Baptistcare Gracehaven

2 Westralia Gardens, ROCKINGHAM, WA, 6168

1. AssessmentJun 23, 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 23/06/2025, 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) – siteOct 14, 2024

   Prepared by J Wilson

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3. Assessment contact Performance ReportSep 13, 2024

   An assessment contact was conducted with this service on 12/09/2024 to 13/09/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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4. Assessment contact (performance assessment) – siteMar 22, 2024

   Prepared by A. Kasyan

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5. Assessment contact Performance ReportJan 31, 2024

   An assessment contact was conducted with this service on 30 January 2024 to 31 January 2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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6. Assessment Contact - SiteSep 21, 2023

   Prepared by M Glenn

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7. Assessment contact Performance ReportAug 31, 2023

   An assessment contact was conducted with this service on 31 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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8. Accreditation decisionApr 4, 2023

   Following a site audit conducted on 14 February 2023 to 16 February 2023, the Commission made a decision on 04 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 04 April 2026.

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9. Site AuditApr 4, 2023

   Prepared by A. Kasyan

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

   The service performs well in maintaining consumer dignity, providing a safe environment, encouraging feedback, and ensuring human resources are competent. However, there are significant areas for improvement in ongoing assessment and planning, personal care and clinical care, services and supports for daily living, performance monitoring of staff, and organizational governance related to minimizing restrictive practices.

   Standard 1 Consumer dignity and choiceCompliant

   The service treats consumers with respect, supports their choices, and maintains privacy.

   • Met Requirement 1(3)(a) — Consumers reported feeling respected and valued.
   • Met Requirement 1(3)(b) — Staff were knowledgeable about providing culturally safe care.
   • Met Requirement 1(3)(c) — Consumers felt supported to make decisions and maintain relationships.
   • Met Requirement 1(3)(d) — The service supports consumers in taking risks, such as leaving the facility independently.
   • Met Requirement 1(3)(e) — Information was provided to consumers in a timely and understandable manner.
   • Met Requirement 1(3)(f) — Consumers' privacy is respected, and personal information is kept confidential.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The service needs to improve its ongoing assessments and care plans for all risks.

   • Not met Requirement 2(3)(a) — Assessment and planning did not inform safe and effective care, particularly in diabetes management.
   • Met Requirement 2(3)(b) — The service has guidelines for end-of-life care planning.
   • Met Requirement 2(3)(c) — Collaboration with other organizations and individuals is demonstrated in documentation.
   • Met Requirement 2(3)(d) — Outcomes of assessment are effectively communicated to consumers.
   • Met Requirement 2(3)(e) — Care and services are reviewed regularly for effectiveness.

   Risks: Consumers A, B, and C had risks not effectively managed in their care plans.

   Recommendations: Ensure assessments and care plans are comprehensive and accurately identify each consumer’s needs to inform strategies to manage risks.

   Standard 3 Personal care and clinical careNon-compliant

   The service must improve its management of high-impact or high-prevalence risks.

   • Met Requirement 3(3)(a) — Consumers receive safe and effective personal care.
   • Not met Requirement 3(3)(b) — Ineffective management of falls, pressure injuries, and restrictive practices.
   • Met Requirement 3(3)(c) — End-of-life care is focused on comfort and dignity.
   • Met Requirement 3(3)(d) — Deterioration or changes in consumer conditions are recognized and responded to timely.
   • Met Requirement 3(3)(e) — Information about the consumer’s condition, needs, and preferences is documented and communicated.
   • Met Requirement 3(3)(f) — Timely referrals to specialists are made as needed.
   • Met Requirement 3(3)(g) — Infection-related risks are minimized through standard precautions and appropriate antibiotic use.

   Risks: Consumers A, B, and C had ongoing issues with falls, pressure injuries, and inappropriate medication use.

   Recommendations: Ensure each consumer’s high-impact and high-prevalence risks are managed effectively including management of wounds, medications, and falls.

   Standard 4 Services and supports for daily livingNon-compliant

   The service must ensure all consumers receive effective services tailored to their needs.

   • Not met Requirement 4(3)(a) — Three dementia-diagnosed consumers were not engaged in activities of interest.
   • Met Requirement 4(3)(b) — Services promote emotional, spiritual, and psychological well-being.
   • Met Requirement 4(3)(c) — Consumers can participate in community activities and maintain social relationships.
   • Met Requirement 4(3)(d) — Information about the consumer’s condition, needs, and preferences is communicated effectively.
   • Met Requirement 4(3)(e) — Timely referrals to specialists are made as needed.
   • Met Requirement 4(3)(f) — Meals provided are varied and of suitable quality and quantity.
   • Met Requirement 4(3)(g) — Equipment is safe, clean, well-maintained, and functioning effectively.

   Risks: Three dementia-diagnosed consumers were not engaged in activities of interest.

   Recommendations: Ensure services and supports for daily living are provided to each consumer in line with their assessed needs and promote their well-being and quality of life.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is welcoming, safe, clean, and enables consumers' independence.

   • Met Requirement 5(3)(a) — Environment optimizes each consumer’s sense of belonging.
   • Met Requirement 5(3)(b) — The environment is safe, clean, well-maintained, and comfortable.
   • Met Requirement 5(3)(c) — Furniture, fittings, and equipment are safe, clean, well-maintained, and suitable for the consumer.

   Standard 6 Feedback and complaintsCompliant

   Consumers feel supported to provide feedback and make complaints.

   • Met Requirement 6(3)(a) — Consumers are encouraged and supported to provide feedback.
   • Met Requirement 6(3)(b) — Consumers have access to advocates, language services, and other methods for raising complaints.
   • Met Requirement 6(3)(c) — Appropriate action is taken in response to complaints with an open disclosure process used when things go wrong.
   • Met Requirement 6(3)(d) — Feedback and complaints are reviewed and used for continuous improvement.

   Standard 7 Human resourcesNon-compliant

   The service must improve its performance assessment, monitoring, and review processes.

   • Met Requirement 7(3)(a) — Workforce planning enables the delivery of safe and quality care.
   • Met Requirement 7(3)(b) — Staff interactions are kind, caring, and respectful.
   • Met Requirement 7(3)(c) — The workforce is competent with relevant qualifications and knowledge.
   • Met Requirement 7(3)(d) — Staff are recruited, trained, equipped, and supported to deliver required outcomes.
   • Not met Requirement 7(3)(e) — Performance reviews were not conducted regularly for staff members.

   Risks: Ten staff members had not had a performance discussion in over 12 months.

   Recommendations: Ensure staff performance is effectively monitored to identify deficits and corrective actions are taken.

   Standard 8 Organisational governanceNon-compliant

   The service must improve its clinical governance framework for minimizing the use of restrictive practices.

   • Met Requirement 8(3)(a) — Consumers are engaged in care and service development.
   • Met Requirement 8(3)(b) — The governing body promotes a culture of safe, inclusive, and quality care.
   • Met Requirement 8(3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, feedback, and complaints.
   • Met Requirement 8(3)(d) — Risk management systems and practices are effective.
   • Not met Requirement 8(3)(e) — The service could not demonstrate understanding of environmental restrictive practices or appropriate consent for their use.

   Risks: Ineffective minimization of the use of restrictive practices, particularly chemical and environmental restraints.

   Recommendations: Ensure the clinical governance framework is implemented effectively to minimize restrictive practices.

   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.

10. Site audit Performance ReportFeb 16, 2023

    A site audit was conducted with this service on 14 February 2023 to 16 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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11. Exceptional CircumstancesDec 14, 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 10 July 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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12. Exceptional CircumstancesJun 22, 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 until 03 January 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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13. Exceptional CircumstancesDec 2, 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 10 July 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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14. 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 10 January 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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15. AssessmentApr 12, 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 10 July 2021.

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16. AssessmentApr 8, 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 10 July 2018.

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17. AssessmentMay 2, 2012
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18. AssessmentApr 22, 2009
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No regulatory actions recorded.