Strengthening Provider Governance

Over the past 6 months a number of new providers both residential and Home Care have started to undergo accreditation and or quality reviews with assessors starting to look at the “Strengthen Provider Governance” requirements. As a result, we would like to share with you some feedback on what has been experienced during these audits:

Feedback from the Current Commission Reviews

  • There has been particular focus on the Governing Board , Quality Care Advisory Body (QCAB) and Consumer Advisory Body (CAB). The assessors have reviewed in some instances and questioned the following:
    • Suitability of the membership of these Boards and bodies especially in areas of skills and qualifications for governing body members and their Independence to the Organisation.
    • Membership of the CAB did not reflect the diversity of the consumers groups within thew organisation.
    • Lack of suitably qualified clinical member for the Governing Body.
    • Lack of induction of the governing body , QCAB and CAB members.
    • Lack of Governing Board education regarding areas  of Approved provider responsibilities,  Reform updates and clinical governance.
    • Lack of documentation regarding requests for follow-up and investigation by the Governing Board and QCAB when data demonstrates key areas of risk such as a SIRS event.  
    • List of current Governing Board Key personnel did not align to the Commission information.
    • Poor reporting to the QCAB, and CAB – information not reflective of the current issues in the organisation and poor quality data management.
    • Lack of documentation regarding suitability for key personnel when required and not meeting the 14 days material notification requirements.
    • Lack of written Documentation when areas of risk have been identified to the Governing board and no acknowledgement by Governing board when issues have been raised.  
    • Poor minute taking, minutes do not reflect the agenda nor provides the governing body with an accurate reflection of the meeting.  
    • Membership at the QCAB and CAB does not meet the requirements.  
    • Lack of information related to the change management process in the Plan for continuous improvement for all 3 groups and other strengthening Provider Governance information.
    • Lack of governance structures for all groups – including no Terms of reference, report structures, recruitment strategies, lack of written documentation regarding refusal to be on bodies by consumers.  
    • Issues in relation to privacy of information – detailed personal consumer information shared in QCAB and CAB meeting.
    • Poor alignment of information to the clinical governance frameworks and quality care principles.
    • Unable to demonstrate documentation and recruitment information including expressions of interest for membership on the CAB for 100% of Consumers.  
    • Lack of appropriate resources allocated to the QCAB and CAB.  
  • Governing Board systems and processes do not reflect best practice corporate governance processes or systems.  
  • Key Personnel Suitability assessment not undertaken or commenced. Governing body and Executive are not aware of the requirements of the assessment nor what is required. No detail is noted in policies or processes and  there is no system in place for the suitability assessment to be completed.
  • No systems in place to support the building of capability and skills in the senior management workforce. No records of education sessions attended or development plans in place.  
  • Policies and procedures did not reflect the changes in legislation or best practice processes.  

Opportunities / Tips

  • Highly recommend that you review the Strengthening Provider Governance in aged care documentation.
  • Ensure your Governance Boards utilises the guidance and resource documentation from the commission to inform them as to what they should be asking.
  • Remember effective board directors triangulate information and critically think about the issues rather than accepting matters at face value. Recommend your QCAB and Governing Board read the red flag approach
  • Make sure you have everything written down – document all conversations or matters raised between Governing board, QCAB and CAB – no matter how small the matter is.
  • Review your membership for the governing board, QCAB and CAB– make sure they meet the requirements as per the legislation.
  • Review who is deemed Key personnel in your organisation and ensure the correct documentation is in place and this documentation is available for assessor review.  
  • Commence the process to review the suitability of key personnel.
  • Update your PCI to ensure it captures all of the Strengthening Provider Governance changes and have regular updates on progress.
  • Review all members of the organisation and ensure development plans are put into place and commence the building of capability and skills.
  • Review the Governing board systems and processes and ensure they reflect best practice.
  • Ensure all Governing board, QCAB and CAB members have appropriate education and induction.
  • Ensure appropriate resources are allocated to the QCAB and CAB.   

It is important to remember any providers that have commenced operation after the 1st December 2022 are required to meet the new governance requirements now. Whilst If you are an existing provider you will need to comply as of the 1st December 2023. You need to ensure you get started on the reforms requirements now as there are no extensions available on these timelines.

Solution for you

CSS has developed a package for providers to work through the establishment of QCAB and CAB’s. The following establishment package will provide the information you require to get started:

  • Sample Terms of Reference, Standing Agenda and associated documentation for both QCAB and CAB.
  • Provide required recommended wording for CI plan and provide Action Plan to support the implementation of the QCAB and CAB.
  • PPT education presentation to support the implementation of the program.
  • Provide a template Expression of Interest Form for the consumers and representative to consider.

We can also assist in running induction/onboarding training for your QCAB and CAB to ensure they are aware of their roles and responsibilities and how to ensure they meet the requirements of the legislation.

Alternatively we can also support in becoming an advisor to the QCAB and CAB.

If you are struggling to work out a clear strategy to address these reforms please don’t hesitate to reach out we are here to help. Give me a call on 0414 588 795 or email me on

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