C4. Governance & Quality

How we set and uphold service standards
“The standard you walk past is the standard you accept.” — David Morrison

Policy Purpose

The purpose of this policy is to ensure that governance, quality assurance, and continuous improvement processes at Trust Children and ReadyStepGrow are consistent, transparent, and values-led. This policy ensures that all policies, procedures, and practices are regularly reviewed, remain aligned with child safe standards, professional and funding requirements, and reflect the evolving needs of children, families, and our team.

Policy Statement

Governance and quality are shared responsibilities across the organisation. All staff are expected to engage in reflective practice, policy review, and service improvement processes. Governance is grounded in our values of trust, kindness, courage, integrity, and excellence. Quality is achieved not through compliance alone, but through collaboration, accountability, and continuous learning.

Policy Details

Governance

• Governance of policies and practice is overseen by the Clinical Director, supported by team leaders.
• All policies are expected to be reviewed according to the review cycle (quarterly in the first year, annually thereafter).
• Policies are expected to be accessible to all staff, with clear links between related policies.
• Staff are expected to follow the manual in daily practice, while also providing feedback when improvements are needed.

Governance processes ensure accountability to:

• Families and children, for safe and effective care.
• Professional standards and registration bodies.
• Funders such as NDIS and Medicare.
• Child safe organisational requirements.

Quality

Quality is defined as safe, ethical, effective, and family-centred care.

Continuous quality improvement (CQI) is expected to be embedded through:

• Supervision and reflective practice.
• Policy review and updates.
• Feedback from children, families, and staff.
• Audit of documentation, service delivery, and compliance processes.
• Ongoing professional development and training.

Governance also extends to oversight of new technologies (e.g., AI), ensuring their use is safe, ethical, de-identified, and consistent with professional standards and this manual.

Data collected (e.g., service records, family feedback, supervision logs) is expected to be reviewed and used constructively to strengthen practice.

Review & Continuous Improvement

• Each policy includes a scheduled review date and identified owner.
• Reviews are expected to assess alignment with values, professional standards, legal/funding requirements, and staff/family feedback.
• Where improvements are identified, they are expected to be documented, actioned, and communicated transparently to the team.
• The Policy Index in this manual provides a live record of review status and next steps.

Document Control

Document control ensures that policies remain accurate, transparent, and audit-ready.

• Versioning

  • v1.0 = Initial release of a new policy.
  • v1.1, v1.2 = Minor updates or clarifications that do not change overall intent.
  • v2.0 = Major rewrite or structural change to intent or requirements.

• Review cycle

  • Quarterly for the first 12 months after launch (Aug 2025 → Jan 2026, May 2026, Aug 2026).
  • Annually from Jan 2027 onward, unless significant changes occur earlier (legislation, professional standards, funding, or risks).

• Archiving

  • Superseded versions are exported to PDF and stored securely in the policy register.
  • Archived versions remain accessible for compliance, audit, or legal purposes.
  • Only the current version is published in the live manual.

• Improvement Log

  • Suggestions, edits, and issues are recorded in the Policy Improvement Log.
  • Each entry notes: date, policy, change type, and action taken.
  • This ensures transparency and a clear trail of decisions.

Accountability

• The Clinical Director is accountable for ensuring governance structures are in place, reviews occur, and policies are kept current.
• Senior Clinicians are accountable for embedding governance and quality processes in supervision, team meetings, and service development.
• Each staff member is accountable for raising concerns, contributing feedback, and applying updated policies in practice.
• Accountability is supportive — missed responsibilities or gaps are expected to be addressed through supervision, coaching, and team reflection.

How to Raise a Concern

If staff identify an issue with governance, quality, or document control (e.g., outdated policies, unclear procedures, or gaps in compliance), they must:

1. Raise the concern with their supervisor in the first instance.
2. If unresolved, escalate to the Clinical Director.
3. Document the concern in service records if it impacts service delivery.
4. Use supervision or team meetings to reflect on and suggest improvements.
5. Where concerns impact child safety, escalate immediately under the Child Safety Policy.

Related Policies and How They Connect

• Child Safety Policy – ensures governance aligns with National Principles for Child Safe Organisations.
• Clinical Documentation Policy – quality assurance includes audit and review of documentation.
• Communication Standards Policy – governance ensures communication processes are values-led and consistent.
• Confidentiality & Consent Policy – governance ensures privacy and consent practices remain compliant and ethical.
• Guiding Practice Principles – provides the cultural foundation that governance and quality processes reinforce.
• Roles & Responsibilities Policy – clarifies leadership and staff duties within governance and quality processes.
• Supervision & Performance Policy – supervision is a central tool for embedding governance and quality.
• Therapy Plan Policy – governance ensures therapy planning processes remain consistent and funder-compliant.
• Visual Identity & Branding Policy – governance protects brand integrity and consistency.
• Artificial Intelligence (AI) Use Policy – details safe, de-identified, and accountable AI use in therapy planning and communication.

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Document Control: v1.1 · Created: Aug 2025 · Updated: Sep 2025 (added Document Control section; included AI oversight line) · Review cycle: Quarterly in first 12 months (Jan, May, Aug 2026), then Annual (Jan 2027 onward) · Owner: △△D Pty Ltd

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