Aegis Shawford

4 Shawford Place, INNALOO, WA, 6018

1. Assessment Contact - SiteAug 21, 2023

   Prepared by M Glenn

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2. Assessment contact Performance ReportJul 11, 2023

   An assessment contact was conducted with this service on 11 July 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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3. Accreditation decisionMar 23, 2023

   Following a site audit conducted on 15 February 2023 to 17 February 2023, the Commission made a decision on 23 March 2023 to re-accredit this service. The period of accreditation of the service will expire on 23 March 2026.

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4. Site AuditMar 23, 2023

   Prepared by K. Richards

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   AI report insightsAI-extracted · qwen2.5:32b

   The performance report for Aegis Shawford identifies non-compliance in Standards 1 (Consumer dignity and choice), 6 (Feedback and complaints), and 7 (Human resources). Compliance is noted in the remaining standards. The provider must ensure consumers are supported to take risks, appropriate action is taken in response to complaints, and regular assessment of workforce performance is conducted.

   Standard 1 Consumer dignity and choiceNon-compliant

   The standard is non-compliant due to Requirement (3)(d) where consumers are not supported to take risks that enable them to live their best life.

   • Met (3)(a) — Consumers and representatives said they were treated with dignity and respect, and staff demonstrated familiarity with consumers' culture and identity.
   • Met (3)(b) — Staff spoke of the importance of understanding consumers’ cultures and backgrounds as it can impact on care preferences. Consumers said they felt culturally safe.
   • Met (3)(c) — Consumers were supported to maintain relationships of importance to them, make decisions about their care, or who should be involved in their care.
   • Not met (3)(d) — The service did not demonstrate each consumer is supported to take risks to enable them to live their best life. Examples include Consumer A's inability to get out of bed independently and Consumer D's request for an electric wheelchair.
   • Met (3)(e) — Consumers were satisfied with the written information they receive, including menus and activity planners displayed on noticeboards.
   • Met (3)(f) — Staff members described actions to maintain privacy and protect consumer information. Handover was observed to occur in office areas away from consumers.

   Risks: Consumer A advised they were not supported to get out of bed independently if they did not want to wait for staff.; Consumer D advised they were not supported to have an electric wheelchair to improve their independence moving throughout the service.

   Recommendations: Ensure consumers are supported to take safely take risks they want to take and make informed risk-taking decisions.; Document risk discussions and decisions, identify appropriate risk mitigation strategies, and consistently implement them.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The standard is compliant as all requirements have been met. The service demonstrates ongoing partnership with the consumer in assessment and planning.

   • Met (3)(a) — Assessment and planning, including consideration of risks to the consumer’s health and well-being, informs the delivery of safe and effective care.
   • Met (3)(b) — Consumers confirmed their needs, goals and preferences were known by staff and captured within care planning.
   • Met (3)(c) — The service demonstrated ongoing partnership with the consumer in assessment and planning.
   • Met (3)(d) — Consumers were informed of the outcomes of assessments, and care plans were provided on request or following review.
   • Met (3)(e) — Care plans were updated where there was a decline or change in health status, following incidents or for reconsideration of consumer preferences.

   Standard 3 Personal care and clinical careCompliant

   The standard is compliant as all requirements have been met. Consumers receive safe and effective personal and clinical care tailored to their needs.

   • Met (3)(a) — Consumers received best practice wound care and diabetes management, with personalized management plans.
   • Met (3)(b) — Staff described risks and management strategies for individual consumers, and the process to escalate risks if required.
   • Met (3)(c) — Clinical staff advised they have sufficient policies and procedures to guide them in recognizing and managing consumers entering end of life stage.
   • Met (3)(d) — Staff recognized when consumers were entering end-of-life care, with increased focus on consumer comfort.
   • Met (3)(e) — Information about the consumer’s condition, needs and preferences was documented and communicated within the organization.
   • Met (3)(f) — Consumers confirmed timely and appropriate referrals are made for care and services.
   • Met (3)(g) — Staff described practices to promote appropriate use of antibiotics, including using only when the consumer is symptomatic or has a history of infection-related illness.

   Standard 4 Services and supports for daily livingCompliant

   The standard is compliant as all requirements have been met. Consumers receive safe and effective services that meet their needs, goals, and preferences.

   • Met (3)(a) — Consumers described supports for daily living to assist with maintenance of independence.
   • Met (3)(b) — Staff could give examples of providing emotional support to consumers and engaging with pastoral care or external organizations for psychological support.
   • Met (3)(c) — Consumers were supported to maintain relationships of importance to them, and staff described supports provided to consumers to participate in activities within and outside the service.
   • Met (3)(d) — Staff said they are kept informed of consumers’ conditions, needs and preferences through handovers and reviewing documents.
   • Met (3)(e) — Consumers confirmed timely and appropriate referrals are made for care and services.
   • Met (3)(f) — Consumers were satisfied with the variety and quantity of food, and there were plenty of choices for each meal.
   • Met (3)(g) — Equipment was observed to be clean and in working order, and the service had processes in place for ongoing maintenance and cleaning.

   Standard 5 Organisation’s service environmentCompliant

   The standard is compliant as all requirements have been met. The service environment is safe, clean, well maintained, and comfortable.

   • Met (3)(a) — Consumers’ rooms were observed to be furnished to reflect consumer interests and preferences.
   • Met (3)(b) — The environment was clean, well maintained, and consumers could manage natural light, fresh air, and temperature in their rooms.
   • Met (3)(c) — Consumers felt safe during use of equipment, including mobility aids and hoists. The service has a maintenance schedule with arrangements for specialized maintenance needs.

   Standard 6 Feedback and complaintsNon-compliant

   The standard is non-compliant due to Requirement (3)(c) where appropriate action was not taken in response to all complaints, including use of an open disclosure process.

   • Met (3)(a) — Consumers and representatives said they felt encouraged and supported to give feedback.
   • Met (3)(b) — Consumers were aware of advocacy services, and had seen brochures available for advocates and external complaints processes.
   • Not met (3)(c) — The service did not demonstrate appropriate action is taken in response to all complaints, including use of an open disclosure process. Examples include a consumer's complaint resulting in an incident report through the Serious Incident Response Scheme without any response by time of the site audit.
   • Met (3)(d) — Feedback and complaints were reviewed and used to improve the quality of care and services. Feedback was recorded in an electronic system that creates quality improvement actions where there is an identified benefit or need for change.

   Risks: Three representatives said they were not satisfied with the complaints resolution process.

   Recommendations: Ensure action is consistently taken in response to complaints and open disclosure practiced when things go wrong.; Implement an effective complaints and feedback system, train staff in complaints handling and open disclosure.

   Standard 7 Human resourcesNon-compliant

   The standard is non-compliant due to Requirement (3)(e) where regular assessment, monitoring, and review of the performance of each member of the workforce are not undertaken.

   • Met (3)(a) — The workforce is planned to enable delivery and management of safe and quality care.
   • Met (3)(b) — Staff interactions with consumers are kind, caring, and respectful of each consumer’s identity, culture, and diversity.
   • Met (3)(c) — The workforce is competent and the members have qualifications and knowledge to effectively perform their roles.
   • Met (3)(d) — Workforce is recruited, trained, equipped, and supported to deliver outcomes required by standards.
   • Not met (3)(e) — A significant number (over 60%) of annual performance appraisals were overdue. Organizational procedures for disciplinary action had not been followed for staff with training overdue by more than six months.

   Risks: Over 60% of annual performance appraisals were overdue.; Incidents citing poor staff behavior or error had not resulted in timely investigation.

   Recommendations: Ensure each member of the workforce has regular assessment, monitoring and review of their performance.; Support staff with adequate time and resources to complete relevant training and monitor completion.

   Standard 8 Organisational governanceCompliant

   The standard is compliant as all requirements have been met. The organization has effective risk management systems and practices, including but not limited to managing high impact or high prevalence risks associated with the care of consumers.

   • Met (3)(a) — Consumers are engaged in the development, delivery and evaluation of care and services.
   • Met (3)(b) — The governing body promotes a culture of safe, inclusive and quality care and is accountable for their delivery.
   • Met (3)(c) — Effective organization-wide governance systems relating to information management, continuous improvement, financial governance, workforce governance, regulatory compliance, feedback and complaints.
   • Met (3)(d) — The service has effective risk management systems and practices, including managing high impact or high prevalence risks associated with the care of consumers.
   • Met (3)(e) — Where clinical care is provided, a clinical governance framework exists to minimize use of restraint and practice open disclosure.

   Generated by qwen2.5:32b on 11 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

5. Site audit Performance ReportFeb 17, 2023

   A site audit was conducted with this service on 15 February 2023 to 17 February 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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6. Exceptional CircumstancesOct 28, 2022

   During the COVID-19 pandemic, the Aged Care Quality and Safety Commission has temporarily modified our Regulatory Program, including the suspension of site audits to determine whether to accredit, not to re-accredit or vary the periods of accreditation for a service. In order to give effect to continuity of accreditation the Department of Health has, under Section 42.5 of the Aged Care Act 1997, made a decision to grant ‘exceptional circumstances’ to this service 01 May 2023 The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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7. Accreditation decisionSep 29, 2021

   Following a site audit conducted on 19 March 2019 to 21 March 2019, the Commission made a decision on 11 April 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 29 September 2021. The period of accreditation of the service will expire on 01 November 2022.

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8. Assessment contact Performance ReportOct 15, 2020

   An assessment contact was conducted with this service on 15 October 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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9. AssessmentMar 21, 2019

   Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 01 May 2022.

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10. AssessmentFeb 11, 2016

    Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 01 May 2019.

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11. AssessmentFeb 6, 2013
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12. AssessmentMar 5, 2010
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No regulatory actions recorded.