Baptistcare Bethel

2 BETHEL Way, YAKAMIA, WA, 6330

1. Accreditation decisionJul 24, 2025

   Following a site audit conducted on 21 February 2023 to 23 February 2023, the Commission made a decision on 21 April 2023 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 24 July 2025. The period of accreditation of the service will expire 21 April 2026.

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2. AssessmentMay 16, 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 16/05/2025, 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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3. Assessment contact (performance assessment) – siteSep 5, 2024

   Prepared by G Tonarelli

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4. Assessment contact Performance ReportAug 6, 2024

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

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5. Assessment contact (performance assessment) – siteNov 20, 2023

   Prepared by A. Kasyan

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6. Assessment contact Performance ReportSep 19, 2023

   An assessment contact was conducted with this service on 18 September 2023 to 19 September 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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7. Accreditation decisionApr 21, 2023

   Following a site audit conducted on 21 February 2023 to 23 February 2023, the Commission made a decision on 21 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 21 October 2025.

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8. Site AuditApr 21, 2023

   Prepared by T Wilson

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

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

   Standard 1 Consumer dignity and choiceCompliant

   Consumers confirmed staff treat them with respect, provide culturally appropriate care, support choices, and ensure privacy.

   • Met Requirement 1(3)(a) — Staff are generally good and treat consumers with dignity and respect.
   • Met Requirement 1(3)(b) — Consumers confirmed staff delivered care that was culturally appropriate for them.
   • Met Requirement 1(3)(c) — Staff support consumers to make choices about their care and services, including risks.
   • Met Requirement 1(3)(d) — Consumers are supported to take risks to live the best life they can.
   • Met Requirement 1(3)(e) — Information is provided in a way that enables consumers to exercise choice.
   • Met Requirement 1(3)(f) — Consumers' privacy is respected and personal information is kept confidential.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   Assessments and charting are not effectively used to inform care plans, particularly for depression, sleep, and bowel management risks.

   • Not met Requirement 2(3)(a) — Assessments and charting are not effectively used to inform care planning.
   • Not met Requirement 2(3)(b) — Advance care directives or palliative care plans were not in place for some consumers, and goals of care were not consistently noted.
   • Met Requirement 2(3)(c) — Assessment and planning includes other organisations involved in the consumer's care.
   • Met Requirement 2(3)(d) — Outcomes of assessment and planning are effectively communicated to consumers.
   • Met Requirement 2(3)(e) — Care is reviewed regularly for effectiveness, especially after incidents or changes in circumstances.

   Risks: Consumers did not have advance care directives or palliative care plans in place.; Goals of care were not consistently noted in each care plan.

   Recommendations: Ensure assessments and charting are effectively used to inform care planning, especially for depression, sleep, and bowel management risks.

   Standard 3 Personal care and clinical careNon-compliant

   Consumers did not receive safe personal care in some instances, and best practice was not followed for urinary tract infections.

   • Not met Requirement 3(3)(a) — Consumers did not receive safe personal care in some instances.
   • Not met Requirement 3(3)(b) — Effective management of high impact or high prevalence risks was lacking, particularly for medication and nutrition.
   • Met Requirement 3(3)(c) — Consumers nearing the end of life receive comfort care that is suitable to them.
   • Met Requirement 3(3)(d) — Deterioration or changes in mental health, cognitive function, and physical condition are recognized and responded to timely.
   • Not met Requirement 3(3)(e) — Information about the consumer’s condition is not always effectively communicated within the organization.
   • Met Requirement 3(3)(f) — Timely and appropriate referrals to other providers of care are made.
   • Not met Requirement 3(3)(g) — Infection-related risks were not minimized through effective practices.

   Risks: Consumers suffered unexplained bruising and skin tears.; Medication errors occurred, impacting consumer well-being.

   Recommendations: Ensure safe personal care is provided following best practice guidelines.; Effectively manage high impact or high prevalence risks associated with the care of each consumer.

   Standard 4 Services and supports for daily livingCompliant

   Consumers are supported to engage in activities of choice, maintain independence, and have social interactions both within and outside the service.

   • Met Requirement 4(3)(a) — Consumers are supported to engage in activities of choice.
   • Met Requirement 4(3)(b) — Services and supports promote emotional, spiritual, and psychological well-being.
   • Met Requirement 4(3)(c) — Consumers are supported to maintain social interactions both within the service and externally.
   • Met Requirement 4(3)(d) — Information about consumers' conditions is communicated effectively.
   • Met Requirement 4(3)(e) — Timely and appropriate referrals are made to other providers of care.
   • Met Requirement 4(3)(f) — Meals provided are varied, suitable in quality and quantity.
   • Met Requirement 4(3)(g) — Equipment is safe, clean, well maintained.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is welcoming and supports consumers' independence and interaction.

   • Met Requirement 5(3)(a) — Service environment optimizes each consumer’s sense of belonging, independence, interaction.
   • Met Requirement 5(3)(b) — The service environment is safe, clean, well maintained and comfortable.
   • Met Requirement 5(3)(c) — Furniture, fittings, and equipment are safe, clean, well maintained.

   Standard 6 Feedback and complaintsNon-compliant

   Consumers were not aware of external advocacy or language services available to them.

   • Met Requirement 6(3)(a) — Consumers are encouraged and supported to provide feedback.
   • Not met Requirement 6(3)(b) — Consumers were not aware of external advocacy or language services available.
   • Not met Requirement 6(3)(c) — Appropriate action is not always taken in response to complaints and open disclosure process is not used consistently.
   • Not met Requirement 6(3)(d) — Feedback and complaints are not reviewed effectively for continuous improvement.

   Risks: Consumers were unaware of external advocacy or language services.; Complaints are not consistently documented, investigated, or used for continuous improvement.

   Recommendations: Ensure consumers are aware of and have access to advocates and other methods for raising complaints.

   Standard 7 Human resourcesNon-compliant

   Staff interactions with consumers were not always kind and caring, and staff competencies and training were lacking.

   • Met Requirement 7(3)(a) — The workforce is planned to deliver safe and quality care.
   • Not met Requirement 7(3)(b) — Staff interactions with consumers were not always kind, caring, or respectful.
   • Not met Requirement 7(3)(c) — Staff competencies and training are lacking in some areas.
   • Not met Requirement 7(3)(d) — Training and support for staff to deliver required outcomes is inadequate.
   • Not met Requirement 7(3)(e) — Regular assessment, monitoring, and review of staff performance are not effectively undertaken.

   Risks: Staff interactions were sometimes rough or disrespectful.; Medication errors occurred due to lack of competency.

   Recommendations: Ensure all staff are trained and competent in their roles.; Regularly monitor and review staff performance.

   Standard 8 Organisational governanceNon-compliant

   Governance systems for feedback, complaints, continuous improvement, workforce governance, regulatory compliance, risk management, and clinical governance are not effective.

   • Met Requirement 8(3)(a) — Consumers are engaged in the development, delivery, and evaluation of care.
   • Met Requirement 8(3)(b) — The governing body promotes a culture of safe, inclusive, and quality care.
   • Not met Requirement 8(3)(c) — Governance systems for feedback, complaints, continuous improvement, workforce governance, regulatory compliance are not effective.
   • Not met Requirement 8(3)(d) — Risk management systems and practices are ineffective in managing high impact risks and responding to abuse.
   • Not met Requirement 8(3)(e) — Clinical governance framework is not effective, particularly for antimicrobial stewardship and open disclosure.

   Risks: Feedback and complaints are not effectively managed.; Regulatory compliance was not always fulfilled.

   Recommendations: Improve governance systems to ensure all areas of care are effectively managed.

   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.

9. Site audit Performance ReportFeb 23, 2023

   A site audit was conducted with this service on 21 February 2023 to 23 February 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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10. Exceptional CircumstancesOct 28, 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 07 May 2023 The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Assessment contact Performance ReportMar 15, 2022

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

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12. Assessment contact Performance ReportMar 9, 2021

    An assessment contact was conducted with this service on 09 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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13. Assessment contact Performance ReportSep 3, 2020

    An assessment contact was conducted with this service on 03 September 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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14. Compliance monitoring updateDec 3, 2019

    An assessment contact was conducted by the Aged Care Quality and Safety Commission (Commission) on 3 December 2019 at Baptistcare Bethel 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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15. AssessmentAug 29, 2019

    Following a site audit the Commission made a decision on 20 September 2019 that this service met six of the eight Aged Care Quality Standards. The service is re-accredited for three years until 07 November 2022.

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16. AssessmentJul 21, 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 07 November 2019.

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17. AssessmentAug 7, 2013
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18. AssessmentAug 11, 2010
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No regulatory actions recorded.