Preparing for new Aged Care Provider Governance requirements

On December 1, 2023, further changes to the Aged Care Act regarding provider governance will come into effect. The changes aim to strengthen the governance and leadership of aged care providers, while increasing the levels of accountability and transparency of aged care governing bodies. The culture and values of a provider are set at the top levels of the organisation, meaning that an effective and strong governance system is integral to the success of the organisation in practice.  

 Broadly speaking, the new requirements align with: 

  • Standards 6, 7, & 8 of the Aged Care Quality Standards; and, for those looking ahead,  
  • Standards 2 & 5 of the Strengthened Aged Care Quality Standards Pilot Draft.

Who has to comply?

Approved providers of residential, home and flexible aged care services must comply with the provider governance requirements, including providers involved in short-term, multi-purpose and transition care. Providers who became approved on or after 1 December 2022 will already be subject to these requirements, and any provider approved prior to this date must ensure compliance from 1 December 2023 

Providers operating under grant agreements such as the Commonwealth Home Support Programme (CHSP) or National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP) are not required to comply with the provider governance changes. However, they should consider whether aspects of these requirements could be implemented in their organisation as best practice governance.  

What are some of the key requirements?

Who’s on the governing body?

There are new requirements about the skills and qualifications of governing body members, designed to ensure that governing bodies have a strong mix of experience and expertise to drive the right culture and governance systems across the whole organisation. The key requirements are: 

  • The right mix of skills, experience and expertise: Providers should appoint board members who can challenge and analyse how the organisation operates, hold management to account, and who have skills and experience that are relevant to the services their organisation provides.  
  • Experience in clinical care: At least one member of the governing body must now have experience in providing clinical care, in order to provide insights and perspectives of their experience. The input they provide will be important guidance in making decisions about the clinical care operations of the organisation. The type of clinical experience required is not specified, as it will differ amongst providers, but it should be relevant to the care and services provided.  For example, if a large proportion of the clinical care provided to older people involves physiotherapy, it would be good practice to have a person with physiotherapy experience as a Board member.
  • Majority of independent non-executives: A majority of the governing body members must now be independent non-executive members. This change is designed to reduce conflicts of interest for those serving on boards, and ensure that decisions are made objectively and in the best interests of care recipients. There is no prescribed definition of “independent non-executive members”, so whether a person is independent or not will be a matter for each organisation to determine. Organisations should consider whether each candidate for Board membership is able to perform their duties independently, without the influence or conflict of any outside or personal interests. Some examples of people who would not be independent would include:
    • Paid staff members of the organisation; and
    • Owners of the organisation, including shareholders and employees of parent or holding companies.

Some providers don’t need to meet the governing body requirements

If a provider is one of the following, they are exempt from these requirements: 

  • Approved providers that are a state, territory or local government authority; 
  • Providers who have fewer than 5 members in their governing body and provide care to fewer than 40 care recipients; and 
  • Approved providers that are Aboriginal Community Controlled Organisations (ACCOs). 

If these circumstances change, the organisation will be required to comply, for example if they begin to provide services to 40 or more care recipients.  

Additionally, providers who cannot meet the governing body requirements may apply to the Commission for a determination, but this should only be attempted after exhausting all possible avenues for meeting the requirements, and is not designed to be a permanent exemption from compliance. In particular, providers in rural or remote areas might face greater difficulties in finding suitable members to serve on their governing bodies, although this is not an automatic justification for exemption. Organisations should use alternative attempts to facilitate compliance, such as online meeting software or networking with other providers in similar situations to find candidates, before making an application.  

Advisory body requirements

The new changes set out various requirements for advisory bodies, specifically a quality care advisory body and a consumer advisory body. Advisory bodies are groups that assist governing bodies by providing advice and information about specific issues. They are separate from the governing body and don’t have the responsibilities of a governing body. 

The quality care advisory body

This advisory body is designed to support the governing body with their decision-making and continuous improvement, by identifying and reporting on any issues of concern relating to the quality of the care provided by the organisation.  

The quality care advisory body must provide a written report to the governing body at least every 6 months, and can also provide feedback at any other time.  The report will be based on the quality care advisory body’s review of a range of performance indicators, including: 

  • Feedback and complaints about the quality of care; 
  • Any regulatory action taken, or performance reports provided, by the Commission; 
  • The organisation’s progress against its continuous improvement plan; 
  • Information about staffing arrangements; 
  • Any reportable incidents; and 
  • Feedback and details about the quality of food provided (for residential aged care providers). 

The governing body must provide a written response to feedback and reports from the quality care advisory body, in which it responds to the issues identified and sets our proposed actions to address those issues. 

Organisations don’t need to create a new body for this purpose if an existing body or group meets all the requirements and performs the same functions. Membership of the quality care advisory body must include:  

  • a member of the organisation’s key personnel (ideally not someone who is on the governing body) who has experience providing aged care;  
  • a staff member who is directly involved in providing aged care or clinical care services; and  
  • a member representing the interests of older people/care recipients (for example, a care recipient, family member, carer or representative).  

It is recommended that the chairperson of the quality care advisory body is independent, and not an executive of the organisation. 

The consumer advisory body

At least once every 12 months, organisations must make a written offer to older people to establish a consumer advisory body, and invite them to join it (or to join an existing consumer advisory body, if one or more already exist).  It is not mandatory to actually have a consumer advisory body, however it is mandatory to make the annual offer in writing to establish one. 

This body provides the governing body feedback, concerns and suggestions from the consumer perspective, highlighting areas of focus that the governing body may otherwise miss, and helping to incorporate the views and wishes of consumers into how services should be designed and improved . Issues, concerns and feedback a consumer advisory body provides must be considered by the governing body in their decision-making and continuous improvement processes, and a written report must be provided to the consumer advisory body explaining how their feedback has been considered. 

Additional provider governance changes

  • Governing bodies need to make sure their staff have appropriate skills, qualifications and experience to fulfil their roles when delivering aged care services, including providing staff withy professional and skill development opportunities; and  
  • Organisations that are a wholly-owned subsidiary of another body corporate (known as a holding company) which is not an approved provider must ensure their constitution requires company directors to act in the best interest of older people rather than prioritising the interests of their holding company. 

Commission resources

The Aged Care Quality and Safety Commission has created several fact sheets on provider governance changes: 

They have also published responses to common questions about the new governing body requirements, which could be a good place to start if you have further questions about how the governing body requirements and determination process work.  

BNG resources

We’ve created 5 new templates and revised some of our existing policy documents to help providers with their new governance requirements: 

  • Template: Consumer Advisory Body Terms of Reference 
  • Template: Invitation to join Consumer Advisory Body 
  • Template: Written response to Consumer Advisory Body Report 
  • Template: Quality Care Advisory Body Terms of Reference 
  • Template: Written response to Quality Care Report 
  • Policy: Provider Governance (Aged Care) 

These new resources join our existing package of provider governance resources that we released in late 2022, which includes: 

  • Policy: Key Personnel 
  • Template: Key Personnel Suitability Checklist 
  • Template: Key Personnel Declaration and Undertaking 
  • Template: Governing Body Requirements Checklist 

We also have a whole range of aged care self-assessment modules in SPP including for: 

  • The current Aged Care Quality Standards 
  • The Strengthened Aged Care Quality Standards Pilot Draft 
  • Clinical Governance 
  • The Aged Care Prudential Standards 
  • The Aged Care Code of Conduct 
  • Provider Governance Reforms 

Ensure you're ready for provider governance reform.

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What makes a good Quality Management system?

Managing and continuously improving quality is the core business of every service provider. Quality management is the action you take to make sure that you always provide the best possible service to your clients. It involves:

  • Evaluating your services to ensure they align with performance indicators contained in relevant standards;
  • Listening to clients, workers and other stakeholders, and valuing their feedback;
  • Understanding what is working well;
  • Identifying where improvements are needed; and
  • Taking action in order to best meet the needs of clients, workers and other stakeholders.

All major sets of Standards require organisations to have effective quality management and continuous improvement systems in place.

The quality improvement process

Quality improvement is not a singular action. It requires a cycle of continuous improvement, in which you are reviewing your systems, services and processes to evaluate whether you are providing the best possible service to each client. 

This cycle is commonly known as the ‘Plan/Do/Check/Act’ cycle and follows four key stages.


The planning stage involves evaluating the current state of your organisation and identifying where improvements can be made. In this phase, you should reflect on how you are delivering the services you are providing, your organisation’s compliance with relevant Standards, and feedback and complaints received to determine areas for improvement. Any incidents and near misses that have occurred should also inform your evaluation. The results of this evaluation should be used to plan ways that your service provision can improve, set goals and identify actions to put the plan into practice.


The next step of the quality improvement cycle is to action your planned changes. This could involve implementing improvements in stages, or testing variations of a planned change to determine the best solution in practice. Relevant stakeholders should be informed of the changes, and what that could mean for them. Adequate resources should be allocated for the purpose of executing the changes successfully, whether that involves extra funding, increased staffing, or more time. It is important that you document the decisions made during this stage, as this data will be used in the next stage of the process.


During the checking stage, you should be analysing both qualitative and quantitative results from the changes, to determine whether they are achieving the expected outcomes and resulting in better services. Feedback from stakeholders should be sought on their experiences with the changes, as well as any comments they have on further improvements. You should consider reflective questions during this stage to aid evaluation, such as:

  • Are the improvements delivering the outcomes as we intended?
  • What were the major gaps in our service delivery from our planning process, and have we addressed these gaps?
  • Are there any unforeseen outcomes from the changes?
  • Are there further improvements we can make, or can we make the process more efficient?


In this part of the cycle you should decide whether or not to implement the changes based on your evaluation. If the evaluation results demonstrate the changes were not successful, you should revert back to the planning stage to repeat the process and determine a new plan that is based on learnings from the unsuccessful trial.

If the results do show improvements meeting or exceeding your established goals, you should implement the changes and incorporate them into your regular service delivery. You should inform all stakeholders of the changes, including the differences between the old and new procedures, and ensure that all workers are trained in the new processes. Make sure you also update your policy and procedure documents where appropriate, to reflect the changes you’ve implemented.

Feedback, Complaints, Incidents and Near Misses

One of the most important ways you can gather information about the services you provide is through the information you receive from stakeholders, including workers, clients and their support people. Efficient and accessible feedback and complaints mechanisms ensure that those who are impacted can easily communicate their opinions and experiences with the service. In particular, if there is a lived experience disconnect between your clients and decision-makers in your organisation (for example services for children or young people), feedback is an important way to broaden perspectives in the quality management process.

In addition, encouraging clients to work in collaboration with your organisation to tailor services to their unique needs allows you to both provide the best possible service to your clients , as well as meet wider standards obligations. The requirements in many sets of standards include partnering with clients and providing culturally competent services for each individual. Meeting these standards requirements is part of consistently providing the best possible service to your clients and ensuring quality care.

So, what does a good quality management system look like?

An effective quality management system underpins your organisation’s approach to service delivery, and provides the framework for how you deliver quality and safe services for each individual.  Quality management should be incorporated as a core facet of the service and be explained clearly in your quality management policies and procedures, as well as policies on related areas.

Your quality management system should:

  • Be founded on core policies and procedures that are communicated and understood across your organisation, so that your approach and processes are transparent to everyone, set clear expectations and responsibilities for workers and the organisation, and are consistently followed;
  • Be supported by other, related policies and procedures covering areas such as:
    • risk management;
    • compliance monitoring;
    • complaints management; and
    • incident reporting
  • Be integrated with your Standards compliance status;
  • Allocate responsibilities to team members for identified improvements; and
  • Be easy to manage, and provide you with up-to-date reports on compliance, improvements identified and how you are tracking towards achieving them.

In conclusion, having a good quality management system is important for organisations to ensure they are providing the best possible services for their clients as well as fulfilling their standards obligations.

Improving your quality management system with SPP

SPP has a wide variety of information sheets and templates available to help you reach your quality management goals, from a template quality improvement register and quality improvement plan to a sample quality management and continuous quality improvement policy. We also have a “Towards Best Practice” self-assessment module on Continuous Improvement.

In addition, we have a range of resources on related topics like risk, complaints, and incidents support the delivery of quality service. 

Need QMS resources?

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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.

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self-assessments in SPP.

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?

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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. 

Clinical governance

The Aged Care Quality Standards and the National Safety and Quality Health Service Standards include requirements for organisations to have a clinical governance framework, as well as policies to address infection control, antimicrobial stewardship and open disclosure processes.

It is a mandatory requirement for all Australian hospitals and day procedure services to be assessed through an independent accreditation process to determine whether they are in compliance with the National Safety and Quality Health Service Standards.

What is clinical governance?

The set of relationships and responsibilities between a health service organisation and its relevant stakeholders to guarantee good outcomes and continuously strive to improve clinical care for clients.

At its core, effective clinical governance fosters a culture within an organisation in which healthcare professionals of all levels routinely question: ‘Am I doing it right? How can I do better?’.

Purpose of clinical governance

The purpose of clinical governance is to ensure that everyone is accountable to clients and the community for delivering good clinical outcomes and meeting clinical indicators. It is an all-encompassing framework, and also includes infection prevention, antimicrobial stewardship and waste management.

Six key components of the Clinical Governance Framework

  1. Governance, leaderships and culture
  2. Partnering with clients
  3. Roles and responsibilities
  4. Client safety and quality improvement systems
  5. Clinical performance and effectiveness
  6. Safe environment for the delivery of care

Policies related to Clinical Governance can be found in the SPP Reading Room:

  • Info Sheet: Clinical Governance
  • Policy: Clinical Governance
  • Policy: Open Disclosure
  • Policy: Infection Prevention and Control
  • Policy: Antimicrobial Stewardship
  • Policy: Waste Management