Anglican Care Bishop Tyrrell Place

60 Princes Street, CUNDLETOWN, NSW, 2430

1. AssessmentApr 28, 2025

   The Aged Care Quality and Safety Commission (the Commission) has monitored the provider’s progress in implementing improvements in the service to ensure compliance with the Aged Care Quality Standards. Based on the information submitted by the provider, as of 28 April 2025, the Commission is satisfied actions have been taken to address the non-compliance with the Aged Care Quality Standards. The Commission will continue to monitor the provider’s performance.

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2. Accreditation decisionOct 18, 2024

   Following a site audit conducted on 09 September 2024 to 11 September 2024, the Commission made a decision on 18 October 2024 to re-accredit this service. The period of accreditation of the service will expire on 15 December 2027.

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3. Site AuditOct 18, 2024

   Prepared by P. Wallner

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4. Site audit Performance ReportSep 11, 2024

   A site audit was conducted with this service on 09/09/2024 to 11/09/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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5. Assessment contact (performance assessment) – siteJan 8, 2024

   Prepared by E Woodley

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6. Assessment contact Performance ReportNov 30, 2023

   An assessment contact was conducted with this service on 29 November 2023 to 30 November 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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7. Accreditation decisionApr 6, 2023

   Following a site audit conducted on 21 February 2023 to 23 February 2023, the Commission made a decision on 06 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 15 December 2024.

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8. Site AuditApr 6, 2023

   Prepared by E Woodley

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

   The service demonstrates strengths in providing a safe environment and supporting consumer dignity. However, there are significant areas for improvement related to workforce planning, risk management, ongoing assessment processes, and engagement with consumers. The service needs to address these gaps to ensure consistent delivery of high-quality care.

   Standard 1 Consumer dignity and choiceCompliant

   The service supports consumer dignity, respect, and independence. However, there are gaps in processes to ensure consumers' decisions about who should be involved in their care are obtained and followed.

   • Met 1(3)(a) — Consumers reported being treated with dignity and respect.
   • Met 1(3)(b) — The service provides culturally safe care and services.
   • Met 1(3)(c) — Consumers generally reported being supported to exercise choice and independence.
   • Met 1(3)(d) — The service supports consumers to take risks for a better life.
   • Met 1(3)(e) — Information provided is clear and easy to understand, allowing consumers to exercise choice.
   • Met 1(3)(f) — Consumers' privacy is respected, and personal information is kept confidential.

   Recommendations: Ensure processes are in place to document how consumers wish representatives to be involved in decisions about their care.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The service does not consistently include considerations of risks to consumer’s health and well-being, or inform safe and effective care delivery. There are also gaps in partnering with consumers and representatives in the assessment process.

   • Not met 2(3)(a) — Risks to consumer’s health and well-being are not identified in the assessment process or following incidents.
   • Met 2(3)(b) — Assessment and planning generally identify and address consumers' needs, goals, and preferences.
   • Not met 2(3)(c) — The service does not demonstrate an effective process in place to partner with consumers and their representatives in the assessment and care planning process.
   • Met 2(3)(d) — Consumers are informed of the outcomes of assessment and planning, and some are involved in care plan reviews.
   • Not met 2(3)(e) — Care and services are not reviewed regularly when circumstances change or incidents impact on needs, goals, or preferences.

   Risks: Risks to consumer’s health and well-being are not identified in the assessment process or following incidents.

   Recommendations: Ensure effective processes for ongoing partnership with consumers and representatives.; Regularly review care and services, especially after incidents.

   Standard 3 Personal care and clinical careNon-compliant

   The service does not consistently provide best practice personal and clinical care tailored to consumer needs. There are also gaps in documenting and communicating information about consumers' conditions, needs, and preferences.

   • Not met 3(3)(a) — Consumers do not consistently receive best practice personal and clinical care tailored to their needs.
   • Met 3(3)(b) — High impact or high prevalence risks are managed effectively.
   • Met 3(3)(c) — Needs, goals, and preferences of consumers nearing the end of life are recognized and addressed.
   • Met 3(3)(d) — Deterioration or change in consumer’s condition is recognized and responded to timely.
   • Not met 3(3)(e) — Information about the consumer's current condition, needs, and preferences is not consistently documented and communicated effectively.
   • Met 3(3)(f) — Timely referrals to other care providers are made.
   • Not met 3(3)(g) — Infection-related risks are not consistently minimized through standard and transmission-based precautions.

   Risks: Consumers do not receive best practice personal care tailored to their needs.; Information about the consumer's condition, needs, and preferences is not communicated effectively.

   Recommendations: Ensure all staff are aware of consumers' current conditions and needs.; Implement effective infection control measures.

   Standard 4 Services and supports for daily livingNon-compliant

   The service generally provides safe and effective services that meet consumer’s needs, goals, and preferences. However, there are gaps in supporting consumers to participate in activities of interest.

   • Met 4(3)(a) — Consumers generally receive services that meet their needs and preferences.
   • Met 4(3)(b) — Services promote emotional, spiritual, and psychological well-being.
   • Not met 4(3)(c) — Consumers are not consistently supported to participate in activities of interest.
   • Met 4(3)(d) — Information about the consumer’s condition, needs and preferences is communicated within the organisation.
   • Met 4(3)(e) — Timely referrals to other care providers are made.
   • Met 4(3)(f) — Meals provided are varied and of suitable quality and quantity.
   • Met 4(3)(g) — Equipment is safe, clean, and well maintained.

   Recommendations: Ensure all consumers are supported to participate in activities of interest.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is safe, clean, and well maintained. It optimizes consumer independence and interaction.

   • Met 5(3)(a) — The service environment is welcoming and easy to understand.
   • Met 5(3)(b) — The environment enables free movement for consumers.
   • Met 5(3)(c) — Furniture, fittings, and equipment are safe, clean, well maintained, and suitable.

   Standard 6 Feedback and complaintsCompliant

   Consumers feel supported to provide feedback and make complaints. The service uses this information for continuous improvement.

   • Met 6(3)(a) — Consumers are encouraged and supported to provide feedback.
   • Met 6(3)(b) — Consumers have access to advocates and other methods for raising complaints.
   • Met 6(3)(c) — Appropriate action is taken in response to complaints.
   • Met 6(3)(d) — Feedback and complaints are reviewed for service improvement.

   Standard 7 Human resourcesNon-compliant

   The workforce is not consistently planned or equipped to deliver safe and quality care. There are gaps in staff competency, training, and performance review.

   • Not met 7(3)(a) — The number and mix of the workforce do not enable safe and quality care.
   • Met 7(3)(b) — Workforce interactions are kind, caring, and respectful.
   • Not met 7(3)(c) — Staff do not consistently have the necessary knowledge to perform their roles effectively.
   • Not met 7(3)(d) — The workforce is not trained, equipped, and supported to deliver required outcomes.
   • Not met 7(3)(e) — Regular assessment of staff performance does not occur consistently.

   Risks: Insufficient staffing impacts the quality of care and services provided.

   Recommendations: Ensure workforce planning aligns with consumer needs.; Provide ongoing training to ensure competency.

   Standard 8 Organisational governanceNon-compliant

   The service lacks effective systems for engaging consumers in care and services, managing risks, and ensuring continuous improvement. There are also gaps in workforce governance and regulatory compliance.

   • Not met 8(3)(a) — Consumers are not actively engaged in the development, delivery, and evaluation of care.
   • Met 8(3)(b) — The governing body promotes a culture of safe and quality care.
   • Not met 8(3)(c) — Governance systems for information management, continuous improvement, workforce governance, regulatory compliance, and feedback are not effective.
   • Not met 8(3)(d) — Risk management systems do not effectively manage incidents or prevent abuse and neglect.
   • Met 8(3)(e) — A clinical governance framework is in place, including policies for antimicrobial stewardship and open disclosure.

   Risks: Gaps in workforce governance impact the quality of care provided.; Regulatory compliance gaps exist, particularly with SIRS requirements.

   Recommendations: Implement effective systems to engage consumers actively.; Ensure continuous improvement and regulatory compliance.

   Generated by qwen2.5:32b on 12 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

9. Site audit Performance ReportFeb 23, 2023

   A site audit was conducted with this service on 21 February 2023 to 23 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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10. Accreditation decisionJun 15, 2021

    Following a site audit conducted on 11 May 2021 to 13 May 2021, the Commission made a decision on 15 June 2021 to re-accredit this service. The period of accreditation of the service will expire on 15 June 2023.

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11. Site audit Performance ReportMay 13, 2021

    A site audit was conducted with this service on 11 May 2021 to 13 May 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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12. Exceptional CircumstancesDec 16, 2020

    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 until 14 July 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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13. Exceptional CircumstancesJun 17, 2020

    During the COVID-19 pandemic, the Aged Care Quality and Safety Commission has temporarily modified our Regulatory Program, including 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 until 14 January 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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14. Compliance updateDec 5, 2019

    Following an assessment contact conducted on 05 December 2019, the Commission made a decision that improvements have been made to the service to ensure that the Aged Care Quality Standards are complied with.

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15. Non-compliance updateSep 4, 2019

    Following an assessment contact conducted on 04 September 2019, the Commission made a decision that the approved provider of the service is non-compliant with one requirement of the Aged Care Quality Standards.

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16. Serious risk decisionSep 4, 2019

    Following an unannounced assessment contact conducted on 4 September 2019 a delegate of the Aged Care Quality and Safety Commissioner made a finding that Anglican Care failed to meet one Aged Care Quality Standard (Quality Standards) in relation to Anglican Care Bishop Tyrrell Place. On 25 October 2019 a decision was made that failure to meet one Quality Standard has placed the safety, health or well-being of an aged care consumer of the service at serious risk. The Department of Health has been notified of the risk. Serious risk is not an ongoing state; it is a statutory decision based on evidence at a point in time.

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17. AssessmentMay 3, 2017

    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 14 July 2020.

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18. AssessmentMay 7, 2014

    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 14 July 2017.

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19. AssessmentMay 3, 2011
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No regulatory actions recorded.