Alexander Aged Care

16 Victor Road, BROOKVALE, NSW, 2100

1. Accreditation decisionFeb 28, 2023

   Following a site audit conducted on 18 January 2023 to 20 January 2023, the Commission made a decision on 28 February 2023 to re-accredit this service. The period of accreditation of the service will expire on 28 February 2026.

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2. Site AuditFeb 28, 2023

   Prepared by G. Hope-Simpson

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

   Alexander Aged Care was compliant with most standards but non-compliant with Standard 8 due to issues in incident and Serious Incident Reporting Scheme (SIRS) reporting. The service demonstrated effective care planning, personal and clinical care, services for daily living, a welcoming environment, feedback mechanisms, and human resources management. However, there were concerns about staff understanding of SIRS requirements and the need for better training and evaluation measures to ensure compliance.

   1 Consumer dignity and choiceCompliant

   Consumers reported being treated with respect and their choices were respected.

   • Met 1(3)(a) — Consumers said they were treated with dignity and respect; staff were aware of consumers from diverse cultural backgrounds.
   • Met 1(3)(b) — Care planning documents showed acknowledgment of consumer culture, diversity, and identity.
   • Met 1(3)(c) — Consumers felt they were given choices about care and their choices were respected by staff.
   • Met 1(3)(d) — Staff supported consumers to take risks, with documentation including dignity of risk forms.
   • Met 1(3)(e) — Consumers felt they were provided with clear and understandable information.
   • Met 1(3)(f) — Nurses' stations were locked, computers password-protected to protect consumer privacy.

   2 Ongoing assessment and planning with consumersCompliant

   Consumers felt they had a say in care planning processes.

   • Met 2(3)(a) — Care plans identified consumer needs, goals, and preferences.
   • Met 2(3)(b) — Advance care planning was discussed on admission.
   • Met 2(3)(c) — Consumers actively participated in the care planning process.
   • Met 2(3)(d) — Care plans were readily available and effectively communicated to consumers.
   • Met 2(3)(e) — Care planning was reviewed regularly, including when circumstances changed.

   3 Personal care and clinical careCompliant

   Consumers received safe and effective personal and clinical care.

   • Met 3(3)(a) — Care was tailored to individual needs.
   • Met 3(3)(b) — High-impact risks were managed through regular monitoring and mitigation strategies.
   • Met 3(3)(c) — Palliative care was provided in accordance with end-of-life wishes.
   • Met 3(3)(d) — Signs of deterioration were recognized and responded to timely.
   • Met 3(3)(e) — Information about consumer conditions was documented and communicated effectively.
   • Met 3(3)(f) — Timely referrals to other health professionals were made as needed.
   • Met 3(3)(g) — Infection control practices were observed and antibiotics use was minimized.

   Risks: For one consumer, wound charting progress entries were not always taken at a consistent angle or included ruler measurements.

   4 Services and supports for daily livingCompliant

   Consumers felt supported to participate in activities they liked.

   • Met 4(3)(a) — Services optimized consumers' independence and quality of life.
   • Met 4(3)(b) — Consumers reported their emotional, spiritual, and psychological needs were supported.
   • Met 4(3)(c) — Consumers could participate in activities within and outside the service.
   • Met 4(3)(d) — Information about consumer conditions was communicated effectively.
   • Met 4(3)(e) — Timely referrals to external services were made as needed.
   • Met 4(3)(f) — Consumers expressed satisfaction with the variety, quality, and quantity of food.
   • Met 4(3)(g) — Equipment was safe, clean, well-maintained, and in good condition.

   5 Organisation’s service environmentCompliant

   The service environment was welcoming and easy to navigate.

   • Met 5(3)(a) — Consumers felt the environment made them feel welcome.
   • Met 5(3)(b) — The service was safe, clean, well-maintained, and allowed free movement.
   • Met 5(3)(c) — Equipment was checked, cleaned, and maintained regularly.

   6 Feedback and complaintsCompliant

   Consumers felt comfortable providing feedback or making a complaint.

   • Met 6(3)(a) — Processes were in place to encourage and support consumers to provide feedback.
   • Met 6(3)(b) — Consumers knew about external complaints, language, and advocacy services.
   • Met 6(3)(c) — Appropriate action was taken in response to complaints.
   • Met 6(3)(d) — Feedback and complaints were reviewed for service improvement.

   7 Human resourcesCompliant

   The workforce was planned to deliver safe and quality care.

   • Met 7(3)(a) — There were sufficient staff to provide quality care.
   • Met 7(3)(b) — Staff interactions with consumers were kind, caring, and respectful.
   • Met 7(3)(c) — Staff were competent and qualified to perform their roles.
   • Met 7(3)(d) — Staff were trained, equipped, and supported for their roles.
   • Met 7(3)(e) — Performance assessments of staff were up to date and completed annually.

   Risks: Some care staff did not demonstrate a clear understanding of SIRS reporting requirements.

   8 Organisational governanceNon-compliant

   The service was non-compliant due to issues with incident and SIRS reporting.

   • Met 8(3)(a) — Consumers were engaged in the development, delivery, and evaluation of care.
   • Met 8(3)(b) — The governing body promoted a culture of safe, inclusive, and quality care.
   • Not met 8(3)(c) — The service did not comply with SIRS reporting requirements for Priority 2 incidents.
   • Met 8(3)(d) — Effective risk management systems were in place.
   • Met 8(3)(e) — Clinical governance frameworks ensured the quality and safety of clinical care.

   Risks: The service had not reported a single incident to SIRS in the previous 12 months.

   Recommendations: Training on mandatory reporting obligations for all staff, including management.; Evaluation measures for improvement effectiveness.

   Generated by qwen2.5:32b on 11 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

3. 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 01 September 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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4. Site audit Performance ReportJan 20, 2023

   A site audit was conducted with this service on 18 January 2023 to 20 January 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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5. Exceptional CircumstancesJul 12, 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 01 March 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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6. Accreditation decisionJan 28, 2021

   Following a site audit conducted on 29 May 2018 to 30 May 2018, the Commission made a decision on 10 July 2018 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 28 January 2021. The period of accreditation of the service will expire on 31 August 2022.

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7. AssessmentMay 30, 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 31 August 2021.

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8. AssessmentJul 22, 2015

   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 31 August 2018.

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9. AssessmentJul 4, 2012
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10. AssessmentMay 28, 2009
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No regulatory actions recorded.