systems

2 December 2025

Following our analysis of the systemic flaws and structural gaps in the NDIS from Lifestyle Solutions safety failures, we now shift our focus to actionable solutions. This is:

Part C: the Action Plan

Possible best practices

If you’re reading this, there’s a good chance you are already feeling the pain of being an NDIS service provider. The contradictions. The structural gaps. The impossible expectations. The market design flaws everyone sees but no-one has fixed.

Most readers, especially those working in Supported Independent Living (SIL), will recognise the truth in it. The scheme is flawed.

Systemically, deeply, and predictably flawed.

And while it is easy to feel validated by naming those faults, we also need to face the uncomfortable reality: those flaws are not going away.

We’ve already seen:

• • Bills introduced to Parliament
  • Discussion papers on new Practice Standards
  • Additions to the Code of Conduct
  • Own motion inquiries
  • Incremental tweaks to incidents, reporting, and quality rules.

But none of these changes touch the root causes: the market design, the capacity assumptions, the funding constraints, the fragmentation, or the sheer mismatch between expectations and workforce conditions.

Yes, we can and should continue to advocate for structural reform. But advocacy alone will not protect providers.

Especially SIL providers.

Because until the system changes (if it ever does) the risk sits with you.

And it might not be fair, but the risk has to sit somewhere. Vulnerable people who deserve better need someone to own it and improve it.

So providers have a decision to make: Change the way you operate now, or risk becoming the next provider in front of the Federal Court.

The Commission has shown its hand. It took them four years to create precedent for penalising SIL providers for deaths in support. They are now building their remit for reasonable practice and have set the precedent to separate operational harm from systemic compliance neglect.

Meaning:

• • increased scrutiny
  • deeper investigations
  • more aggressive enforcement
  • and now a new Bill proposing significantly higher penalties for breaches of the NDIS Act.

The Commission has quietly and intentionally moved the sector from a reactive model → preventative accountability model.

Providers can no longer continue to rely on:

• • templates over agile decision making
  • forms over decisions
  • containment over redesign
  • and habit over safeguarding

So ask yourself honestly: With higher penalties on the table, is “business as usual” a risk you’re willing to take?

Participants deserve better. Staff deserve safer. And organisations deserve clarity, even if the system itself remains unclear.

Which is why, flawed as the scheme may be, there is a best possible way to operate within it. Practices that reduce harm, increase safety, strengthen culture, and withstand scrutiny.

This next section outlines those practices not as idealised theory, but as the operational behaviours that separate safe, resilient SIL providers from the ones who end up in judgments like Lifestyle Solutions safety failures.

Visualising the solution: The participant lifecycle

The practical steps we outline below are designed to move your organisation away from static compliance and into dynamic operational safety.

The goal is to move beyond simply documenting incidents to building a responsive system that reduces risk and complexity at every stage. Without pretending providers can solve everything.

This model shows how understanding the longer term operational demands allows service providers to build a more comprehensive participant lifecycle journey starting with Robust Onboarding, which leads directly to Tier-based Staffing and Integrated Practice Loops, ensuring systems respond to emerging challenges (Escalating Complexity Triggers) before they become catastrophic failures.

Let’s get practical.

The new rules:

1. A documented system is not evidence of safety: If it doesn’t change practice, it’s paperwork, not safeguarding.
2. Patterns are now evidence: If the same harm happens multiple times, that’s a system failure, not bad luck.
3. Timeliness is a safeguarding control, not administration: Late reporting = reduced protection = legal risk.
4. Frontline leaders are not shielded by organisational structure: Delegation now comes with legal accountability.
5. You won’t get unlimited chances: Escalation will now be expected after early indicators, not after a crisis.

Old thinking	New leadership thinking
“We have reporting.”	“We have learning loops that change support.”
“It’s documented.”	“It is implemented, reviewed and evidenced.”
“This is complex behaviour.”	“This is predictable risk requiring system redesign.”
“We’re doing our best.”	“We are actively eliminating or reducing harm.”

 

Providers need to avoid the knee-jerk reactions of ceasing support to more complex participants or imposing harsher threats on the frontline to ‘do better’. As leaders, we need to remember that a healthy system learns. It uses mistakes, near-misses and failures as data to adapt.

At present, key learning mechanisms are:

• • Incident reporting and investigations
  • Behaviour support reporting
  • Audits and non-conformity findings
  • Royal Commissions, inquiries and court cases.

These mechanisms are slow, often adversarial, and not experienced as safe vehicles for learning by providers, workers or the people being supported. The dominant emotional tone is often fear and defensiveness, not curiosity. In a just culture, people are held accountable for reckless or negligent behaviour, but the system responds to honest mistakes and system-induced errors with learning and redesign, not automatic blame.

When people are punished for exposing risk and error, the system will learn less, not more. Under-reporting is a system response, not a moral failure.

People deliver the quality, not paperwork

Many providers have built enormous towers of policies, forms, templates, and frameworks. All technically compliant, most archaic in their design and intent but practically useless.

Frontline workers don’t need more paperwork. They need clarity, support, and systems designed around how humans actually think, work, and respond under pressure.

 

The participant lifecycle: Business as Usual (BAU) quality enhancements

Review

I appreciate many auditors lack the skills to effectively determine this (not the individuals’ fault, but again, a systematic contradiction), but that is not a reason to not do it.

Leaders must take an honest look at their operational systems and ask:

• • does this tool make practice easier or harder?
  • does this form produce insight or just tick a box?
  • does this process help staff respond faster or slow them down?
  • does this template protect participants or protect us from auditors?
  • do workers use this in real time, or only in training rooms?

If the answer is unclear, the system needs refinement. Great support is usually delivered when frontline workers have:

• • consistent routines
  • clear expectations
  • stable teams
  • usable tools
  • predictable escalation pathways
  • strong and engaged leadership
  • simple ways to report concerns
  • feedback loops that close
  • time to focus on people instead of admin.

As a leader in this sector, we are passionate about supporting people. But we can often forget that our workforce are people too. They are limited. They have complex ranges of emotions, make mistakes, get tired or freeze under pressure.

Think about the last big mistake that was made in your organisation. Did the system punish humans for being human? Or did the system make it really hard for the human to do the right thing?

Refine

The success of disability support is often built upon the quality of the relationships built. But most Service Providers start these relationships with limited information and uninformed decisions.

A safe onboarding system must include a full complexity assessment before acceptance.

Collect data across:

• • behaviour
  • communication
  • sensory profile
  • medical needs
  • trauma history
  • family dynamics
  • compatibility with existing residents
  • staffing intensity required
  • risk triggers and warning signs.

Not from one report but from a triangulated review of all available information. Now, I know the truth here: You almost never get the full picture. You often get partial reports. Sometimes you get nothing at all. You don’t need every document to move forward but you also can no longer afford to wait passively and hope for the best.

You can use other information sources (with consent) such as:

• • talk directly to the previous provider
  • call every clinician on the plan
  • ask support coordinators for verbal summaries
  • speak with the family or guardian
  • ask the participant what they want, fear, need
  • check hospital discharge summaries
  • review NDIA goals and past funding patterns
  • look for behavioural clues in daily routines.

Bottom line, before beginning supports, you must have enough to answer three questions:

1. 1. can we safely support this person with our current workforce?
   2. is this home the right environment?
   3. is the mix of residents viable?

If you cannot answer these with confidence, you should not proceed.

The Federal Court has been very clear: Providers are liable for the risks they take on, even when the information was withheld or missing. And remember, documentation becomes your protection. If you don’t have it, make it. Document your response to these questions along with what you requested, when you requested it, and who responded and what they provided. Store it in the CRM for easy access.

Many providers currently operate under a now flawed traditional sequence of:

Ask for info → Sign Service Agreement → Start service → Build full plan → Gather new plans and reports.

I’m a fan of a Provisional 90-Day Service Agreement. It clearly states:

• • support is accepted provisionally
  • the first 90 days are a “stabilisation and assessment period”
  • full service agreement will be finalised at Day 90
  • ratios may change as risk becomes clearer
  • onboarding may stop if information gaps remain
  • PBS/OT/clinical reviews will shape the final plan
  • environment suitability must be confirmed.

This process protects the participant and the provider.

Build a Version Zero Support Plan

Especially in the onboarding period, your team need guidance on how to support this person safely. The NDIS only requires supports to be safe, documented and appropriate. Having a Version Zero plan meets this and acknowledges the plan will be expanded.

You need to give your team the minimum information to support:

• • communication
  • daily routine
  • medication
  • immediate risks
  • de-escalation basics
  • known triggers
  • WHS considerations
  • legal requirements (consent, privacy, RPs).

This is your safe operating baseline, simply designed to prevent immediate harm. Make it a 2-page attention-grabbing doc. And remember, there is no requirement for Day 1 perfection, just Day 1 safety and ongoing improvement.

90-day dynamic onboarding period

We know risk escalates or stabilises during the first 90 days. It is also the period where you will have the most uncertainty.

Use this window to intensively monitor:

• • environmental fit
  • early warning signs
  • responses to staffing
  • behaviour support implementation practicalities
  • incompatibilities.

It also gives you the opportunity to:

• • engage with Behaviour Support
  • OT / environmental review occurs
  • initiate communication assessments
  • meet with family / guardian
  • gather lived data
  • analyse incident patterns
  • assess compatibility
  • review workforce capability.

This process is the start of iterative design and creates a clear signal that you are no longer static planning.

Every 30 days → Support Plan Version 1, 2, and 3 are issued.

This should be looked upon favourably at audit as updating support plans as new information emerges is considered best practice and aligns with incident-management, duty of care, and PBS obligations. By Day 90, you now have confidence that you can support this individual safely and help them to achieve quality outcomes. The confidence is driven by:

• • real lived information
  • known triggers
  • known patterns
  • stabilised routines
  • aligned RPs and PBS strategies
  • a full understanding of complexity
  • environmental modifications
  • workforce allocation certainty
  • final compatibility outcomes.

Now you can safely and confidently issue:

✔ Finalised Support Plan

✔ Final Service Agreement

✔ Final Rostering Model (based on complexity)

✔ Final Behaviour Support Strategy

Document what matters

Stop and think about the documentation a frontline worker must complete each shift:

• • Shift handover notes: often duplicated across multiple platforms like Teams, shift notes, CRM.
  • Shift notes / daily support notes: usually a detailed narrative or structured notes.
  • Medication documentation: always high stakes but often time-consuming and undervalued by frontline.
  • Incident reports: repeated variations of the same communications depending on the audience.
  • Behaviour support data collection: often through the Practitioner and poorly integrated back into practice.
  • Restrictive practice data: high compliance burden but rarely used to inform practice.
  • Goal development records: usually very poorly completed as goals are not well understood or implemented into practice.
  • Meal preparations and nutrition logs: often an add-on, but something that quickly becomes imperative if there is an issue.
  • Money handling / financial accountability: high compliance and exposure risk.
  • Health monitoring charts: again these are often double-handled or avoided until there is a problem.
  • Communication logs: repetitive and often summarised to the point of no longer being useful.

or what happens when the vital comms stays buried in someone’s inbox but timesheets? This one usually always gets done, funny that.

Now, tell me, of those documents what gets regularly and routinely used?

Many organisations fall into the trap of a one-size-fits-all compliance approach. But if you invest your time upfront, designing quality service delivery, you minimise the ongoing impost and over-reporting.

I believe you can set a minimum reporting approach that then builds as the complexity of the participant increases.

These 5 essential documentation items per shift, with clear triggers for when additional documentation is required, protects the participant, the worker, and the provider. Without the noise.

1. 1. Shift Attendance Record (MANDATORY): Proves the shift happened and who was responsible.
   2. Participant Sight & Safety Check (MANDATORY): 1–2 lines per participant confirming wellbeing and supervision.
   3. Medication Confirmation (MANDATORY IF APPLICABLE): Tick + signature only:
      • ✔ “Medication administered as per MAR” OR
      • ❗ “Variance — incident lodged”
   4. Shift Notes (MINIMAL & FACTUAL): 2–3 bullet points with the focus on confirming the support plan was delivered to and documenting any changes in mood, behaviour, or health.
   5. Handover Summary (MANDATORY): Short, practical, frontline-only information for next shift.

Your frontline should ONLY complete additional documents if triggered by one of these three categories:

1. 1. Incident / near miss
   2. Behaviour Support Data (ONLY if required by current PBS plan and not being captured through incident reporting already)
   3. Health Monitoring Plan (ONLY if the participant has the need identified in their support plan).

(Note: For those interested, I have formed another business with two new partners, Support Signal. We are hoping in early 2026 to launch an AI tool that supports you to do this all through a single ‘moments that matter’ entry. And get the learnings straight away).

Continuous feedback loops (the system self-corrects)

Complex systems and supports stabilise through feedback and consistent decision making. The issue with relying on documents to support this is that they get lost in the noise.

Bring it to the surface with:

1. 1. Weekly House Risk Huddle: Same time each week – online chat thread → What’s better? What’s worse?
   2. Monthly Behaviour/Clinical Review: Patterns → triggers → alerts → environment adjustments.
   3. Quarterly Participant/Family Insight Check: Hear from the person → their experience → their unmet needs.
   4. Biannual Service Agreement & Plan Review: Formal adjustments by agreement.

This ensures that the plan is kept alive and adaptive at all levels of involvement.

Escalating complexity triggers

If any of the following occur, the model should trigger more formal behavioural / clinical reviews:

• • 3+ behavioural incidents in 30 days
  • frequent self-harm attempts
  • assaults on staff or residents
  • increasing environmental damage
  • inability to be safely redirected
  • high staff turnover due to the participant
  • emerging medical or mental health concerns.

Depending on participant complexity and what is in the Service Agreement, providers could also run a monthly “complexity review panel”. This panel includes the operations manager, practice leader, and all other participant stakeholders.

The panel tracks whether risk is trending up, stable, or down and agrees to what needs changing. This is an efficient way for SIL providers to ensure some of the quality risks are transitioned to sit with all stakeholders and not just them.

Scalable staffing skills

By investing in robust support planning, it underpins every later decision such as staffing intensity, skill mix, supervision level, roster design, and escalation pathways. Providers need to focus on designing supervision and support based on assessed need, risk, and complexity. This means:

• • Conducting thorough assessments (behavioural, clinical, communication, environmental).
  • Implementing clearly defined support models aligned to each participant. This needs to then be delivered by well-trained, stable, and supported staff.
  • Ensuring strong frontline leadership (with reasonable span of control).
  • Building systems for dynamic review such as increasing staffing or supervision when risk escalates, decreasing when risk stabilises.
  • Embedding continuous practice evaluation, not just numeric compliance.

The target should be “evidence-based, needs-responsive supports” with strong leadership, clinical governance and capacity for escalation, with the frontline knowing they can rely upon:

• • short, direct, behavioural expectations from them as an employee
  • translated needs → strategies → expected staff actions
  • clearly defined how to support each person
  • integrated PBS, OT, clinical, and daily living supports
  • outlined proactive and reactive approaches
  • highlighted environmental considerations
  • known risk triggers and early warning signs.

The goal of a support plan is that frontline staff know exactly what to do, which reduces variability, drift, and unsafe improvisation. Instead of relying on endless documentation, audits, and checklists, providers can utilise their frontline leaders to shift to quality-focused evaluation:

• • is the plan being delivered as intended?
  • are the staff confident and capable?
  • are risks decreasing or increasing?
  • are participants achieving outcomes?
  • is the environment supporting regulation?
  • what early warning signs are emerging?

By building a system that allows you to adjust allocations in real time, such as:

• • increasing staffing or supervision when risk escalates
  • decreasing intensity when a participant stabilises
  • adding coaching or clinical oversight where needed
  • shifting experienced staff into homes with emerging complexity.

we are more responsive to the participant need, as well as financially more viable.

“It costs too much to change” — the myth that keeps providers stuck and exposed

“We’d love to improve, but we’re not funded for that.”

“We can’t afford more change.”

“We don’t have the margin.”

And yes. There is always a cost to change. Whether you do it internally or hire external help, there will be a cost to building better support plans, redesigning workflows, training staff, creating leadership pathways, and improving risk monitoring.

But:

You are already paying for inefficiency.

You are already paying for risk.

You are already paying for turnover.

You are already paying for crisis.

You are already paying for poor practice.

The question isn’t whether you’ll pay. You are probably already operating at a loss. So the question becomes do I take control of what I’m paying for, or risk ongoing inefficiency and unimaginable penalties?

The key drivers that produce efficiency

The truth is simple: you are already paying the cost of inefficiency, through:

• • turnover,
  • crisis response,
  • avoidable incidents,
  • vacancies,
  • administrative overload, and
  • legal exposure.

The question is no longer whether you will pay. The question is whether you will direct those costs deliberately or continue absorbing them reactively. Efficiency in SIL doesn’t come from working harder, documenting more, or tightening compliance checklists. It comes from reshaping the core drivers that determine practice:

• • how you gather information,
  • how you design supports,
  • how you allocate staff,
  • how you lead,
  • how you monitor risk,
  • how you train people, and
  • how your operational systems work together.

These are the strategic levers that shift resources away from crisis and churn and into predictable safety, capability, and stability.

A key first step is considering the structures that no longer serve you or are silently locking you into unsafe patterns.

Service Agreements are one example. When written as rigid contracts, they trap organisations into fixed ratios, fixed routines, and fixed expectations that cannot adapt to the shifting reality of complex support.But this principle extends far beyond contracts. If any part of your organisational architecture is static while the support environment is dynamic, inefficiency grows, risk escalates, and staff stability collapses.

Build operational flexibility

The following section outlines how to build operational flexibility into the core of your organisation through adaptive contracting, funded non-face-to-face work, dynamic support planning, scalable staffing skills, and an integrated approach to learning, leadership, and risk monitoring.

These are not compliance tasks. They are the structural drivers that make your organisation safer, more capable, and more efficient. Redirecting effort and investment into these areas generates immediate returns, reducing administrative load by up to 80%, improving frontline consistency, lowering turnover, and strengthening daily practice.

Put simply: You don’t need more resources. You need your resources aligned to what actually produces outcomes.

Change your service agreements

One of the biggest mistakes SIL providers make is treating Service Agreements like compliance-enforced, fixed-term commercial contracts.

They lock themselves into fixed staffing ratios, fixed routines, fixed inclusion/exclusion lists, fixed pricing, fixed deliverables, and fixed expectations… then spend the next 12 months breaking their own contract every time a participant’s needs change.

Modern SIL agreements must include:

✔ Provisional onboarding period (e.g., 90 days): Because real needs only become clear after lived experience, not paperwork.

✔ Variable staffing based on dynamic need: Agree to a range, justified by risk.

✔ Capacity for clinical oversight adjustments: PBS, OT, allied health, and medical recommendations must be allowed to reshape the model.

✔ Right to pause or modify unsafe supports: A provider must legally reserve the right to stop unsafe practice. It’s a good idea to have an agreed way this will occur.

✔ Shared responsibility clauses: Support Coordination, clinicians, families, and previous providers must contribute information.

✔ Conditions for service continuation: Including behaviour plans, risk assessments, medication information, environmental suitability.

The NDIS Price Guide explicitly permits NDIS providers to claim reasonable and necessary non-face-to-face supports, including:

• • staff training directly tied to a participant (not generic and routine training)
  • PBS plan implementation work
  • attending case conferences
  • incident follow-up
  • documentation required to deliver safe support
  • behaviour assessments
  • environmental modification planning
  • complex risk assessments.

You need a clause that states clearly:

“This service includes essential non-face-to-face work required to ensure the participant’s safety, support quality, and ongoing outcomes. This may include planning, coordination, documentation, training, and communication with key stakeholders as outlined in the NDIS Price Guide.”

Invest in support planning

Use that now funded non-face-to-face time to rebuild support plans. Build them from the perspective of how your frontline will use the information and associated infrastructure.

This one is a no-brainer. By focusing attention up-front, providers will reduce admin time by 60–80%, increase real support time, reduce errors, decrease audit risk, improve staff morale, and strengthen practice.

Get an approach to learning that improves outcomes

Again, a financial no-brainer. A stable, skilled workforce reduces turnover (the single biggest cost burden in SIL), inconsistency for participants (a lead driver of incidents), training duplication, compatibility failures, and rostering chaos. Remember that replacing one worker costs $12,500–$18,000. Stability is a financial strategy.

You are probably using an online learning system. But does it allow you to align training, supervision, and organisational systems into one continuous improvement engine? Bridging the gap between training and operations Most providers rely on generic online learning systems that tick compliance boxes but fail to change frontline behaviour.

The Supporting Potential Strategic Development LMS is different. It doesn’t just offer isolated courses; it aligns training, supervision, and organisational systems into one continuous improvement engine.

We built this system to solve the specific problems highlighted in the Lifestyle Solutions judgment: variability, inconsistency, and the disconnect between policy and practice. By embedding shared language and standardising routines, we help you make practice predictable, repeatable, and safe.

When everyone learns the same frameworks, uses the same tools, and understands the same expectations, the whole organisation can improve together, not in fragments.

The writing is on the wall

The conditions that created the Lifestyle Solutions judgment are not extraordinary; they are present in every SIL business. They are outdated structures that haven’t adapted since the block funding days:

• • static agreements,
  • underdeveloped support plans,
  • weak onboarding, or
  • overwhelmed frontline systems.

This is the root cause driving the quality of service that the most vulnerable in the NDIS are receiving. And now the expectation is shifting. Quietly, consistently, unmistakably.

• • providers are losing money,
  • margins are shrinking,
  • turnover is rising,
  • vacancies are hard to fill, and
  • regulatory action is escalating.

The Commission is signalling an expectation, no longer a suggestion, that only resilient, agile and modernised operators will survive. The question is whether leaders will respond deliberately or continue to drift.

Most of the changes outlined in this paper can be done internally, if you can create the space to stop daily firefighting long enough to rebuild the foundations. But that requires stepping back from service delivery pressure, challenging long-held assumptions, and confronting the traditional biases that no longer serve your organisation or the people you support.

For many organisations, bringing in external support provides the additional muscle, independence, and momentum needed to break through operational inertia. A consultant is not a cost; they are a circuit-breaker, a structural amplifier, and a tempo setter who accelerates change that would otherwise take years.

As you prepare your Q3 2026 budget, consider reframing it to support you to move resources away from crisis management and into the strategic levers that produce stability:

• • dynamic risk systems,
  • adaptive contracts,
  • modern documentation,
  • scalable staffing capability,
  • strong practice leadership, and
  • learning systems that genuinely change behaviour.

The sector cannot afford another Lifestyle Solutions and most individual providers can’t afford to drift into the same conditions that produced it.

The organisations that act now—boldly, deliberately, and with strategic intent—will be the ones left standing.

The rest will be the ones we read about.

The choice is yours.

The next step: turn risk into real change

Ready to act?

Before you close this page, consider your next action.

Your whole leadership team is invited to a practical, high-impact webinar designed to help you turn these insights into real changes inside your services.

Use your time wisely—walk away with solutions:

• Attend together, challenge your assumptions, and confront traditional biases.

• Develop business solutions shaped through innovative workshopping and real case examples.

• Gain practical suggestions you can apply the very next day.

If you want your organisation to improve, don’t leave this to chance. Bring your team, bring your questions, and let’s get to work.

Register your interest via this form NDIS practice redesign masterclass for NDIS service providers

 

Get involved and get connected!

• We would love to know if you’ve tried any of the activities we’ve suggested or done something similar in the past – and what the outcomes were! You can reach out to us in the Get in touch section at the bottom of this page.
• We also share practical tips, real life examples, and expert insights every week on LinkedIn. Follow along, join the conversation, and share these posts with your network.
• Join our mailing list here to receive notifications up upcoming instalments and webinars. We truly value the insights and experiences attendees are bringing to our webinars!

Get in touch

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.

Let’s build a stronger, more adaptable NDIS community, together.

Ange

Angela Harvey
Managing Director of Supporting Potential

Your partner in achieving compliance, growth and sustainability

To read all our other blogs visit here

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.

Get involved and get connected!

• We would love to know if you’ve tried any of the activities we’ve suggested or done something similar in the past – and what the outcomes were! You can reach out to us in the Get in Touch section at the bottom of this page.
• We also share practical tips, real life examples, and expert insights every week on LinkedIn. Follow along, join the conversation, and share these posts with your network.
• Join our mailing list here to receive notifications up upcoming instalments and webinars. We truly value the insights and experiences attendees are bringing to our webinars!

Get in touch

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.

Let’s build a stronger, more adaptable NDIS community, together.

Your partner in achieving compliance, growth and sustainability 

Angela Harvey
Managing Director of Supporting Potential

To read all our other blogs visit here

23 October 2025

On 10 October 2025, the Federal Court imposed a $2,200,000 civil penalty on Aurora Community Care for contraventions of ss 73J and 73V of the NDIS Act however in February 2024, Aurora went into voluntary administration, so it’s unlikely the penalty will ever be paid.

So what’s the point?

Both the Commission and the courts have operated on the assumption that high-profile prosecutions and large penalties will deter other providers.

As the then NDIS Commissioner Tracey Mackey stated: “The Commission expects every support worker and provider in the NDIS to act at all times with integrity, honesty and transparency and deliver safe and quality services to participants. If they fail to do so, the Commission will act.”

But for that deterrence to work, providers must be clear on what to avoid.

Aurora Community Care was found to have more than 130 breaches. The Court noted that the conduct was repeated, ongoing, and unrectified even after Aurora had been notified of its shortcomings.

The goal of this article is to articulate those shortcomings and identify mechanisms to prevent them because any CEO who reads this judgment and thinks “That won’t happen in my organisation” is the most vulnerable of all.

This case demonstrates that the most dangerous moment in any organisation isn’t when someone makes a mistake, it’s when that mistake becomes routine.

• When we grow complacent.
• When we’re too overstretched to notice the Swiss-cheese holes beginning to line up.

Risk hides in plain sight. Not usually through reckless action, but through comfortable and continued inaction.

Sometimes, the greatest risk isn’t what you do; it’s what you avoid:

• Not opening an email.
• Not reporting a restraint.
• Not checking when a door opens at 1 a.m.

Background

Aurora Community Care became a Pty Ltd company on 30 January 2017 and an NDIS-registered provider on 8 February 2017.

For anyone wondering how that was possible so early, their initial registration occurred under the state-based NDIS system in NSW and automatically transitioned to national regulation on 1 July 2018 when the Commission commenced in NSW.

In FY 2021–22, Aurora reported around $5.9 million in NDIS revenue. The following year, they experienced 15 per cent revenue growth (for those who believe revenue growth equates to quality—take note).

In the 12 months before Ankur Gupta’s avoidable death on 17 March 2023, Aurora supported 38 participants.

After the incident and despite a significant post-incident revenue hit, they still earned $3.55 million in NDIS revenue in FY 2023–24, before entering voluntary administration in February 24. It wasn’t until 19 November 2024 that the NDIS Quality and Safeguards Commission imposed a 10-year personal banning order on sole director Mohamed Issak, effective until November 2034.

The Man Behind the Story

Ankur Gupta was a much-loved son, brother and friend. Born in 1984, he lived with multiple complex conditions, including intellectual disability, epilepsy and tuberous sclerosis.

But he is more than his diagnosis. There is not a lot of public information about him, but we can piece together that he loved simple pleasures: watching television, sharing a Pepsi, listening to familiar sounds around his home.

Ankur began receiving support from Aurora Community Care in July 2021 while in Logan Hospital. He later moved to a supported independent-living residence at Dyandra Drive, Eagleby, Queensland, on 16 February 2022.

Court evidence showed that Ankur had significant executive-function and behavioural challenges, with functioning comparable to a five-year-old child.

He was funded for 2:1 active supports, including active night shifts. Aurora’s responsibility was to maintain constant observation as doors and gates were intentionally unlocked. Vigilance was critical.

At about 1:45 a.m. on 17 March 2023, Ankur left his home unnoticed. One support worker had fallen asleep beside him; the other heard a door but did not check.

Ankur was struck by a vehicle near the M1 exit at Eagleby. He died from his injuries at only 38 years old.

Aurora had already identified the risks. A risk assessment dated 30 March 2022 stated that staff must “always watch him so he’s not absconding.” His PBS plan, dated 28 June 2022, confirmed ongoing aggression and property damage, recommending continuous 2:1 support.

Aurora also had other warning signs that there could be a problem:

• Four weeks before his death, Ankur set fire to his mattress with a lighter while alone in his room.
• On multiple occasions, his parents found support workers asleep on duty and made verbal complaints that went unanswered.

What is most concerning, is on the night of his death, staff were shown a trailer of what could happen when risks are not responded to.

That very day, on the 3 p.m.–11 p.m. shift, one staff member left early at 10:20 p.m., leaving a single worker. At 10:35 p.m., Ankur exited through the back gate and sat in the middle of the road, saying he wanted to go in an ambulance.

The night-shift worker, who would later fall asleep, arrived at 10:45 p.m. and worked with the other staff member to called an ambulance, and returned Ankur home to wait.

There were warnings. They just weren’t heeded.

Then, to make matters worse, misinformation followed.

At 6:30 a.m., Mr Issak phoned Ankur’s parents, claiming he had “run away” but was safe and with police. The family learned of Ankur’s death later that morning, from their other son, a Queensland Police officer.

Aurora did not notify the Commission until 28 March 2023, eleven days later. On that date, they also registered his behaviour support plan and uploaded restrictive-practice details.

Inside the Governance Failure

A man lost his life.

A provider was penalised.

A regulator made its point.

On paper, a provider can appear flawless. This was a registered provider. They had all the policies, reporting systems, compliance dashboards to pass an audit. But paperwork cannot stop poor judgment or apathy. Procedures can’t replace vigilance.

The Commission is using this tragedy as an entry point to expose every related failure beneath it. This isn’t about one night in Eagleby; it’s about what that night revealed.

When governance fails at the point of practice, everything that follows becomes evidence of what we should have seen. Instead of fixating on penalties, we must ask: how did systems built for safety allow risk to become normal and why did the alarms go unheard?

Aurora’s wider convictions included:

• Unauthorised restriction of television at least 19 times and Pepsi seven times without plan coverage or reporting.
• Use of chemical restraint under short-term state approvals, without reporting to the Commission, despite five reminder emails between February and December 2022.

By July 2022, deeper governance cracks should have been seen.

A community visitor found the coordinator uncertain about what constituted a restrictive practice, which practices were authorised, and the conditions of approval. Staff admitted they “just know” when to administer medication.

When the community visitor followed up by email, Mr Issak’s reply did not address the questions about how or when restrictive practices were reported to the Commission.

Where Accountability Really Begins

Registered Providers currently operate in a self-reporting system. One where breaches often go unnoticed until harm occurs and someone decides to look.

We need to be aware, that the Commission’s response after harm is swift, forceful and brings out all of the skeletons in the closet.

Whilst we do not know the exact weightings of the penalties applied. We do know that The Commission allocated less than 25% of the total fine to the actions that directly contributed to Ankur’s preventable death. About 15% were for breaches to his human rights.

And the rest? Administration and reporting failures.

So whilst you may not get caught. Accountability for past breaches can still be enforced at the point of tragedy.

This means the onus sits with providers to design and implement their own harm-prevention mechanisms and self-policing strategies.

By its nature, some types of disability support are high risk. Documentation and reporting matter but they only prove what happened after the fact.
The real test of quality is how effectively an organisation identifies, responds to, and prevents risk before it becomes harm.

Five Practices Shifts to Prevent Following in Aurora’s Footsteps

1. Redefine “ratios of care” and “awake night support” as an active safety system.
Move beyond roster notes and ROC compliance. There’s reason active nights are funded. Ensure your staff understand why. Reinforce the       seriousness through real-time verifications, such as spot checks, digital logs, exception alerts. The goal must be to confirm presence and attentiveness, not just attendance.

2. See triggers as insight, not control.
When behaviour plans identify triggers like television or Pepsi, treat them as early-warning data, not levers for restriction. Build alternative strategies and teach staff to recognise escalation cues before control measures are reached.

3. Put PRN and restrictive practices under clinical governance, not routine habit.
Every PRN restrictive practice use should spark a reflective review, not just an entry in a medication log. Create feedback loops between behaviour support practitioners, nursing oversight, and frontline staff to analyse why the intervention was needed and how to prevent it next time.

4. Make silence visible.
Non-response is a risk signal. Escalate unanswered emails, missed incident follow-ups, or overdue reviews automatically. Set internal SLAs that treat no action as an alert, not a neutral state.

5. Evidence prevention, not paperwork.
Documentation should prove that safety is embedded. Not that compliance boxes were ticked. Capture data that reflects practice: night-shift wakefulness, restrictive-practice reviews, participant choice measures. If something still goes wrong, use that data to tell a story of safe, empowering support and not bureaucratic compliance.

The Road Ahead

Based on the ANAO audit, the Commission is likely to keep regulating after harm for at least the next 18 months. But providers, we must regulate before it. People’s lives depend on it.

Ask yourself: how quickly would you notice the small signals Aurora missed?

• At Aurora, staff sleeping on night shifts wasn’t treated as a critical safety failure. It was ordinary.
• Restricting Pepsi or television, despite being known triggers, became “just how things are done.”
• Failing to reply to five departmental emails about restrictive-practice reporting was dismissed as being too busy.

It wasn’t good enough for Ankur and the answer isn’t more red tape.

Ankur’s story reminds us that every person deserves to be seen beyond their diagnosis. He had challenging behaviours, yes, but he was also a whole human being whose safety, comfort and dignity were non-negotiable.

His life, and the way it ended, challenge our sector to do better: to stay awake, to notice, and to act with care before harm occurs.

The Aurora penalty sends a strong accountability signal. But the deeper lesson is operational: if your organisation still relies on “should be awake,”“we just know,” or “we’ll report later,” you’re gambling with things you can’t afford to lose. You need to contact us ASAP.

There’s no judgment. Just urgency and appreciation for being brave enough to say, “I’m not confident we are doing this well, and the people we support deserve better”.

Deterrence is a consequence; prevention is a system and we want to help you build a better one.

Come to our webinar, where we use real case studies against routine operating models. We want you to have the time, space and clarity to prepare for more risk aware support delivery

Date: Thursday, 6 November 2025
Time: 11:00am – 12:00pm (UTC+10:00)
Format: Live & interactive online session
Registration: Limited spaces for executives and senior leaders

👇 Secure your place now

https://events.teams.microsoft.com/event/51436a4e-fa8e-4264-872b-a7a8bf7ddd59@d8fe5969-e9bc-4d6b-ba5a-62e8825302c8

How we can help

In today’s climate of tight overhead margins and a competitive labour market, resourcing your transformation team entirely with internal staff may not be feasible. That’s where we come in. Our experienced project and change managers can provide the specialised support you need to keep your transformation on track.

We also offer skilled facilitation for transformation team meetings, maximising your time and ensuring meaningful, high-quality outcomes.

For broader strategic needs, we provide executive advisory and tailored support packages designed to empower NDIS businesses at every stage of growth and development.

Get involved and get connected!

• We would love to know if you’ve tried any of the activities we’ve suggested or done something similar in the past – and what the outcomes were! You can reach out to us in the Get in Touch section at the bottom of this page.
• We also share practical tips, real life examples, and expert insights every week on LinkedIn. Follow along, join the conversation, and share these posts with your network.
• Join our mailing list here to receive notifications up upcoming instalments and webinars. We truly value the insights and experiences attendees are bringing to our webinars!

Get in touch

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.

Let’s build a stronger, more adaptable NDIS community, together.

Your partner in achieving compliance, growth and sustainability 

Angela Harvey
Managing Director of Supporting Potential

To read all our other blogs visit here

23 September 2025

Welcome to Part 9 of our  Survive & Thrive strategic leadership series for NDIS leaders who want to move beyond surface-level compliance and into transformational leadership.

In Part 8, we detailed how providers can leverage compliance, governance, participant feedback, and advanced Practice Standards to not only meet requirements but also improve participant experiences and gain a real competitive advantage in today’s market through quality practice.

In Part 9, we show leaders how to shift from noise to clarity by turning communication into your strongest safeguard and gain strategic advantage by driving clarity, trust, and decisive action across the organisation.

Why organisations, especially NDIS providers, need clear communication strategies

The NDIS has been in a consistent state of turmoil. Different changes or threats of changes are affecting participants, providers, and the media. Heightening our fight, flight, freeze, or fawn responses, whilst being mindful that as leaders, we do not just carry the responsibility of making decisions. We carry the responsibility of ensuring those decisions are understood, contextualised, and acted on at every level of the business.

All storms eventually pass. It is comforting to look at external factors and say “that was the problem!”. But what really breaks organisations is not the turbulence itself. It is the silence, the half-truths, the lack of follow through, and the unanswered questions that erode trust while the storm is raging.

Have a quick look at your organisational documents. Communication underpins safety, governance, and culture:

“Staff are trained.”
“Families are informed.”
“Participants know their rights.”

These imply communication has happened. Add in your risk registers, policies, and procedures and you probably believe you over-communicate.

However, this information transfer is superficial and undermines the foundations of good communication. Communication is not just a transfer of words, but the creation of shared meaning, clarity, and trust. For this to occur, communication must be:

• Two-way: involves listening and feedback.
• Dynamic: adapts to audience, context, and need.
• Action-oriented: aims to change behaviour, align expectations, or reduce uncertainty.
• Verified: not complete until the other party has understood and can act on it.

Big ask right?

And in the scheme of the storm we are currently in, it would be the simple thing to de-prioritise. But before you make that decision, remember.

Deprioritising communication strategies is one of the most dangerous decisions an NDIS leader can make. Without a deliberate strategy, every message risks getting distorted:

• • Frontline staff soften feedback to avoid blowback → Risks stay hidden until they explode.
  • Middle managers filter issues before they reach the board → Boards make poor decisions without the full picture.
  • Executives receive glossy versions of the truth → Staff disengage because they do not feel heard.
  • Participants are left navigating systems they barely understand. → Participants lose trust when they get conflicting answers.

🛑 This is not just inefficient. It is dangerous.

Why communication makes or breaks an organisation

• Clarity amidst chaos: Teams do not need polished answers, they need honest updates — what is changing, what is not, and what is still unknown.
• Closed loops build trust: Sharing information once is not enough. Follow up, check back, and confirm it has been received and understood. Communication is not complete until the loop is closed.
• Expectations drive behaviour: If staff do not know what is expected of them during uncertainty, they will fill the void with assumptions. Expectations stated clearly and consistently anchor people in times of disruption.

What a resilient communication plan looks like

• Documented, not assumed: A written plan that outlines who communicates what, when, and how.
• Feedback channels: Two-way communication so leaders can test understanding and surface resistance before it escalates.
• Outcomes over activity: The goal is not sending emails or holding town halls. The goal is reduced anxiety, increased alignment, and staff who know how to act.

The 4 pillars of a strong communication strategy

To move beyond compliance and into genuine governance maturity, providers need to embed strategic communication into their DNA. Using four simple but powerful pillars that make the difference between paperwork and practice.

1. Clarity of purpose

Every message should answer one question: “Why does this matter?”

Too often, staff are told what to do without the why. Policies say “report incidents” but do not explain that early reporting prevents harm. Leaders say “follow the plan” but do not connect it to dignity, safety, or choice.

👉 When the “why” is missing, compliance feels like red tape.
👉 When the “why” is clear, staff lean in because they see impact.

2. Channels & standards

Clarity is not just about what is said, but how and where it is said.

Without standards and usable systems, teams create their own communication shortcuts. House A uses WhatsApp, House B relies on a whiteboard, House C leaves notes in a diary. The result is crucial messages slip through cracks.

A strong strategy sets clear rules of engagement:

• What gets emailed, what gets logged, what gets phoned.
• Timeframes for reporting and response.
• Who is accountable at each stage.

👉 It is not bureaucracy. It is reliability built upon understanding expectations.

3. Feedback loops

This is the most broken part of communication in most NDIS providers, the leader assuming that action alone is enough.

They take steps, fix issues, or make decisions. And then it stops — job done. Or worse, we see some communication and assume someone else has taken it for action, only to discover they have not.

The result is critical actions vanish into silence. Action without communication does not just create inefficiency. It actively undermines resilience and creates large risk blind spots. Without a deliberate communication strategy, your dedicated and tiring work risks being wasted, duplicated, or distorted. That gap between what we do and what others know is where trust unravels, where risks escalate, and where businesses fail.

Staff say: “I reported it, but nothing happened.”
Families say: “We complained, but no one told us what changed.”
Boards say: “We only hear about problems once they become crises.”

👉 Communication without feedback is noise. Communication with feedback is trust. Providers need to close the loop: acknowledge, act, and report back.

4. Consistency across sites

One of the biggest risks in Supported Independent Living (SIL) is inconsistency.

When every house, or even every shift, runs its own version of “the rules,” participants are not experiencing support, they are experiencing chance. Their support depends less on their needs and more on the personal opinion of whoever is rostered that day.

Leaders may believe policies are being followed, but in reality, practice varies wildly across sites. What feels safe and structured at head office often looks fragmented and unpredictable on the floor. This might not seem like a major issue, but often it is the root cause of all other issues.

👉 Why?

• When rules and routines change with each shift, participants cannot trust what will happen day-to-day. For someone with intellectual or psychosocial disability, this unpredictability can create stress, distress behaviours, or withdrawal.
• One staff member might encourage independence, while another might “just do it for them.” Over time, participants stop expecting consistency, and their personal goals are undermined.
• Erosion of trust: Families and advocates quickly notice when communication and practices are inconsistent. Trust in the provider declines, complaints rise, and relationships fracture.
• Variability means greater chance of errors, injuries, or restrictive practices being used differently across shifts. This increases compliance exposure.
• Inconsistent expectations leave staff frustrated. They either disengage (“I’ll just do what I think”) or leave for a more structured workplace.
• More incidents, higher turnover, and constant “firefighting” drive up costs. Resources are wasted responding to preventable problems.
• Inconsistency is hard to hide. If an auditor sees that policies exist but practice varies wildly, it signals poor governance maturity.

The payoff

At its core, communication is culture.

If leaders dodge tough conversations, staff will too.
If managers reward silence, risks will stay buried.
If executives only want “good news”, that is exactly what they will get. Until something explodes.

Culture is what people communicate when no one is watching. A strong communication strategy makes transparency, accountability, and respect the unspoken norm.

This payoff is enormous:

• Participants trust the service because they are consistently heard.
• Staff feel safe and engaged because their voices matter.
• Boards make better decisions because they see reality, not spin.
• Governance matures because communication turns from compliance noise into a driver of outcomes.

The leadership question

Here is the question for executives and boards: “Do we have a communication strategy, or do we just assume messages are landing?”

Because in the NDIS, poor communication is not just inefficient. It is a risk. Good communication is not just a governance tool. It is the foundation of culture and quality.

More than words: communication that makes an impact

The NDIS Executive Command Centre helps leaders:

• Diagnose silent risks within their business.
• Map cultural friction points that drive harm.
• Build leadership capacity for uncertainty and scaling.
• Turn risk intelligence into strategic decisions.

No boardroom posturing. No empty models. Just real tools, real language, real change.

🧭 Ready to stop managing risk and start leading through it?
Join the NDIS Executive Command Centre and finally get ahead of what’s holding your organisation back.

Enjoy unlimited access to all our courses for just A$75.00 per month. Try all courses for 1 month free of charge!

Join our upcoming webinar!

Part 9 – From noise to clarity: turning communication into your strongest safeguard
Wednesday, 1 October 2025
11:30 am – 12:30 pm

https://events.teams.microsoft.com/event/17c59c54-7f1c-4e04-a45b-491f9d43490a@d8fe5969-e9bc-4d6b-ba5a-62e8825302c8

Coming next in the final instalment of our NDIS Survive & Thrive series

Part 10 – Identify, plan, monitor, pivot, and know where it is safe to fail

For all the great ideas out there, you are only as good as your implementation. Great ideas are only as powerful as their execution. Remember, what you can measure, you can improve.

Outcome – strategic implementation plans and key indicators of success.

Get involved and get connected!

• We would love to know if you’ve tried any of the activities we’ve suggested or done something similar in the past – and what the outcomes were! You can reach out to us in the Get in Touch section at the bottom of this page.
• We also share practical tips, real life examples, and expert insights every week on LinkedIn. Follow along, join the conversation, and share these posts with your network.
• Join our mailing list here to receive notifications up upcoming instalments and webinars. We truly value the insights and experiences attendees are bringing to our webinars!

How we can help

In today’s climate of tight overhead margins and a competitive labour market, resourcing your transformation team entirely with internal staff may not be feasible. That’s where we come in. Our experienced project and change managers can provide the specialised support you need to keep your transformation on track.

We also offer skilled facilitation for transformation team meetings, maximising your time and ensuring meaningful, high-quality outcomes.

For broader strategic needs, we provide executive advisory and tailored support packages designed to empower NDIS businesses at every stage of growth and development.

Get in touch

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.

Let’s build a stronger, more adaptable NDIS community, together.

Your partner in achieving compliance, growth and sustainability 

Angela Harvey
Managing Director of Supporting Potential

To read all our other blogs visit here

29 August 2025

Welcome to Part 8 of our Survive & Thrive strategic leadership series for NDIS leaders who want to move beyond surface-level compliance and into transformational leadership.

In Part 7, we looked at structuring your approach to risk as well as your best approach to staying out of court, and out of the public eye for the wrong reasons. We also provide a clearer picture of where your key risks likely lie and the development of core mitigation strategies.

In Part 8, we detail how providers can leverage compliance, governance, participant feedback, and advanced Practice Standards to not only meet requirements but also improve participant experiences and gain a real competitive advantage in today’s market through quality practice.

Why Moving from Bureaucracy to Quality Practice is Vital

Since 2018, being an NDIS-registered provider has carried an implicit badge of quality. Registration was framed as a symbol of trust, the line between the “professional” providers and the so-called “dodgy” ones.

But here’s the uncomfortable truth: registration only proves you can produce paperwork that satisfies an audit. It doesn’t prove your teams can spot risks in real time, manage complexity, or keep participants safe.

We’ve grown comfortable living in this mirage of paper-based differentiation. The ‘I ❤️ NDIS’ logo has become shorthand for credibility. We’ve told ourselves that registration was financially unviable, but worth it, because we care. We’ve pointed to the Practice Standards as proof of quality, when in reality they are a baseline, not a benchmark of excellence.

Now, with mandatory registration on the horizon, the landscape is shifting beneath our feet. The real question for every provider isn’t whether you’ll be compliant, it’s whether you will not only be capable, but how you will stand out when everyone else is too.

Mandatory Registration – the Great Levelling

Picture this scenario: A high-value participant and their support network have asked you and five other providers to pitch to them, why your service is the best fit for their needs.

• Every single one of you holds the same registration
• You all tick the same compliance boxes with similar forms
• You meet the same Practice Standards, and
• You are values-led and provide ‘person-centred support’

How do you then answer the question:

“So, why should we choose you?”

This is the reality mandatory registration creates. It transforms compliance from a differentiator into an entry ticket. The providers who thrive in this new environment won’t be those who simply meet standards, they’ll be those who’ve learned to use governance as a strategic weapon.

Now, many of you might not be too fazed on missing out on a single client, but what if the speculation and rumours are true? What if we go back to block funding models and the answer to ‘why should we choose you?’ doesn’t simply add revenue to your organisation but could be the sole reason why your organisation can exist?

The Audit Illusion and Quality Reality

Why audits are one of our sector’s most significant blind spots:

• Audits are a snapshot in time. They check what can be documented and demonstrated on the day, not what happens at 10pm in a SIL house when a participant is distressed.
• Audits don’t test real-time decision making. They don’t assess how a team leader responds under pressure, or whether a support worker feels safe to escalate concerns.
• Audits can be gamed. If your culture rewards looking good on paper rather than telling the truth, the audit will “pass”, with real risks going unseen.

Before we go further, we need to understand a simple premise that registration is built upon:

👉 Compliance is about operating at the minimum legal standard.

👉An Audit is the external check that confirms compliance is being met.

👉 Governance is about how you choose to operate whilst ensuring compliance.

This regulatory framework creates an illusion of quality assurance that masks substantial operational differences between providers. Two organisations can both maintain their registration, one operating with sophisticated, participant-centred governance systems, the other running on ad hoc decision-making and fragmented processes.

NDIS Auditors focus on what can be quickly verified: documented policies, training records, incident reports, and evidence that required processes exist on paper. They’re not conducting deep analyses of decision-making quality or evaluating whether governance systems actually create better participant experiences. This means organisations can maintain compliance while operating with Frankenstein quality systems that create daily inefficiencies, staff frustration, and missed opportunities for participant impact. The current audit environment doesn’t reward sophisticated decision-making frameworks or innovative approaches to ensuring the participant is directing their life.

Audits (and software providers who are removed from Operations) create a secondary challenge, which is that their data systems are designed to satisfy regulatory requirements rather than support operational quality. Most organisations of a certain size can produce reports showing policy compliance, training completion, and incident response times. But how many can demonstrate that the governance system created better participant experiences or more effective decision-making processes?

So whilst many of us understand that registration status tells you almost nothing about operational excellence, innovation capacity, or participant outcome achievement, many providers still operate as if maintaining registration equals delivering quality. This reinforces why registration is meaningless as a quality indicator. And the misconception is only becoming more dangerous as the competitive landscape intensifies and the signs point to systemic change for all service providers, not just those that are unregistered.

The Hidden Hierarchy of Governance Maturity

Auditing is a process. Compliance is a simple yes or no. Governance is a capability that can ebb and flow.

The key issue with the current compliance-based audit approach is that most executives believe their organisation sits comfortably in the “good governance” category, failing to look beneath the surface. We see this repeatedly when working with providers across Australia. Leaders confidently describe their robust policies, their committed staff, and their compliant operations. Yet when we dig deeper, a different picture emerges.

Consider how your organisation currently approaches governance.

Do you find yourself:

• Focused on avoiding penalties and maintaining registration? This might feel responsible, but it positions governance as a cost centre rather than a value creator. When every conversation about quality starts with “we need to do this because the Commission says so,” you’ve unconsciously communicated that excellence is about avoiding the bad, rather than striving for the good.

• Viewing policies as protective shields rather than enabling frameworks? Many providers develop comprehensive policy suites designed primarily to demonstrate compliance during audits. These policies sit in binders or digital folders, referenced only at audit or when you want to performance manage someone out of the business. Staff follow parts of them because they have repeatedly been told to, not because they see them as tools that help them to do their jobs well.

Moment of self-reflection: do you know the content of all of your organisation’s policies? When did you last review an action you took to see if it aligns with what the procedure says you will do?

• Measuring success through the absence of problems rather than the presence of innovation? If your governance reports focus heavily on incident rates, complaint numbers, and audit findings, you’re unconsciously training your organisation to see governance as damage control. While risk management is crucial, this approach rarely generates the energy needed to drive continuous improvement or participant-led innovation.

These patterns aren’t failures, and you are certainly not alone. They’re our natural responses to a regulatory environment that has been more punitive than developmental. When the message is “self-report your mistakes and we’ll sanction you for them,” organisations learn to manage optics instead of addressing risks. We build systems to avoid punishment, not to enable learning.

The question you and your board need to be asking on the eve of mandatory registration is: “What could your organisation achieve if it operated more cohesively?”

Real governance capability sits on a hierarchy. Some layers are visible, but many are hidden beneath the surface.

What would it look like to move beyond checking compliance boxes to displaying evidence of quality outcomes, systematic decision-making, and genuine participant impact? Ideally, the providers who’ve built governance systems that generate this evidence naturally will have a significant advantage over those scrambling to retrofit measurement systems.

Assessing Your Governance Maturity

Like everything in our work, governance maturity functions on a spectrum. It isn’t about how tidy your registers looks, it’s about the depth of thinking that sits beneath them. And, like an iceberg, the visible paperwork is only the tip. The real strength is in the cultural and process foundations below the surface.

What defines your governance maturity isn’t having governance, it’s how well it works in practice to deliver quality outcomes.

Take incident management as an example:

• Foundational providers operate at the compliance level. They meet reporting requirements and document corrective actions because that’s what the regulator expects. It’s reactive, necessary, but surface-level.
• Professional-level providers go deeper. They don’t stop at “fixing the issue.” They add root cause analysis and process improvement, treating each incident as a data point that can refine systems and reduce recurrence.
• Advanced providers go deeper still. They see incidents not just as problems to solve but as innovation opportunities. They ask: “What does this reveal about how support is designed, and how could we use this learning to build something better?”

This mindset shift creates a profound competitive advantage. While most providers are busy defending why their incident rates are “acceptable,” advanced providers are showing how challenges have been turned into improved models of support that others haven’t even considered.

That’s the hidden hierarchy of governance maturity in action:

• Surface-level governance explains
• Mid-level governance improves
• Advanced governance innovates and differentiates

And in the NDIS market, it’s the providers who learn to operate at that advanced level who will set the benchmarks others are forced to follow.

Building Your Mobilisation Strategy

The transition to advanced governance maturity doesn’t happen overnight, but it can be systematic and strategic. The most successful transformations we’ve supported follow a clear mobilisation approach:

• Start with honest assessment. Many providers are surprised by what they discover when they objectively evaluate their current governance maturity. The assessment process itself often creates valuable insights about opportunities that weren’t previously visible. Understanding your starting point accurately is essential for developing a realistic transformation timeline.
• Map the Practice Standards impact. New Practice Standards will affect different aspects of your operations differently. Advanced providers are already mapping these potential impacts against their current systems to identify where they can turn required changes into competitive advantages. Rather than seeing Standards updates as compliance burdens, they’re exploring how these changes could strengthen their market position.
• Design integration rather than addition. The goal isn’t to add new governance layers onto existing systems. Again, that’s how you build a Frankenstein quality system. It’s to transform existing systems so they naturally generate both compliance evidence and competitive advantages. And that might actually mean taking things away. Start thinking systemically about how governance, operations, and participant experience intersect.
• Build capability before need. The providers who thrive during transition periods are those who’ve built organisational capabilities before external pressures demand them. This means developing staff skills, system capacities, and cultural practices that support advanced governance approaches before they become urgent requirements.
• Integrate outcome measurement into daily operations. Staff don’t just complete compliance tasks. They contribute to ongoing quality evidence through their regular work.
• Actively seek out participant feedback, even if it’s difficult. Remember, participant feedback doesn’t just satisfy reporting requirements, it drives continuous system improvements that create measurable outcomes and delivers a clear point of difference in today’s competitive market.

Your Leadership Moment is NOW

Every CEO or Managing Director is facing a choice in the current environment. Most will continue operating at foundation governance levels, focusing on meeting requirements and managing risks. They will remain registered and compliant and might even maintain their current market position, at least temporarily.

or

You can be the leader who recognises that the regulatory environment is creating an unprecedented opportunity for providers willing to invest in governance excellence. While competitors focus on meeting standards, you can build systems that use standards as platforms for greatness. While others demonstrate compliance, you can demonstrate impact, and you are highly likely to do this at a much lower cost. This approach delivers immediate results while increasing the long-term likelihood of establishing a market leadership position that becomes increasingly difficult for others to challenge.

Moving Forward

The question isn’t whether your organisation can afford to invest in governance excellence, it’s understanding the true cost when you don’t.

Supporting Potential provides effective internal audit assessments that not only meet your registration requirements but also strengthen your governance maturity. Our team specialises in supporting NDIS providers through governance maturity transformations that create both regulatory confidence and market differentiation.

Robbie, our SIL Living Experience Advisor, engages directly with participants to uncover what they truly need and want, while I conduct a formal audit to help you get ahead of the compliance curve.

Discover how real participant insights can drive measurable improvements and give your organisation a clear edge.

Book a FREE no-obligation consultation today and start creating sustainable outcomes that set your organisation apart.

Click here to book your free no-obligation consultation today!

 

Part 8: Moving from Bureaucracy to Quality Practice Webinar
Thursday, 11 September 2025
11:30 am – 12:30 pm

https://events.teams.microsoft.com/event/17c59c54-7f1c-4e04-a45b-491f9d43490a@d8fe5969-e9bc-4d6b-ba5a-62e8825302c8

Coming up in the next fortnightly instalment in our NDIS Survive & Thrive Series

Part 9 – Communication is King

How will you communicate with your broader team? All storms eventually pass, you need to understand how you will build resilience within yourself, your team and the organisation.

Outcome – a documented communications and outcome plan designed to provide clarity amidst chaos, build and strengthen resilience, and reduce resistance to change management.

Get Involved and Get Connected!

• We would love to know if you’ve tried any of the activities we’ve suggested or done something similar in the past – and what the outcomes were! You can reach out to us in the Get in Touch section at the bottom of this page.
• We also share practical tips, real life examples, and expert insights every week on LinkedIn. Follow along, join the conversation, and share these posts with your network.
• Join our mailing list here to receive notifications up upcoming instalments and webinars. We truly value the insights and experiences attendees are bringing to our webinars!

How we can help

In today’s climate of tight overhead margins and a competitive labour market, resourcing your transformation team entirely with internal staff may not be feasible. That’s where we come in. Our experienced project and change managers can provide the specialised support you need to keep your transformation on track.

We also offer skilled facilitation for transformation team meetings, maximising your time and ensuring meaningful, high-quality outcomes.

For broader strategic needs, we provide executive advisory and tailored support packages designed to empower NDIS businesses at every stage of growth and development.

Get in touch

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.

Let’s build a stronger, more adaptable NDIS community, together.

Your partner in achieving compliance, growth and sustainability 

Angela Harvey
Managing Director of Supporting Potential

To read all our other blogs visit here

24 July 2025

Welcome to Part 7 of our Survive & Thrive strategic leadership series for NDIS leaders who want to move beyond surface-level compliance and into transformational leadership.

In Part 6, we dove into the essential relationship between cost, value and price and, how to help you identify what’s driving real value in your organisation, what needs attention, and what’s consuming resources without meaningful return.

In Part 7, we look into structuring your approach to risk as your new competitive advantage as well as your best approach to staying out of court, and out of the public eye for the wrong reasons. We also provide a clearer picture of where your key risks likely lie and the development of core mitigation strategies.

NDIS Providers Are Failing at Risk Management

Let’s drop the polite language for a minute and engage in some uncomfortable dialogue that may prevent you from becoming the next negligent provider splashed across the front page.

Most NDIS service providers are terrible at risk assessment and management. Not because they are unethical. Not because they do not care, but because their systems, cultures, and leadership approaches are not designed to manage the real risks this sector faces.

Risk identification is not a form, nor is it a 70-line register.

Risk identification is whether you will see the next major problem before it hits, and risk management is whether you have the right actions in place to prevent the major problem you have identified and mitigate the impact of those that can’t be avoided.

Right now, most providers will not.

Take Valmar and LiveBetter for example. They were fined a collective $3.5 million in civil penalites. Why? Because they did not pre-empt known risks.

• LiveBetter: Instinctively, we all know it is possible to be burnt in a bath. LiveBetter took assumed knowledge and applied it across a broad range of services. They failed to ensure risks were tailored to the specific requirements of each person being supported. They also had no mechanism to test actual knowledge or preventative steps to minimise harm. In this case, the services LiveBetter provided scaled in complexity and risk, but the governance around the support did not. Commissioner of the NDIS Quality and Safeguards Commission v Valmar Support Services Ltd [2025] FCA 11
• Valmar: This case confirmed that risks generally are not captured in paperwork. They live in the gaps in between. Fragmented communication between allied health teams, SIL staff, and families meant no one took ownership of the choking risks within a support setting. Add staff using their own initiative—building on actions that had worked before—and you can see how a catastrophic outcome occurred so easily.  Commissioner v LiveBetter Services Ltd [2024] FCA 374 (LiveBetter)

LiveBetter and Valmar could have been any number of NDIS service providers. Our systems have been shaped by years of external pressures and learned behaviour and we have all been systematically conditioned along the way. We have stopped benchmarking against what we should be doing and instead aim for what will simply be tolerated.

The easy excuse is “sector fatigue” but really, it is sector-wide learned helplessness, wrapped in compliance language, and passed off as risk management.

The only way we can change this is by calling out the 5 biggest illusions driving poor risk management, which are often overlooked in any risk appetite statement.

The 5 Biggest Illusions Driving Poor Risk Management

1. Illusion: Growth Is a Sign of Success

Reality: Too Many NDIS Providers Scale Faster Than They Build Capability

The NDIS was designed as a consumer-driven market, but it forgot to build in the gateways that test if consumers have the capability and capacity to reform market operations. This mirage was always going to take hold, as there was more demand than support and the systems reward a ‘billable hour’ and not a quality service.

It has been relatively easy for providers take on new homes, new supports, new risk profiles, without the infrastructure, leadership depth, or data intelligence to handle it.

This isn’t bold growth. We are confusing responsiveness with readiness and that can result in calculated negligence. Yes, roles are filled, rosters are built, generic one size fits all training is provided, so the provider continues to say yes.

But who is asking the hard questions?

• Are we clinically prepared?
• Are our leaders equipped to supervise complexity? 
• Do we have the infrastructure to effectively negotiate with more stakeholders from multiple different lenses?
• Most importantly, has there been scrutiny applied to whether the data systems are catching risk and responding to minor escalation, prior to major problems?

Providers aren’t resourced to step back and reassess safely. So they push on, burn out, or break down.

So whilst growth is often an aspiration for many businesses, in NDIS it needs to be approached with nuance and caution. Growth doesn’t just increase risk, it multiplies exposure and dilutes control.

2. Illusion: Being A Registered NDIS Provider Means We Have Good Risk Controls and Governance

Reality: Provider Audits Are About Compliance Not Competence

The NDIS Practice Standards have created the illusion of capability. The Standards say that if you have policies, registers, and forms, your organisation demonstrates appropriate risk maturity.

The problem? Auditors assess documentation, NOT decision making and especially not decision making under pressure.

Risk management in the NDIS has become performative. Don’t believe me?

How many of the following can you answer positively?

• You have an organisational risk matrix
• You have considered the impact of “staff turnover” and “participant injury”
• You have a risk management policy
• There is an agenda item on the meeting schedule for risks
• Staff complete online risk management training

My guess is most providers would have done pretty well with those questions.

Now, openly assess your confidence level that you can say you would be aware of:

• A burnt-out team leader who has not had supervision in 3 months?
• A participant whose restrictive practice data is trending upwards, but no one has looked into it?
• A participant with razor thin funding, escalating needs and poor-quality support plans from their allied health providers?
• A SIL participant with some mild disorientation and difficulty with road safety (but no major incidents) wanting to walk to the shops on their own yet their family says it’s too dangerous?
• A disengaged worker who spends more time on their phone than providing support?
• A participant risk management plan that has a mitigation strategy of “refer to BSP”?
• Staff who are afraid to support a participant due to their aggressive behaviours?

These aren’t hypothetical. They’re daily occurrences. And they’re happening because we confuse documentation with risk aware service delivery, but real risk leadership means seeing the early signals, owning the hard calls, and acting before the system fails. It is so much more than having paperwork and recording what happened after something has gone wrong.

3. Illusion: A Network of Supports Means Risks Are Caught Early

Reality: Fragmented Services Create Blind Spots No One Owns

The NDIS was built on intersectionality. Support coordinators, allied health professionals, behaviour practitioners, SIL providers, day programs, plan managers, clinical teams, families, and advocates. A web of services and stakeholders that should catch risks before they spiral, right?

But what this has meant in practice is support delivered through silos.

Does this sound familiar?

1. Support coordinators often drive service planning without full insight into behavioural risks or trauma history.

2. Allied health teams deliver functional assessments and prescribe goals with little understanding of staffing limitations, site dynamics, or family complexities.

3. SIL providers are held responsible for 24/7 outcomes yet frequently operate without access to full psychosocial or clinical profiles.

We have created a system where communication is transactional, responsibilities are compartmentalised, and real risk lives in the white space between roles.

And the most complex, human risks involving behaviour, trauma or psychosocial complexity definitely do not fit neatly into a single service stream. They emerge at points of overlap, often compounded by friction between services.

As an organisation, when did you last document:

• Where a participant’s goals clash with their capacity?
• Where reasonable and necessary plan funding is grossly misaligned to safe service delivery needs? or
• Where different professionals interpret the same data in completely different waysor or don’t buy in at all?

When something goes wrong, it’s rarely because one provider failed. It’s often because we have failed to view the system of supports around a participant to ensure there were no gaps and no overlaps.

4. Illusion: If We Say We Deliver Best Practice, It Must Be True

Reality: Repeating What Worked Once Isn’t a Substitute for Support

“Best practice” in the NDIS is everywhere. Providers frequently use the term to signal quality or compliance, but it’s rarely tied to tangible measures or verified impact and even fewer can say what excellence truly means in their context. Add this to the lack of formal ‘best practice’ definition from the NDIS Quality and Safeguards Commission, which simply encourages providers to be “contemporary, evidence-based, and person-centred” and you can feel the risks begin to simmer beneath the surface.

This bubbling risk is better known as Best Practice Paralysis. Providers repeat the same rosters, use the same templates and run the same routines, not because they’re effective, but because they’re safe, they passed audit, and it works within the funding. It’s risk-averse repetition disguised as quality. It kills off innovation, responsiveness, and the space to actually design supports around real lives. And I can prove it.

How many providers still use the following?

• Person centred ‘About me’ or ‘Individualised Support’ plans?, or
• A ‘My Safety Plan’ or Risk Assessment checklist?

How many organisations have implemented tools to routinely track ability (physical or mental) to participate in activities of daily living?

How many have created templates that show micro improvements in capacity building?

Many might even still have the same look and feel of their state based government department templates.

What we’re seeing is a kind of ‘sameness’ creep.

• Every SIL house ends up with the same rules: meals at 5pm, outings on Tuesday, staff who rotate every three days.
• Behaviour support looks identical, even though the people are not.
• Support Coordinators push participants into whatever’s available, not what’s meaningful.
• Allied Health goals seem to be totally disconnected from what staff can realistically deliver.

The system is teaching us all to think the same, plan the same, and operate the same. It assumes that if something works once, it’ll work everywhere. It assumes that quiet houses mean happy participants. It assumes that just because we’ve seen it before, it’s the right fit.

And that’s how we miss the early signs. We ignore boredom, frustration, or distress because it doesn’t look like a reportable incident. We say we’re person-centred, but we run programs that could support anyone, which means they truly support no one. If we want to lift quality, we need to stop templating support and start noticing people.

Service providers need to question if their ‘best practice’ is creating an environment of missed changes in participant needs, overlooked warning signs, and drifting away from responsive support. By not measuring outcomes, reflecting on implementation, or adapting based on feedback, risk becomes invisible by design.

5. Illusion: If We Have Policies and Reporting Systems, We’re Covered

Reality: Culture Eats Risk Systems for Breakfast

The biggest risk that most organisations fail to call out, let alone manage, is their own cultural blindness. This isn’t a gap in procedure, nor is it likely to get picked up in an audit. It’s the broken feedback loop between risk, responsibility, and reality.

It shows up subtly when:

• A support worker sees something unsafe but keeps it to themselves because the last time they spoke up, nothing changed.
• A team leader edits an incident report to tone it down because they’re worried about how the exec team will react.
• A regional manager decides not to escalate a staffing issue because “we’ve all been under pressure lately.”
• When execs get told what they want to hear, not what they need to know.

And the kicker? Every one of these signs appears long before something blows up.

But only if you’re looking in the right places and most risk frameworks miss this critical concept: You can’t mitigate what you don’t see.

The Human Complexity of Risk

This is especially dangerous in human services, where the core product isn’t a process or a product that meets specs. It’s a relationship where outcomes depend not just on what’s written down, but on what’s actually said, felt, and acted on between people every day.

And this is the root cause of why disability service providers suck at risk management.

People complexity can’t be managed through templates, protocols, or assumptions. This sector isn’t driven by systems or even logical and rational explanations. It’s driven by human beings, and that means unpredictability, emotion, pressure, and nuance live in every layer of your organisation:
Frontline workers carry emotional labour, ethical tension, and the burden of real-time decision-making, often with little support. We provide them with training on how to provide personal care or write an incident report but vary rarely do we train them in emotional intelligence or communication skills.

So, you need to include in your organisation risk assessments:

• Burnout that goes unspoken until it ends in resignation.
• Incidents stemming from missed cues or exhausted judgement.
• Staff disengaging emotionally long before they walk out physically.
• Participant experiences being limited by staff beliefs.

I hear you. In NDIS Services, everything can be a risk and that’s exactly the problem.

When leaders treat all risks equally, they often end up focusing on the most visible or administratively convenient ones: overdue reports, audit gaps, documentation errors or the latest incident report which shows your pants pulled down.

Real risk management isn’t about catching everything, it’s about prioritising what matters and that requires reminding ourselves to think in terms of likelihood × consequence. It’s not just what might happen, but how serious it would be if it did. A staff member skipping a daily log note might not be high-risk but a team culture where no one flags concerns? That’s a critical failure in the making.

The goal isn’t to be risk averse, it’s to be risk intelligent and that starts by learning to see what matters most.

The 10-Point Reality Check 

Start with this 10 point checklist. For each checkpoints you answer in the negative, or even just hesitate at, ask yourself, how likely is it that this might turn into a big problem for the organisation and how big is the actual big problem?

The more often you repeat this process, the greater the consequences might be for your organisation.

Download our Risk Management Self-Assessment Checklist

This is a hard checklist. It intentionally goes beyond intentions and looks to what occurs in routine practice. It is designed to challenge most current practices as we need to rewire how we define readiness, risk, and success. Otherwise, you are likely to become another nameless “best practice’ provider that grew too fast, carried too much liability, and collapsed under complexity they were never supported to hold.

If you’re a CEO, board member, or executive leader in the NDIS, you need to stop asking whether you have a risk register. Instead, ask yourself: Would I know if something critical slipped tomorrow — today?

If the answer is no, that’s where your risk starts. But you don’t need another audit to tell you that, you need a leadership space to look risk in the eye, without performative bullshit. 

That is what Supporting Potential’s NDIS Executive Command Centre is for. Stepping into real risk leadership

Supporting Potential’s NDIS Executive Command Centre

Built for NDIS leaders by NDIS leaders and people with disabilties inside and outside of the Scheme

Inside, CEOs and executives are guided to:

• Diagnose silent risks within their business
• Map cultural friction points that drive harm
• Build leadership muscle for uncertainty and scaling
• Translate risk intelligence into strategic decision-making

No boardroom posturing. No theoretical models. Just real tools, real language, real change.

🧭 So are you ready to stop managing risk and start leading through it?

Join the NDIS Executive Command Centre and finally get ahead of what is holding your organisation back.

The Key Takeaways….

• Risk is a potential event, not paperwork. Real risk management is about seeing problems before they happen and taking proactive action, not just keeping forms and registers.

• Compliance ≠ safety. Audits and policies create an illusion of control but don’t test decision-making under pressure or detect cultural risks.

• Growth without capability multiplies risk. Many providers scale too quickly, diluting control, governance, and oversight.

• Fragmented services create blind spots. Siloed roles and poor communication mean risks often live in the gaps no one owns.

• Culture drives outcomes. Even with systems in place, a culture where staff fear speaking up or leaders soften bad news will always fail to catch risks early.

• “Best practice” often masks stagnation. Repeating what worked once leads to templated, risk-averse routines that miss early warning signs.

• Risk leadership is about prioritising what matters most. Treating all risks equally wastes focus; leaders need to build risk intelligence, not just compliance.

Click here to book your NDIS Critical Systems Audit today!

This isn’t about judgment. It’s about protection and progress because in today’s high-stakes NDIS environment, “good enough” is never safe enough and the gap between providers is widening. The next reform wave won’t treat everyone equally.

The Value of a Critical Systems Audit

You don’t have to do all this alone. When you’re working inside the system every day, it’s easy to miss the slow drifts, silent risks, and legacy processes that no longer serve.

That’s where a NDIS Critical Systems Audit becomes invaluable and why outsourcing it makes strategic sense.

An Independent Critical Systems Audit brings more than just fresh eyes. It brings:

• Unbiased insight into whether your systems are truly aligned to the NDIS Practice Standards, not just on paper, but in quality practice.
• Early identification of red flags that could lead to non-compliance, service gaps, or reputational harm.
• Cross-sector benchmarking, helping you learn from high performers and avoid pitfalls others didn’t see coming.
• A clear, actionable roadmap to move from “barely surviving” to “really thriving.”

Outsourcing also preserves your internal capacity. Your leaders stay focused on delivery while specialists dig deep into the bones of your organisation. It looks at your:

• Service models
• Financial viability
• Incident response
• Documentation trails
• Governance, and
• Frontline systems of accountability

Join our supplementary webinar via the link below

Part 7 – Structuring Your Approach to Risk

Wednesday, 30 July at 11am.

https://events.teams.microsoft.com/event/17c59c54-7f1c-4e04-a45b-491f9d43490a@d8fe5969-e9bc-4d6b-ba5a-62e8825302c8

Coming up in the next fortnightly instalment in our NDIS Survive & Thrive Series

Part 8 – Reframing Compliance to be Your Competitive Advantage

Mandatory registration will mean being registered is no longer a quality indicator. How are you going to adapt to new Practice Standards quicky whilst developing data that proves the quality is being delivered?

Outcome – the development of a mobilisation plan which identifies how changes to the Practice Standards might impact your operations, and how you will shift your approach to support efficient and effective quality.

Get Involved and Get Connected!

• We would love to know if you’ve tried any of the activities we’ve suggested or done something similar in the past – and what the outcomes were! You can reach out to us in the Get in Touch section at the bottom of this page.
• We also share practical tips, real life examples, and expert insights every week on LinkedIn. Follow along, join the conversation, and share these posts with your network.
• Join our mailing list here to receive notifications up upcoming instalments and webinars. We truly value the insights and experiences attendees are bringing to our webinars!

How We Can Help

In today’s climate of tight overhead margins and a competitive labour market, resourcing your transformation team entirely with internal staff may not be feasible. That’s where we come in. Our experienced project and change managers can provide the specialised support you need to keep your transformation on track.

We also offer skilled facilitation for transformation team meetings, maximising your time and ensuring meaningful, high-quality outcomes.

For broader strategic needs, we provide executive advisory and tailored support packages designed to empower NDIS businesses at every stage of growth and development.

Get in Touch

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.

Let’s build a stronger, more adaptable NDIS community, together.

Your partner in achieving compliance, growth and sustainability 

Angela Harvey

Managing Director of Supporting Potential

To read all our other blogs visit here