Royal Commission Series: new governance standard

Over the past few weeks, we have been highlighting a number of the Royal Commission’s recommendations, as well as updating you on resources that can help you implement best practices.

Our focus today is on Recommendation 90: New governance standard.

The Royal Commission’s executive summary of its final report emphasised the need to ensure high standards of governance within aged care providers:

“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.

“Governance arrangements provide for the systems by which an organisation is controlled and operates, and the mechanisms by which the organisation and its people are held to account. They are set by the leaders of an organisation, in particular the board or governing body. They are implemented by executive leaders and workers who report to those executive leaders. They involve everyone in an organisation.”

In the Royal Commission’s view, the existing governance requirements under the Aged Care Quality Standards “do not provide a sufficiently strong basis for the governance and leadership of aged care providers.”

The Commission's recommendations

Recommendation 90 sets out a proposal for more robust governance requirements to be introduced, to drive improvements to the aged care system.  Key components of the recommendation include requirements that providers:

  • Have governing body members who possess the appropriate mix of skills, experience and knowledge of governance responsibilities, to ensure the delivery of safe and high-quality care by the provider;
  • Have a care governance committee, to monitor and ensure accountability for the quality of all care provided;
  • Seek and receive regular feedback from consumers, their representatives and staff, on the quality and safety of the services they deliver, and ways in which the services could be improved;
  • Have an integrated complaints management system, including regular reporting to the governing body about complaints, any patterns, and underlying reasons for the complaints;
  • Have effective risk management practices in place covering care risks and also financial and other organisation risks;
  • Give particular consideration to ensuring continuity of care in the event of default by contractors or subcontractors; and
  • Have a governing body representative provide an annual attestation that the governing body has satisfied itself that the provider has structures, systems and processes in place to deliver safe and high-quality care.

How can BNG help?

SPP’s existing self-assessment for the Aged Care Quality Standards is an excellent way for providers to better understand the core components of a comprehensive approach to governance.

The self-assessment goes well beyond just listing the requirements of the standards.  It guides providers through the core approaches and processes they should implement in order to achieve best practice across their organisation, and in the area of governance it includes detailed, educative, best practice modules covering topics such as:

  • Organisational structure and accountabilities; governing body recruitment, induction and training; and reporting;
  • Clinical governance;
  • Risk management systems;
  • Financial controls and management; and
  • Performance monitoring and evaluation, and quality improvement.

It also includes modules on client and community feedback and complaints.

All of the modules include downloadable resources such as policy templates, to help providers develop their own policies and procedures.

Towards Best Practice: Clinical Governance self-assessment

We also have a separate self-assessment for Clinical Governance, which is based on guidance from the Aged Care Quality and Safety Commission. It addresses clinical governance at a more granular level and details the processes that should be in place for a clinical governance framework. The self-assessment outlines the roles and responsibilities of all individuals involved in care including the governing body, senior executive team, operational manager, the workforce, health practitioners and consumers.


We have many resources which will assist providers to implement a comprehensive approach to governance across their organisation, including a whole resource topic on “Governance and Management”.  You can find this section in the Reading Room under the heading “SPP Resources by Topic”.

You can also search for other resources using the search bar in the Reading Room. A number of our resources address Recommendation 90, including information sheets and policies covering:

  • Client Feedback;
  • Quality Management and Continuous Quality Improvement;
  • Complaints Management; and
  • Risk Management.

While the governance requirements are yet to be formally implemented, your organisation can get ahead by working through our self-assessments and implementing best practice policies and procedures across the organisation.  

To access these resources, and hundreds more, log in to SPP.

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You can access these governance resources and many more in the SPP platform. 

What’s in a best practice complaints management system?

We recently gave a webinar on how to develop and implement a best practice complaints management system, and thought we’d summarise the key points in this short blog post. 

Complaints are a valuable feedback tool!

Receiving complaints can seem like a negative outcome for your service, but on the positive side, it can actually mean that you have a simple and accessible process for people to make complaints. Complaints are a valuable source of feedback on your services, and can help you identify areas in which your organisation can learn and improve.

To facilitate complaints and improve services, your organisation should have in place a complaints management system which:

  • Cultivates a positive complaints culture in the organisation;
  • Encourages and supports all complaints, feedback and suggestions;
  • Integrates person-centred principles (e.g. supporting people to make a complaint, keeping them informed of the process and outcomes, and considering their desired outcome);
  • Facilitates open communication with complainants, and within the organisation;
  • Ensures every complaint is reflected upon to improve what could be done better next time; and
  • Follows the principles of procedural fairness, impartiality and fairness.

The complaints management process

The following steps make up the complaints management process, from developing and documenting a policy and procedures, to investigating and reviewing the handling of a complaint.

  1. Develop, document and communicate the complaints policy and procedures. Make sure stakeholders are involved in the development of the policy, and it is understood by clients, staff and other stakeholders.
  2. Receive the complaint, listen to the complainant, clarify the issue/s and find out their desired outcome.
  3. Acknowledge the complaint and inform the complainant of how you will proceed.
  4. Assess the risk, priority level, and complainant’s desired outcome.
  5. Plan (if required) what information is needed for the investigation and how it will be obtained.
  6. Investigate (if required) the complaint, ensuring it is impartial, confidential and transparent.
  7. Respond to the complaint, explaining how you made the decision, and agree on a response with the complainant.
  8. Follow up with the complainant, see if they are satisfied with the response, and if not, refer them to the relevant external body for further support or investigation.
  9. Keep records in a secure and confidential location, for the specified retention period.
  10. Review data from complaints and analyse how the system could be improved.

Need help with these steps?

To guide your organisation through all of the above steps, we’ve recently updated our suite of complaints-related resources in the Reading Room, with new and updated information sheets, and template policies and registers.

  • Complaint submission form template
  • Complaint process tracking form template
  •  Complaint information sheet for clients template
  • Complaint acknowledgement letter template
  • Complaint response letter template
  • Child safe complaints management policy template
  • Complaints management policy template
  • Complaints register
  • Complaints management information sheet