Anglican Care Kilpatrick Court

152 Brighton Avenue, TORONTO, NSW, 2283

1. Accreditation decisionOct 23, 2024

   Following a site audit conducted on 18/09/2024 to 20/09/2024, the Commission made a decision on 23/10/2024 to re-accredit this service. The period of accreditation of the service will expire on 31/12/2027

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2. Site AuditOct 23, 2024

   Prepared by P. Sherin

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3. Site audit Performance ReportSep 20, 2024

   A site audit was conducted with this service on 18 September 2024 to 20 September 2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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4. Assessment contact (performance assessment) – siteDec 22, 2023

   Prepared by T Solomon

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5. Assessment contact Performance ReportNov 23, 2023

   An assessment contact was conducted with this service on 22 November 2023 to 23 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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6. Accreditation decisionMay 19, 2023

   Following a site audit conducted on 14 March 2023 to 17 March 2023, the Commission made a decision on 19 May 2023 to re-accredit this service. The period of accreditation of the service will expire on 31 December 2024.

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7. Site AuditMay 19, 2023

   Prepared by M Wyborn

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

   The service demonstrated compliance in Standards 1, 6 but was non-compliant in Standards 2, 3, 4, 5, 7, and 8. Key areas for improvement include ongoing assessment and planning with consumers, personal care and clinical care, services and supports for daily living, the organization’s service environment, human resources, and organizational governance.

   Standard 1 Consumer dignity and choiceCompliant

   The service demonstrated person-centred care, respecting consumer choices and privacy.

   • Met Requirement 1(3)(a) — Each consumer is treated with dignity and respect.
   • Met Requirement 1(3)(b) — Care and services are culturally safe.
   • Met Requirement 1(3)(c) — Consumers are supported to exercise choice and independence.
   • Met Requirement 1(3)(d) — Support for consumers to take risks.
   • Met Requirement 1(3)(e) — Information provided is clear and easy to understand.
   • Met Requirement 1(3)(f) — Privacy respected and personal information kept confidential.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The service demonstrated effective assessment and planning but failed to show routine reviews of consumer care plans.

   • Met Requirement 2(3)(a) — Assessment and planning informs safe and effective care.
   • Met Requirement 2(3)(b) — Identifies and addresses consumer needs, goals, and preferences.
   • Met Requirement 2(3)(c) — Partnership with consumers in assessment and planning.
   • Met Requirement 2(3)(d) — Outcomes effectively communicated to the consumer.
   • Not met Requirement 2(3)(e) — Care plans not regularly reviewed when due or needs change.

   Risks: Increased behavioural incidents reported without accurate recent data.; Lack of investigation into falls and behaviour incidents.

   Recommendations: Ensure consumer care planning documentation records current needs, goals, and preferences.; Establish a system for routine consultation or maintenance of appropriate records.

   Standard 3 Personal care and clinical careNon-compliant

   The service demonstrated effective processes for end-of-life care but failed to show timely recognition and response to changes in consumer conditions.

   • Met Requirement 3(3)(a) — Safe and effective personal and clinical care.
   • Met Requirement 3(3)(b) — Effective management of high impact or high prevalence risks.
   • Met Requirement 3(3)(c) — Recognition and addressing needs for end-of-life care.
   • Not met Requirement 3(3)(d) — Deterioration or change not recognized promptly on a routine basis.
   • Met Requirement 3(3)(e) — Information documented and communicated effectively.
   • Met Requirement 3(3)(f) — Timely referrals to other care providers.
   • Met Requirement 3(3)(g) — Minimization of infection risks through appropriate practices.

   Risks: Delay in recognizing decline in mental health and providing non-pharmacological support.

   Recommendations: Ensure effective system for recording, monitoring, and reviewing consumer care plans.; Provide education to staff on referral processes.

   Standard 4 Services and supports for daily livingNon-compliant

   The service demonstrated safe and effective services but failed to show that meals are varied and of suitable quality and quantity.

   • Met Requirement 4(3)(a) — Services meet consumer needs and promote independence.
   • Met Requirement 4(3)(b) — Promotion of emotional, spiritual, and psychological well-being.
   • Met Requirement 4(3)(c) — Support for community participation and personal relationships.
   • Met Requirement 4(3)(d) — Information communicated effectively within the organization.
   • Met Requirement 4(3)(e) — Timely referrals to other care providers.
   • Not met Requirement 4(3)(f) — Meals not varied and of suitable quality and quantity.
   • Met Requirement 4(3)(g) — Safe, suitable, clean, and well-maintained equipment.

   Risks: Dissatisfaction with meal services among consumers and representatives.

   Recommendations: Ensure routine review of consumer feedback regarding meals.

   Standard 5 Organisation’s service environmentNon-compliant

   The service demonstrated a safe, clean, well-maintained environment but failed to show consideration for dementia design wayfinding.

   • Not met Requirement 5(3)(a) — Environment not welcoming or easy to understand.
   • Met Requirement 5(3)(b) — Safe, clean, well-maintained environment enabling free movement.
   • Met Requirement 5(3)(c) — Furniture and equipment safe, clean, well-maintained, and suitable.

   Risks: Environmental risks in outdoor areas not inviting or well maintained.; Difficulty navigating the service environment for consumers with reduced cognition.

   Recommendations: Review environment relating to appropriate signage within the memory support unit.

   Standard 6 Feedback and complaintsCompliant

   The service demonstrated effective processes for feedback and complaint handling.

   • Met Requirement 6(3)(a) — Consumers encouraged to provide feedback.
   • Met Requirement 6(3)(b) — Access to advocates and methods for raising complaints.
   • Met Requirement 6(3)(c) — Appropriate action taken in response to complaints.
   • Met Requirement 6(3)(d) — Feedback used to improve care and services.

   Standard 7 Human resourcesNon-compliant

   The service demonstrated competent workforce interactions but failed to show effective workforce planning and regular performance reviews.

   • Not met Requirement 7(3)(a) — Workforce not planned or deployed effectively.
   • Met Requirement 7(3)(b) — Kind and respectful interactions with consumers.
   • Met Requirement 7(3)(c) — Competent workforce with relevant qualifications and knowledge.
   • Met Requirement 7(3)(d) — Recruitment, training, and support for delivering outcomes.
   • Not met Requirement 7(3)(e) — Regular assessment of staff performance not undertaken.

   Risks: Staff shortages impacting consumer care.; Call bells not evaluated for trending data.

   Recommendations: Adopt effective workforce planning strategies.; Provide regular performance appraisals.

   Standard 8 Organisational governanceNon-compliant

   The service demonstrated a culture of safe and quality care but failed to show effective governance systems, risk management practices, and clinical governance framework.

   • Not met Requirement 8(3)(a) — Consumers not effectively engaged in development of care services.
   • Met Requirement 8(3)(b) — Culture promoting safe and quality care.
   • Not met Requirement 8(3)(c) — Governance systems not effective for information management or continuous improvement.
   • Not met Requirement 8(3)(d) — Risk management systems and practices ineffective.
   • Not met Requirement 8(3)(e) — Clinical governance framework not up to date.

   Risks: Outdated policies and procedures.; Deficiencies in managing high-impact risks associated with consumer care.

   Recommendations: Review suite of organisational policies.; Ensure effective risk management systems.

   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.

8. Site audit Performance ReportMar 17, 2023

   A site audit was conducted with this service on 14 March 2023 to 17 March 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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9. Accreditation decisionApr 21, 2021

   Following a site audit conducted on 16 March 2021 to 18 March 2021, the Commission made a decision on 21 April 2021 to re-accredit this service. The period of accreditation of the service will expire on 01 June 2023.

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10. Site audit Performance ReportMar 18, 2021

    A site audit was conducted with this service on 16 March 2021 to 18 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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11. Assessment contact Performance ReportJan 14, 2021

    An assessment contact was conducted with this service on 14 January 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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12. Assessment contact Performance ReportJul 16, 2020

    An assessment contact was conducted with this service on 15 July 2020 to 16 July 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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13. Accreditation decisionFeb 20, 2020

    Following a site audit conducted on 17 to 20 February 2020, the Commission made a decision on 23 March 2020 to re-accredit this service. The period of accreditation of the service will expire on 1 June 2021. The Performance Report is attached.

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14. Non-compliance updateNov 5, 2019

    Following an assessment contact conducted on 05 November 2019, the Commission made a decision that the approved provider of the service is non-compliant with 3 requirements of the Aged Care Quality Standards.

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15. AssessmentApr 6, 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 01 June 2020.

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16. AssessmentApr 15, 2016

    This is a new home and is accredited for one year until 01 June 2017. We made the decision on 22 April 2016.

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No regulatory actions recorded.