As aged care providers strive for excellence in care, the importance of good clinical governance cannot be overstated. Good clinical governance starts by separating the functions of doing and reviewing. Consistent and ongoing oversight/review from an impartial third party ensures issues are addressed promptly while mitigating the risk of unresolved gaps. Good governance prepares key personnel for real-life assessment contact, ensuring they are well-equipped to respond to the challenges of hard questioning.

We understand that real life experiences are more meaningful than generalised statements so we provided four (4) case studies from our clients who have benefited from proactively engaging us to provide third party compliance assurance services.

As each client achieved full compliance against all the ACQSC Standards in subsequent audits, you can be confident that Pride Living’s Quality and compliance team can reduce your risk of an adverse outcome.

Partner – Quality & Clinical Governance

Case Study 1

Single operator, Not-for-profit, NSW metro


  • Not previously audited under the new standards
  • New management team
  • Needed an overview of key risks across the 8 standards

Our client reported the following benefits from our Key Risk Audit

  • The Provider adequately prepared their staff for the experience of an audit, ensuring they were familiar with the expectations and processes associated with it.
  • Our report helped the Provider recognise there were areas where they had not sufficiently detailed their processes as required under the standards.
  • During the Commission’s audit, the Provider successfully demonstrated the excellent level of care they provide to the residents.

Case Study 3

Multi-site operator, Not-for-profit, VIC regional


  • Recently commissioned facility
  • No record of non-compliance
  • The CEO was aware of the issues within the facility but sought an assurance audit to validate them.
  • Required an overview of key risks across all ACQSC standards, followed by a follow-up audit to assess progress.
  • Our report was to be used to update their Plan of Continuous Improvement (PCI).

Our client reported the following benefits from our Key Risk Audit (initial)
and Follow-Up Assurance Audit:

  • The follow-up audit provided the CEO and Board assurance of progress in implementing the PCI actions.
  • The home was able to demonstrate the quality improvement cycle during the Commission audit.
  • The Commission was satisfied the facility was aware of the issues and had measures in place to identify, act and evaluate remediation plans.

Case Study 2

Single operator, Not-for-profit, NSW regional


  • Record of non-compliance – the facility had previously been sanctioned
  • The accreditation was nearing its expiration date
  • While the CEO acknowledged that significant work had been done, the care manager was new to the role and had not previously experienced an audit.
  • The care manager required support and coaching to navigate through the audit process.
  • Needed an overview of key risks across all ACQSC standards

Our client reported the following benefits from our
Key Risk Audit and complimentary remote support during re-accreditation:

  • Our guidance supported the staff to effectively demonstrate outcomes and increase their readiness for the process.
  • Following the coaching, the care manager was able to effectively respond to the questions in a manner that demonstrated how the facility met the specific requirements during the Commission’s audit.

Case Study 4

Single operator, Not-for-profit, TAS regional


  • Previous record of non-compliance that had been remedied
  • Awaiting reaccreditation
  • New management team
  • Required a review of their compliance against the industry’s top 10 unmet standards

Our client reported the following benefits from our Top 10 Non-Compliance Audit with consumer experience survey

  • The top 10 non-compliance audit identified weakness and provided the team with direction to develop key priority areas for improvement.
  • Based on our pressure testing of the facility’s existing systems, the executive team gained insights that underpinned the design of appropriate support structures for the facility.
  • Our audit facilitated the implementation of internal processes to enhance overall clinical and quality performance.

In each of the above cases, our clients’ goal was to improve their governance and quality assurance processes. We did this by testing their systems, providing guidance on compliance with standard requirements, and supporting them through the audit and re-accreditation processes.

Through proactive good governance and quality assurance, our clients were able to:

Enhance the preparedness of key personnel and proactively address issues.
Proactively identify and address risks, which lead to enhanced quality management systems and improved clinical governance frameworks.
Give their boards confidence in their risk management framework and risk management practices.

How Pride can help

While reaccreditation testing of your clinical governance is sound risk management, good clinical governance is not an isolated activity that precedes reaccreditation. Constant training and external reviews are proven to lift standards and performance.

As clinical failure is a high risk high consequence in aged care, we recommend all providers and especially those facing reaccreditation, or who have a history of non-compliance, engage an external quality assurance expert to test and provide assurance that their policies and procedures are appropriate to their specific circumstances.

Pride Living’s Compliance Assurance services include:

Key Risk Audit: We examine all 8 Standards but focus on key risk areas that are likely areas of risk to non-compliance.

Top 10 Non-Compliance Audit: We assess against the top 10 non-compliances. If this audit identifies systemic issues, it can be upgraded to our Key Risk Audit service.


To see all our Quality Management and Clinical Governance services, click here.

If you would like to discuss your organisation's needs for Quality Management and Clinical Governance, please contact Katrina Ong on 02 9060 6445 or email