Ashleigh House Hostel

20-24 Bergen Crescent, SALE, VIC, 3850

1. AssessmentMay 8, 2025

   The Aged Care Quality and Safety Commission (the Commission) has monitored the provider’s progress in implementing improvements in the service to ensure compliance with the Aged Care Quality Standards. Based on the information submitted by the provider, as of 08/05/2025, the Commission is satisfied actions have been taken to address the non-compliance with the Aged Care Quality Standards. The Commission will continue to monitor the provider’s performance.

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2. Assessment contact (performance assessment) – siteAug 29, 2024

   Prepared by N Eastwood

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3. Assessment contact Performance ReportAug 8, 2024

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

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4. Accreditation decisionJun 8, 2023

   Following a site audit conducted on 18 April 2023 to 28 April 2023, the Commission made a decision on 08 June 2023 to re-accredit this service. The period of accreditation of the service will expire on 15 July 2026.

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5. Site AuditJun 8, 2023

   Prepared by D. Fekonja

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6. Site audit Performance ReportApr 28, 2023

   A site audit was conducted with this service on 26 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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7. Assessment Contact - SiteJan 13, 2023

   Prepared by D. Fekonja

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

   The performance report for Ashleigh House Hostel highlights non-compliance in Standards 2 (Ongoing assessment and planning), 3 (Personal care and clinical care), and 8 (Organisational governance). Compliance was found in Standards 4 (Services and supports for daily living) and 5 (Service environment). The service needs to improve risk management, falls management processes, behavior support plans, and documentation of pain management strategies.

   2Non-compliant

   The service was found non-compliant due to inconsistent care plan reviews and lack of follow-up after incidents.

   • Met 2(3)(a) — Assessments were not completed in a timely manner, but the provider acknowledged deficits and submitted updated evidence for some consumers.
   • Met 2(3)(b) — The service did not always update care plans promptly, but behavior charting and plans have been completed for identified consumers.
   • Not met 2(3)(e) — Care plan reviews were inconsistent; post-incident monitoring was incomplete. The provider is trialling a new falls management process, but improvements are not yet embedded.

   Risks: Lack of timely risk assessments and interventions for skin integrity deterioration, falls, fluid restriction, self-administration of medications, and driving.

   Recommendations: Ensure care and services are reviewed following changes in consumer health and incidents. Ensure consistent follow-up after falls.

   3Non-compliant

   The service was found non-compliant due to ineffective management of chemical restraint, pain management, and high-impact risks.

   • Not met 3(3)(a) — Chemical restraints were not managed effectively; one consumer's care plan did not document pain location or management strategies.
   • Not met 3(3)(b) — Behavior support interventions for consumers with responsive behaviors were incomplete, and neurological observations following falls were inconsistent. Diabetes care had gaps in blood glucose monitoring.
   • Met 3(3)(g) — Infection control measures were effective; staff demonstrated understanding of infection prevention and control.

   Risks: Severe impact on consumer health due to insufficiently treated pain, ineffective management of responsive behaviors, and diabetes care gaps.

   Recommendations: Ensure accurate documentation of pain in care plans. Develop comprehensive behavior support plans for consumers with responsive behaviors. Ensure consistent neurological observations following falls.

   4Compliant

   The service was compliant, demonstrating that services and supports cater to consumer interests and preferences.

   • Met 4(3)(c) — Activities consider consumer preferences; consumers are assisted in participating in community activities.
   • Met 4(3)(f) — Meals are varied, of suitable quality and quantity; menu options respond to consumer feedback.

   5Compliant

   The service was compliant with the requirement that the environment is safe, clean, well-maintained, and enables free movement.

   • Met 5(3)(b) — Consumers can move freely indoors and outdoors; the environment is safe, clean, well-maintained.

   8Non-compliant

   The service was found non-compliant due to inadequate risk management systems and practices.

   • Not met 8(3)(d) — Risk management did not effectively address high-impact risks, including skin integrity, diabetes, falls. Behavior support plans were incomplete.
   • Met 8(3)(e) — Policies and procedures for antimicrobial stewardship and open disclosure are understood by staff; psychotropic register now includes required information.

   Risks: Inadequate risk management systems, including failure to report psychological and emotional abuse incidents promptly.

   Recommendations: Ensure all incidents, especially those involving psychological or emotional abuse, are reported and investigated with root cause analysis. Improve falls management processes and behavior support plans.

   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.

8. Assessment contact Performance ReportNov 16, 2022

   An assessment contact was conducted with this service on 15 November 2022 to 16 November 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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9. Accreditation decisionJul 15, 2021

   Following a site audit conducted on 17 May 2021 to 20 May 2021, the Commission made a decision on 15 July 2021 to re-accredit this service. The period of accreditation of the service will expire on 15 July 2023.

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10. Exceptional CircumstancesJun 18, 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 January 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Site audit Performance ReportMay 20, 2021

    A site audit was conducted with this service on 17 May 2021 to 20 May 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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12. AssessmentApr 18, 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 July 2021.

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13. AssessmentApr 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 11 July 2018.

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14. AssessmentApr 18, 2012
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15. AssessmentApr 13, 2011
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No regulatory actions recorded.