8. Significant Improvement Required

National Law

[ National Regulations, Regulation 59 ] A rating of Significant Improvement Required can be applied at standard and quality area level. If a rating of Significant Improvement Required is given for any standard or quality area, the overall service rating is Significant Improvement Required.

Using the Significant Improvement Required rating

The Significant Improvement Required rating may be given when an authorised officer (in consultation with their manager) is satisfied that the service does not meet a standard, quality area, or relevant regulation for that quality area in a way that poses: ‘a significant risk to the safety, health or wellbeing of any child or children being educated and cared for by the service’ (regulation 59).

A significant risk is more likely to arise when there is non-compliance with the physical environment, children’s health and safety, or staffing requirements, but it could arise in other parts of the NQS. For example, poor educational programming requirements could pose a significant risk to the wellbeing of a child or children given the implications for children’s learning and development.

Determining ‘significant risk’ to a child or children

Authorised officers must always make a case-by-case assessment (in consultation with their manager) of whether there is a ‘significant risk to a child or children. Authorised officers may draw on a risk matrix to assist in determining the level of risk present and the appropriate course of action to address the risk. Further guidance on assessing risk is available in Good Regulatory Practice.

Risk Matrix

Consequences

Likelihood

 

Rare

Unlikely

Possible

Likely

Almost Certain

Major

Moderate

High

High

Critical

Critical

Significant

Moderate

Moderate

High

High

Critical

Moderate

Low

Moderate

Moderate

High

High

Minor

Very low

Low

Moderate

Moderate

Moderate

Insignificant

Very low

Very low

Low

Moderate

Moderate

 

If the authorised officer determines that a ‘high’ or ‘critical’ level of risk to the health, safety or wellbeing of children is present as a result of service practice in a particular standard, quality area, or relevant regulation for that quality area, it is likely that further action would be taken.

Where an authorised officer identifies an issue that constitutes a significant risk, the authorised officer (in consultation with their manager) will need to decide whether it is appropriate to continue the visit. In the case that the assessment and rating visit is stopped, the authorised officer should ensure the decision to stop the visit is documented. If the risk can be satisfactorily addressed at the time of the visit, the assessment and rating visit may continue. The regulatory authority may choose to give the Significant Improvement Required rating for the standard or quality area where the risk was identified.

In general, authorised officers should seek to complete assessment and rating visits to ensure that sufficient evidence is gathered to allow the service to be rated against every standard. This also ensures that all major compliance issues at the service are identified. Regulatory authorities are required to give a rating for every quality area, even if one quality area is rated as Significant Improvement Required.

The assessment and rating process may only be suspended if the regulatory authority decides to take one of the actions outlined under section 137 of the National Law.

Suspending a rating assessment

The assessment and rating process can only be suspended if the regulatory authority decides to take one of the following actions:

National Law & Regulations

[ National Law, Section 137 ]

Unless one of the actions listed in section 137 is taken, the rating must be determined within 60 days of the completion of the assessment and rating visit to the education and care service premises.

  • suspend or cancel the service approval or provider approval
  • issue a compliance notice to the approved provider in respect of the service
  • issue an emergency action notice to the approved provider in respect of the service
  • remove or cause the removal of a child or children from the service (emergency removal).
National Law & Regulations

[ National Law, Sections 136, 137 ] If one of the actions is taken, the regulatory authority must give the approved provider a written notice which states that the provider will be given the outcome of the rating assessment within 60 days after the end of the final period of review for the compliance action, or if a review is sought, the determination of the review. Emergency action notices and emergency removal of children are actions listed under section 137 which are not reviewable decisions and therefore do not have a period of review available. In these cases, the provider will be given the outcome of the rating assessment within 60 days of the emergency action notice being given or the emergency removal of children being undertaken.

If the service or provider approval is cancelled, the regulatory authority cannot give a rating for the service. If the service or provider approval is suspended, the rating assessment recommences once the suspension expires.

Other compliance actions

While there are other compliance actions which regulatory authorities might take in response to identifying an issue during an assessment and rating visit, only the actions listed under section 137 have the effect of suspending the assessment and rating timeframe. In all other cases, the regulatory authority must still determine the rating within 60 days of the assessment and rating visit.

When a rating of Significant Improvement Required is given

Regulatory authorities should reassess services which have been rated as Significant Improvement Required as soon as practicable. The reassessment is an opportunity to check the service is meeting minimum requirements to ensure the health, safety and wellbeing of children in attendance.

Actions that can cause the suspension of the assessment and rating process

The provider approval or the service approval for the service is suspended or cancelled

A compliance notice has been given to the approved provider in respect of the service

A notice has been given under section 179 in respect of the service (emergency action notices)

An action has been taken under section 189 in respect of a child or children being educated and cared for by the service (emergency removal of children).

If the rating is suspended, the regulatory authority must give written notice to the approved provider. The notice must state that the service rating will be given under section 136 within 60 days after:

  • the end of the final period for review of the decision or action that has resulted in the suspension of the rating assessment, or
  • if a review has been sought, the determination of the review of the decision or action that has resulted in the suspension of the rating assessment.

Additional guidance

If a compliance notice is issued, the approved provider has 14 days to request a review of the notice. If the approved provider does not request a review, the 60 days to issue a service rating begins at the end of the 14 day period. If the approved provider does request a review of the notice, the 60 day period does not begin until the date of the review decision.

For example, the rating visit is day one. A compliance notice is issued on the sixth day. The provider has 14 days to request a review of the notice. If the provider does not request a review, the regulatory authority has 60 days from the end of the 14 days to issue the rating. The total time taken is 80 days.

If the compliance notice is issued on day six and the provider requests a review of the notice on day 15, and the regulatory authority makes a decision on review request on day 28, the regulatory authority has 60 days from the date of review decision to issue the rating. The total time is 88 days.

The regulatory authority may need to determine the rating for the service before the period for complying with the compliance notice has expired, for example if the regulatory authority gives the provider 90 days to comply with the compliance notice.