Arcare Glenhaven

93 Glenhaven Road, GLENHAVEN, NSW, 2156

1. Accreditation decisionJun 24, 2025

   Following a site audit conducted on 31 May 2022 to 02 June 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 24 June 2025. The period of accreditation of the service will expire on 12 January 2026.

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2. Assessment contact (performance assessment) – siteApr 15, 2024

   Prepared by Therese Solomon

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3. Assessment contact Performance ReportMar 5, 2024

   An assessment contact was conducted with this service on 05 March 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. Assessment Contact - SiteAug 18, 2023

   Prepared by Melissa Buhagiar

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

   The performance report for Arcare Glenhaven highlights non-compliance in Standards 1 and 3, with specific issues around consumer dignity and choice, and the management of high impact or high prevalence risks. Compliance was found in Standard 4 (meal service), Standard 6 (feedback and complaints process), and Standard 7 (workforce planning). The report also notes that Standards 2 and 5 were not assessed.

   1Non-compliant

   The service was found non-compliant due to deficiencies in consumer feedback indicating undignified treatment and issues with personal care, continence management, call bell response times, cleaning of bathrooms, and staff attitude.

   • Not met 1(3)(a) — Consumers and representatives provided feedback indicating they felt undignified, disrespected, embarrassed, and scared to speak up due to fear of retribution. Issues included personal care, continence management, call bell response times, cleaning of bathrooms, and staff attitude.

   Risks: Consumers may feel undignified and disrespected, leading to a lack of trust in the service.; Failure to recognize changes in consumer condition due to refusal of care could lead to further health deterioration.

   Recommendations: Continue with immediate internal audits of staff training needs and implementation of toolbox talks covering privacy, dignity, and choice.; Conduct case conferences with consumers and families identified as being dissatisfied.; Ensure call bell systems are working and staff are aware of organizational policies regarding response times.

   3Non-compliant

   The service was found non-compliant for the management of high impact or high prevalence risks, but compliant in recognizing and responding to changes in consumer health.

   • Not met 3(3)(b) — The service did not consistently reflect current care needs, goals, and preferences in assessments and care plans. There were issues with pressure injuries, weight loss, and falls management.
   • Met 3(3)(d) — Consumers and representatives provided positive feedback regarding recognition and response to deterioration. Documentation showed quick responses and escalation when necessary.

   Risks: Inconsistent management of high impact or high prevalence risks could lead to further health issues for consumers, such as pressure injuries, weight loss, and falls.

   Recommendations: Continue with training programs on assessment and care planning, pressure injury prevention, skin integrity checks, escalation of clinical risks, improving nutritional status, non-verbal pain management, SIRS, pain management, falls management, and wound prevention and management.; Ensure all worklogs are completed and closed off manually to avoid unnecessary tasks.

   4

   The service was compliant in providing varied meals of suitable quality and quantity. However, the standard is not rated as only one requirement has been assessed.

   • Met 4(3)(f) — Consumers and representatives were generally satisfied with meal service quality and variety. The service implemented improvements such as increased frequency of food focus meetings, menu reviews by dietitians, and installation of heat lamps.

   Recommendations: Continue to monitor the satisfaction levels of consumers regarding meals and maintain efforts in improving meal services.

   6

   The service was compliant with taking appropriate action on complaints and using an open disclosure process. However, the standard is not rated as only one requirement has been assessed.

   • Met 6(3)(c) — Consumers and representatives expressed satisfaction with complaint resolution processes. The service demonstrated responsiveness to feedback through the complaints register, resident meeting minutes, and food focus forums.

   Recommendations: Continue to encourage consumer feedback and use it to improve services provided.

   7

   The service was compliant in workforce planning and deployment. However, the standard is not rated as only one requirement has been assessed.

   • Met 7(3)(a) — Consumers and representatives were generally satisfied with staffing levels and staff availability. The service uses a casual pool of staff to fill vacant shifts.

   Recommendations: Continue to monitor staffing levels, especially in the memory support unit, and ensure adequate coverage on weekends.

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   5

   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.

5. Assessment contact Performance ReportJul 14, 2023

   An assessment contact was conducted with this service on 13 July 2023 to 14 July 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 decisionJul 12, 2022

   Following a site audit conducted on 31 May 2022 to 02 June 2022, the Commission made a decision on 12 July 2022 to re-accredit this service. The period of accreditation of the service will expire on 12 July 2025.

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7. Site audit Performance ReportJun 2, 2022

   A site audit was conducted with this service on 31 May 2022 to 02 June 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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8. Exceptional CircumstancesFeb 24, 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 11 September 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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9. 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 11 March 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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10. AssessmentJun 7, 2018

    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 11 September 2021.

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11. AssessmentSep 6, 2017

    This is a new home and is accredited for one year until 11 September 2018. We made the decision on 06 September 2017.

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No regulatory actions recorded.