Clinical Governance & Safeguards

Royal Rehab’s commitment to providing safe and high-quality care, along with a focus on continuous improvement, is backed by a robust clinical governance framework.

This framework is effectively implemented across various settings, including our healthcare and disability services, ensuring that quality and safety are consistently prioritised in all our actions throughout the organisation.

Our staff comply with their respective professional regulatory requirements and are actively involved in governance activities such as incident management, quality improvement and feedback management.

Our Managers and Executive ensure systems are effective, and report on performance to the Board. The Board reviews and monitors performance information regularly to ensure the system remains robust and relevant. This systematic approach ensures that our clinical governance and safeguarding systems are implemented consistently and effectively, supporting safer, and better care for our patients, clients and customers.

We encourage our customers/clients and patients to partner with us throughout their involvement with our services as we believe this helps us deliver better services and achieve better healthcare outcomes. Clients are involved in the design of their treatment and care, and they work closely with staff to develop the outcomes they want from our services.

Consumer representatives are also involved in the development of documentation, service delivery and governance through our Consumer Advisory Groups which are comprised of prior and current patients/clients and carers.

Our staff have a clear understanding of our services, and the multidisciplinary skill sets available. This allows them to work effectively with clients to clarify and set goals, and work with their peers to design programs that support  client objectives.

Royal Rehab hospitals are fully accredited against the National Safety and Quality Health Service Standards, which are a nationally consistent set of standards concerning the level of care consumers can expect from all hospitals. Accreditation involves an independent review and assessment from a team of external healthcare and human services experts.

Disability Services are certified across a different set of standards including:

  • National Disability Insurance Scheme (NDIS) Practice Standards.
  • Australian Community Industry Standard (ACIS).
  • National Standards for Disability Services (NSDS) Indicators of Practice.
  • Quality Improvement Council (QIC) Health and Community Services Standards.
  • Human Services Standards.
  • Department of Education, Skills, and Employment (DESE) Right Fit for Risk.
  • Royal Rehab’s Disability Services (including breakthru) are certified against these standards and have  passed all accreditation and certification standards.

Risk management is an ongoing process that we take seriously. We have implemented robust risk management systems and policies to hold ourselves accountable for managing all types of risk, including clinical and corporate risks.

Our ultimate objective is to continuously improve the quality and safety of care provided and to maintain a safe and secure environment for all.

We believe it’s critical for safety and quality improvement to be integrated into governance processes so we can actively manage and improve the safety and quality of care across our operations.

A good safety culture is underpinned not only by the reporting of incidents but also the analysis and management of subsequent actions following incidents, as this helps drive continuous improvement. Incident reporting can improve safety, highlight areas of risk, and improve processes and practice.

At Royal Rehab staff are encouraged to report all incidents including near misses and minor incidents as this information is critical in identifying systemic issues. Incidents are comprehensively managed to prevent recurrences by taking action, sharing lessons learned and transforming these findings into proactive clinical governance improvement mechanisms.

The Australian Charter of Healthcare Rights and the NDIS Commission’s Practice Standards outline the rights as well as what to expect when receiving healthcare with the ultimate goal of improving the quality of care. The Charter’s guiding principles include:

  • Access to services and treatment
  • Safety
  • Respect
  • Partnership
  • Information
  • Privacy
  • Feedback

Royal Rehab handles personal information in compliance with all relevant privacy laws, principally being the Privacy Act 1988 (Cth). It also manages personal information in compliance with the relevant State and Territory based health records and privacy laws.

Legislation prescribes:

  • What information we can collect and how we collect it.
  • How we store and protect information.
  • How you can find out what information we hold and correct it if it is wrong.
  • How we can use and disclose your information including special protection for health and other sensitive information.
  • How you can complain about breaches of your privacy.

In accordance with applicable privacy legislation, Royal Rehab:

  • Ensure personal health information is collected, stored, and used in accordance with the relevant legislation.
  • Ensure privacy of patient information is protected.
  • Take appropriate steps to protect personal information held by us, against misuse, interference, loss, unauthorised access, modification, or disclosure.

Wherever possible, Royal Rehab collects information from our patients and clients (prospective and actual). If this is not possible, we may collect information from another person who has legal responsibility for our patient or client.  At times, we may collect information from a third party, such as another service provider. This only occurs where there is prior agreement, or where this is the only possible way to collect information to provide a service to the patient or client. 

We welcome all forms of feedback and will make every effort to address patient/customer/client concerns and find a satisfactory outcome. Our priority is to be continuously improving our services.

We treat all feedback and any complaints professionally and confidentially.

In the first instance if you have feedback or a complaint, we encourage you to speak with the Local Manager or General Manager, of the specific service to which your experience relates.

Should your matter not be resolved to your satisfaction, please use the contacts below for further help. Every effort will always be made to address your concerns and find a satisfactory outcome.

Disability Accommodation
Royal Rehab Petersham
Royal Rehab
Sargood on Collaroy

For formal compliments, feedback and suggestions, you can fill in the following  online form which will be automatically forwarded to the appropriate service

In the event, that any issue/concerns remain unresolved and relate to Royal Rehab Private, Community Services or any of the private and public inpatient services, you can contact the Health Care Complaints Commissioner at

If your unresolved issue relates to our Disability Services, you can contact the NDIS Commission at

If your unresolved issue relates to our Disability Employment services, you can contact the Complaints Resolution and Referral Service at