Anglicare Goodhew Gardens & Bay Breeze

2-28 Alexander Avenue, TAREN POINT, NSW, 2229

1. Assessment contact (performance assessment) – siteSep 11, 2024

   Prepared by Therese Solomon

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2. Assessment contact Performance ReportAug 7, 2024

   An assessment contact was conducted with this service on 06/08/2024 to 07/08/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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3. Assessment Contact - SiteOct 12, 2023

   Prepared by Gill Jones

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4. Assessment contact Performance ReportSep 7, 2023

   An assessment contact was conducted with this service on 07 September 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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5. Accreditation decisionJun 26, 2023

   Following a site audit conducted on 24 April 2023 to 28 April 2023, the Commission made a decision on 26 June 2023 to re-accredit this service. The period of accreditation of the service will expire on 26 June 2026.

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6. Site AuditJun 26, 2023

   Prepared by G-M. Cain

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

   The service demonstrated compliance with most standards, particularly regarding consumer dignity and choice, ongoing assessment and planning, services and supports for daily living, feedback and complaints, human resources. However, non-compliance was noted in personal care and clinical care due to medication management issues, and organizational governance due to ineffective risk management systems.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers reported being treated with respect and having their cultural needs met, though some feedback was raised regarding Anzac Day celebrations and religious services.

   • Met Requirement 1(3)(a) — Consumers confirmed they were treated with dignity and respect, and staff demonstrated an understanding of each consumer's needs.
   • Met Requirement 1(3)(b) — Staff described processes for respecting consumers' cultural backgrounds and ensuring care is culturally safe.
   • Met Requirement 1(3)(c) — Consumers confirmed they were supported to make decisions about their own care, including who was involved in it.
   • Met Requirement 1(3)(d) — Staff described processes for supporting consumers who wish to take risks.
   • Met Requirement 1(3)(e) — Consumers and representatives said the service regularly communicated about care and provided timely information.
   • Met Requirement 1(3)(f) — Staff confirmed they receive privacy training, and observations showed staff respecting consumer privacy.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Consumers were actively involved in developing care plans that considered their needs, goals, and preferences.

   • Met Requirement 2(3)(a) — Care documents demonstrated consideration of potential risks to consumers' health and well-being.
   • Met Requirement 2(3)(b) — Consumers confirmed that the assessment process included their current needs, goals, and preferences.
   • Met Requirement 2(3)(c) — Staff described how consumers were involved in assessing and planning care.
   • Met Requirement 2(3)(d) — Consumers confirmed they were regularly updated on outcomes of assessments and had access to their care plans.
   • Met Requirement 2(3)(e) — Care documentation demonstrated regular review and update of care plans, including after incidents.

   Standard 3 Personal care and clinical careNon-compliant

   Consumers received safe and effective personal and clinical care tailored to their needs. However, there were issues with medication management.

   • Met Requirement 3(3)(a) — Consumers received safe and effective personal care tailored to their needs.
   • Not met Requirement 3(3)(b) — Several medication management incidents were identified, including missed doses and medications found in consumers' rooms.
   • Met Requirement 3(3)(c) — Consumers confirmed that end-of-life care had been discussed and documented.
   • Met Requirement 3(3)(d) — Staff recognized signs of deterioration in consumers' health and took prompt action.
   • Met Requirement 3(3)(e) — Information about the consumer’s condition, needs, and preferences was documented and communicated within the organization.
   • Met Requirement 3(3)(f) — Consumers confirmed timely referrals to healthcare professionals.
   • Met Requirement 3(3)(g) — Staff confirmed they had received training in infection prevention and control strategies.

   Risks: Medication management issues, including missed doses and medications found in consumers' rooms.

   Recommendations: Continue to implement the plan for continuous improvement related to medication management by 1 August 2023.

   Standard 4 Services and supports for daily livingCompliant

   Consumers received services that met their needs, goals, and preferences, promoting independence and quality of life.

   • Met Requirement 4(3)(a) — Consumers were satisfied with services that met their needs and enabled them to maintain independence.
   • Met Requirement 4(3)(b) — The service promoted consumers' emotional, psychological, and spiritual well-being through various activities.
   • Met Requirement 4(3)(c) — Consumers were supported to participate in community activities and engage in social interactions.
   • Met Requirement 4(3)(d) — Information about the consumer’s condition, needs, and preferences was communicated within the organization.
   • Met Requirement 4(3)(e) — Consumers confirmed timely referrals to healthcare professionals.
   • Met Requirement 4(3)(f) — Consumers enjoyed the meals provided and had input into menu development.
   • Met Requirement 4(3)(g) — Equipment was observed to be clean and well maintained.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, and enabled consumers' independence. However, there were concerns about cleanliness.

   • Met Requirement 5(3)(a) — Consumers found the service welcoming and easy to navigate.
   • Not met Requirement 5(3)(b) — Feedback raised concerns about cleanliness, including stained carpets and uncleaned bathrooms. Immediate actions were taken to address these issues.
   • Not met Requirement 5(3)(c) — Concerns were raised regarding the cleanliness of furniture fittings and fixtures. Actions have been initiated to improve cleaning schedules.

   Risks: Cleanliness issues in service environment, including stained carpets and uncleaned bathrooms.

   Recommendations: Continue implementing actions detailed in the plan for continuous improvement related to cleanliness by 1 August 2023.

   Standard 6 Feedback and complaintsCompliant

   Consumers were encouraged to provide feedback and make complaints, which were promptly addressed.

   • Met Requirement 6(3)(a) — Consumers confirmed they were encouraged to provide feedback and complaints.
   • Met Requirement 6(3)(b) — Information was observed throughout the service environment informing consumers of ways to raise feedback and complaints.
   • Met Requirement 6(3)(c) — Staff described processes for addressing complaints and using open disclosure principles.
   • Not met Requirement 6(3)(d) — Feedback raised concerns about the use of feedback to improve care. Immediate actions were taken to address these issues.

   Recommendations: Continue implementing actions detailed in the plan for continuous improvement related to feedback and complaints by 1 August 2023.

   Standard 7 Human resourcesCompliant

   The workforce was planned and managed effectively, though some staff felt rushed due to staffing levels.

   • Met Requirement 7(3)(a) — Workforce planning included recruitment of additional staff and ongoing monitoring.
   • Met Requirement 7(3)(b) — Staff interactions with consumers were mostly kind, caring, and respectful.
   • Met Requirement 7(3)(c) — All staff had the qualifications and knowledge to perform their roles effectively.
   • Met Requirement 7(3)(d) — Staff were recruited, trained, equipped, and supported to deliver safe care.
   • Met Requirement 7(3)(e) — Regular performance assessments were conducted for each member of the workforce.

   Standard 8 Organisational governanceNon-compliant

   Consumers were engaged in care and service development, but there were issues with risk management systems.

   • Met Requirement 8(3)(a) — Consumers considered themselves partners in improving care delivery and services.
   • Met Requirement 8(3)(b) — The governing body promoted a culture of safe, inclusive, quality care and was accountable for its delivery.
   • Not met Requirement 8(3)(c) — Deficiencies were identified in information management and continuous improvement monitoring. Immediate actions have been taken to address these issues.
   • Not met Requirement 8(3)(d) — Issues with managing high-impact risks, including medication management and inconsistent notifications under the Serious Incident Response Scheme.
   • Met Requirement 8(3)(e) — The service had a clinical governance framework supported by policies, procedures, and training.

   Risks: Ineffective management of high-impact risks concerning medication management.; Inconsistent notifications under the Serious Incident Response Scheme.

   Recommendations: Continue implementing actions detailed in the plan for continuous improvement related to risk management by 1 August 2023.

   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.

7. Exceptional CircumstancesApr 28, 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 05 November 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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8. Site audit Performance ReportApr 28, 2023

   A site audit was conducted with this service on 24 April 2023 to 28 April 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. Assessment Contact - SiteJan 10, 2023

   Prepared by G Cherry

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10. Assessment contact Performance ReportDec 14, 2022

    An assessment contact was conducted with this service on 14 December 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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11. Exceptional CircumstancesOct 27, 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 05 May 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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12. Exceptional CircumstancesApr 27, 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 05 November 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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13. Assessment contact Performance ReportJan 19, 2021

    An assessment contact was conducted with this service on 19 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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14. AssessmentMar 1, 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 05 May 2022.

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15. AssessmentFeb 18, 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 05 May 2019.

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16. AssessmentFeb 14, 2013
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17. AssessmentFeb 4, 2010
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No regulatory actions recorded.