When an incident system isn’t enough: what senior NDIS leaders must learn from the latest Federal Court judgment (Part A & B)

1 December 2025

The NDIS Commission is now willing to use its sharpest tool, and the sector must pay attention.

Over the past month, the NDIS Quality and Safeguards Commission has finalised enforcement actions against two additional providers, bringing the total number of providers who have now faced the highest tier of regulatory enforcement, civil penalty proceedings in the Federal Court, to five.

What’s notable is not just that the Commission acted, but how it acted. Lifestyle Solutions is the first to:

• be prosecuted using two separate proceedings for different classes of failure
• have an employee (the house-level leader) specifically named and not just the organisation
• be penalised in a case where no one died. (I appreciate this sounds glib; I do not intend it to be, nor do I wish to minimise the experiences of the participants involved in the Lifestyle Solutions case).

The latest finding against Lifestyle Solutions clearly shows we have moved beyond warnings → compliance actions → enforceable undertakings into a phase where the Commission is demonstrating:

✔  Strategic escalation

✔  Legal confidence

✔  Willingness to test new enforcement pathways

✔  Increasing interpretation strength of the NDIS Act and Rules

✔  Consequences will be severe, even in the absence of physical harm or death, if it is determined that systems, culture and risk practices were deemed foreseeably unsafe.

This is going to be a lengthy blog, broken into three parts:

Part A – A summarised overview of the statement of agreed facts between the Commission and Lifestyle Solutions.

Part B – An opinion piece on if the NDIS Commission, and more broadly the Australian Government, is doing enough to ensure people with disability receive safe, sustainable and capability-driven practice.

Part C –  What best practice could look like, based on what we know wasn’t enough.

It is lengthy because I am still struggling to understand some of the foundation this case was built on, and I fundamentally believe people with disability deserve better.

The Australian taxpayer is committing over $50 billion a year, and yet as a sector we are still struggling with the simplest obligation of all: ensuring that people who cannot advocate for themselves are not living each day scared, unheard, or unsafe.

I also have to fundamentally believe in the goodness of people, particularly those who choose to work in this sector. I don’t know anyone involved in the Lifestyle Solutions case personally, but I have to assume they did not knowingly or deliberately set out for people to be scared or hurt.

I am not opposed to the NDIS Commission’s use of Federal Court action, nor am I critical of the need for strong enforcement. In fact, I support the Commission’s recent decisions, which have ratcheted upwards in both legal framing and penalty severity in a way that sends a clear message: preventable risk will no longer be tolerated.

But I am also deeply concerned and frankly confused. Despite this escalation, we are still lacking both conceptual and practical guidance on what good practice actually looks like.

Part A – Lifestyle Solutions

Contraventions

Over a period of five years there was a total of 1,907 civil contraventions found against Lifestyle Solutions, a registered NDIS provider, across two proceedings:

• 1,811 contraventions were for the late reporting of reportable incidents (the Reportable Incidents Proceeding).
• 96 contraventions were specific to the safety failures at Hakone House (the Hakone House Proceeding) where repeated physical harm, risk, and injury occurred between 2018 and 2020.

Recorded incidents

There were 46 recorded incidents of physical aggression and property damage at Hakone House. Of these 46 incidents:

• 18 incidents were serious enough to be deemed a breach of the NDIS Act.
• 22 incidents involved actual physical harm.

(Note: The Federal Court judgment text refers to 47 incidents of physical aggression, while the review document cites 46.)

Hakone House

Five residents were living in Hakone House; however the legal case revolves mostly around incidents involving Ashlee:

There were numerous unprovoked incidents of AT and MC physically assaulting Ashlee, as well as an unprovoked assault by SB. Some assaults by AT occurred when Ashlee was asleep, without warning and with no identifiable triggers.

See Appendix A for our timeline of events.

Overall, the 46 recorded incidents paint a picture of residents regularly harming themselves and each other. There were head-banging episodes that broke windows, biting that tore skin, hair-pulling, headlocks, attempts to grab, pinch and bite staff, spitting, screaming and crying, property damage and prolonged periods of severe distress.

On two occasions, Ms Leicester was taken to see a GP for her injuries. Staff often had to redirect, separate or physically manage situations to prevent further harm, while also frequently being subjected to physical and verbal assaults, including locking themselves and participants in a room.

Judicial findings

Justice Abraham stated:

“Lifestyle Solutions was responsible for the care and support of five highly vulnerable members of the community, living at Hakone House, a facility which Lifestyle Solutions both created and administered. Each of the Residents was unable to care for themselves and required a high degree of care. They and their families depended on Lifestyle Solutions to care for and protect them… The Residents were entitled to live free from abuse and neglect, and to have their worth and dignity respected. That did not occur.”

The judge continued:

“It can be inferred Ms Leicester feared for her safety in her own home and what should have been a protected and supportive environment… The abuse was not managed, assessed or responded to adequately or appropriately.”

So what happened?

This has been a difficult article to articulate, as many contributing details were not included in the court documents. What we know is, Lifestyle Solutions had:

• incident reports
• behaviour support plans
• internal reviews
• after-incident emails
• medication changes and
• notes in the risk management system.

What they failed to do was provide a safe shared environment appropriate to the needs of the people being supported.

As the judge noted:

“The risks to participants and workers were not properly identified and managed… These behaviours presented known risks that resulted in repeated instances of aggression and injury over more than two years… Residents and staff suffered actual injuries, the risk of further or more serious injuries, and significant distress.”

Precedent set by the Court

You can have documentation, policies, trained staff and internal reporting and still fail to keep people safe.

When risk becomes routine, the law will not view it as an unfortunate pattern. It is a systemic governance failure.

• Problems kept occurring without any meaningful change. Plans existed, but they weren’t implemented, monitored, or updated.
• Known risks were left unmanaged. Residents who were unsafe together remained together. Staff were placed in impossible situations.
• Leadership oversight was minimal.

Warnings and escalations

What we can infer from the timeline and the penalties imposed is that Lifestyle Solutions had five warnings, in the form of contextual incidents.

• The first penalty they received on 24 October 2019, was for breaching the Practice Standard for Safe Environment – ‘Each participant accesses supports in a safe environment that is appropriate to their needs’. That breach was based on Ashlee not having a safe environment. This particular incident didn’t result in physical harm to Ashlee, but she was taken into the bathroom with a closed door to prevent it. In the five preceding contextual incidents, Ashlee had been bitten once on 23 June 2019, and in 3 of the proceeding contextual incidents, the only person who was physically harmed was AT.
• A second breach was recorded soon after on 16 November 2019. This time Ashlee received a bite mark on her arm, resulting in penalties for breaching the Safe Environment as well as the Freedom from Violence, Abuse, Neglect, Exploitation and Discrimination Practice Standards, requiring ‘Each participant accesses supports free from violence, abuse, neglect, exploitation or discrimination’.
• There is another prosecuted breach of the same two practice standards on 7 March 2020. This time, the injured party was MC, with a bite mark to his left elbow.
• The incident on 29 April 2020 marks the first time the Commission has issued a penalty for failing to protect staff from risk.

The Agreed Facts suggest that prior to Incident 13 on 29 April 2020, Lifestyle Solutions should have taken steps such as:

• Separating AT from living with the other Residents, or to removing AT from Hakone House
• Implementing (or seeking to facilitate funding for) 1:1 supervision of AT as a measure to protect the other Residents and support staff, particularly Ashlee
• After each incident of physical aggression from AT, investigating and preparing reports which had proper regard to all previous such incidents.

There was an added action following Incident 17 on 22 August 2020, that Lifestyle Solutions failed in:

• Taking steps to replace the role and responsibilities of a dedicated House Manager for Hakone House, when it ceased to employ a person in that role from about June 2020.

The Agreed Facts also suggest that from incident MC 11 on 17 September 2021 “Lifestyle Solutions failed to adequately respond to, manage or learn from previous incidents involving physical aggression from MC, specifically car travel, in that it did not take such steps as the following:

• Having and implementing a restrictive practice which would effectively ensure that MC was not able to harm Ashlee or the driver; and
• Otherwise ensuring that MC could not harm Ashlee while travelling, such as by driving them separately”.

Around this stage, it appears as though Lifestyle Solutions was producing internal incident review reports, leading Justice Abraham to the conclusion that the reporting to senior managers was insufficient. The Lifestyle Solutions CEO signed a confidential report on 11 September 2020, which was prepared following AT Incident 17. It can readily be accepted the report was, as described by the Commissioner, “deeply inadequate”.

It included:

• A review of incident reports in respect of … AT identified only one other reported incident (Incident 14) involving physical aggression towards [Ms Leicester] resulting in minor injury.
• Incident 14 refers to an occasion when AT was left unattended and bit Ms Leicester on the right-hand side of her face, on her cheek close to the eye, following which Ms Leicester was prescribed antibiotics for 5 days, and recommended to follow up with a tetanus vaccination.
• The confidential report did not include reference to several key issues and incidents, to which Lifestyle Solutions has now admitted contraventions.
• When Ms Leicester’s family subsequently raised concerns directly with senior management, Lifestyle Solutions failed to prevent further incidents.

13 May 2020 marks the point that the Commissioner deemed that the House Coordinator, Ms Susan Edwards, “did not take reasonable steps to eliminate or minimise:

• The risk of physical aggression by AT to the other Residents, particularly Ashlee, and support workers at Hakone House
• The risk of injury to other residents, particularly Ashley and support workers at Hakone House caused by physical aggression by AT”.

A staff member has been penalised

Ms Edwards, the House Coordinator, was also civilly prosecuted for breaching the NDIS Code of Conduct. Ms Edwards did not receive a financial penalty, with the court stating:

“The Commissioner does not apply for any penalty against Ms Edwards in circumstances where a substantial penalty is being imposed on Lifestyle Solutions. It is also submitted the declarations recording her contraventions are sufficient deterrence in the circumstances of this proceeding.”

Background of employment with Lifestyle Solutions

Ms Edwards had been employed by Lifestyle Solutions since June 2007, starting as a Community Support Worker and was promoted to House Coordinator / Manager in 2010. She was again promoted to Service Specialist in 2020, whilst these issues were occurring in a House she managed.

Whilst employed as a House Coordinator, Ms Edwards was responsible for managing Hakone House and two other residential services, including their staff, residents, resident budgets and clinical orders.

As a Service Specialist – Disability, Ms Edwards was responsible at Hakone House (and eight other houses) for:

• Incident support prevention and response (as part of a wider team);
• Assurance of compliance with contractual, regulatory and safeguarding standards and requirements; and
• Service-based compliance and monitoring of quality of service.

The outcome

Breakdown of financial penalties by incident

The Court imposed a specific penalty amount for each of the 18 incidents where Lifestyle Solutions failed to meet the NDIS Practice Standards or Code of Conduct.

Date	Incident	Description	Penalty Amount
24 Oct 19	AT Incident 6	AT banging head, damaging property, support workers retreated for safety.	$157,500
16 Nov 19	AT Incident 8	AT bit Ashlee on the right forearm.	$105,000
07 Mar 20	AT Incident 12	AT attacked MC, biting his left elbow and tearing skin.	$105,000
29 Apr 20	AT Incident 13	AT attacked a support worker, causing her to fall, then lay on top of her.	$131,500
13 May 20	AT Incident 14	AT bit Ashlee on the face (cheek close to eye).	$131,500
22 Aug 20	AT Incident 17	AT forcefully grabbed Ashlee’s breast and attempted to bite her face.	$111,000
09 Feb 21	MC Incident 9	MC put Ashlee in a headlock, pulled her hair and bit her head.	$111,000
29 Mar 21	AT Incident 23	AT bit MC on his left arm while he was asleep/resting.	$30,000
11 Apr 21	AT Incident 24	AT entered Ashlee’s room while she slept and bit her face; also bit a worker’s breast.	$166,500
18 Apr 21	AT Incident 25	AT pinched and bit a support worker, causing bruising and drawn blood.	$166,500
02 Jun 21	AT Incident 29	AT grabbed Ashlee by the arms and attempted to bite her.	$30,000
06 Jul 21	AT Incident 30	AT bit a support worker on the top of her hand.	$30,000
26 Jul 21	AT Incident 31	AT attacked a worker, pulling out a significant chunk of hair; bit another worker’s wrist.	$139,000
25 Aug 21	AT Incident 33	AT grabbed Ashlee’s jacket and bit onto her ponytail.	$30,000
02 Sep 21	MC Incident 10	MC grabbed Ashlee by the hair in the car, causing her to scream.	$111,000
17 Sep 21	MC Incident 11	MC grabbed Ashlee by the throat and hair in the car; hit a worker in the face.	$139,000
13 Oct 21	AT Incident 35	AT bit and latched onto a support worker’s inner wrist; also bit Ashlee’s hand.	$139,000
25 Oct 21	AT Incident 36	AT bit a support worker’s middle finger.	$166,500
Total			$2,000,000

Judge’s considerations for the penalty

Justice Abraham applied specific considerations (under section 82(6) of the Regulatory Powers Act) to determine that the $2 million penalty was appropriate, with consideration given to the following:

1. Nature and seriousness of the conduct

• Systemic failure: The judge found the contraventions serious because they involved a pattern of aggression over two years in a shared living environment created and controlled by Lifestyle Solutions.
• Vulnerability: The residents were highly vulnerable and unable to care for themselves. Their families placed trust in the provider to keep them safe, which Lifestyle Solutions failed to do.
• Known risks: The risks were not new or unexpected. The provider had knowledge of AT and MC’s propensity for aggression but failed to manage it.
• Impact: Residents and workers suffered actual physical injuries and significant distress. Ashlee Leicester lived in fear for her safety in her own home.

2. Size and financial position

• Deterrence: Lifestyle Solutions is a very substantial provider with significant revenue. The judge noted that a substantial penalty was required to serve the purpose of deterrence given the size of the organisation.
• Not-for-profit status: The fact that the provider is a not-for-profit entity did not reduce the need for a serious penalty.

3. Corporate culture and management

• Inadequate reporting: Reports to senior management were described as “deeply inadequate” and omitted key details required for risk assessment.
• Poor culture: The number of incidents over two years suggested a poor culture of compliance. The incidents were recorded in the system but not treated with sufficient seriousness.

4. Mitigating factors (Why the penalty wasn’t higher)

• Cooperation: Lifestyle Solutions admitted liability at the earliest possible stage, which saved court resources and public funds.
• No prior record: The provider had no prior record of contraventions found by a court.
• Corrective action: The company has since implemented a suite of new policies and procedures to prevent recurrence.
• New ownership: The company was acquired by Independence Australia Group (IAG) and the senior leadership team was replaced. The judge accepted this reduced the need for specific deterrence (deterring this specific company) but did not eliminate it.

5. Totality principle

• Checking the total: The judge applied the “totality principle” to ensure the total penalty of $2 million was not oppressive but was appropriate for the entire course of conduct.
• Course of conduct: For each incident, multiple breaches (e.g., Code of Conduct and Practice Standards) were grouped together so the provider wasn’t punished twice for the same act.

Justice Abraham summarised the case by stating:

“the number and extent of contraventions at Hakone House, over a period of two years, suggests a poor culture of compliance even though each of the incidents was recorded in Lifestyle Solutions’ “Riskman” database. The incidents were not treated sufficiently seriously, and the risks posed by AT and MC were not sufficiently managed or acted upon. It was only after two years of consistent abuse and injury to Ms Leicester, did the CEO of Lifestyle Solutions come to the realisation that the Hakone House residence was “not the right solution for this cohort”. I accept the Commissioner’s submission that the conclusion was obvious well before then”.

Source: https://www.judgments.fedcourt.gov.au/judgments/Judgments/fca/single/2025/2025fca1393

Part B – Opinion piece

People with disability, like all people, deserve to live in a home where they feel safe, respected, and free from abuse. A place where daily life supports their wellbeing, not undermines it. Where they can grow, try new things, build confidence, and simply be their best selves.

Supported Independent Living is not just a rostered service. It is the foundation of someone’s everyday life. This creates a profound responsibility for support workers and providers. Every shift, every interaction, and every decision shapes a person’s sense of safety, dignity, and autonomy.

Good support work doesn’t just respond to needs:

• It protects
• It enables
• It uplifts

It ensures that people are safe from harm. It creates an environment where people can learn, participate, and thrive. And it recognises that quality support is not a task list. It is a commitment to human rights, everyday safeguarding, and genuine care.

The issue is no one knows how to do this well. Even with the supplementary case law, I can say I’m more confused now than ever before.

The core contradiction

The NDIS is built on clear principles: people with disability have the right to live free from abuse to exercise choice and control, to experience the least restrictive supports, and to live in a home that is truly their home and not an extension of a service provider.

But the Lifestyle Solutions case exposes a deep and uncomfortable contradiction inside the system.

On one hand, the Commission expects providers to:

• Uphold human rights.
• Minimise restrictive practices.
• Never use physical intervention except as an absolute last resort.
• Always respect the person’s autonomy and environment.

On the other hand, providers are often placed in situations where:

• Residents live together in arrangements they did not choose.
• Behavioural risk is high but staffing ratios are tied to NDIA “reasonable and necessary” decisions, not actual daily need.
• Homes are both someone’s sanctuary and simultaneously a workplace.
• Restrictive practices are discouraged, yet the environment is unsafe without immediate protective responses.

This next section isn’t about blame. Nor is it attempting to absolve service providers of their responsibility to deliver a safe, empowering and consistent service. I am trying to highlight the fundamentals faults in the way we have designed the scheme and built the supporting systems.

Lifestyle Solutions: A case study in failure

Lifestyle Solutions sits at the centre of this contradiction. That said, I want to caveat the remainder of this paper; by saying I believe Lifestyle Solutions should have done more.

In the Lifestyle Solutions 2020 Annual report, they state:

• We are pleased to report a net surplus of $4.17 million for the 12 months to 30 June 2020. We achieved this through effective cost management and by focusing on delivering the services that we do well.
• Our net customer satisfaction score has continued the upward trend to 91 per cent.
• Our staff engagement score has increased for the third consecutive year to 71 per cent.
• Over 95 per cent of our people accessed tailored training programs during the 2020 financial year. All of our training is underpinned by safeguarding, risk management, active support and the relevant understanding in therapeutic and health supports.
• Our risk-based approach to governance provides a critical lens across the decisions we make as an organisation and provides transparency to monitor our risk profile.
• We have zero tolerance for putting the people we support and our teams at risk.

So here we have a large provider, with significant profit, promoting their commitment to quality, while the Commission rightly found systemic failures.

This behaviour is right to be singled out and penalised. Not just from a Practice Standards perspective but more simply that they have failed to meet the requirements that they have commercially said they can deliver. This includes being an NDIS Registered provider who can continuously adhere to the Practice Standards.

Where I find this approach problematic is that it reinforces a single bad actor narrative, whilst ignoring that the system is fundamentally flawed.

Outcomes like the Lifestyle Solutions case are good at shining a light on what needs to be done better by individual entities, but it is terrible at highlighting the broader systematic issues at play, such as:

• Structural tensions
• Over reliance on restrictive practices
• NDIA setting “reasonable and necessary” separately from environmental realities
• Clinical execution from a workforce built on minimum wage
• “Choice and Control” assumes capacity
• Quality Standards Are high but clarity and practical guidance are low
• Unconditional positive regard but only in selected circumstances.

Structural tensions

The NDIS Practice Standards, even in the proposed reform discussion papers, are:

• broad in wording,
• aspirational in tone,
• inconsistent in operational direction, and
• silent on the “how” that frontline workers and service managers desperately need.

NDIA funding decisions and the Price Guide, the backbone of the Scheme’s economic architecture, suffer from the same structural ambiguity:

• broad in categorisation but narrow in application,
• administratively burdensome rather than practice (and life) enhancing,
• interpreted differently and
• silent on the operational reality of how supports must be delivered to be safe, ethical, and sustainable.

This creates:

• Principles without practice.
• Outcomes without instructions.
• Penalties without pathways.

The current mechanisms for supporting people with a disability to lead a life comparable to those without disability is not aligned with the actual conditions under which disability support occurs.

As a sector, we are trying to design, implement and meaningfully enforce a standard that has never been explicitly articulated. The response mechanism is to punish poor implementation in a system that has never described what effective implementation looks like.

We have created a system where some rules are extraordinarily precise while others remain profoundly ambiguous. The financial rules may be exact about what can be claimed, yet the operational rules are vague about what must be delivered.

The Standards outline rights in sweeping, aspirational terms, while the day-to-day realities of how to enact safe, consistent practice remain undefined. Regulatory enforcement is rigid and punitive, yet the guidance on risk-informed care models is flexible to the point of inconsistency.

The Commission themselves, are not even making decisions guided by a risk-based strategy, with the ANAO 2025 audit stating:

“Since starting operations in 2018 (national from 2021), the Commission had not established a consistent framework to assess, prioritise and manage risks tied to provider non-compliance”.

Further, the ANAO found that the Commission’s “Regulatory Approach”, “Operating Model” and “Compliance & Enforcement Policy” were not informed by data or risk assessments.

This leaves the burden of interpretation to fall disproportionately on providers. They are not only navigating standards and funding logic, but also interpreting behavioural plans, community treatment orders, clinical recommendations, guardian directions, housing conditions, workforce limitations, and participant preferences.

And when any of these components are unclear, contradictory, or disconnected from the real-world context, the consequences land on the people least able to absorb them: frontline workers and the individuals supported.

The issue here is that we have significant documents, tools, and guidance, all specifically addressing single elements. This results in complexity and high potential for error. When a system is built on unclear expectations, no entity can generate consistent outcomes.

A sector asked to deliver high-stakes, safety-critical, relationship-based support within structures that do not align, either conceptually or practically, will inevitably struggle, regardless of how committed or ethical its providers may be.

People with disability deserve a system whose parts work together, not against each other. We need to strengthen the connective tissue with shared definitions, shared practices, shared decision-making, and shared accountability.

Restrictive practices

The Commission is a Commonwealth agency established to protect and prevent people with disability from experiencing harm arising from poor quality or unsafe supports or services under the National Disability Insurance Scheme (NDIS).

This includes monitoring the use of regulated restrictive practices and promoting their reduction and elimination. By their own words:

“The decision to use a restrictive practice needs careful clinical and ethical consideration, taking into account a person’s human rights and the right to self-determination. Restrictive practices must:

• be used only as a last resort in response to risk of harm to the person with disability or others, and after the provider has explored and applied evidence-based, person-centred and proactive strategies
• be the least restrictive response possible in the circumstances to ensure the safety of the person or others
• reduce the risk of harm to the person with disability or others
• be in proportion to the potential negative consequence or risk of harm”.

Yet the statement of Agreed Facts, only provides about six suggestions for what Lifestyle Solutions should have done. Two potentially centre on restrictive practices:

• Having and implementing a restrictive practice which would effectively ensure that MC was not able to harm Ashlee or the driver; and
• Separating AT from living with the other Residents, or to removing AT from Hakone House.

The Commission’s own documentation states that “restrictive practices do not address the underlying factors that cause the behaviour of concern”.

Without fully understanding the structural layout of the home, separating AT from other residents could border on seclusion, particularly if she isn’t funded at 1:1 (which one of the other items suggests). The Commission states “Seclusion should only be used as a last resort for serious behaviours of concern to prevent significant harm to the person or others when other strategies have not worked”.

At the point that the Commission suggests that Lifestyle Solutions “ought to have done more” there had been 12 incidents in 10 months, three recorded physical harm.

As someone who has sat on many Restrictive Practices Panels, I’m not sure I would have approved it.

Lifestyle Solutions was not right to take no action, but I’m concerned that 1/3 of the suggestions that Lifestyle Solutions should have done, involve restrictions or removing someone from their home. Surely, we want providers to take proactive steps to prevent these outcomes from being necessary?

Reasonable and necessary ratios

One of the most significant contradictions in the NDIS is the split between who decides the supports and who carries the liability when those supports fail.

The NDIA alone determines what is “reasonable and necessary”. In this case, and I am reading between the lines of the court papers to assume that Hakone House ran at a 3:5 ratio during the day and 2:5 at night. We know that Ashlee’s mother was supported to apply for 1:1 funding which was rejected.

We can also assume that AT also didn’t have 1:1 funding as one of the suggested actions was “Implementing (or seeking to facilitate funding for) 1:1 supervision of AT as a measure to protect the other Residents and support staff, particularly Ashlee”.

The NDIA sets funding levels based on paperwork (which may or may not be read), not an on-site risk assessment. Yet when incidents occur:

• the Commission blames the provider,
• the Court penalises the provider,
• workers are injured,
• participants are traumatised,
• families lose trust.

The NDIA, meanwhile, is never held accountable for approving a ratio that was objectively insufficient for the behavioural profile, communication needs, or environmental reality of the participant.

I acknowledge that providers should refuse to provide support to participants that they believe are unfunded, particularly if the underfunding is going to impact on safety, but there were 42,353 plan reassessment requests in the Sept 2025 quarter.

Whilst there isn’t a direct correlation to the number that would result in providers refusing services, it is still a large number of people that would potentially go without service.

I agree with the Agency standpoint “We fund supports. We don’t run services.” But its decisions directly affect:

• safety
• supervision ability
• incident frequency
• restrictive practice risk
• compatibility of residents
• clinical outcomes

Even when providers escalate concerns, NDIA reviews routinely take weeks for urgent requests, months for standard reviews, and sometimes more than a year.

During that time, the onus doesn’t change for providers. They must continue to provide the same level of support, without the funding, staff intensity, or environmental changes needed to do so safely.

The NDS State of the Sector 2025 report confirms this. It found:

“Seventy-seven per cent of organisations delivered unfunded services last year, at an average cost of almost $500,000 per provider”.

My crude math suggests that an extra $111 million that the scheme isn’t considering in their financial projections.

Clinical execution from a workforce built on minimum wage

One of the most significant and least acknowledged contradictions in the NDIS is the gap between what workers are expected to deliver and how the workforce is structured.

At a policy level, the Commission expects support workers to demonstrate:

• trauma-informed practice
• behavioural risk management
• active supervision
• least-restrictive decision-making
• accurate clinical documentation
• crisis de-escalation
• safeguarding and professional boundaries
• incident analysis and early warning detection

These are clinical skills, not entry-level tasks. Yet the workforce expected to deliver this is:

• predominantly award-wage
• heavily casualised
• mixed-literacy, mixed-language
• working irregular shifts across multiple houses
• trained primarily through Certificate III programs, if at all.
• experiencing high turnover, burnout, and psychosocial injury
• given limited supervision and inconsistent on-the-job coaching

This is not a criticism of the workforce; it is a failure of system design. Frontline workers are routinely placed in situations requiring skills they were never formally trained for and are not adequately supported to develop.

Like in every other business, providers have the responsibility to train, supervise, and upskill their staff regardless of the award wage. The difference is the emphasis we put on that skill.

For many in our sector and the general public, support work is an unskilled role. Yet it requires some of the most complex emotional intelligence.

Ms Edwards the Hakone House Coordination and then Service Specialist, followed a very typical promotion pathway. She began work with Lifestyle Solutions as a support worker. Her formal qualifications are not known.

As a House Coordinator, she was probably employed at a level aligned to a SCHADS Level 3 or 4. Meaning:

“although still under general direction, there is greater scope to contribute to the development of work methods and the setting of outcomes. However, these must be within the clear objectives of the organisation and within budgetary constraints” and “solutions to problems generally found in precedents, guidelines or instructions with assistance usually available”.

Ms Edwards admitted that she did not raise issues with her senior leaders with the appropriate urgency but systems this complex also shouldn’t be reliant upon individuals to do the right thing.

The expectations of a frontline leader are further complicated by the NDIA’s determination of what a reasonable supervision ratio is within their reasonable cost model. Whilst the 1:15 FTE ratio has been removed from later published cost models; the financial alignment remains the same.

World regarded sources such as Harvard Business Review and McKinsey consistently note that a leader’s span of control (number of direct reports) is one of the strongest predictors of:

• quality of supervision
• speed of escalation
• performance consistency
• employee engagement
• burnout rates
• culture stability

Across industries, the effective span of control is generally 6–10 direct reports for frontline or operationally complex work.

When the work is high-risk, unpredictable, interpersonal, or cognitively demanding, HBR proposes a span closer to 5–7. Yet the NDIA, in their wisdom, have essentially doubled it.

Bain and Company service delivery research (“The Firm of the Future” (2017) ) shows that when supervisors have too many reports, they become:

• admin managers rather than performance leaders
• reactive rather than preventative
• unavailable for coaching
• blind to early warning signs

I have had to call my own unconscious bias into play when considering this finding. Lifestyle Solutions and Ms Edwards have been civilly prosecuted. They have owned their wrongdoing, yet almost every provider (even the great ones) are experiencing the same predictable outcomes of:

• inconsistent practice
• variable quality
• over-reliance on restrictive responses
• escalating behaviours
• staff injury
• burnout
• high turnover
• and ultimately, unsafe environments for participants

If the NDIS wants safe, skilled, person-centred practice, it must invest in:

• structured career pathways
• clinical supervision
• uplifted minimum qualifications
• paid training time
• behavioural skill development
• and realistic staffing models

Otherwise, the mismatch between expectations and capability will remain one of the most critical risks in the scheme.

Choice and control assumes capacity

“Choice and control” is the philosophical centrepiece of the NDIS. It assumes that participants will actively direct their supports, compare providers, understand quality, make informed decisions, and recognise when something isn’t working.

It also assumes that various clinicians, support coordinators, behaviour practitioners, therapists, and providers will naturally align around the participant’s best interests.

But this vision quietly depends on three conditions that the scheme does not actually provide:

1. that the participant has the capacity to exercise informed choice,.
2. that someone is coordinating a unified, clinically-sound plan, and
3. that participants understand what “good quality” looks like well enough to demand it

These assumptions rarely hold true in real life, especially for people with complex support needs requiring 24/7 care.

The NDIS is a market-based scheme where “quality” is meant to be controlled by the consumer. But for a market to function, consumers need:

• accessible information
• the ability to compare options
• an understanding of what “good” looks like
• the authority and capacity to switch providers
• the skills to identify poor practice

And most importantly, a safe and stable environment in which to make choices. Asking someone who is dependent on the service to provide negative feedback and ‘vote with their feet’ is not only confronting, but also near impossible.

How many people have had a bad haircut or meal and made the choice to not complain, but never return? Or you do complain, hoping it will be fixed, but knowing if it becomes unpleasant you can leave and won’t have to deal with them again?

We are asking NDIS participants, especially those with cognitive disability, psychosocial disability, limited communication, or complex behaviours, to take actions that many of us are uncomfortable to do, even when the stakes are significantly lower.

Expecting a person living in crisis, trauma, or cognitive impairment to “shop for quality” is not choice and control, it is abdication disguised as empowerment.

Combine this with a system operating in silos:

• therapists write reports for funding
• support coordinators focus on budgets and service linkages
• SIL providers focus on rosters
• behaviour practitioners focus on isolated behaviours
• the NDIA focuses on cost
• the Commission focuses on compliance

No one is responsible for the whole person. For people with high needs, there must be:

• a single point of coordination
• integrated clinical oversight
• unified goals
• consistency across all providers
• shared behavioural understanding
• monitoring to ensure reports translate into practice
• oversight that is skilled, not administrative

But the NDIS design removes any single, central coordinating authority. Everyone has a piece but the court findings have proven, it is SIL providers that are responsible for the whole.

The Lifestyle Solutions case illustrates this brutally: expensive reports existed; risks were known; actions were recommended. But without integration, no one stitched those insights into a safe, coherent environment for the residents. This service doesn’t exist in the price guide or the Reasonable Cost Model.

There is also a very loud silence in the Hakone House judgement. It was never asked why Ashlee’s Support Coordinator didn’t raise service concerns, or why the Behaviour Support Practitioner didn’t develop stronger, more appropriate strategies to minimise the behaviours of concern from AT and MC.

Support Coordination exists to monitor the quality of services and escalate concerns. Behaviour Support exists to analyse why behaviours occur and recommend interventions that reduce them. Both roles are intended to provide separate set of eyes focused on the person’s best interests.

Yet in this case, neither appears as an active safeguarding force.

• No documented concerns
• No urgent requests for environmental changes
• No formal escalations
• No new strategies
• No challenge to the provider’s capacity to support this mix of participants safely

This isn’t just an omission. It’s a symptom of a deeper issue in the scheme, the assumption that multiple external professionals will naturally coordinate, challenge, and intervene.

But the reality is when everyone assumes someone else is monitoring quality, no one truly is.

I accept that this wasn’t within the court’s remit in this case, but it is within the purview of the Commission.

SIL providers have to accept a higher level of accountability on the basis of their ‘whole of life’ involvement, however they are technically adhering to the same rules.

In order for holistic change to be possible, we need to look at all the Swiss cheese holes that allowed this situation to occur.

Limited practical guidance

If the Commission is to drive safety through deterrence, it must also drive safety through knowledge, capability, and practical instruction. Because without that balance, we risk creating a sector that is compliant on paper, fearful in practice, and unsafe in reality.

The same day that the court finalised the proceedings, Commissioner Louise Glanville proudly announced the court’s decision stating:

“Registered providers have legal obligations to report serious incidents within required timeframes. Failure to do so leaves participants at serious risk of harm and prejudices our regulatory work.”

She went on to say:

“The NDIS Commission will not hesitate to use every power – including civil proceedings – to protect the human rights of people with disability.”

But they didn’t use every power. The Commission lodged their claim with the courts on 21 November 2024. Lifestyle Solutions and Ms Edwards signed the statement of Agreed Facts on 25 July 2025. I appreciate they couldn’t produce anything formally until the outcome had been decided by Justice Abraham BUT they could have used those 3 months to build a compelling case study on what good SHOULD have looked like in this case.

I run a small business, with very limited resources. I’ve done it in less than 2 weeks… it’s not perfect. But it doesn’t have to be. By virtue of human services, there will always be variance and cause for adaptation. The key to this guidance is to inspire action and support providers to improve their daily practice.

Lacking unconditional positive regard from the entity built to uphold it

People with complex support needs deserve to be met with unconditional positive regard. To be understood through the lens of trauma, communication barriers, sensory overwhelm, and unmet needs. Every person in SIL should be seen as someone worthy of care, safety, and dignity, no matter how challenging their behaviours may look on the surface.

And yet, reading the Lifestyle Solutions judgment, it’s what isn’t said.

AT appears throughout the document only in terms of her actions and very rarely her context. There is almost no reference to her being:

• a funded NDIS participant
• largely non-verbal
• living with significant communication barriers
• a person experiencing extreme distress and physical pain
• someone repeatedly harming herself
• someone highly vulnerable and reliant on others for safety

The judgment catalogues every moment she hit, grabbed, screamed, bit, or banged her head but almost nowhere does it acknowledge the why.

Her behaviour is framed as risk, but not as communication. That absence matters.

Because regardless of how confronting her behaviour became, AT was a person who needed a safe environment, therapeutic support, consistent routines, and staff who understood the sensory and emotional drivers behind her distress. She needed a home designed around her needs, not one that exposed her to triggers that continuously escalated her behaviour.

Lifestyle Solutions did not provide her with that environment.

The Commission and Court focused on compliance failures. Which I appreciate is one of the limited levers in the legislation, but they missed a huge opportunity to highlight her humanity.

AT was not the problem. The conditions around her were. The same can be said for MC.

Her self-injury, her distress, her reactions. These were symptoms of an environment that did not meet her needs and did not keep her safe.

This element is never mentioned, yet as an NDIS Participant, she is covered by the same legislation and Practice Standards as Ashlee. The violence abuse and neglect standard may not apply, but risk management, incident management and safe environment all do.

Ashlee deserved to live in a home without fear. But AT and MC also deserved supports that helped them to communicate in ways that didn’t harm others.

And if unconditional positive regard means anything in this sector, the powers that be need to see the person behind the challenges, not just her behaviour.

We need learn, that even in retrospect, and from a punitive lens, it wasn’t recognised that the whole system failed to provide AT and to a lesser extent MC with what every person with disability deserves: safety, dignity, stability, and a home where they can regulate, not deteriorate.

If we want to prevent another Lifestyle Solutions, The Agency, the Commission and the Broader Australian Government need to address the contradictions. Not just the compliance failures. Real reform means aligning the system with its own values, not just holding SIL providers to account for outcomes they were never fully empowered to prevent.

Appendix A

Stay tuned for Part C where I dive into what best practice could look like, based on what we know wasn’t enough.

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If you would like confidential assistance in looking at this differently, book in a time to have a no obligation chat via my  bookings calendar or email me at  angela@supportingpotential.com.au.

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Your partner in achieving compliance, growth and sustainability 

Angela Harvey
Managing Director of Supporting Potential

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