Anglican Care McIntosh Court

Toronto Road, BOORAGUL, NSW, 2284

1. Accreditation decisionAug 14, 2024

   Following a site audit conducted on 03/07/2024 to 05/07/2024, the Commission made a decision on 14/08/2024 to re-accredit this service. The period of accreditation of the service will expire on 07/10/2027

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2. Site AuditAug 14, 2024

   Prepared by Katherine Richards

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3. Site audit Performance ReportJul 5, 2024

   A site audit was conducted with this service on 03/07/2024 to 05/07/2024. 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) – siteFeb 27, 2024

   Prepared by Katrina Platt

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5. Assessment contact Performance ReportJan 16, 2024

   An assessment contact was conducted with this service on 16 January 2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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6. Assessment Contact - SiteAug 4, 2023

   Prepared by G Jones

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7. Assessment contact Performance ReportJun 27, 2023

   An assessment contact was conducted with this service on 27 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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8. Accreditation decisionOct 7, 2022

   Following a site audit conducted on 07 September 2022 to 09 September 2022, the Commission made a decision on 07 October 2022 to re-accredit this service. The period of accreditation of the service will expire on 07 October 2024.

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9. Site AuditOct 7, 2022

   Prepared by E Woodley

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

   The performance report indicates that Anglican Care McIntosh Court is non-compliant in seven out of eight Aged Care Quality Standards. The primary areas for improvement include maintaining consumer privacy and dignity (Standard 1), reviewing care plans effectively following incidents (Standard 2), providing best-practice tailored care (Standard 3), ensuring services meet consumers' needs and preferences (Standard 4), creating a dementia-friendly environment (Standard 5), staffing levels to deliver quality care (Standard 7), and effective risk management and clinical governance (Standard 8). The service is compliant with Standard 6, which focuses on feedback and complaints.

   1Non-compliant

   The service is non-compliant due to ineffective processes for maintaining consumer privacy and dignity.

   • Met 1(3)(a) — Consumers are treated with dignity and respect, with their identity, culture, and diversity valued.
   • Met 1(3)(b) — Care and services provided are culturally safe.
   • Met 1(3)(c) — Consumers are supported to exercise choice and independence, including making decisions about their care and involving others in their care.
   • Met 1(3)(d) — Consumers are supported to take risks to live the best life they can.
   • Met 1(3)(e) — Information provided is current, accurate, and communicated in a way that enables consumers to exercise choice.
   • Not met 1(3)(f) — The service did not demonstrate effective processes for maintaining consumer privacy and dignity. Visiting health professionals were observed providing care in common areas without respecting consumer privacy.

   Recommendations: Implement steps to ensure treatments by external health providers occur in locations that respect consumer privacy.

   2Non-compliant

   The service is non-compliant due to ineffective review of care and services when incidents impact on the well-being and safety of consumers.

   • Met 2(3)(a) — Assessment and planning inform safe and effective care delivery.
   • Met 2(3)(b) — Assessment and planning identify and address consumer needs, goals, preferences, including advance care planning.
   • Met 2(3)(c) — The service demonstrates ongoing partnership with consumers in assessment and planning.
   • Met 2(3)(d) — Outcomes of assessment and planning are effectively communicated to the consumer and documented.
   • Not met 2(3)(e) — Care and services were not reviewed for effectiveness when incidents impacted on well-being and safety. Documentation did not reflect review for consumers with behaviors requiring support.

   Recommendations: Ensure care plans are reviewed regularly, especially following incidents that impact consumer needs or preferences.

   3Non-compliant

   The service is non-compliant due to ineffective management of high-impact risks and lack of best-practice tailored care.

   • Not met 3(3)(a) — Consumers were not receiving best practice, tailored care that optimizes health and well-being.
   • Not met 3(3)(b) — High-impact risks associated with consumer care were not effectively managed. Behavior support plans were not individualized or effective.
   • Met 3(3)(c) — Needs, goals, and preferences of consumers nearing end-of-life are recognized and addressed.
   • Met 3(3)(d) — Deterioration or change in consumer condition is recognized and responded to timely.
   • Met 3(3)(e) — Information about the consumer’s condition, needs, and preferences is documented and communicated effectively.
   • Met 3(3)(f) — Timely and appropriate referrals to other care providers are made.
   • Met 3(3)(g) — Infection-related risks are minimized through standard precautions and antibiotic stewardship practices.

   Recommendations: Implement individualized behavior support plans and ensure all care is best practice and tailored to consumer needs.

   4Non-compliant

   The service is non-compliant due to ineffective services and supports for daily living that do not meet consumers' needs, goals, or preferences.

   • Not met 4(3)(a) — Services and supports for daily living did not optimally meet consumer needs, goals, or preferences.
   • Not met 4(3)(b) — Emotional, spiritual, and psychological well-being support was lacking for some consumers who felt unsafe due to behaviors requiring support.
   • Met 4(3)(c) — Consumers are supported in participating in community activities and maintaining social relationships.
   • Met 4(3)(d) — Information about consumer needs is communicated effectively within the organization and with others.
   • Met 4(3)(e) — Timely referrals to other care providers are made appropriately.
   • 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: Engage additional staff to gather individualized data for each consumer to develop person-centered care plans.

   5Non-compliant

   The service is non-compliant due to an environment that does not optimize consumer independence, interaction, and function.

   • Not met 5(3)(a) — Service environment did not reflect dementia-enabling principles and was difficult for consumers to navigate.
   • Not met 5(3)(b) — The service environment was not clean, well-maintained, or comfortable. Some areas were unsafe due to behaviors requiring support.
   • Met 5(3)(c) — Furniture, fittings, and equipment are safe, clean, well-maintained, and suitable for consumers.

   Recommendations: Engage a dementia-specific consultant to ensure the environment reflects dementia-enabling principles.

   6Compliant

   The service is compliant with effective feedback and complaint processes.

   • Met 6(3)(a) — Consumers are encouraged to provide feedback and make complaints.
   • Met 6(3)(b) — Consumers have access to advocates, language services, and methods for raising and resolving complaints.
   • Met 6(3)(c) — Appropriate action is taken in response to complaints with an open disclosure process used when things go wrong.
   • Met 6(3)(d) — Feedback and complaints are reviewed for quality improvement.

   7Non-compliant

   The service is non-compliant due to insufficient staffing levels affecting the delivery of safe and quality care.

   • Not met 7(3)(a) — Insufficient number of staff available to provide quality care, especially for managing behaviors requiring support.
   • Met 7(3)(b) — Workforce interactions with consumers are kind and respectful.
   • Met 7(3)(c) — The workforce is competent, qualified, and knowledgeable to perform their roles.
   • Met 7(3)(d) — Workforce recruitment, training, equipment, and support are adequate for delivering required outcomes.
   • Met 7(3)(e) — Regular assessment, monitoring, and review of workforce performance is undertaken.

   Recommendations: Engage new staff in 'support' roles to assist with care delivery and commence a recruitment process for additional care, nursing, and lifestyle staff.

   8Non-compliant

   The service is non-compliant due to ineffective risk management systems and clinical governance.

   • Met 8(3)(a) — Consumers are engaged in the development, delivery, and evaluation of care.
   • Met 8(3)(b) — The governing body promotes a culture of safe, inclusive, and quality care.
   • Met 8(3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, feedback, and complaints.
   • Not met 8(3)(d) — Risk management systems were not effective in identifying high-impact risks or managing incidents appropriately.
   • Not met 8(3)(e) — Clinical governance framework did not consistently ensure safe and quality clinical care, particularly for managing consumer behaviors.

   Recommendations: Implement staff training on risk management and clinical governance, increase monitoring processes, and appoint an advisor to assist with the risk management framework.

   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.

10. Site audit Performance ReportSep 9, 2022

    A site audit was conducted with this service on 07 September 2022 to 09 September 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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11. Exceptional CircumstancesJun 21, 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 07 January 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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12. Exceptional CircumstancesDec 2, 2021

    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 07 July 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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13. Exceptional CircumstancesJun 18, 2021

    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 07 January 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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14. Assessment contact Performance ReportMar 3, 2021

    An assessment contact was conducted with this service on 02 March 2021 to 03 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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15. 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 07 July 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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16. AssessmentOct 11, 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 07 January 2021.

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17. AssessmentOct 17, 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 07 January 2018.

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18. AssessmentOct 14, 2011
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No regulatory actions recorded.