Strengthening provider governance

Membership of governing bodies

Changes relating to the composition of governing bodies commence on 1 December 2023.

These changes are already in effect for providers who applied for approval after 1 December 2022.

The following approved providers are not required to meet the governing body composition requirements:

• state or territory approved provider (including a state or territory authority), or a local government authority
• providers with a governing body with fewer than 5 members and who provide care to fewer than 40 recipients
• providers that are an approved Aboriginal Community Controlled Organisation (ACCO).

Governing bodies have the ultimate responsibility and influence over the care and service provided to older Australians. They need the right mix of people to drive the continuous improvement processes that deliver the high quality of care and services that older Australians deserve.

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

The governing body member/s with experience in providing clinical care will have an important contribution to make to the governing body’s consideration of and decisions about clinical aspects of care. Clinical care workers have a wide range of skills and qualifications. The most important element to consider is whether the person has qualifications and experience relevant to the types of care and services that a provider delivers.

The legislation does not specify who qualifies as an independent non-executive member. Each organisation needs to consider the independence of proposed members and whether the person’s interests, positions and relationships enable them to bring independent judgement on issues considered by the governing body.

If you are required to meet the governing body membership requirements but are unable to do so, you can apply to the Commission for a determination that one or both of the requirements do not apply.

Advisory Bodies

Changes relating to advisory bodies commence on 1 December 2023.

These changes are already in effect for providers who applied for approval after 1 December 2022.

This requirement does not apply to state or territory approved providers or authorities or to local government authorities.

You may already have advisory bodies in your organisation. You can use these existing bodies for this purpose, providing they meet the new requirements.

Quality care advisory body 

Quality care advisory bodies present opportunities for providers to draw on further expertise and be given additional inputs into their decision-making. 

Governing bodies of approved providers are obligated to establish and continue a quality care advisory body. You can use existing bodies for this responsibility if they meet the requirements. 

Quality care advisory bodies 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)

You can decide how to attract, engage and appoint members. You can also decide how the quality care advisory body will operate within your governance structure. You could consider the following:

• its scope and terms of reference
• how it will be governed
• procedures to define how to establish, manage and operate the body. 

Consumer advisory body

Consumer advisory bodies provide valuable feedback to the governing body and give consumers a voice.

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 management in the design of their care.

Even if you already have a consumer advisory body or bodies, you must formally approach your consumers 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.

You can have more than one consumer advisory body depending on consumer interest and your organisational needs.

Suitability of key personnel

These changes are in effect for all approved providers.

Key personnel play a vital role in your organisation and ensure the delivery of safe, quality care and services.

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.      

Due diligence in gathering information and assessing your staffs’ ongoing suitability is essential.

To safeguard your organisation and consumers, you must ensure that your key personnel are suitable to provide aged care. You need to assess key personnel suitability at least every 12 months against the ‘suitability matters’ specified in the Aged Care Quality and Safety Commission Act 2018.

Providers must report a change of circumstance relating to a suitability matter in writing and within 14 days of the change. It is an offence not to do this. This offence carries a maximum of 30 penalty units for an individual.

Notifying the Commission of certain matters

These changes are in effect for all providers.

You need to notify the Commission about changes that relate to key personnel and anything that may materially impact your suitability as an approved provider. It is important that the Commission is aware of these changes to support you manage any related risks.

Changes that impact your suitability, and any changes to key personnel, must be reported to the Commission within 14 days of the change.

Key personnel who work for organisations which are corporations, also have a responsibility to notify the provider of any change in their suitability within 14 days of that change.

Staff qualifications, skills and experience

Changes relating to the staff qualifications, skills and experience commence on 1 December 2023.

These changes are already in effect for providers who applied for approval after 1 December 2022.

This requirement does not apply to state or territory approved providers or authorities or to local government authorities.

Competent, experienced staff are central to the quality of care and services provided by your organisation. The Royal Commission noted that investments in workplace development are rewarded with higher staff performance, commitment and retention which benefits you and consumers.

Your governing body needs to make sure staff members have the appropriate skills, qualifications and experience necessary to fulfil their duties. It must also ensure that staff have development opportunities that support and build provider capability.

Provider’s constitution

Changes relating to provider’s constitution commence on 1 December 2023.

These changes are already in effect for providers who applied to for approval after 1 December 2022.

This responsibility applies to an organisation that is a wholly-owned subsidiary of another body corporate (known as a holding company) that is not an approved provider.

A constitution is a legally binding set of rules controlling the operations of an organisation. It outlines the responsibilities and powers of directors, the governing body, management and members; and describes a provider's main services and objectives.

In some organisational structures, an approved provider may be a wholly owned subsidiary owned by another body corporate (known as a holding company). Often in these cases, the company constitution allows directors to prioritise the holding company over the subsidiary company. This means that directors can prioritise the holding company over your organisation and your consumers.

Providers need to: ensure the organisation’s constitution requires directors of the company to operate in the best interests of older Australians, over those of the holding company.

Providers may wish to seek legal advice about how to amend their constitution and what effects this requirement may have on how its governing body operates. 

Provider Operations report

These changes are in effect for all providers.

The reporting period begins on 1 July and ends on 30 June every year. To meet the submission deadline, you need to lodge the information and signed statement of compliance before 31 October.

To encourage accountability and transparency, you will need to submit your annual Provider Operations report to the Department of Health and Aged Care through the Government Provider Management System. The information collected will become available on My Aged Care for each of the services your organisation provides. This will assist consumers and their representatives to make informed decisions about their care.

Governing for Reform in Aged Care Program

The Governing for Reform in Aged Care Program (the Program) is an innovative and highly tailored learning program for aged care leaders.

The Program assists aged care leaders to implement best practice in aged care organisational and clinical governance and ensure the provision of safe and high-quality care to consumers.

The Program provides participants with access to highly specialised learning materials and supports. This includes workshops, online learning modules and resources, podcasts, networking opportunities, coaching and webinars.

We encourage all governing body members and aged care executive leaders to participate in the Program and to be part of a collective drive to transform the aged care sector.

Enrolment in the Program is free for all governing body members and aged care executive leaders of approved providers of residential and home care services.

Learn more about the Program and enrol now.

Letter from the Commissioner to approved providers

On 20 September 2022, the Commissioner wrote to Board Chairs and CEOs of approved care providers, encouraging participation in the Governing for Reform in Aged Care program.

Your questions answered

Refer to the Your questions answered page for detailed answers to questions submitted to the Commission.

To submit a question to be answered, email agedcarereform@agedcarequality.gov.au

Further information and resources

In addition to the information above, please read the Provider responsibilities relating to governance: Guidance for approved providers November 2022 for additional details, examples and scenarios to further support you to understand these responsibilities.

To view the legislation, go to:

• Aged Care and Other Legislation Amendment (Royal Commission Response) Act 2022
• Aged Care Legislation Amendment (Governance and Reporting for Approved Providers) Principles 2022. 

The Commission has also produced the following resources for providers:

• Provider governance - provider responsibilities 1 December 2022 - video
• Provider governance - provider responsibilities 1 December 2023 - video
• Strengthening provider governance - eLearning module
• Strengthening provider governance – webinar, presentation slides and Q&As
• Notify the Commission of certain matters – fact sheet
• Key personnel – reporting changes to suitability matters – fact sheet
• Consider suitability of key personnel – fact sheet
• Provider governance quick reference – poster.
• Prepare to provide information to the Department of Health and Aged Care - fact sheet
• Consumer advisory body - poster
• Quality care advisory body -  fact sheet
• Staff qualifications - fact sheet
• Organisation’s constitution – fact sheet
• Consumer advisory body – fact sheet
• Consumer advisory body, Queen Victoria Care Residential Advisory Committee experiences - video