ANHF Thornleigh Nursing Home

3 Hillmont Avenue, THORNLEIGH, NSW, 2120

1. Assessment contact (performance assessment) – siteJul 10, 2024

   Prepared by J Durston

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2. Assessment contact Performance ReportJun 4, 2024

   An assessment contact was conducted with this service on 03/06/2024 to 04/06/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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3. Accreditation decisionAug 14, 2023

   Following a site audit conducted on 07 June 2023 to 09 June 2023, the Commission made a decision on 14 August 2023 to re-accredit this service. The period of accreditation of the service will expire on 14 February 2026.

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4. Site AuditAug 14, 2023

   Prepared by J. Howard

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

   The service was compliant with Standards 1, 2, 4, and 5. However, it was non-compliant with Standards 3, 6, 7, and 8 due to issues related to personal care and clinical care, feedback and complaints management, human resources, and organizational governance.

   Standard 1 Consumer dignity and choiceCompliant

   The service treated consumers with dignity and respect, valued their identity, culture, and diversity, supported them to exercise choice and independence, communicated information clearly, and respected privacy.

   • Met 1(3)(a) — Consumers were treated with dignity, respect, and staff valued them as individuals.
   • Met 1(3)(b) — Staff provided care consistent with consumers' traditions and preferences.
   • Met 1(3)(c) — Consumers were supported to communicate decisions about their care and maintain relationships of choice.
   • Met 1(3)(d) — Consumers were supported to take risks, exercise choice, and maintain independence.
   • Met 1(3)(e) — Information was provided in a way that enabled consumers to exercise choice.
   • Met 1(3)(f) — Consumers' personal information was kept confidential and privacy respected.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service involved consumers in the assessment and planning process, identified their needs, goals, and preferences, partnered with them and external providers, documented outcomes effectively, and reviewed care regularly.

   • Met 2(3)(a) — Consumers were involved in the assessment process which considered risks to their health.
   • Met 2(3)(b) — Care plans identified and addressed consumers' current needs, goals, and preferences.
   • Met 2(3)(c) — The service partnered with consumers and external providers in assessment and planning.
   • Met 2(3)(d) — Outcomes of assessment were documented in care plans readily available to consumers.
   • Met 2(3)(e) — Care and services were reviewed regularly for effectiveness, especially when circumstances changed or incidents occurred.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not demonstrate that each consumer received safe and effective personal and clinical care tailored to their needs, though it managed risks effectively.

   • Not met 3(3)(a) — Five consumers advised that their personal and clinical care needs were not always met.
   • Met 3(3)(b) — The service managed risks through regular monitoring, trending, reporting, and applying individualized mitigation strategies.

   Risks: Consumers reported issues such as not being showered when planned or needed, poor staff knowledge of vital observations, inadequate hydration, poor continence management, and rough handling on some occasions.

   Recommendations: Implement case conferences with consumers and representatives to address concerns.; Ensure all new staff attend training in manual handling and refresher courses for existing staff.; Include staff training in taking vital observations in the service’s Plan for Continuous Improvement (PCI).; Conduct a 'toolbox talk' on taking vital observations.

   Standard 4 Services and supports for daily livingCompliant

   The service supported consumers to participate in activities that optimized their independence, health, well-being, and quality of life.

   • Met 4(3)(a) — Consumers confirmed they were supported to participate in activities that optimized their independence.
   • Met 4(3)(b) — Consumers received emotional, spiritual, and religious supports needed for psychological well-being.
   • Met 4(3)(c) — Consumers participated in community activities and maintained personal relationships.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, clean, well-maintained, and promoted a sense of independence and belonging.

   • Met 5(3)(a) — Consumers felt at home within the service environment.
   • Met 5(3)(b) — The service environment was safe, clean, well-maintained, and consumers moved freely both indoors and outdoors.

   Standard 6 Feedback and complaintsNon-compliant

   Consumers were not always encouraged or supported to provide feedback and make complaints, and the service did not consistently review feedback to improve care.

   • Not met 6(3)(a) — 50% of interviewed consumers and representatives stated they were not comfortable making a complaint.
   • Not met 6(3)(d) — There was no evidence to show feedback and complaints were regularly analyzed and trended to improve care.

   Risks: Consumers believed that making a complaint would result in the consumer being moved to another service within the broader organization.

   Recommendations: Implement a responsive feedback procedure.; Provide all consumers with a feedback form and information about how to submit feedback.; Strengthen the care partnership with consumers and representatives to give confidence in providing feedback.

   Standard 7 Human resourcesNon-compliant

   The service did not demonstrate that its workforce was competent, trained, equipped, supported, or regularly assessed for performance.

   • Not met 7(3)(c) — Consumers and representatives identified concerns about staff competence in manual handling and providing care.
   • Not met 7(3)(d) — Staff were not consistently trained, equipped, or supported to deliver outcomes required by the Quality Standards.

   Risks: Staff competence in manual handling and complaints management was a concern.

   Recommendations: Use skilled-based assessments for staff.; Ensure all new staff hold a Certificate III in Individual Support (Ageing).; Provide additional education sessions on manual handling and SIRS reporting.

   Standard 8 Organisational governanceNon-compliant

   The service did not demonstrate effective organization-wide governance systems for workforce governance, regulatory compliance, feedback and complaints, or risk management.

   • Not met 8(3)(c) — The service had ineffective governance systems in relation to workforce governance, regulatory compliance, and feedback and complaints.
   • Not met 8(3)(d) — Staff did not consistently use the risk management system or were adequately trained in identifying and responding to abuse and neglect.

   Risks: Staff did not follow reporting guidelines for incidents of rough manual handling witnessed by other staff members.

   Recommendations: Ensure all critical incidents are escalated to the quality team.; Provide additional education on risk management and SIRS reporting.

   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 ReportJun 9, 2023

   A site audit was conducted with this service on 07 June 2023 to 09 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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6. Assessment Contact - SiteApr 28, 2023

   Prepared by T Solomon

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7. Assessment contact Performance ReportMar 8, 2023

   An assessment contact was conducted with this service on 08 March 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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8. 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 14 September 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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9. Accreditation decisionJan 28, 2022

   Following a site audit conducted on 19 June 2019 to 20 June 2019, the Commission made a decision 23 July 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 28 January 2022. The period of accreditation of the service will expire on 14 March 2023.

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10. AssessmentJun 20, 2019

    Following an audit we decided that this service met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 14 September 2022.

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11. AssessmentJul 30, 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 14 October 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 14 September 2019. The reconsideration decision and audit report is attached.

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12. AssessmentJul 30, 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 14 October 2018.

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13. AssessmentAug 1, 2012
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14. AssessmentAug 19, 2009
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No regulatory actions recorded.