A Foundation for Workforce Capability, Culture and Compliance

Effective human resource management is essential for building a skilled, competent, and supported workforce that can provide safe, high-quality care and services. A strong HR framework ensures that providers meet workforce planning and human resource management requirements under the strengthened Aged Care Quality and NSQHS Standards.

HR management goes beyond recruitment. HR underpins workforce capability, risk management, and quality systems, ensuring staff are equipped with the right skills, qualifications, and supervision to meet regulatory expectations and provide person-centred care.

Read our Training Requirement: Safety and Quality Training for a comprehensive guide on understanding and implementing safety and quality training actions, including how education supports workforce capability.

Using this Training Requirement

This Training Requirement provides guidance on understanding and implementing the workforce planning and human resource management actions outlined in the NSQHS Standards and Strengthened Aged Care Quality Standards.

While training and education are essential, building workforce capability relies on strong HR systems, governance, and processes. Where relevant, we will link to training modules and resources that support the implementation of best practices in human resource management.

Understanding the Relevant Actions in the Standards

NSQHS Standards:

Action 1.22 Performance Management

The health service organisation has valid and reliable performance review processes that:

• Require members of the workforce to regularly take part in a review of their performance.
• Identify needs for training and development in safety and quality.
• Incorporate information on training requirements into the organisation’s training system.

Understanding the Relevant Actions in the Standards

NSQHS Standards:

Strengthened Aged Care Quality Standards:

The following actions are from Standard 2: The Organisation in the strengthened Aged Care Quality Standards. This Training Requirement focuses specifically on:

Accountability for Human Resources

The successful implementation of workforce planning and human resource management requires clear accountability across all levels of an organisation.

Governing Body Accountability

The governing body is responsible for ensuring the organisation has a workforce strategy that meets the strengthened Aged Care Quality Standards requirements. This includes:

• Overseeing workforce planning to ensure there are sufficient qualified and competent staff.
• Monitoring workforce performance, training, and supervision.
• Ensuring compliance with minimum care requirements and legislative obligations.

Operational Accountability

The executive and management teams are responsible for workforce planning and HR systems by:

• Implementing and maintaining workforce strategies to support staff capability, retention, and wellbeing.
• Ensuring training systems are in place and regularly reviewed.
• Providing supervision, escalation pathways, and support resources for staff.
• Mitigating risks related to staff shortages and vacancies.

Workforce Roles and Responsibilities

All aged care workers are responsible for:

• Maintaining their qualifications and competencies relevant to their roles.
• Participating in supervision, training, and performance reviews.
• Providing feedback to improve workforce systems, training effectiveness, and overall workplace culture.

Meeting Human Resource Requirements

Meeting workforce planning and human resource management requirements requires a structured, strategic approach. Organisations must move beyond thinking about just minimum compliance to actively build workforce capability, support staff wellbeing, and ensure continuous improvement.

The following key areas outline how organisations can broadly think about meeting these standards:

1. Workforce Strategy and Planning
2. Recruitment, Qualifications, and Record Management
3. Supervision, Support and Workforce Wellbeing
4. Training, Competence, and Continuous Improvement
5. Performance Monitoring

Key Area	Meeting the Requirements
Workforce Strategy and Planning	Develop a workforce strategy aligning staffing with care needs and service delivery requirements. Implement roster planning to meet minimum care requirements, including direct care minutes and 24/7 RN availability. Establish strategies to reduce workforce shortages and ensure staff availability. Monitor staffing levels, workforce mix, and skill requirements to adapt to changing needs.
Recruitment, Qualifications, and Record Management	Maintain pre-employment checks, qualification verification, and experience records. Ensure position descriptions align with role expectations and are up-to-date. Prioritise direct employment over agency staff where possible. Keep accurate and up-to-date workforce records to support compliance and audits.
Supervision, Support, and Workforce Wellbeing	Provide structured supervision and escalation pathways for all staff. Ensure access to support and culturally appropriate resources, particularly for staff with English as a second language. Foster psychological safety and staff wellbeing through proactive workforce support initiatives. Encourage staff engagement and feedback mechanisms to improve workplace culture.
Training, Competence, and Continuous Improvement	Implement an effective training system that ensures staff have the necessary skills and competencies to perform their role. Provide competency-based training on core matters. Regularly review and improve training system effectiveness based on workforce feedback, incidents, and performance reviews. Integrate individuals' experience into training.
Performance Monitoring	Conduct regular performance reviews and competency assessments. Use feedback, complaints, and incident data to drive workforce improvements. Track and report on workforce performance metrics, including staff turnover and competency gaps.

Evidence of Compliance

Organisations can demonstrate compliance with workforce planning and human resource management requirements by maintaining clear documentation, structured processes, and governance oversight.

Refer to detailed lists of evidence that may be audited by viewing:

• Strengthened Aged Care Quality Standards Evidence Mapping Framework (the auditor's tool)
• NSQHS Standards Action 1.22 Examples of evidence

High-Priority Items

The following high-priority evidence items are commonly requested to assess compliance with workforce strategy, staff qualifications, supervision, training, and performance management.

Evidence Area	Examples
Workforce Strategy and Planning	Workforce strategy detailing staff mix, recruitment, and retention approaches.
	Risk mitigation strategies for workforce shortages and staffing gaps.
	Master roster and shift records, including unfilled shifts.
	Plans for continuous improvement in workforce planning.
Recruitment, Qualifications, and Record Management	Pre-employment records (background checks, qualification verification, experience records).
	Policies and processes for tracking worker qualifications, competencies, and training.
	Sample position descriptions for clinical and non-clinical roles.
	Agency and subcontractor agreements detailing qualification and competency expectations.
	Worker files showing up-to-date employment records.
Supervision, Support, and Workforce Wellbeing	Policies and procedures for supervision and escalation pathways.
	Evidence of culturally appropriate support resources, particularly for staff with English as a second language.
	Survey results or feedback reports demonstrating staff satisfaction and workplace safety (physical and psychological).
	Meeting minutes showing governance oversight of workforce wellbeing initiatives.
Training, Competence, and Continuous Improvement	Training policies and procedures detailing core, non-core and competency-based training requirements.
	Training system records, including training needs analysis, training matrix and competency assessments.
	Performance review documentation, linking training to staff development.
	A process demonstrates how a review of the training system's effectiveness led to improvements based on feedback and incidents.
Performance Monitoring and Compliance	Performance review policies and documented development systems aligned with professional guidelines.
	Audit results on staff competency, training completion rates, and workforce performance.
	Mentoring and peer review reports supporting professional development.
	Meeting minutes where workforce performance, credentialing, and training are reviewed.
	Feedback from the workforce on training effectiveness and ongoing development needs.

Effective workforce planning and human resource management are essential for not just compliance but building workforce capability and a stable, supported workforce that provides high-quality care.

Organisations can meet regulatory requirements by implementing strong governance, structured training, and performance monitoring while building a resilient, well-supported workforce.

Relevant Resources

Explore our Guide to Ausmed’s Audit Readiness Tool for a structured approach to meeting evidence requirements.

Watch our webinar, Getting Your Training System Ready for an Audit, for a detailed look at how training, learning, and development requirements align with audit expectations.

• Strengthened Aged Care Quality Standards - Aged Care Quality and Safety Commission
• Strengthened Quality Standards Provider Guidance - Aged Care Quality and Safety Commission
• Evidence Mapping Framework - Aged Care Quality and Safety Commission

Author