Provider governance

About the responsibilities

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

Recent amendments to The Aged Care Act 1997 and the Aged Care Quality and Safety Commission Act 2018 have strengthened the governance arrangements of approved providers. These changes are specifically aimed at:

improving leadership and culture
increasing transparency and accountability.

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

They align with (and are in addition to) the organisational requirements in 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 and transition care.

All approved providers must:

ensure 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 continue a quality care advisory body
annually offer to set up a consumer advisory body
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 following programs:

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

We issued a regulatory bulletin on Strengthening provider governance responsibilities –body requirements to support providers in meeting the new requirements. It discusses the responsibilities for approved providers concerning their governing body. It also explains how we will regulate these responsibilities.

Our Governing for Reform in Aged Care Program empowers aged care leaders to stay ahead of these reforms and best practices.

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.

Membership of governing bodies

Your governing body is vital to the delivery of 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 and
at least one member with experience in providing clinical care.

This Regulatory Bulletin discusses the strengthened provider governance responsibilities regarding the membership of governing bodies. It explains the purpose of this reform and how we’ll regulate this change.

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:

how technology could be used to engage members from neighbouring towns or medical practices remotely
working with other approved providers who are facing the same 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:

Advisory bodies

Quality care advisory body

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

Members need the right skills and experience to 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 who have appropriate 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 consumer or representative, a member of the consumer advisory body (if established), a member of an organised consumer advisory service, or a consumer advocate.

Further information: Quality care advisory body fact sheet

Consumer advisory bodies

Consumer advisory bodies provide valuable feedback to your governing body about the quality of care and services they receive. It helps build a person-centred culture committed to quality aged care.

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

Even if you already have a consumer advisory body or bodies, you must formally approach the people under your care at least every 12 months to offer to revise/improve the current advisory body arrangements. This ensures that any changes in the care and services provided, or the advisory body membership or needs of members, are considered and addressed at least annually.

Watch this video to hear directly from Maggie, Jo and Jan from Queen Victoria Care in Tasmania. They talk about what matters to them, and how they partner with the governing body in the design of their care.

Transcript for 'Queen Victoria Care Residential Advisory Committee experiences'

If you already have advisory bodies, you can use them as long as they meet the new requirements. Your consumer advisory body:

can include care recipients and their representatives. Ideally, the body should include mostly current care recipients and their representatives.
must reflect the diverse backgrounds of care recipients and support care recipients with barriers to participate
must have opportunities to give feedback to the governing body on the quality of aged care provided
should have representatives from the different services and care offered.

Further information:

Consumer advisory body fact sheet

Consumer advisory bodies – information for older people

Consumer advisory body – fact sheet for older people

Consumer advisory body – Being part of a consumer advisory body

Consumer advisory body – meeting discussion guide

Consumer advisory body poster

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 are as defined in section 8B of the Aged Care Quality and Safety Commission Act 2018 and include people who:

are responsible for the executive decisions of a provider, or 
have authority or responsibility for, or significant influence over, planning, directing, or controlling the activities of a provider, or 
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 us of certain matters

Key personnel – reporting changes to suitability matters

Consider suitability of key personnel

Notifying the Commission of certain matters

Please inform us about changes in key personnel or any other matters impacting your service.

You must report any changes within 14 days after the change occurs.

Key personnel in corporate organisations must notify the provider of changes in their suitability within 14 days of the change.

Further information:

Notifying us of certain matters

Notify the Commission of certain matters- fact sheet

Staff qualifications, skills, and experience

As the Royal Commission acknowledged, investing in workplace development improves staff performance, commitment and retention. This also 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 receive development opportunities that enhance capability and support professional growth.

The following aren't required to meet the staff qualifications responsibilities:

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.

The following aren't required to meet this requirement:

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 on an annual basis.

Information regarding your organisation's services will be published on the My Aged Care website.

This enables people receiving aged care to make informed decisions about their care.

This page has tips on using GPMS, including help and trouble-shooting Government Provider Management System (GPMS).

Reporting period

The reporting period runs from 1 July to 30 June each year. To meet the deadline, you must submit the information and a signed statement of compliance to the Department of Health and Aged Care by 31 October.

Governing for Reform in Aged Care Program

The Governing for Reform 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.

Our Governing for Reform in Aged Care Program empowers aged care governing bodies, leaders and aspiring leaders to stay ahead of reforms and best practices. All governing body members, aged care executive leaders and emerging leaders are encouraged to take part.

This innovative learning Program was developed by the Commission in response to the Royal Commission into Aged Care Quality and Safety’s final report which identified the need to strengthen clinical and organisational governance capability of aged care residential and home care providers. Almost 7000 aged care sector leaders have participated in the Program to date.

The Program provides participants with flexible learning pathways and a comprehensive set of practical governance activities and resources.

Participants can access specialised learning activities and resources. These include workshops, online modules, resources, podcasts, networking opportunities, coaching and webinars.

Learn more about the Program here.

Can’t find what you are looking for? Contact us at governingforreform@agedcarequality.gov.au.