Under sections 78–80 of the Aged Care Act 2024, every registered aged care provider must maintain a register of responsible persons — the individuals who hold key positions of authority within the organisation. This is not just a governance formality. The ACQSC uses responsible person information to assess whether your organisation has suitable people in positions of influence, and failure to maintain an accurate register is a compliance risk that can lead to conditions on registration or enforcement action.
This guide covers who qualifies as a responsible person, the 11 suitability matters assessment, ongoing monitoring obligations, ACQSC notification deadlines, governing body skills matrices, and the most common compliance gaps identified during assessment contacts.
Who is a responsible person?
A responsible person includes any individual who is:
- A member of the governing body (board directors, trustees, committee members) - The CEO or equivalent senior executive - The company secretary - A nominee of the provider - Any individual in a position to exercise significant influence over the management or administration of the provider
For trust structures, this extends to trustees and trust managers. For incorporated associations, it extends to all committee members. For partnerships, it includes all partners.
The definition is deliberately broad. If someone can influence how the organisation operates — even informally — they may meet the threshold. This catches individuals who may not have a formal title but who exercise de facto control over organisational decisions. The ACQSC has stated that it will look at substance over form when determining whether someone is a responsible person.
Common examples of responsible persons that providers sometimes miss: - The operations manager who reports directly to the CEO and effectively runs day-to-day services - A family member of the owner who has no formal role but participates in governance decisions - A consultant or advisor who has ongoing influence over strategic decisions - The clinical governance lead who oversees all clinical care standards
The 11 suitability matters assessment
Each responsible person must undergo a suitability assessment covering the 11 suitability matters defined in section 13 of the Act (paragraphs (a)–(k)). These are:
(a) Whether the person has been convicted of an indictable offence (b) Whether the person is or has been an insolvent under administration (c) Whether the person has been disqualified from managing a corporation under the Corporations Act 2001 (d) Whether the person has been involved in the management of a registered provider whose registration has been revoked or suspended (e) Whether the person has been subject to a banning order under the Act (f) Whether the person has contravened a civil penalty provision under the Act (g) Whether the person has been found to have breached the Code of Conduct (h) Whether the person has been involved in the management of an organisation that has been wound up or deregistered for reasons related to fraud, mismanagement, or non-compliance (i) Whether the person is of good character, having regard to their honesty, integrity, and reputation (j) Whether the person has the skills, qualifications, and experience appropriate to the position they hold (k) Any other matter that the ACQSC considers relevant to the person's suitability
The assessment is not a one-time check. Providers must have ongoing monitoring arrangements to identify changes in suitability — for example, if a board member is charged with a relevant offence after their initial assessment. The ACQSC can request updated suitability information at any time.
Screening requirements for responsible persons
All responsible persons must hold current police checks and NDIS Worker Screening Checks where applicable. The screening requirements for responsible persons are the same as for aged care workers — National Police Check plus NDIS Worker Screening Check where required by the relevant state or territory.
Screening records must be maintained with expiry dates tracked and renewal alerts in place. Police checks are valid for 3 years and must be renewed before expiry. A lapsed screening check for a responsible person is a serious compliance gap that the ACQSC will identify during assessment contacts.
For new board appointments, screening should be completed before the person commences in the role. If this is not possible due to processing timeframes, the provider should document the interim risk assessment and ensure the person does not have unsupervised access to care recipients until screening is complete.
ACQSC notification obligations
Providers must notify the ACQSC of changes to responsible persons within 14 days. This includes:
- New appointments — when a new person joins the governing body, becomes CEO, or takes on a role that meets the responsible person definition - Departures — when a responsible person leaves the organisation or ceases to hold a qualifying role - Changes to suitability status — when a responsible person's suitability changes (e.g., they are charged with an offence, become insolvent, or have their professional registration suspended)
Late notification is itself a compliance failure. The ACQSC treats missed notification deadlines as an indicator of weak governance systems — and may look more closely at other governance obligations as a result.
Providers with frequent board changes (common in smaller community-based providers) need robust processes to capture appointment and departure dates and trigger ACQSC notifications within the 14-day window.
Governing body skills matrix
Best practice — and increasingly an expectation during ACQSC assessments — is to maintain a skills matrix for your governing body. This maps each board member's qualifications, experience, and expertise against the competencies needed to govern an aged care provider effectively.
Areas typically covered include: - Aged care operations and service delivery - Clinical governance and quality improvement - Financial management and prudential compliance - Risk management and assurance - Human resource management and workforce compliance - Legal and regulatory compliance - Cultural safety and diversity - Consumer engagement and advocacy
Gaps in the skills matrix should drive recruitment and professional development priorities. For example, if no governing body member has clinical governance expertise, the provider should either recruit a member with that background or arrange for existing members to undergo relevant training.
The Aged Care Act 2024 emphasises that the governing body must be accountable for the quality and safety of care. A skills matrix demonstrates that the governing body has the collective competence to discharge this accountability.
Common compliance gaps identified by the ACQSC
Based on ACQSC assessment contact findings, the most frequently identified responsible persons compliance gaps are:
Incomplete register. The register does not include all persons who meet the responsible person definition. Commonly missed: operations managers with significant influence, trust managers, and family members involved in governance.
No ongoing suitability monitoring. The initial suitability assessment was conducted at appointment, but there is no process to monitor for changes between assessments.
Lapsed screening. Police checks or NDIS Worker Screening Checks have expired and not been renewed. This is particularly common for long-serving board members.
Late or missing ACQSC notifications. Changes to responsible persons (appointments, departures, suitability changes) were not notified within 14 days.
No skills matrix. The governing body cannot demonstrate it has the collective skills needed to govern an aged care provider.
Inadequate suitability documentation. Suitability assessments are cursory or use generic templates that do not address all 11 matters specifically.
Connection to Quality Standard 2
Responsible persons compliance is directly assessed under Strengthened Quality Standard 2 (The Organisation). This standard requires providers to demonstrate that the governing body is accountable for the quality, safety, and governance of the organisation, and that the provider has effective systems for managing risk, workforce, and continuous improvement.
Your responsible persons register, suitability assessments, screening records, ACQSC notifications, and skills matrix are all primary evidence sources for Standard 2. An incomplete or poorly maintained register undermines your compliance position across the standard — not just on the specific responsible persons requirements.
For a broader guide to governance best practices including board reporting, risk management, and clinical governance, see our dedicated governance guide.
How Statura Care helps
The Responsible Persons module in Statura Care provides a centralised register with built-in suitability assessments covering all 11 matters, screening record tracking with automated expiry alerts, ACQSC notification templates with 14-day deadline management, and a governing body skills matrix with gap analysis.
All data is audit-trailed and feeds into Quality Standards evidence for governance reporting. When a responsible person's screening is due to expire, the system alerts both the individual and the compliance officer. When a new appointment is made, the ACQSC notification deadline is calculated and tracked automatically.
The Responsible Persons module is part of Statura Care's aged care compliance software — 35 modules covering every obligation under the Aged Care Act 2024.