Residential Aged Care Assessments: What to Expect in 2021

The Aged Care Quality and Safety Commission (ACQSC) recently released its Sector Performance Report for the period July to September 2020.

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An Essential Guide to Standard 8 and Governance, Risk and Compliance for Residential Aged Care Boards and Managers

If you missed our recent webinar on Standard 8 and Governance, Risk and Compliance for Residential Aged Care Boards and Managers, you can request the recording here.

Meanwhile, here is a quick guide to the points we covered, accompanied by timecodes so you can jump to your key areas of interest when you watch the webinar.


What is Organisational Governance in Residential Aged Care? (11:25)

We’ve drawn on the language used in the Aged Care Quality Standards to define governance as:

“The policies, procedures and systems in place to assess, monitor and drive improvement in the quality and safety of the care and services the facility provides."


Why Does Governance Matter? (25:55)

Good governance is a legal requirement: such requirements include board members’ legal obligations, Standard 8 of the Aged Care Quality Standards, and the common law duty of care.

Good governance keeps you on track: your organisation is on a path to maturity and improvement, or at least you want it to be. There will be challenges and obstacles. Good governance is a strong foundation designed to keep you from stumbling and falling off the path.

Good governance makes you better at what you do: in the case of aged care homes, good governance makes you better at delivering quality care to consumers.


How to Meet Your Governance Requirements: Risk Management and Compliance

To achieve good governance and meet your governance requirements you need a:

  • Compliance Program
  • Enterprise Risk Management System  


What is a Compliance Program and Why Do We Need One? (26:30)

A compliance program is a system that helps you keep track of what requirements you have to meet, when you have to meet them, how you can meet them and how you can demonstrate that you’ve met them.

A good compliance program will cover:

  • Commitment and Leadership from the “Top Down”
  • Resourcing the Compliance Function
  • Documenting Compliance Framework
  • Documenting Policies and Procedures
  • Allocating Roles and Responsibilities
  • Training Staff
  • Implementing Controls (An Assurance System)
  • Identifying Obligations and Assessing Risk
  • Monitoring, Measuring Activity
  • Analysing and Evaluating
  • Reporting
  • Implementing Corrective Actions
  • Continuous Improvement

Why do you need a whole program for compliance? Because there are hundreds of interrelated aged care compliance requirements and some of them change on an almost daily basis. Compliance in aged care is simply too complex to keep track of in an ad hoc way.


What is Enterprise Risk Management? (35:00)

“Risk management is a structured process which assists organisations to predict future events which may impact on their activities, and allows them to take appropriate actions to address the likelihood of the event happening, and/or the impact of the event should it occur.”

Risk management is something that aged care workers do daily. Everything from cleaning up a spill to recording a dose of medication is risk management. But these activities are not necessarily Enterprise Risk Management (ERM).

ERM is a strategic approach to managing risks that looks at the whole of the organisation and is led by the board.


A Risk Management System is Legally Required

Risk management is a requirement in the Aged Care Quality Standards. Standard 8 Requirement (3)(d) says that an organisation must provide:

Effective risk management systems and practices, including but not limited to the following:

(i) managing high-impact or high-prevalence risks associated with the care of consumers

(ii) identifying and responding to abuse and neglect of consumers

(iii) supporting consumers to live the best life they can.

This represents the minimum in risk management that your facility must provide.


An Effective Risk Management System

An effective risk management system is one that:

  • identifies and assesses risks to consumers
  • identifies and evaluates incidents and ‘near misses’ (both clinical incidents and incidents in delivering care and services)
  • provides information to improve performance and how it delivers quality care and services
  • escalates risk/s to ensure timely management within and with out the organisation
  • continues to monitor risks to consumers and others and take action if a risk has increased.


Benefits of Enterprise Risk Management (45.00)

  • Higher Quality of Care and Services
  • Increase Certainty with Fewer Surprises
  • Increase Organisational Resilience
  • Quickly Identify Opportunities and Threats
  • Effective Board and Management Reporting
  • More Efficient Resource Allocation
  • Confidence in Systematic Risk Assessment Process
  • Support Execution of Organisational Strategy
  • Systematic Approach to Legal and Regulatory Compliance
  • Improve Change Readiness
  • Reduce likelihood and mitigate consequences of adverse events
  • Promote Continuous Improvement


Improving Your Governance: Tips for Getting Started

  • Begin with commitment from the top down: it’s up to the board/leadership team to set the tone.
  • Systematise the things you already do well: many aged care staff already follow effective processes for compliance and risk management, but few of them have ever written these processes down. Start there. Turn great personal processes into great written processes, then apply them to other areas as well.
  • Get your documents in order: document your policies and procedures and ensure your staff are trained on them.


Finally, remember to pace yourself and get help when you need it. Governance is not something you can set and forget. It is an endless, dynamic process that requires ongoing maintenance.


Additional Resources

Prior to Standard 8 in the Aged Care Quality Standards, there was no mention of Governance in the accreditation frameworks for Aged Care. And whilst the Royal Commission Aged Care commenced in October 2018, it wasn’t until mid-November 2019 that - for the first time - the focus of the Commission was Governance in aged care.

So, it’s no wonder that the Aged Care team at CompliSpace are finding that many Residential Aged Care Board members and Managers do not fully understand governance, risk and compliance and the true responsibilities of their roles. Afterall, it’s not uncommon for board members to be volunteers or to be from backgrounds that are not specific to aged care.

Available Now

Request the webinar recording discussed in this article - "Essential Guide to Standard 8 and Governance, Risk and Compliance or Residential Aged Care Board Members and Managers". You will also get the slides and accompanying resources. Request your access here.

Upcoming Resources to Request

Training video: Enterprise Risk Management for Residential Aged Care.

This video will be released on Wednesday December 9th. To pre-order this free training video, please click here and complete the form.

Free Webinar: Demonstration: How to Simplify Continuous Compliance with Standard 8 - in Practice


This webinar will show you how you can you improve your efficiency and effectiveness as a Residential Aged Care Board and Management Team by ensuring you have the right information to help you make decisions and to create a sustainable compliance culture your staff will embrace. Register for the webinar here.

Mark Bryan
Mark is a Legal Research Consultant at CompliSpace and the editor for ACE. Mark has worked as a Legal Policy Officer for the Commonwealth Attorney-General’s Department and the NSW Department of Justice. He also spent three years as lead editor for the private sessions narratives team at the Royal Commission into Institutional Responses to Child Sexual Abuse. Mark holds a bachelor’s degree in Arts/Law from the Australian National University with First Class Honours in Law, a Graduate Diploma in Writing from UTS and a Graduate Certificate in Film Directing from the Australian Film Television and Radio School.

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