enforceable undertakings that are in effect will also be made available on the OCG’s website.

The OCG has expressed its intention to use a ‘light touch’ in its approach to regulation, focusing on education and building on organisations’ existing strengths. However, these enforcement measures will be exercised in some cases, where necessary to ensure the safety, welfare and wellbeing of children. 

Capability building

The Bill sets out the Children Guardian’s responsibility to work collaboratively with child safe organisations to build capacity for child safe practice.

These provisions indicate that the Children’s Guardian may develop further guidelines to assist organisations and the broader community to implement the Child Safe Standards. If any such guidelines are developed, they will be published on the OCG’s website, and may include templates that can be used by child safe organisations.

The Bill specifies that the Children’s Guardian may provide training on the implementation of the Child Safe Standards, and that it may charge fees to cover any reasonable costs of the training.

Additional changes

The Bill includes a requirement for prescribed agencies to develop a ‘child safe action plan’. This requirement will not apply to community-based organisations in NSW, as it is limited to significant public sector departments, offices and agencies.

The Bill also includes an information sharing provision, which allows the Children’s Guardian to share information with other States/Territories or the Commonwealth, where a matter has relevance to another jurisdiction.

Access the Child Safe Standards on SPP

Sign up for a free trial now to self-assess against the NSW Child Safe Standards in the SPP platform. 

Is your aged care board equipped to govern successfully?

Quality services arise from good leadership. As an aged care provider, your governing body plays an integral role in promoting a culture of safe, inclusive and quality care and services, and overseeing your organisation’s operations.


Under the Aged Care Quality Standards, the governing body is accountable for the delivery of safe and high quality care and services to all consumers in the organisation’s care. 

Each member of the governing body must be satisfied that the organisation has in place the culture, strategies, policies, practices and behaviours to ensure delivery of care and services to that standard.

Challenges for non-executives

But boards are usually (and should be!) composed of non-executive directors, who very often will be fulfilling their role on a voluntary basis.  On any one board there may be directors with varying levels of knowledge about the specific requirements of the Aged Care Quality Standards.  Directors may be located remotely from the provider and, especially over the last 18 months with COVID, opportunities for face to face on site meetings has been extremely limited.

And yet, individually, each director shares the responsibility to oversee that their provider delivers safe, quality and compliant care.

Problems highlighted by the Royal Commission

The importance of strong governance in aged care was a central finding of the recent Royal Commission into Aged Care Quality and Safety. In their Final Report, Commissioners Pagone and Briggs were blunt in their assessment of the failures of some aged care providers’ governing bodies:

“Provider governance and management directly impact on all aspects of aged care. Deficiencies in the governance and leadership of some approved providers have resulted in shortfalls in the quality and safety of care. Some boards and governing bodies lack professional knowledge about the delivery of aged care, including clinical expertise. There is a risk that they may focus on financial risks and performance, without a commensurate focus on the quality and safety of care.”

The Commissioners spoke unambiguously of the duty held by governing body members:

“Accountability begins and ends with the leaders of an organisation, the board and senior management. If boards and governing bodies do not have the knowledge or skills to understand the care that is being delivered, they are unable to ensure that this care is high quality and safe. The values and behaviour of people in these senior positions have a significant impact on workplace culture and the quality of care that is delivered.”

It is clear that scrutiny of aged care provider governing bodies will be a focus of the Aged Care Quality and Safety Commission – now and into the future. Already, government has begun legislating for greater accountability and responsibilities for governing bodies, with the recent Aged Care and Other Legislation Amendment (Royal Commission Response No. 2) Bill 2021 signalling strengthened governance arrangements from March 2022.

Now, more than ever, providers must ensure that their governing bodies are highly informed, involved, and are advocates for quality and safety in the aged care sector.

Our solution: the Board Governance Toolkit

In response to the findings of the Royal Commission, and requests from our customers, we have developed the Board Governance Toolkit.

Our new Board Governance Toolkit addresses all of the requirements in the Aged Care Quality Standards for oversight of the organisation’s provision of quality and safe care and services, and oversight of management and staff.

For each requirement, we ask a series of questions that walk directors through the necessary avenues of enquiry, so that they understand their obligations and are guided to ask the right questions and receive the correct and relevant information from management. Directors also have the opportunity to comment on how their organisation is meeting that requirement, or how it could improve.

Our Toolkit helps each individual board member to:

  • Understand their ACQS responsibilities
  • Record their assessment of organisational performance
  • Engage effectively with senior management
  • Identify gaps and areas for improvement
  • Regularly review progress and update priorities

Our Toolkit facilitates regular review and continuous quality improvement.  As part of regular quality improvement processes, governing body members should revisit the Toolkit and update their comments, for review and discussion at board level on a regular basis.

Click here to view our Board Governance Toolkit flyer.

Seeking guidance for your board?

Access the Board Governance Toolkit on SPP.

New key standards for the digital mental health space

The National Safety and Quality Digital Mental Health (NSQDMH) Standards were released in November 2020, and are the first of their kind. Developed by the Australian Commission on Safety and Quality in Health Care in consultation with consumers, service providers, academics, regulators and technical experts, the NSQDMH Standards aim to improve the quality of digital mental health service provision, and protect service users and their support people from harm.

What is a digital mental health service?

In the current context of the COVID-19 pandemic, coupled with the rapid evolution of digital technologies, telehealth services are being used more widely than ever before. As the take-up of these digital services increases, it makes sense to improve the regulation of the digital health service provision space.

So what does a digital mental health service look like?

The NSQDMH Standards define digital mental health as a mental health, suicide prevention or alcohol and other drug (AOD) service that uses technology to facilitate engagement and deliver care. Traditionally mental health, suicide prevention and AOD were considered distinct sectors, however the NSQDMH Standards refer to these digital services collectively.

Digital mental health services include:

  • Services that provide information
  • Digital counselling services
  • Treatment services (including assessment, triage and referral services)
  • Peer-to-peer support services

Digital mental health services may be delivered by:

  • Telephone (including mobile phone)
  • Videoconferences
  • Online services (such as web chats)
  • SMS
  • Mobile health applications (apps)

What are the National Safety and Quality Digital Mental Health Standards?

The three NSQDMH Standards are:

  • Clinical and Technical Governance Standard
  • Partnering with Consumers Standard
  • Model of Care Standard

The three standards include 59 actions related to clinical and technical aspects of digital mental health services. They describe the level of care and the safeguards that a digital mental health service should provide.

The NSQDMH Standards create a nationally consistent quality assurance mechanism for digital mental health service providers. Providers can assess areas of compliance as well as areas for improvement, with respect to their safety and quality assurance systems.

The standards are modelled on the National Safety and Quality Health Service Standards (NSQHS). Providers who already meet NSQHS are only required to implement actions specific to the NSQDMH Standards, which are relevant to their service.

Implementation of the NSQDMH Standards is currently voluntary. Self-assessing against the standards is an excellent way for service providers to demonstrate best practice in this space.

To assist providers to learn more about these standards and measure themselves against them, we are pleased to offer a self-assessment for the NSQDMH Standards on SPP. Our self-assessment consists of quizzes for each action across the three standards, as well Evidence Guides and linked resources to accompany each quiz.

You can find the self-assessment for the National Safety and Quality Digital Mental Health Standards in SPP under the Standards tab > Australian National Standards.

Want to learn more?

Self- assess against the National Safety and Quality Digital Mental Health Standards on SPP.