Provider governance responsibilities

On this page:

About the responsibilities
Membership of governing bodies
Quality care advisory body
Consumer advisory bodies
Suitability of key personnel
Notifying the Commission of certain matters
Staff qualifications, skills, and experience
Constitution
More information

About the responsibilities

Effective governing bodies lead and set the culture of an organisation to ensure older Australians get the highest quality aged care. 

These responsibilities address key recommendations from the Royal Commission into Aged Care Quality and Safety.

They align with – and extend beyond - Standards 1, 6, 7 and 8 of the Aged Care Quality Standards. They apply to approved providers of residential, home and flexible care including:

short-term restorative care
multi-purpose services transition care.

All approved providers must:

make sure their governing body has a majority of independent non-executive members and at least one member with experience in providing clinical care
set up and maintain a quality care advisory body
offer to set up a consumer advisory body annually
assess the suitability of key personnel at least once a year
notify the Commission of certain matters including key personnel notifications, within 14 days
ensure their staff have the appropriate qualifications, skills and experience.
prioritise older Australians (not the holding company) if the organisation is a wholly owned subsidiary
submit their completed annual Provider Operations Report to the Department of Health and Aged Care by 31 October each year.

The responsibilities don't apply if the provider operates under a grant agreement for:

the Commonwealth Home Support Programme
the National Aboriginal and Torres Strait Islander Flexible Aged Care Program.

The Governing for Reform in Aged Care Program is now open to anyone working in the aged care sector who is interested in strengthening their governance and leadership skills. It is free for staff and governing body members of approved aged care providers.

Download our provider governance checklist to ensure you allocate time, at least annually, to review the procedures you have in pace to ensure you are meeting your obligations.

Legislation

Membership of governing bodies

Your governing body plays a critical role in delivering the best possible aged care.

Residential, home and flexible aged care providers must ensure their governing body:

has a majority of independent non-executive members
includes at least one member with experience in providing clinical care.

This Regulatory Bulletin explains the purpose of these requirements and how we regulate compliance.

We recognise that it can be challenging for providers operating aged care services in a rural or remote area to attract and retain skilled governing body members, especially people with clinical care experience.

In these situations, you should consider:

using technology to engage members from neighbouring towns or medical practices remotely
working with other approved providers facing similar circumstances. Providers may be able to work together to find a solution that is mutually beneficial
seeking expressions of interest including through local organisations and professional bodies.

If you have explored and tested all available options without success, you can apply for a determination that one or both requirements don't apply.

The following aren't required to meet the governing body requirements:

state or territory-approved providers (including a state or territory or local government authorities)
providers with a governing body of fewer than 5 members and who provide care to fewer than 40 recipients
approved Aboriginal Community Controlled Organisations.

Further information:

Quality care advisory body

You must establish a quality care advisory body to support your governing body.

Members should have the right skills and experience to identify issues, solve problems and improve services.

You can decide how to appoint members and how the body will operate to meet your obligations.

A quality care advisory body must include:

key personnel with experience providing aged care
a staff member directly involved in the delivery of aged care, or a staff member directly involved in the delivery of clinical care (only required if your organisation provides clinical care)
a member who represents the interests of consumers, for example, a care recipient or representative, advocate, or consumer advisory body member.

Further information:

Quality care advisory body fact sheet

Consumer advisory bodies

Consumer advisory bodies provide valuable feedback to your governing body on the quality of care and services they receive. They help build a person-centred culture committed to high-quality aged care.

You can establish multiple consumer advisory bodies according to user interests and organisational needs.

Even if a consumer advisory body or bodies already exists, you must formally offer care recipients the opportunity to review or improve advisory body arrangements at least once every 12 months. This makes sure evolving needs and service changes are considered and addressed at least annually.

Watch this video to hear from Maggie, Jo and Jan from Queen Victoria Care in Tasmania. They talk about their experiences partnering with their governing body in the design of their care.

Transcript for 'Queen Victoria Care Residential Advisory Committee experiences'

Consumer advisory bodies must:

include care recipients and their representatives. Ideally, the body should include mostly current care recipients and their representatives.
reflect the diverse backgrounds of care recipients and support those who face participation barriers
have opportunities to give feedback to the governing body on the quality of aged care provided
represent the different services and care types offered.

Further information:

Suitability of key personnel

Key personnel are the foundation of quality care and services. That's why it's essential to assess the ongoing suitability of your staff at least once every 12 months.

Key personnel as defined in section 8B of the Aged Care Quality and Safety Commission Act 2018 includes individuals who:

are responsible for the executive decisions
have authority or responsibility for, or significant influence over, planning, directing, or controlling a provider’s activities
are responsible for the nursing services provided by the aged care service and hold a recognised qualification in nursing, or
are responsible for the day-to-day operations of the aged care service.

Further information:

Notifying the Commission of certain matters

You must inform us of certain changes or events that affect your suitability to continue as an approved provider. You also need to let us know about changes to your key personnel and their suitability.

You must notify us within 14 days about:

changes affecting your suitability as a provider
people who become or stop being key personnel
changes relating to the suitability of any key personnel

Key personnel in corporate organisations must also notify providers regarding changes to their suitability within 14 days of the change.

Further information:

Staff qualifications, skills, and experience

As highlighted by the Royal Commission into Aged Care and Quality, investing in staff development improves performance, commitment and retention. This benefits providers and people receiving aged care.

Your governing body must ensure staff members have the necessary skills, qualifications and experience to perform their duties. Staff should also have access to and receive development opportunities that enhance capability and support professional growth.

These requirements do not apply to:

state or territory-approved providers (including a state or territory or local government authorities)
providers with a governing body of fewer than 5 members and who provide care to fewer than 40 recipients
approved Aboriginal Community Controlled Organisations

Further information:

Staff qualifications fact sheet

Constitution

This requirement only applies to a limited number of providers, as specified below.

A constitution is a legally binding set of rules that govern organisational operations. It outlines the responsibilities and powers of directors, the governing body, management and members. It also describes the primary services and objectives of the provider.

An approved provider may sometimes be a wholly owned subsidiary owned by another corporate entity (a 'holding company').

The company's constitution must require directors to act in the best interests of care recipients. This is applicable if your service is a wholly owned subsidiary of another body corporate that is not the approved provider.

This requirement does not apply to:

state or territory-approved providers or authorities
local government authorities
approved Aboriginal Community Controlled Organisations

Provider operations reporting

You must submit information on your operations to the Department of Health and Aged Care annually.

Information regarding your organisation's services will be published on the My Aged Care website. This helps older Australians make informed decisions about their care.

The reporting period runs from 1 July to 30 June each year. Reports must be submitted, along with a signed statement of compliance, to the Department of Health and Aged Care by 31 October.