Baptistcare David Buttfield Centre

649 NORTH BEACH Road, GWELUP, WA, 6018

1. Assessment Contact - SiteSep 7, 2023

   Prepared by M Glenn

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2. Assessment contact Performance ReportAug 14, 2023

   An assessment contact was conducted with this service on 14 August 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. Assessment Contact - SiteJun 8, 2023

   Prepared by R Beaman

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

   The performance report for Baptistcare David Buttfield Centre highlights non-compliance with Standard 3 Personal care and clinical care, specifically Requirement (3)(b). The service was unable to effectively manage high impact or high prevalence risks associated with consumer care, including falls, weight loss, changed behaviors, and skin integrity issues. While the provider provided evidence of actions taken for some consumers, these were not deemed sufficient by the Assessment Team to demonstrate compliance.

   Standard 3 Personal care and clinical careNon-compliant

   The service was found to be unable to effectively manage high impact or high prevalence risks associated with the care of each consumer, particularly in relation to falls, weight loss, changed behaviors, and skin integrity.

   • Not met (3)(b) Ensure staff have the skills and knowledge to: provide appropriate care and effectively manage the risks associated with the development of pressure injuries in a timely manner. — The service did not demonstrate effective management of high impact or high prevalence risks for three consumers, including falls, weight loss, changed behaviors, and skin integrity issues. For example, Consumer A experienced significant weight loss and multiple falls without consistent interventions; Consumer B had a pressure injury that was not identified in a timely manner; and Consumer C developed four pressure injuries over five weeks.

   Risks: Consumer A experienced more than 10kg of weight loss between admission and April 26, 2023, with multiple falls causing pain and skin tears.; Consumer B had a pressure injury that was not identified in a timely manner and deteriorated over time.; Consumer C developed four pressure injuries over five weeks without consistent monitoring or intervention.

   Recommendations: Implement more effective strategies for managing high impact risks such as falls, weight loss, and skin integrity issues.; Ensure staff are adequately trained in identifying and responding to changes in consumer conditions promptly.; Regularly review and update care plans based on the evolving needs of consumers.

   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.

4. Assessment contact Performance ReportApr 26, 2023

   An assessment contact was conducted with this service on 26 April 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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5. Exceptional CircumstancesJan 30, 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 12 August 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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6. Accreditation decisionJan 23, 2023

   Following a site audit conducted on 13 December 2022 to 16 December 2022, the Commission made a decision on 23 January 2023 to re-accredit this service. The period of accreditation of the service will expire on 23 January 2026.

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7. Site AuditJan 23, 2023

   Prepared by K. Richards

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

   The service demonstrated compliance with most standards but had a non-compliance issue related to the management of high impact or high prevalence risks associated with personal care and clinical care, particularly concerning pain management for one consumer. The report recommends reviewing practices and policies to ensure effective monitoring and adjustment of care plans when circumstances change.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers reported being treated with respect and receiving culturally safe care. Staff supported consumers to exercise independence and make choices, including taking risks.

   • Met Requirement 1(3)(a) — Consumers and representatives said staff treat them with dignity and respect.
   • Met Requirement 1(3)(b) — Staff provided examples of culturally safe care that considers consumer preferences.
   • Met Requirement 1(3)(c) — Consumers and representatives could give examples of being supported to exercise choice and independence.
   • Met Requirement 1(3)(d) — Consumers were supported to take risks to live their best lives.
   • Met Requirement 1(3)(e) — Information provided was current and communicated in a way that is clear and easy to understand.
   • Met Requirement 1(3)(f) — Privacy was respected and personal information kept confidential.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Assessments were conducted to identify risks and consumer needs, goals, and preferences. Care plans included directives from other organizations involved in care.

   • Met Requirement 2(3)(a) — Assessments were undertaken to identify risks.
   • Met Requirement 2(3)(b) — Advance care planning was discussed during admission and captured in care plans.
   • Met Requirement 2(3)(c) — Consumers were involved in assessment and planning with other organizations included.
   • Met Requirement 2(3)(d) — Care plans were communicated to consumers and documented effectively.
   • Met Requirement 2(3)(e) — Reviews of care and services were conducted regularly.

   Recommendations: Consider the effectiveness of current processes in relation to review of care and services following changes.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not effectively manage high impact or high prevalence risks, particularly related to pain management for one consumer.

   • Met Requirement 3(3)(a) — Consumers reported receiving safe and effective care.
   • Not met Requirement 3(3)(b) — Pain management was not consistently monitored following hospital admissions for severe pain.
   • Met Requirement 3(3)(c) — End-of-life care needs were recognized and addressed.
   • Met Requirement 3(3)(d) — Deterioration or change in consumer conditions was recognized and responded to.
   • Met Requirement 3(3)(e) — Information about the consumer’s condition was documented and communicated effectively.
   • Met Requirement 3(3)(f) — Timely referrals were made to other organizations for care.
   • Met Requirement 3(3)(g) — Infection-related risks were minimized through appropriate practices.

   Risks: Serious pain and falls risk for one consumer due to ineffective management of high impact or high prevalence risks.

   Standard 4 Services and supports for daily livingCompliant

   Consumers were supported in their independence, emotional well-being, and social connections. Meals and equipment provided met quality standards.

   • Met Requirement 4(3)(a) — Services and supports met consumer needs.
   • Met Requirement 4(3)(b) — Supports promoted emotional well-being.
   • Met Requirement 4(3)(c) — Consumers were supported to participate in community and maintain relationships.
   • Met Requirement 4(3)(d) — Information about the consumer’s condition was communicated effectively.
   • Met Requirement 4(3)(e) — Timely referrals were made to other organizations for care.
   • Met Requirement 4(3)(f) — Meals provided were varied and of suitable quality and quantity.
   • Met Requirement 4(3)(g) — Equipment was safe, clean, well-maintained.

   Standard 5 Organisation’s service environmentCompliant

   The environment was welcoming and easy to understand. It was safe, clean, and enabled consumers to move freely.

   • Met Requirement 5(3)(a) — Environment was welcoming and personalized.
   • Met Requirement 5(3)(b) — Service environment was safe, clean, well-maintained, and comfortable.
   • Met Requirement 5(3)(c) — Furniture and equipment were safe, clean, well-maintained.

   Standard 6 Feedback and complaintsCompliant

   Consumers felt supported to provide feedback and make complaints. Complaints led to improvements in care.

   • Met Requirement 6(3)(a) — Feedback and complaint processes were accessible.
   • Met Requirement 6(3)(b) — Consumers had access to advocates and language services.
   • Met Requirement 6(3)(c) — Appropriate action was taken in response to complaints.
   • Met Requirement 6(3)(d) — Feedback led to improvements in care and services.

   Standard 7 Human resourcesCompliant

   The workforce was planned effectively and staff were competent and respectful. Performance reviews were conducted regularly.

   • Met Requirement 7(3)(a) — Workforce planning ensured safe and quality care.
   • Met Requirement 7(3)(b) — Staff interactions were kind and respectful.
   • Met Requirement 7(3)(c) — Staff had the qualifications and knowledge to perform their roles.
   • Met Requirement 7(3)(d) — Recruitment and training processes were effective.
   • Met Requirement 7(3)(e) — Performance reviews were conducted regularly.

   Standard 8 Organisational governanceCompliant

   Consumers were engaged in care and services. Effective risk management systems were in place.

   • Met Requirement 8(3)(a) — Consumers were engaged in the development of care.
   • Met Requirement 8(3)(b) — Governing body promoted safe and quality care.
   • Met Requirement 8(3)(c) — Effective governance systems were in place for various areas.
   • Met Requirement 8(3)(d) — Risk management systems and practices were effective.
   • Met Requirement 8(3)(e) — Clinical governance framework was in place.

   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. Site audit Performance ReportDec 16, 2022

   A site audit was conducted with this service on 13 December 2022 to 16 December 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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9. Exceptional CircumstancesJul 13, 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 12 February 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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10. Assessment contact Performance ReportJun 8, 2022

    An assessment contact was conducted with this service on 08 June 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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11. Assessment contact Performance ReportApr 29, 2021

    An assessment contact was conducted with this service on 29 April 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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12. AssessmentMay 23, 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 12 August 2022.

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13. AssessmentMay 24, 2017

    Following an audit we decided that this home met 42 of the 44 expected outcomes of the Accreditation Standards and would be accredited for two years until 12 August 2019.

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14. AssessmentMay 7, 2014

    Following an audit we decided that this home met 43 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 12 August 2017.

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15. AssessmentJun 7, 2012
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No regulatory actions recorded.