Continuous improvement is an obligation for registered providers (providers) under the Aged Care Act 2024 (Aged Care Act) and the Aged Care Rules 2025 (Aged Care Rules). Providers are expected to assess, monitor and improve the quality of the aged care services they deliver.
This page explains what a continuous improvement plan (CIP) is, who needs one, what we expect it to contain, and when we can ask you to give us one.
What continuous improvement means
Continuous improvement is a systematic, ongoing effort to improve care and services. It’s based on the needs of the people receiving your services, how well your systems work and the outcomes you want to achieve.
Under the Aged Care Act, every provider is required to show they are capable of, and committed to, continuous improvement. This applies to all providers in all registration categories.
Continuous improvement is also built into the strengthened Aged Care Quality Standards (Quality Standards). For example, Standard 2: The organisation requires your governing body to lead a culture that focuses on continuous improvement. And it requires you to use a quality system that helps you improve the services you deliver.
What a continuous improvement plan is
A CIP is a written plan that sets out how you intend to:
- improve the quality of the aged care services you deliver
- comply with the conditions we’ve put on your registration that relate to the quality of your services.
Your CIP should be a living document. Keep it up to date. This includes updating it as you start, continue or complete your improvement actions.
Who needs a continuous improvement plan
You need to have a CIP if you’re registered in:
- Category 4: Personal and care support in the home or community
- Category 5: Nursing and transition care
- Category 6: Residential care.
If you’re only registered in categories 1 to 3, you don’t need to have a CIP. However, you still need to show you’re capable of, and committed to, continuous improvement.
When you need to give us a continuous improvement plan
We can ask you to give us a CIP:
- after an audit
- if we’ve put conditions on your registration
- for other reasons.
After an audit
When we audit a service (for example, when we’re deciding if we’ll renew a provider’s registration), we could find they’re not conforming with one or more of the Quality Standards. We call this non-conformance.
Section 109-15 of the Aged Care Rules says we can respond to non-conformance we find during an audit in 3 ways:
- If the provider has addressed the non-conformance, we don’t need to do anything more.
- If the provider still isn’t conforming, we can:
- ask them to update their CIP to set out how they’ll fix the non-conformance by a specific time
- place a condition on their registration.
If we ask you to update your CIP after an audit, you need to update it to show how and by when you’ll fix the issue.
Conditions on your registration
If we put a condition on your registration about the quality of your services, your CIP should explain how you’re going to comply with that condition.
Other reasons
We can ask you for a CIP at other times as part of our regulatory work.
If we ask you for a CIP, we’ll tell you:
- what we need
- when we need it by.
The improvement cycle
A CIP works best when you treat improvement as an ongoing cycle rather than a one-off task. We use a 5-stage framework:
- Identify the issues and the improvements you need to make. Prioritise them based on the risk they pose to older people. Think about how you could improve:
- your systems and processes
- the experience of the people receiving your services.
- Look at the different ways you’ve found to fix the issues. Decide what actions you’ll take and who’ll be responsible. Ask for input from the people who use your services, their families and carers, and your staff.
- Put your plan into practice. Decide who’ll do the work and give them the time and resources they need. Keep everyone affected by the improvement informed. Record the decisions you make in your CIP.
- Check. Measure if the change is working. You can do this by using methods such as audits, assessments and surveys. Record what you find in your CIP.
- If the change worked, make it everyday practice. Update your policies and procedures, train your staff, and keep using it. If it didn’t work, learn from it and try another way.
Take your time with each step. Gradual, well-tested changes often deliver better, longer-lasting results.
What you need to put in your continuous improvement plan
For each improvement you need to make, your CIP should clearly show:
- area for improvement - the issue, and what it relates to (the Quality Standard and outcome, the section of the Aged Care Act, or the condition on your registration)
- planned action - what you’ll do to fix the issue, how you’ll do it, and by when
- person responsible - the person or role responsible for the action
- target completion date - when you expect to finish the action
- evidence of completion - the results you achieved and how you measured them, as evidence you made the improvement
- when we’ve asked you to report back to us - the date you’ll give us evidence you’ve completed the improvement. Where your plan addresses a non-conformance, you are required to give us evidence that you fixed the issue at the end of the specified period.
A strong CIP should also show how you’re using, checking and reviewing each improvement. For example, show:
- that you’re making changes to your policies, training or processes
- how you’ll keep checking to make sure the improvement lasts.
Your CIP should be based on more than the Quality Standards alone. You should also look at other sources of ways to improve, such as complaints and feedback, incident reviews, internal audits, and conditions on your registration.
Related information
We can ask to see your CIP when we audit your service. You can find more information about how we manage personal information in our privacy policy.