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APPLICATION FOR APPOINTMENT TO THE ADMINISTRATOR PANEL AND/OR THE ADVISER PANEL

Completing and Lodging the Application FormThis Application form is to be completed by individuals and corporate entities wishing to be considered for appointment to the Administrator Panel and/or Adviser Panel established by the Department of Social Services (the Department) under section 66A-1 of the Aged Care Act 1997. Please refer to the Administrator Panel and Adviser Panel Application Guide when completing this form. If required, further enquiries can be made at the email address below. Any notices of clarification will be posted as an Addendum on the Department’s website at http://www.dss.gov.au/our-responsibilities/ageing-and-aged-care .

Applications close on 4 March 2014 at 5pm ESDT. Applicants are to lodge their Application and associated documentation electronically via [email protected] .

Please note: From 18 September 2013, responsibility for aged care moved to the Department of Social Services. During this period of transition you may continue to receive correspondence from Department of Health and Ageing email addresses.

Checklist

Submission Submit one Microsoft Word and one PDF copy of your application. The PDF copy must contain signed

declarations.

Section One Nominated Panel Categories, Key Functional Areas and Jurisdictions (To be completed by all Applicants) Applicant Contact Details (To be completed by all Applicants) Corporate Entity Details (To be completed by Corporate Entities) Public Liability and Professional Indemnity Insurance (To be completed by all Applicants)

o Attach proof of existing public liability insurance and professional indemnity insurance or a statement that these will be obtained if Applicant is successful.

Applicant and Specified Personnel Detailso For Applicants that are individuals:

Attach a national criminal history record check and national insolvency search report for the applicant and each specified personnel.

Attach certified copies of qualifications and professional registrations for the applicant and each specified personnel. Attach a one page resume (max) for the applicant and each specified personnel.

o For Corporate Entities: Attach a national criminal history record check and national insolvency search reports for each individual responsible

for executive decisions of the body corporate. Attach certified copies of qualifications and professional registrations for each specified personnel. Attach a one page (max) resume for each specified personnel.

Sub-contractors Details(To be completed by all Applicants)o Attach a copy of national criminal history record check for each sub-contractor listed.

Declaration (To be completed by all Applicants)o Mark in or strike out any declaration that cannot be made and attach details. o Ensure you have selected either statement (a) or (b) in the ‘Conflict of Interest’ section of the declaration. o Ensure you have selected either DO/DO NOT in the ‘Proceedings’ section of the declaration. o Ensure a PDF copy containing the signed declaration is provided.o If applicable, complete and enclose Annex A – Conflict of Interest.o If applicable, attach details of any Proceedings.

Section Two Administrator Evaluation Criteria (To be completed by Administrator Applicants)

o Address all aspects of each criterion. Keep within the word limit.

Section Three Adviser Evaluation Criteria (To be completed by Adviser Applicants)

o Address all aspects of each criterion. Keep within the word limit.

Section Four Referee Report (To be completed for both Administrator and Adviser Applicants)

o Arrange for referees to send their written reports to [email protected] by 4 March 2014.

mailto:[email protected]


http://www.dss.gov.au/our-responsibilities/ageing-and-aged-care


SECTION 1

NOMINATED PANEL CATEGORIES, KEY FUNCTIONAL AREAS AND JURISDICTION

ADMINISTRATOR If applying for Administrator Panel nominate one or more options for Category, Functional Area and Jurisdiction.

Category: Residential Community Settings

Functional Area (relating to Part 4 of the Aged Care Act 1997): Quality of Care User Rights Accountability

Jurisdiction National NSW VIC QLD SA WA TAS NT ACT

ADVISER If applying for Adviser Panel nominate one or more options for Category, Functional Area and Jurisdiction.

Category: Residential Community Settings

Functional Area (relating to Part 4 of the Aged Care Act 1997): Quality of Care User Rights Accountability

Jurisdiction: National NSW VIC QLD SA WA TAS NT ACT

ADDITIONAL SERVICES (optional) Refer to page 8 of the Administrator Panel and Adviser Panel Application Guide.

Yes No

If you agree to be considered for additional services, any information collected as part of this application process may be provided to aged care industry bodies and/or aged care providers seeking these services.

APPLICANT CONTACT DETAILS (All Applicants to Complete) Name of Individual or Corporate Entity (Panel Member)

Street Name and No.

Suburb State Postcode

Work Phone Mobile Phone

E-mail

Web Address

Postal Address (if different to above)Street Name and No.

Suburb State Postcode

Corporate Entity Details (Corporate Entities to Complete) Name/s of Individual/s Responsible for

Executive Decisions of the Body Corporate(including directors, chief executive officer, managing director and any other person with the authority to make executive decisions on

behalf of the corporate entity)

Position

Section 1 –


Corporate Entity Details (Corporate Entities to Complete)Corporate Status

Australian Company Number ABN

Australian Registered Body Number

Registered Business Name or Association Name

Place of Incorporation

Date of Incorporation

If Partnership, Name of Partners

Address of Partners if Different from Above

Registered Office

Principle Place of Business

Name of Contact Person and Position

Work Phone Mobile Phone

E-mail

INSURANCE (All Applicants to complete)Applicant to provide either:

evidence of existing public liability insurance and professional indemnity cover; or a statement that the Applicant will obtain such insurance and indemnity cover and provide evidence of this to

the Department within 28 days of appointment to the Administrator Panel and/or Adviser Panel.

Levels of Insurance: Public Liability - $20,000,000.00 and Professional Indemnity - $10,000,000.00.

Public liability insurance: Name of insurerPolicy number

Insurance renewal date

Amount of current cover

Professional indemnity insurance:Name of insurerPolicy number

Insurance renewal date

Amount of current cover

Section 1 –


APPLICANT AND SPECIFIED PERSONNEL DETAILS (All Applicants to complete)

Please provide the following details for the Applicant and any specified personnel who may assist the Applicant to deliver Panel Member services if the applicant is appointed to the Administrator Panel and/or Adviser Panel.

Applicants that are individuals are to attach: A national criminal history record check and national insolvency search report for the applicant and each

specified personnel Certified copies of qualifications and professional registrations for the applicant and each specified

personnel A one page (max) resume for the applicant and each specified personnel.

Applicants that are corporate entities are to attach: A national criminal history record check and national insolvency search reports for each individual

responsible for executive decisions of the body corporate (including directors, chief executive officer, managing director and any other person with the authority to make executive decisions on behalf of the corporate entity)

Certified copies of qualifications and professional registrations for each specified personnel A one page (max) resume for each specified personnel.

Note: Applicants appointed to the Administrator Panel and/or the Adviser Panel may not use personnel other than those listed. These personnel will be listed in the Schedule of Specified Personnel attached to the Panel Member’s Instrument of Appointment.

Administrator Full Name Role in the Provision of

Administrator ServicesQualifications

Applicant:

Specified Personnel:

Adviser Full Name of Personnel Role in the Provision of

Adviser ServicesQualifications

Applicant:

Specified Personnel:

SUB-CONTRACTORS DETAILS (All Applicants to complete if sub-contractors will be used)Please provide the following details of any sub-contractors who may assist the Applicant to deliver Panel Member services if the applicant is appointed to the Administrator Panel and/or Adviser Panel. Applicants must attach a national criminal history record check for each sub-contractor.

Note: Applicants appointed to the Administrator Panel and/or Adviser Panel may not use sub-contractors other than those listed. These sub-contractors will be listed in the Schedule of Sub-contractors attached to the Panel Member’s Instrument of Appointment.

Administrator

Business or Trading Name/ABN (if applicable)

Role in the Provision of Administrator Services

Qualifications

Adviser

Business or Trading Name/ABN (if applicable)

Role in the Provision of Adviser Services

Qualifications

Section 1 –


REFEREE DETAILS (All Applicants to complete)Applicants are to obtain two written referee reports using the template at Section 4. Referees are to send the report to the Department by 4 March 2014. Applicants should, if possible, provide references from referees that they have assisted within the past two years to remedy non-compliance or have provided similar services in an aged care service. Applicants should indicate when the services were provided.

Applicants can provide referees from within the Department. However, if the Applicant’s referees are members of the Application Evaluation Committee, that referee will not participate in the Department’s evaluation of the application concerned, subject to probity advice.

The Department reserves the right to contact nominated referees and persons other than the referees provided by Applicants for supporting comments as required.

Referee No. 1

Name of Organisation

Name of RefereeClassification / Position

Work phone

Mobile

E-mail

Nature of Relationship Administrator Adviser Other (please specify)

Period Service Provided

Referee No. 2



Work phone

Mobile

E-mail


Period Services Provided

Section 1 –


Referee No. 3



Work phone

Mobile

E-mail



Referee No. 4



Work phone

Mobile

E-mail



If applying for both the Administrator and Adviser Panel, two referees must be provided in regard to each Panel. However, a single reference may support applications for both the Administrator and Adviser Panels.

Section 1 –


DECLARATION (All Applicants to complete)

Note: Any declaration that cannot be made should be struck outThe following declaration must be signed by:

an applicant applying solely on his/her own behalf; or an officer, or officers, authorised to sign on behalf of an applicant which is a corporate entity.

Release of InformationI agree the Department of Social Services (the Department) may collect, use and disclose any personal information collected, or provided to it by the Applicant during the course of this Application process for any of the following purposes:

(a) conduct that is carried out in the establishment of the Administrator Panel and/or Adviser Panel under section 66A-1 of the Aged Care Act 1997 (“the Act”);

(b) conduct that is carried out in the appointment of Administrators and/or Advisers under sections 66A-2 and 66A-3 of the Act; and

(c) conduct that is carried out in the selection of an Applicant or Panel Member for the purposes of providing Additional Services under page 8 of the Administrator Panel and Adviser Panel Application Guide, if that Panel Member has indicated a willingness to be considered for Additional Services.

NB ‘Personal information’ has the same meaning as in the Privacy Act 1988.

Officer or employee of the CommonwealthI agree that neither, I (the Applicant), nor any nominated specified personnel nor any nominated sub-contractors are Commonwealth officers or employees. Under section 66A-1 of the Act, a person is not eligible to be a member of the Administrator Panel or Adviser Panel if the person is a Commonwealth officer or employee.

Conflict of Interest NB All known actual, perceived or potential conflicts of interest are to be declared

(a) I give an undertaking that if appointed to the Administrator Panel and/or the Adviser Panel there would be no conflict of interest between my duties as a Panel Member and any of my other interests or duties.

or

(b) I declare that to the best of my knowledge I have listed at Annex A all known conflicts or potential conflicts of interest between my duties as a Panel Member, if appointed to the Administrator Panel and/or the Adviser Panel, and any of my other interests or duties.

(Delete (a) or (b)).

If appointed to either the Administrator and/or Adviser Panel, and subsequently nominated by an approved provider under subsection 66A-2(2) or subsection 66A-3(2) of the Act, I undertake to declare any actual, potential or perceived conflicts of interest between my duties as a Panel Member and any of my other interests or duties.

I undertake to advise the Department of Social Services in writing if actual, perceived or potential conflicts arise in the future. If there is any change to the interests set out in Annex A, I undertake to advise the Department of Social Services of any alterations or additions to my declaration as soon as practicable.

Disqualified IndividualI understand what is meant by the term ‘disqualified individual’ for the purposes of the Act. I understand that if I, or in the case of an applicant which is a corporate entity any individual responsible for its executive decisions of the body corporate (including directors, chief executive officer, managing director and any other person with the authority to make decisions on behalf of the company) is a disqualified individual, the Applicant will not be eligible to be a Panel Member.

I declare that to the best of my knowledge that I, or in the case of an Applicant which is a corporate entity any individual who is responsible for the executive decisions, is not a disqualified individual:

having not been convicted of an indictable offence; or not being an insolvent under administration; or not being of unsound mind.

Section 1 –


If this application for membership of the Administrator Panel and/or Adviser Panel is successful, I agree to notify the Commonwealth that if, during the period of Panel membership, I, or in the case of an applicant which is a corporate entity any individual who is responsible for its executive decisions, becomes a disqualified individual.

I understand that for the purposes of ascertaining whether I am a disqualified individual, or in the case of an applicant which is a corporate entity, whether any person responsible for its executive decisions is a disqualified individual, the Commonwealth may:

a) carry out a national criminal history record check using personal particulars I have provided for this purpose;b) search the National Personal Insolvency Index (a public record for which my/our name, address and date of

birth are relevant identifiers); c) obtain employment and character references from my nominated referees; andd) give me reasonable notice that it requires me to provide personal information from a registered medical

practitioner about myself, which information I agree to provide.

ProceedingsI declare that I DO / DO NOT (delete one) have any litigation, arbitration, mediation, conciliation or proceedings including any investigations (“Proceedings”), taking place, pending or threatened, against me/the corporate entity that will or have the potential to affect my/the corporate entity’s capacity to perform and fulfil the obligations of a member of the Administrator Panel or Adviser Panel.

If you have any litigation, arbitration, mediation, conciliation or proceedings including any investigations (“Proceedings”), taking place, pending or threatened attach details to this application.

False or misleading informationBy signing this document I acknowledge that it is a serious offence to give false or misleading information to the Commonwealth and that if any of the information provided in this Application changes I must bring it to the attention of the Department immediately.

I make this solemn declaration by virtue of the Statutory Declarations Act 1959 and subject to the penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believing the statements contained in this declaration to be true in every particular.

Individual Applicant:Name of Applicant

Signature

Date

If corporate entity:

Name of Director (if a body corporate) Name of other Director/Company Secretary

Signature of Director Signature of Director/Company Secretary Date Date

Two copies of this Application are required, one in Microsoft Word and one in PDF format. The PDF version must include a scanned signed copy of this declaration.

Annex A – Conflict of Interest

Section 1 –


SECTION 2 ADMINISTRATOR EVALUATION CRITERIA

RESPONSE TO EVALUATION CRITERIA

(Administrator applicants to complete)

Evaluation Criteria 1 and 2 will be applied in assessing applicants’ suitability for appointment to the Administrator Panel. Applicants should provide sufficient information in their responses to allow assessment against each criterion. Weightings reflecting the relative importance of each criterion are assigned by the Department. Applicants are to use the format provided below to respond to the evaluation criteria. Applicants should expand the boxes as required, however each criteria is to be addressed in no more than 800 words.

Criterion 1 – Achieving the Requirement

1A. Provide evidence of your demonstrated skills and experience (either in residential and/or community settings) in:

o identifying causes of system failure o designing, implementing and monitoring governance and business operations interventionso leading change to achieve sustainable outcomes, and building organisational capability

Your response should include evidence to support your nominated category, key functional area and specific area of expertise. (Refer to page 1 of this Application Form.)

CRITERION 1A Response, no more than 800 words.

1B. Provide evidence of your demonstrated skills and experience in:o working with a governance body and senior personnel using evidence-based organisational

management and leadership practiceso addressing the needs and/or sensitivities of stakeholders as relevant to a sanction situation,

e.g. approved providers, governance bodies, key personnel, care staff, care recipients, their relatives, representatives and other interested parties

CRITERION 1B Response, no more than 800 words.

Criterion 2 - Capacity and Availability

2A. Provide examples of recent relevant engagements highlighting:o quality of service o dependabilityo performance


2B. Provide details of experience and strategies for resourcing, in terms of staff, equipment and facilities. If nominating to work in jurisdictions other than the Applicant’s principal place of business, indicate strategies and resource capacity to undertake this work


Section 2–


Information to be provided to approved providers seeking to engage an Administrator Panel MemberIf this application is successful any information collected during the application process, including but not limited to the information below, may be given to providers seeking to engage a member of the Administrator Panel in response to compliance action or for the provision of Additional Services. The information is to assist an approved provider to select an appropriate Panel Member. In completing this section please do not provide personal information or names of organisations without their approval.

Applicant’s Qualifications (Administrator applicants to complete)Please list the qualifications that are relevant to the nominated panel categories and key functional areas identified.

Qualification/Registration Issuing Institution Date

Applicant’s Experience – no more than 20 lines in total. (Administrator applicants to complete)Please summarise applicant’s experience. Substantiate the nominated categories and key functional areas.

Applicant’s specific areas of expertise as an Administrator - no more than 8 lines. (Administrator applicants to complete)Specific areas of expertise might include business management specialties, governance, staff training and education or experience with specific population groups and cultural diversity.

Section 2–


SECTION 3 ADVISER EVALUATION CRITERIA

RESPONSE TO EVALUATION CRITERIA

(Adviser applicants to complete)

Evaluation Criteria 1 and 2 will be applied in assessing applicants’ suitability for appointment to the Adviser Panel. Applicants should provide sufficient information in their responses to allow assessment against each criterion. Weightings reflecting the relative importance of each criterion are assigned by the Department. Applicants are to use the format provided below to respond to the evaluation criteria. Applicants should expand the boxes as required, however each criteria is to be addressed in no more than 800 words.

Criterion 1 – Achieving the Requirement

1A. Provide evidence of your demonstrated skills and experience (either in residential and/or community settings) in:

o identifying causes of system failure o designing and implementing governance and provision of care and service interventions o leading change to achieve sustainable outcomes, and building organisational capability.

Your response should include evidence to support your nominated category, key functional area and specific area of expertise. (Refer to page 1 of this Application Form.)


1B. Provide evidence of your demonstrated skills and experience in:o working with a governance body and senior personnel using evidence-based organisational

management and leadership practices o addressing the needs and/or sensitivities of stakeholders as relevant to a sanction situation,

e.g. approved providers, governance bodies, key personnel, care staff, care recipients, their relatives, representatives and other interested parties.


Criterion 2 - Capacity and Availability

2A. Provide examples of recent relevant engagements highlighting o quality of serviceo dependabilityo performance.


2B. Provide details of experience and strategies for resourcing, in terms of staff, equipment and facilities. If nominating to work in jurisdictions other than the Applicant’s principal place of business, indicate strategies and resource capacity to undertake this work.


Section 3 –


Information to be provided to approved providers seeking to engage an Adviser Panel Member

If this application is successful any information collected during the application process, including but not limited to the information below, may be given to providers seeking to engage a member of the Adviser Panel in response to compliance action or for the provision of Additional Services. The information is to assist an approved provider to select an appropriate Panel Member. In completing this section please do not provide personal information or names of organisations without their approval.

Section 3.1 Applicant’s Qualifications (Adviser applicants to complete)Please list the qualifications that are relevant to the nominated panel categories and key functional areas identified on page 2.

Qualification/Registration Issuing Institution Date

Section 3.2 Applicant’s Experience (Adviser applicants to complete)Please summarise applicant’s experience, in no more than 20 lines - substantiate the nominated categories and key functional areas.

Section 3.3 Applicant’s specific areas of expertise as an Adviser - no more than 8 lines (Adviser applicants to complete) Specific areas of expertise might include clinical expertise, clinical management, staff training and education or experience with specific population groups and cultural diversity.

Section 3 –


Annex A

Declaration of Conflict of Interest

Details of interests or relationshipsThe types of interest and relationships that may need to be disclosed include aged care service investments, shareholdings, trusts or nominee companies, company directorships or partnerships, other significant sources of income, significant liabilities, gifts, additional business interests, employment, voluntary, social or personal relationships that could or could be seen to influence your decisions, actions or service provision. All actual, perceived or potential conflicts of interest are to be declared.

I______________________________________________________________________________________________________________________________________________ (insert full name, residential address and occupation)

have listed below details of interests or relationships which could be seen to influence decisions, actions taken or services provided if appointed as a Panel Member.

1.

2.

3.

4.

Management strategyPlease specify the proposed strategy for managing or resolving the conflict or potential conflict of interest, between the duties of a Panel Member and any other interests or duties of the applicant.

Individual Applicants:

Name of Applicant

Signature

Date

If corporate entity:

Name of Director (if a body corporate) Name of other Director/Company Secretary

Signature of Director Signature of Director/Company Secretary Date Date

This Application must include a PDF signed copy of this declaration.

Annex A – Declaration of Conflict of Interest


REFEREE REPORTTo be completed by the referee and sent directly by the referee to

[email protected] 4 March 2014

Thank you for taking the time to provide this referee report.

When completing the following page, you should provide information as to how the applicant meets the criteria and expand the boxes as required, if you would like to provide additional information to the questions listed, you may attach additional pages to the referee report. Some brief information about the role of administrator and adviser panel members is provided below.

Please email the completed report (ensuring your name and the applicant’s name is the email subject line) to [email protected] by 4 March 2014.

Shane ChisholmA/g Director, Quality ProgramsDepartment of Social Services

Information about the role of Administrators and Advisers

Members of the Administrator Panel and Adviser Panel assist aged care approved providers subject to a sanction to comply with their responsibilities for ensuring care recipients’ health, wellbeing and interests, including financial interests.

The panel member must have expertise in working with approved providers to ensure that all legislative responsibilities are not only met, but are able to be sustained once the sanction period has been completed. Panel members must be highly skilled in working with governance bodies and senior personnel to improve the quality of management and care.

Members of the Administrator Panel principally need to be able to determine and guide the approved provider to implement interventions in relation to the governance and business operations of the service. Using evidence-based organisational management and leadership practices, the Administrator helps build organisational capability to address system issues across the aged care service.

Members of the Adviser Panel principally need to be able to determine and guide the approved provider to implement interventions in relation to the provision of care and services. Using evidence-based clinical management and leadership practices, the Adviser helps build organisational capability to address system issues across the aged care service.

Section 4 – Referee Report



Name of Applicant:

Name of Referee, Organisation and Position

Work phone Mobile phone

E-mailOrganisation Street No. and NameSuburb State Postcode

Nature and period of relationship

1. Demonstrated experience of aged care regulatory compliance in either residential and/or community settings, particularly with respect to identifying causes of system failure and leading change to remedy these causes in a way that achieves sustainable outcomes and builds organisational capability.

2. Demonstrated experience in working with governance bodies and senior personnel to provide effective evidence-based solutions and capability to address the challenges of remedying non-compliance in an aged care service.

3. Demonstrated experience in managing cultural, community and organisational sensitivities relevant to the aged care sector.

4. Demonstrated capacity, experience and skills to deliver the services of the nominated Panel. Details of the Applicant’s capacity to implement strategies for resourcing, in terms of staff, equipment and facilities.

5. Applicant’s quality of service, dependability and performance.

6. Additional comments.

Name:

Signature:

Date:

Section 4 – Referee Report

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