Anglican Care Mirrabooka Place

1 Clement Street, GLOUCESTER, NSW, 2422

1. Accreditation decisionJun 25, 2025

   Following a site audit conducted on 09 May 2022 to 11 May 2022, the Commission made a decision on 12 July 2022 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 25 June 2025. The period of accreditation of the service will expire on 12 January 2026.

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2. Assessment contact (performance assessment) – siteFeb 7, 2024

   Prepared by M Wyborn

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3. Assessment contact Performance ReportJan 10, 2024

   An assessment contact was conducted with this service on 10 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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4. Accreditation decisionJul 12, 2023

   Following a site audit conducted on 09 May 2023 to 11 May 2023, the Commission made a decision on 12 July 2023 to re-accredit this service. The period of accreditation of the service will expire on 12 July 2025.

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5. Site AuditJul 12, 2023

   Prepared by M Wyborn

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

   The performance report for Anglican Care Mirrabooka Place highlights compliance with Standards 1 (Consumer dignity and choice), 5 (Organisation’s service environment), 6 (Feedback and complaints). However, the service was non-compliant in Standards 2 (Ongoing assessment and planning with consumers), 3 (Personal care and clinical care), 4 (Services and supports for daily living), 7 (Human resources), and 8 (Organisational governance) due to issues such as inadequate documentation of consumer assessments, ineffective management of high impact risks, meal quality concerns, workforce shortages, and lack of effective governance systems.

   Standard 1 Consumer dignity and choiceCompliant

   The service demonstrated that consumers are treated with dignity, respect, and their identity is valued. Consumers were supported to exercise choice and independence.

   • Met Requirement 1(3)(a) — The service demonstrated that consumers are treated with dignity and respect, with their identity, culture, and diversity valued.
   • Met Requirement 1(3)(b) — Consumer care and services were culturally safe. The service provided a culturally and linguistically diverse report and arranges theme days to celebrate key events.
   • Met Requirement 1(3)(c) — Consumers advised that they are supported to exercise choice and independence, including involving or not involving others in their care depending on their wishes.
   • Met Requirement 1(3)(d) — The service demonstrated effective management of consumer incidents noted by the Assessment Team Report.
   • Met Requirement 1(3)(e) — Consumers advised they are provided with information that allows them to make choices, and staff demonstrated how they provide consumers with relevant information on exercising their powers to make choices.
   • Met Requirement 1(3)(f) — The service demonstrated respect for consumer privacy and confidentiality of personal information through the use of a password-protected electronic care management system.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The service was compliant in documenting detailed consumer assessments but non-compliant in addressing needs, goals, preferences, and demonstrating ongoing partnership.

   • Met Requirement 2(3)(a) — The service demonstrated that assessment and planning informs the delivery of safe and effective care.
   • Not met Requirement 2(3)(b) — Documentation was generic, and some consumer needs were not assessed and documented in accordance with best practice.
   • Not met Requirement 2(3)(c) — Ongoing partnership with consumers and other organisations and individuals was not routinely demonstrated at the service.
   • Met Requirement 2(3)(d) — The outcomes of assessment and planning were effectively communicated to each consumer and documented in their care plan.
   • Met Requirement 2(3)(e) — Care and services are reviewed regularly for effectiveness, and when circumstances change or incidents impact on the needs, goals, or preferences of consumers.

   Recommendations: Ensure detailed consumer assessment information is documented.; Demonstrate ongoing partnership with consumers and other organizations involved in care.

   Standard 3 Personal care and clinical careNon-compliant

   The service was compliant in providing safe and effective personal and clinical care but non-compliant in managing high impact risks and documenting consumer information.

   • Met Requirement 3(3)(a) — The service demonstrated safe and effective personal care, clinical care that is best practice and tailored to needs.
   • Not met Requirement 3(3)(b) — High impact or high prevalence risks were not managed appropriately, impacting some consumers negatively.
   • Met Requirement 3(3)(c) — The service demonstrated appropriate care for those nearing the end of life with comfort maximized and dignity preserved.
   • Met Requirement 3(3)(d) — Deterioration or change in consumer’s mental health, cognitive function, capacity, or condition was recognized and responded to timely.
   • Not met Requirement 3(3)(e) — Information about the consumer's condition, needs, and preferences is not adequately documented and communicated within the organization.
   • Met Requirement 3(3)(f) — Timely and appropriate referrals to individuals, other organizations, and providers of care were made.
   • Met Requirement 3(3)(g) — The service demonstrated effective infection control practices and antibiotic stewardship.

   Recommendations: Ensure high impact risks are effectively managed.; Improve documentation of consumer information within the organization.

   Standard 4 Services and supports for daily livingNon-compliant

   The service was compliant in providing safe and effective services but non-compliant in meal quality and variety.

   • Met Requirement 4(3)(a) — Services and supports for daily living met consumer needs, goals, and preferences.
   • Met Requirement 4(3)(b) — The service promoted emotional, spiritual, and psychological well-being through community visits and support services.
   • Met Requirement 4(3)(c) — Consumers were supported to participate in community activities and maintain social relationships.
   • Met Requirement 4(3)(d) — Information about the consumer's condition, needs, and preferences was communicated within the organization.
   • Met Requirement 4(3)(e) — Timely and appropriate referrals to individuals, other organizations, and providers of care were made.
   • Not met Requirement 4(3)(f) — Consumers advised that meals provided were not always of suitable quality and variety.
   • Met Requirement 4(3)(g) — Equipment was safe, clean, well maintained, and suitable for consumers.

   Recommendations: Improve meal quality and variety to meet consumer needs.

   Standard 5 Organisation’s service environmentCompliant

   The service was compliant in providing a welcoming, safe, clean, well-maintained, and comfortable environment.

   • Met Requirement 5(3)(a) — Consumers provided positive feedback about the service environment.
   • Met Requirement 5(3)(b) — The service environment was safe, clean, well maintained, and comfortable, enabling consumers to move freely.
   • Met Requirement 5(3)(c) — Furniture, fittings, and equipment were safe, clean, well maintained, and suitable for the consumer.

   Standard 6 Feedback and complaintsCompliant

   The service was compliant in encouraging feedback and making consumers aware of advocates and methods to raise complaints.

   • Met Requirement 6(3)(a) — Consumers were encouraged and supported to provide feedback or make a complaint.
   • Met Requirement 6(3)(b) — Consumers had access to advocates, language services, and other methods for raising complaints.
   • Met Requirement 6(3)(c) — Appropriate action was taken in response to complaints using an open disclosure process.
   • Met Requirement 6(3)(d) — Feedback and complaints were reviewed and used to improve the quality of care and services.

   Standard 7 Human resourcesNon-compliant

   The service was compliant in workforce interactions, competency, training, and performance review but non-compliant in workforce planning.

   • Not met Requirement 7(3)(a) — Staff shortages and shifts not always filled impacted the care provided to consumers.
   • Met Requirement 7(3)(b) — Workforce interactions with consumers were kind, caring, and respectful of each consumer’s identity, culture, and diversity.
   • Met Requirement 7(3)(c) — The workforce was competent and had the qualifications and knowledge to effectively perform their roles.
   • Met Requirement 7(3)(d) — Workforce members were recruited, trained, equipped, and supported to deliver required outcomes.
   • Met Requirement 7(3)(e) — Regular assessment, monitoring, and review of workforce performance was undertaken.

   Recommendations: Ensure effective workforce planning to meet consumer care needs.

   Standard 8 Organisational governanceNon-compliant

   The service was compliant in engaging consumers but non-compliant in promoting a culture of safe, inclusive care and having effective governance systems.

   • Met Requirement 8(3)(a) — Consumers were engaged in the development, delivery, and evaluation of care and services.
   • Not met Requirement 8(3)(b) — The governing body did not promote a culture of safe, inclusive, and quality care and was not effectively involved or accountable for their delivery.
   • Not met Requirement 8(3)(c) — Effective organization-wide governance systems relating to information management, continuous improvement, workforce governance, financial governance, regulatory compliance were lacking.
   • Not met Requirement 8(3)(d) — The service was unable to demonstrate effective risk management systems and practices.
   • Not met Requirement 8(3)(e) — An appropriate documented clinical governance framework was not demonstrated.

   Recommendations: Promote a culture of safe, inclusive care and ensure effective governance systems are in place.; Develop an appropriate documented clinical governance 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.

6. Site audit Performance ReportMay 11, 2023

   A site audit was conducted with this service on 09 May 2023 to 11 May 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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7. Exceptional CircumstancesFeb 27, 2023

   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 27 September 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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8. Exceptional CircumstancesAug 18, 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 23 March 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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9. Exceptional CircumstancesFeb 25, 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 until 23 September 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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10. Exceptional CircumstancesAug 26, 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 23 March 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Assessment contact Performance ReportJan 20, 2021

    An assessment contact was conducted with this service on 20 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. Accreditation decisionAug 10, 2020

    Following an application for accreditation, the Commission made a decision on 21 August 2020 to accredit this commencing service. The period of accreditation of the service will expire on 23 September 2021.

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No regulatory actions recorded.