Governing bodies oversee the governance of your organisation. There are rules about the membership of governing bodies, and how they operate.

Unless you are a sole trader, your governing body should have a mix of members with diverse skills, experience and expertise.

Your governing body must meet these membership requirements:

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

The membership responsibilities for a governing body do not apply if:

• you have less than five members in your governing body, and provide funded aged care to fewer than 40 individuals
• you are a state or territory registered provider, including a state or territory authority, or a local government authority
• you are an Aboriginal Community Controlled Organisation
• you are registered under the co-operatives national law, or the Cooperatives Act in Western Australia
• you have applied to the Commission and the Commission has determined that these requirements don’t apply.

Advisory bodies are formal groups that can give advice on quality of care and suggest improvements. If you are registered in category 5 or 6, you should use feedback from advisory bodies when making decisions and creating strategies for continuous improvement. Your governing body must write to the advisory bodies about how you have considered their report and/or feedback.

There are 2 types of advisory bodies that fall under governance requirements:

• quality care advisory bodies
• consumer advisory bodies.

You have an ongoing obligation to notify us if there are certain changes in your circumstances. 

You need to notify us when: 

• you’re adding or removing service types that you deliver
• something happens that materially affects your suitability to be a registered provider
• there’s a change in your responsible persons, including a change in the suitability of your responsible persons
• there’s a significant change in your organisation or governance arrangements  
• there’s a significant change in the scale of your funded aged care services  
• there’s a specified change in your associated provider arrangements
• certain financial and prudential matters arise
• there’s a specified change to an approved residential care home. 

When you tell us about registration changes, you may also need to complete relevant provider registration forms.

As a registered provider, you must submit regular reports to the Australian Government. This helps to make sure providers are transparent and accountable.

Learn more about your reporting requirements on Aged care provider reporting. This page explains the types of reporting and the information you need to report. It gives you links to the portals you need to use for reporting.

The Government Provider Management System (GPMS) is a tool for providers to use to comply with their reporting and notifications requirements. It allows you to self-manage, view and maintain your records with the government. 

You need to use the GPMS for a range of reporting and notifications requirements such as: 

• 24/7 registered nurse reporting
• financial and prudential reporting
• operations reporting
• Quality Indicator Program data reporting
• care minutes targets reporting.

Learn more about GPMS in:

• Government Provider Management System fact sheet – overview of the management system and key links
• Government Provider Management System resource repository – key links, guides and fact sheets.

The Financial and Prudential Standards set out the minimum requirements for registered aged care providers for good financial and prudential management.  There are 3 Financial and Prudential Standards:

• Financial and Prudential Management Standard
• Liquidity Standard
• Investment Standard 

As a registered aged care provider, it’s a condition of your registration to comply with the Standards that apply to you.

You can find more information about the standards here. 

There are obligations you must comply with to manage accommodation payments. This includes rules around:

• the prices you can advertise and charge
• how you use accommodation payments
• refunding accommodation payments 

You must submit your Quarterly Financial Report (QFR) via GPMS, and your Aged Care Financial Report (ACFR) via the ACFR online forms portal.

Quarterly Financial Reporting

QFR is important because it helps keep your financial operations transparent.

QFR requirements depend on the service you deliver. You must send your QFR by the legislated due date. 

QFR has 5 parts:

1. Viability and prudential compliance questions
    
2. Year to date financial statements
    
3. Residential care labour cost and hours reporting
    
4. Home care labour cost and hours reporting
    
5. Quarterly Food and Nutrition report
    

Aged Care Financial Report

Along with the QFR, you must submit an annual Aged Care Financial Report (ACFR). The ACFR allows the Australian Government to collect financial information for registered providers and parent entities, where necessary. If you hold refundable deposits, you must also submit an Annual Prudential Compliance Statement (APCS) as part of your ACFR. 

Learn more about QFR and ACFR in:

• Guide to the Quarterly Financial Report – overview of reporting requirements, reporting timelines and next steps
• Aged Care Financial Report (ACFR) – overview of reporting requirements, and the reporting schedule
• Annual Prudential Compliance Statement – resources and information about the AFCS
• QFR due dates – overview of the schedule for quarterly financial reporting.

Our role is to support people who have concerns and complaints about a provider’s responsibilities. We will work with you and a complainant to resolve complaints and achieve meaningful outcomes.

The Complaints Commissioner is a separate statutory appointment in the Commission. This means they’re independent from the Aged Care Quality and Safety Commissioner. Having an independent Complaints Commissioner is important for transparency and accountability of complaints handling.

We may take action on any complaint, including complaints about: 

• health care, for example wound care, medication and care assessment
• personal care, for example showering, dispensing medication, feeding and mobility
• communication, for example how information is shared with people receiving care and how you respond to their questions, including complaints
• staff roles, for example how they do their job and provide care
• living environment, for example safety, security, and cleaning
• some fees and charges in care agreements
• choice and preferences, for example showering and meal arrangements and tailored activities.

Learn more about our role in complaints handling in:

• The complaints process – detailed explanation of our role and yours in the complaints process, with key links.

You must have strong complaints and feedback systems that supports people to make complaints. You must show that you encourage and support older people to give feedback or complaints. 

Older people must be told that they have a right to complain, and how to do it. 

People also have the right to have their complaints dealt with fairly and promptly. This means you mustn’t delay handling complaints. 

People have the right to complain free from reprisal. This means they mustn’t receive unfair or negative treatment from your organisation because they’ve made a complaint. 

You must make efforts to resolve complaints within your organisation, but you must also tell the person how they can raise their concerns with us.

Most complaints should be handled within your organisation. Your organisation should have better practice complaints handling processes in place. Better practice complaints handling processes are fair, accessible, responsive and efficient. 

Once a complaint is made, you should follow a clear process to reach a fair outcome. Your organisation must use open disclosure and restorative practices. 

There’s detailed guidance online to help you use good practices in complaints handling. 

Learn more about better practice complaints handling in: 

• What to do if you have a complaint – key steps and links to complain about an aged care service.

Restorative practices inform our complaints handling decisions. 

When there’s a problem, we encourage open communication between the affected individuals. Restorative practices aim to reach an outcome where the provider is accountable for fixing the problem, and trust in the service is restored. 

Learn more about restorative practices in: 

Regulatory Strategy 2024–25 – section 2.4 provides a brief overview of the principle of restorative practices. 
 

Open disclosure is the open discussion a provider has with an older person when something goes wrong and has caused harm or could cause harm.

Providers should support older people to: 

• make informed choices
• have control
• actively take part in their care.

This includes having honest conversations when something goes wrong. 

This means you must listen to older people to understand what’s important to them. The care you deliver must be based on an ongoing partnership with older people. Clear communication at the right times helps support this partnership. 

Open disclosure discussions may also involve the older person’s supporters, family, carers, other support people and representatives, when an older person wants them to be involved. 
 

If a person is asked to leave a residential care home, they have the right to access your complaints resolution process.

They also have the right to access any other processes available to address complaints, including our complaints processes. 

You must include information about how to access these complaints processes in the written notice you give to a person before they leave your service. 

The right to complain free of reprisal means you mustn’t stop people from making a complaint when they’re leaving your service. 
 

Providers delivering care and services in categories 4, 5 and 6 need to meet the Quality Standards outlined in the Aged Care Act. The number of Standards which apply is based on the service types they provide. For example, a category 4 home service may only need to conform with Standards 1-4. 

We assess provider conformance against the Quality Standards.

There are 7 Quality Standards.

Standard 1: The individual

This standard describes the way that providers and aged care workers need to treat older people. It explains how important it is for you to understand that each older person is unique and has a different life story.

Standard 2. The organisation 

This standard holds the governing responsible for setting strategic priorities and encouraging a culture of safety, quality and inclusion. It describes the quality systems and supervision needed to make sure aged care services are delivered safely.

Standard 3. Care and services

This standard describes how you must plan and deliver aged care services. It focuses on the assessment and planning of aged care services, and how you should deliver them to meet older people’s needs. It also focuses on coordination of aged care services.

Standard 4. The environment 

This standard covers environmental aspects of aged care services. It makes sure that older people receive aged care services in a physical environment that is safe, supportive and meets their needs. Effective infection prevention and control measures are a key focus.

Standard 5. Clinical care

This standard describes the responsibilities of registered providers to deliver safe and quality clinical care services, including demonstrating you have systems and processes that enable you to deliver clinical care that is:

• person-centred
• safe
• quality
• based on evidence
• coordinated and multidisciplinary (delivered by different types of registered health practitioners and allied health professionals).

It applies to providers in Categories 5 and 6. Category 4 providers must meet Outcome 5.1 if they provide care management and restorative care management services.

Standard 6. Food and nutrition

This standard describes the aspects of food and nutrition and the overall dining experience. These aspects have an affect on older people’s quality of life. This standard only applies to aged care services delivered in a residential care home.

Standard 7. The residential community

This standard recognises the role community plays in promoting inclusion and belonging for older people. Quality of life is an important part of community. Providers must also make sure older people have a planned transition to and from the service. This standard only applies to aged care services delivered in a residential care home.

Learn more about the Quality Standards in:

• Strengthened Quality Standards – key links and information
• Draft Strengthened Quality Standards Guidance Tool – interactive tool outlining the Quality Standards that apply to your registration category
• Fact sheets on the strengthened Quality Standards – quick guides to each of the Standards.

All providers delivering aged care services must report on the quality of the care they provide.

Category 6 only

The National Aged Care Mandatory Quality Indicator Program (QI Program) includes 14 quality indicators for providers delivering care in a residential care home. The indicators measure, monitor and compare improvement in care quality and outcomes.

Providers delivering aged care services in a residential care home must report on the following quality indicators every 3 months:

• pressure injuries
• restrictive practices
• unplanned weight loss
• falls and major injury
• medication management
• activities of daily living
• incontinence care
• hospitalisation
• workforce
• consumer experience
• quality of life
• enrolled nursing
• allied health
• lifestyle officers. 

Category 4 and 5 only

National Aged Care Mandatory Quality Indicator Program (QI Program) quality indicators for in-home care are currently in development. 

Providers report QI Program data through the Government Provider Management System (GPMS). 

QI Program data will be published at a national, state and territory level, and by how remote an area is for each quarter of reporting.

Learn more about the QI Program and GPMS in:

• About the QI Program – overview of the QI program, how to submit your data and key links
• Government Provider Management System (GPMS) – overview of the GPMS and key links.

Providers delivering aged care services are responsible for having aged care workers who have the necessary skills, competence, training and experience for the role they undertake.

Providers must show that their workforce is suitable. This means you have obligations to screen all your aged care workers (including volunteers) and responsible persons (this includes, but is not limited to, executive leaders and board members).

We regulate aged care workers (this includes volunteers) and responsible persons under the Aged Care Code of Conduct (code). We take proportionate monitoring, compliance and enforcement responses, and may investigate if an aged care worker presents a higher risk to older people.

You must give adequate training to your workforce and make sure aged care workers have the right skills, training, experience and qualifications to deliver care and services in line with their role.

Category 4, 5 and 6 only

Under the Quality Standards, you need to show that your organisation understands and manages its workforce needs and plans.

You’re responsible for:

• having a workforce strategy that makes sure there are enough qualified aged care workers with the right skills to deliver quality and safe care and services
• having a workplace where people are healthy and safe, and where you monitor and manage physical and psychological risks
• having a human resources management system to confirm an aged care worker’s qualifications, experience and skills before you hire them
• having rostering processes that support quality and safe care and services
• delivering a training system that includes access to supervision and resources
• assessing and monitoring worker performance. 

Category 6 only

Providers delivering aged care services in a residential care home must report every 3 months on workforce indicators as part of the National Aged Care Mandatory Quality Indicator Program (QI Program).

The Department of Health, Disability and Ageing publish Star Ratings for providers delivering aged care services in a residential care home. These ratings include a Staffing Star Rating as one of the 4 sub-categories that contribute to the overall Star Rating, which ranges between 1 and 5 stars.

The staffing sub-category measures the average care time older people receive at each residential care home. Care time is based on care minutes delivered by:

• registered nurses
• enrolled nurses
• personal care workers
• assistants in nursing.

The Staffing Star Rating shows how well a residential care home meets or exceeds its minimum care minute targets.

Learn more about your workforce requirements in: 

• Strengthened Quality Standards – overview of the Standards with key links
• What are Star Ratings? Easy Read fact sheet – overview of the Star Ratings in downloadable document form
• Star Ratings – Stakeholder Kit – overview of Star Ratings for residential aged care, in downloadable document form.

Security of tenure is about the person’s rights and the providers’ responsibilities when a person leaves a service. This means people aren’t removed from a residential care home unfairly. Reasons for asking a resident to leave your service must be made clear in the service agreement.

Providers must have enough liquidity to meet their financial and prudential requirements when a person leaves. You must be able to refund the balance on their accommodation payment or bond. 

When a person chooses to leave 

A person using your service can choose to leave or move to another residential care home at any time. 

Once they leave, you must let Services Australia know about the change. 

When you ask a person to leave

There are specific reasons you can ask a person to leave your service. This includes if: 

• the service is closing
• the person is assessed to no longer need the care you provide
• the person hasn’t paid their agreed fees for 42 days since they were due, for a reason within their control
• the person intentionally caused serious damage to the service, or injury to another person
• the person was absent from the service for 7 days or more for reasons that aren’t:
  • emergency leave
  • hospital leave
  • hospital transition leave
  • extended hospital leave, or
  • social leave.

You must give the person at least 14 days' notice before they are required to leave and must give them a written explanation of why they are required to leave.

When you ask a person to leave your residential care home, you’re also responsible for making sure they have suitable alternative accommodation to move into. This means: 

• you must find suitable accommodation that meets the person’s needs
• the new accommodation must be affordable for the person
• you must work with the new service to make sure there is continuity of care, such as care planning and handover.

Once the person leaves your residential care home, you must let Services Australia know about the change. 

You need to show you can provide security of tenure if you apply for a variation of registration that results in people leaving your service. 

Learn more about security of tenure in: 

• Accommodation payments and contributions for residential aged care – overview of accommodation fees and requirements for residential services and key links
• Accommodation bonds  – overview of accommodation bonds and charges and key links
• Notification of changes for residential aged care – overview of provider notification requirements when a resident is exiting or entering your care, with key links.

Providers are responsible for how their organisation responds to all incidents, whether they are reportable incidents or not. 

When there’s an incident you must:

• assess and provide support to respond
• involve the relevant people 
• use an open disclosure process.

You’re also responsible for preventing incidents and learning from any incidents. This will help stop similar incidents from happening again and reduce their harm.

Assessing incidents

When an incident happens, you must assess whether it’s a reportable incident. 

You must assess the incident to decide what response you need to make. You must also assess who needs to be involved in resolving the incident, and who you need to be notify. This may include the person affected by the incident and their carer or representative.

Responding to incidents

Your response to the incident must make sure the person, or people, affected are safe, healthy and well. This means you must take all the actions you need to resolve and improve the situation. 

You must involve all the relevant people. If it’s a reportable incident, you must make the correct notifications. This includes notifying a police officer within 24 hours of being alerted to the incident if there are reasonable grounds to alert the police. 

Learning from incidents

You must collect and review data about incidents to monitor how effective your organisation is at managing and resolving risks. You must consider:

• whether incidents could have been prevented and what actions are needed to prevent them from happening again
• how you can stop incidents from causing more harm. 

It’s important to do this because it allows your organisation to keep improving how it manages risks. This continuous improvement is a provider requirement.

Using an incident management system

You’re responsible for creating and keeping an effective incident management system (IMS). This helps to manage risks, keep improving, and deliver quality care.

You must be able to give IMS records to us if we ask. You also must document your IMS procedures. 

Preventing incidents

You must have processes in place to prevent incidents from happening. This means you must have effective risk management systems and practices.

Learn more about incident management in:

• Effective incident management systems: Best practice guidance – overview of information for providers on best practice management systems, with downloadable guidance
• Incident Management Systems – overview of the incident management systems and key links.

The Serious Incident Response Scheme (SIRS) holds providers responsible for preventing and managing serious incidents. It includes a provider’s notification requirements and time limits for notification when a reportable incident happens. 

The SIRS promotes a safer aged care system. It makes sure providers take responsibility for preventing and resolving serious incidents and keep improving their quality of care.

Providers must notify us when a reportable incident happens. You must submit this notification through the Department’s My Aged Care provider portal, using the SIRS notification webform. You also must manage the incident through your IMS. 

You must notify all reportable incidents in either a Priority 1 or 2 timeframe. You must decide the priority of the reportable incident and report it to us in:

• 24 hours of becoming aware (for Priority 1)
• 30 days of becoming aware (for Priority 2).

Learn more about managing and reporting incidents under the SIRS in:

• Serious Incident Response Scheme – Guidelines for residential aged care providers – detailed guidelines about SIRS responses for residential aged care providers
• Serious Incident Response Scheme – Guidelines for providers of home services – link to downloadable copy of the detailed SIRS response in home services document
• The Serious Incident Response Scheme landing page – overview of SIRS with key links
• SIRS decision support tool – interactive tool that can help you to identify an incident’s priority level, use as a supplement to the guidelines
• Effective incident management systems: best practice guidance – link to downloadable copy of the detailed SIRS best practice guidance for providers
• SIRS provider resources landing page – key links to relevant SIRS resources, based on the services you deliver.