Baptcare - Strathalan Community

50 Braidhill Road, MACLEOD, VIC, 3085

1. Assessment Contact - SiteMar 9, 2023

   Prepared by N Eastwood

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2. Assessment contact Performance ReportFeb 16, 2023

   An assessment contact was conducted with this service on 16 February 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 decisionNov 3, 2022

   Following a site audit conducted on 26 September 2022 to 28 September 2022, the Commission made a decision on 03 November 2022 to re-accredit this service. The period of accreditation of the service will expire on 28 January 2026.

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4. Site AuditNov 3, 2022

   Prepared by Megha Kalra

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

   The service is generally compliant with most Aged Care Quality Standards. However, there are areas for improvement in ensuring meals provided are of suitable taste and quality and having effective processes to record consumers’ dietary needs and preferences consistently.

   1Compliant

   Consumers are treated with dignity and respect, their choices are supported, and privacy is respected.

   • Met 1(3)(a) — Consumers said staff treat them with dignity and respect, and value their identity, culture, and diversity.
   • Met 1(3)(b) — Staff described delivering care in a culturally safe manner.
   • Met 1(3)(c) — Consumers said they are supported to make decisions about their care and services, how it should be delivered, and who should be involved.
   • Met 1(3)(d) — Staff described supporting consumers to take risks to enable them to live their best life.
   • Met 1(3)(e) — Consumers said clear and accurate information is provided to support informed choices.
   • Met 1(3)(f) — Consumers said their privacy is respected and described ways staff uphold their privacy.

   2Compliant

   Ongoing assessment and planning processes are in place to inform safe and effective care.

   • Met 2(3)(a) — Staff confirmed they have access to consumers’ care plans and demonstrated knowledge of consumer risks.
   • Met 2(3)(b) — Consumers and their representatives confirmed the service has discussed and documented consumers’ wishes related to advance care planning.
   • Met 2(3)(c) — Staff described involvement of other health professionals in assessment and planning processes.
   • Met 2(3)(d) — Care plans are reviewed every 2 months or when circumstances change.
   • Met 2(3)(e) — Consumers said staff clearly and regularly communicate the outcomes of assessment and planning.

   3Compliant

   Personal care and clinical care are safe, effective, and tailored to individual needs.

   • Met 3(3)(a) — Consumers considered they received safe and effective personal and clinical care.
   • Met 3(3)(b) — Care documentation confirmed effective management of consumers’ high impact risks.
   • Met 3(3)(c) — End-of-life care was documented and aligned with consumer needs.
   • Met 3(3)(d) — Deterioration or change in condition is identified and responded to timely.
   • Met 3(3)(e) — Information about the consumer’s condition, needs and preferences is documented and communicated within the organisation.
   • Met 3(3)(f) — Timely referrals to external providers occurred for consumers.
   • Met 3(3)(g) — Staff described following infection prevention procedures and practices.

   4Non-compliant

   Services for daily living are safe but meals' quality is inconsistent.

   • Met 4(3)(a) — Consumers feel supported to pursue activities of interest and receive appropriate supports.
   • Met 4(3)(b) — Staff described supporting consumers’ emotional, spiritual, and psychological well-being.
   • Met 4(3)(c) — Consumers said they receive services to participate in their communities and maintain relationships.
   • Met 4(3)(d) — Information about the consumer’s condition is communicated within the organisation.
   • Met 4(3)(e) — Consumers receive suitable referrals to other services and providers.
   • Not met 4(3)(f) — Four named consumers expressed dissatisfaction with meals' quality and concerns regarding temperature and texture. Inconsistent information was recorded in different documentation systems about dietary needs and preferences.
   • Met 4(3)(g) — Consumers said equipment is safe, clean, well-maintained, easily accessible and suitable for their needs.

   Risks: Potential impact on consumers due to inconsistent meal quality and dietary information recording processes.

   Recommendations: Review nutrition assessments to ensure current and correct information.; Provide training for staff regarding food preparation and labelling.

   5Compliant

   The service environment is welcoming, safe, clean, and well-maintained.

   • Met 5(3)(a) — Consumers said the environment felt welcoming, safe, comfortable, and easy to navigate.
   • Met 5(3)(b) — The service environment was observed to be clean, well-maintained, and safe for movement.
   • Met 5(3)(c) — Furniture, fittings, and equipment were described as safe, clean, well maintained, and suitable.

   6Compliant

   Consumers are encouraged to provide feedback and make complaints.

   • Met 6(3)(a) — Staff described encouraging consumers to make complaints and provide feedback.
   • Met 6(3)(b) — Consumers are made aware of advocates, language services, and other methods for raising complaints.
   • Met 6(3)(c) — Appropriate action is taken in response to complaints using open disclosure processes.
   • Met 6(3)(d) — Feedback and complaints are reviewed for quality improvement.

   7Compliant

   The workforce is planned to deliver safe and quality care.

   • Met 7(3)(a) — Consumers considered there were sufficient staff deployed.
   • Met 7(3)(b) — Staff interactions with consumers are kind and respectful.
   • Met 7(3)(c) — The workforce is competent and qualified to perform their roles.
   • Met 7(3)(d) — Workforce recruitment, training, and support are in place for delivering quality care.
   • Met 7(3)(e) — Regular assessment, monitoring, and review of workforce performance is undertaken.

   8Compliant

   Effective governance systems support safe, inclusive, and quality care.

   • Met 8(3)(a) — Consumers are engaged in the development, delivery, and evaluation of care.
   • Met 8(3)(b) — The governing body promotes a culture of safe, inclusive, and quality care.
   • Met 8(3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, feedback, and complaints.
   • Met 8(3)(d) — Risk management systems and practices effectively manage high impact risks and incidents.
   • Met 8(3)(e) — A clinical governance framework supports antimicrobial stewardship, minimising the use of restraint, and open disclosure.

   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 ReportSep 28, 2022

   A site audit was conducted with this service on 26 September 2022 to 28 September 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. Accreditation decisionDec 6, 2021

   Following a site audit conducted on 30 April 2019 to 01 May 2019, the Commission made a decision on 04 June 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 06 December 2021. The period of accreditation of the service will expire on 28 January 2023.

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7. Assessment contact Performance ReportOct 27, 2020

   An assessment contact was conducted with this service on 27 October 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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8. AssessmentMay 1, 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 28 July 2022.

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9. AssessmentMar 30, 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 28 July 2019.

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10. AssessmentMay 8, 2013
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11. AssessmentApr 21, 2010
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No regulatory actions recorded.