Arcare Lisarow The Orchards

15 The Ridgeway -, LISAROW, NSW, 2250

1. Assessment Contact - SiteAug 1, 2023

   Prepared by Melissa Buhagiar

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2. Assessment contact Performance ReportJun 19, 2023

   An assessment contact was conducted with this service on 19 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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3. Accreditation decisionJan 20, 2023

   Following a site audit conducted on 28 November 2022 to 01 December 2022, the Commission made a decision on 20 January 2023 to re-accredit this service. The period of accreditation of the service will expire on 20 January 2026.

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4. Site AuditJan 20, 2023

   Prepared by Denise McDonald

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

   The Orchards Aged Care Service is compliant with most standards, demonstrating effective care and support for consumers' dignity, choice, ongoing assessment, daily living services, service environment, feedback mechanisms, human resources management, and organizational governance. However, there are areas of non-compliance in personal care and clinical care due to deficiencies in managing risks related to falls, fluid restrictions, and medication self-administration.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers are treated with dignity and respect, their identity, culture, and diversity valued, and they are supported to exercise choice and independence.

   • Met Requirement 1(3)(a) — Consumers stated they were treated with dignity and respect, and their identity, culture, and diversity were respected.
   • Met Requirement 1(3)(b) — Care was culturally safe according to consumers and staff observations.
   • Met Requirement 1(3)(c) — Consumers stated they were supported to exercise choice and independence in decision-making and maintaining relationships.
   • Met Requirement 1(3)(d) — Policies and procedures support consumers with risk-taking, and consumer files demonstrated potential risks had been assessed and regularly reviewed.
   • Met Requirement 1(3)(e) — Consumers stated they received information that was current, accurate, timely, clear, and easy to understand.
   • Met Requirement 1(3)(f) — Staff confirmed privacy was respected and personal information kept confidential.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Assessment and planning processes are effective in informing the delivery of safe and effective care, addressing consumer needs, goals, and preferences.

   • Met Requirement 2(3)(a) — Care planning documents were based on each consumer’s assessed needs.
   • Met Requirement 2(3)(b) — Consumers stated staff involved them in the assessment and planning of care for end-of-life wishes if they wished.
   • Met Requirement 2(3)(c) — The service partnered with organizations providing medical or specialized support as required.
   • Met Requirement 2(3)(d) — Consumers stated outcomes of assessments and planning were communicated to them.
   • Met Requirement 2(3)(e) — Care plan reviews were planned through a yearly schedule with progress monitored.

   Standard 3 Personal care and clinical careNon-compliant

   Consumers receive safe and effective personal and clinical care tailored to their needs, but there are ongoing risks related to falls, fluid restrictions, and medication management.

   • Met Requirement 3(3)(a) — Consumers stated they received safe and effective care tailored to their needs.
   • Not met Requirement 3(3)(b) — Deficiencies in managing risks associated with falls, fluid restrictions, and self-administration of medication were identified for two named consumers.
   • Met Requirement 3(3)(c) — Consumers stated they felt confident the service would support them to be as free from pain at end-of-life care.

   Risks: Falls prevention strategies were not effectively monitored or implemented.; Fluid restrictions for a consumer with congestive cardiac failure were not properly managed.; Medication self-administration without staff knowledge and assessment was identified.

   Recommendations: Provide falls management education to staff.; Amend entry processes to ensure all medications taken by consumers are identified.; Strengthen clinical governance to document reportable ranges and instruct staff on required care.

   Standard 4 Services and supports for daily livingCompliant

   Consumers receive safe and effective services that meet their needs, goals, and preferences, promoting independence and well-being.

   • Met Requirement 4(3)(a) — Consumers stated they were supported to live their best lives with valued independence.
   • Met Requirement 4(3)(b) — The service provided supports for emotional and psychological well-being through various activities.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is welcoming, safe, clean, and enables consumers to move freely.

   • Met Requirement 5(3)(a) — Consumers felt at home in the service with easy navigation.
   • Met Requirement 5(3)(b) — The environment was observed to be safe, clean, and well-maintained.

   Standard 6 Feedback and complaintsCompliant

   Consumers are encouraged and supported to provide feedback and make complaints, with appropriate action taken in response.

   • Met Requirement 6(3)(a) — Consumers stated they were familiar with feedback and complaint processes.
   • Met Requirement 6(3)(b) — Staff demonstrated a shared understanding of internal and external complaints avenues.

   Standard 7 Human resourcesCompliant

   The workforce is planned to deliver safe and quality care with kind, caring interactions and regular performance reviews.

   • Met Requirement 7(3)(a) — Management described how they ensure there was enough staff to provide safe and quality care.
   • Met Requirement 7(3)(b) — Staff were observed greeting consumers by their preferred name.

   Standard 8 Organisational governanceCompliant

   Consumers are engaged in care and service development with a governing body promoting safe, inclusive, and quality services.

   • Met Requirement 8(3)(a) — Consumers stated they were partners in improving the delivery of care and services.
   • Met Requirement 8(3)(b) — Management described how the governing body promoted a culture of safe, inclusive services.

   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. Site audit Performance ReportDec 1, 2022

   A site audit was conducted with this service on 28 November 2022 to 01 December 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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6. Exceptional CircumstancesSep 26, 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 22 April 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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7. Assessment contact Performance ReportFeb 3, 2022

   An assessment contact was conducted with this service on 03 February 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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8. Assessment contact Performance ReportJun 1, 2021

   An assessment contact was conducted with this service on 01 June 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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9. Compliance monitoring updateNov 27, 2019

   An assessment contact was conducted by the Aged Care Quality and Safety Commission (Commission) on 27 November 2019 at The Orchards Aged Care to monitor the service’s progress in meeting the Aged Care Quality Standards. The Commission found the service complies with all Aged Care Quality Standards.

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10. AssessmentAug 30, 2019

    Following a site audit the Commission made a decision on 26 September 2019 that this service met seven of the eight Aged Care Quality Standards. The service is re-accredited for three years until 22 October 2022.

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11. AssessmentAug 11, 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 22 October 2019.

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12. AssessmentAug 8, 2013
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13. AssessmentSep 13, 2012
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No regulatory actions recorded.