But Disability and Community Services Commissioner Mary Durkin said that the introduction of an official visitors program has since helped provide better "eyes and ears" on the ground to detect problems.

Ms Durkin also said the challenging staffing situation currently faced by Disability ACT during the National Disability Insurance Scheme transition had not caused an increase in complaints to her office.

Stephanie June Fry, 52, died in 2011 at a supported group home in Stirling, where she had lived for 20 years.

Ms Fry choked to death after being fed sandwiches and allowed to eat unsupervised, in a clear violation of warnings contained on her file.

Those warnings, which were required reading for support workers, said Ms Fry would gorge until she died if given the opportunity, and directed that she not be given bread or allowed to eat alone.

The circumstances of Ms Fry's death, revealed for the first time this month, raised serious questions about staff turnover levels, inadequate induction processes, and the use of casuals in unfamiliar group homes.

On the day of Ms Fry's death, the government was forced to bring in three casual support workers to cover the shift. Two had never worked in the home before, and the other had worked roughly 10 shifts.

One of the new casuals told an independent investigation into the death that she was confused about what food was meant for each client and which of the residents had a choking risk.

She said she wasn't shown around the home before the start of her shift and that "it didn't really help having two people that didn't really know what was going on in the house".

Ms Durkin said the death clearly showed systemic problems within Disability ACT in 2011.

But she said the introduction of an official visitor scheme had helped detect problems since then.

"I think one of the most significant changes since then has been the introduction of official visitors, who have been a valuable addition to the regime of oversight in the ACT in the past two years," she said.

"The official visitors are our 'eyes and ears' on the ground and they regularly refer concerns to my office."

Ms Durkin said six weeks of training was now available to Disability ACT staff.

She said the current situation presented a challenge for Disability ACT's staffing. That was because the government was transitioning out of group home environments with the introduction of the National Disability Insurance Scheme.

"Disability ACT cannot continue to recruit permanent staff when it is moving out of service provision and this will of course be unsettling as staffing ratios change," she said.

"I seek regular updates from the [Community Services] directorate on the situation and am reassured that they are making efforts to engage with people with a disability and families to ensure continuity of support with workers of their choice to the maximum extent possible.

"There has been no increase in complaints to my office from people in Disability ACT group homes since the roll out of the NDIS commenced."

The government said it had taken significant steps to improve the system since Ms Fry's death.

It said it had improved the level of information available to staff, improved staffing continuity, and regularly communicated with casual agencies and reviewed their performance every year.

It had a more consistent approach to maintaining resident information across all homes, making it easier for new workers to learn their needs quickly.

The six-week induction process was also followed by 20 observational shifts in a home and ongoing mandatory training.