Baptistcare Moonya

59 Ipsen Street, MANJIMUP, WA, 6258

1. Assessment contact (performance assessment) – siteMay 8, 2024

   Prepared by R Falco

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2. Assessment contact Performance ReportApr 23, 2024

   An assessment contact was conducted with this service on 23 April 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. Assessment Contact - SiteSep 15, 2023

   Prepared by M Roach

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

   The performance report for Baptistcare Moonya highlights non-compliance with Standard 3 Personal care and clinical care due to deficiencies in the management of skin integrity and diabetes for two consumers. The provider has acknowledged these issues and implemented corrective actions, but further embedding and sustaining improvements is recommended.

   Standard 3 Personal care and clinical careNon-compliant

   The service was found to be non-compliant with safe and effective personal and clinical care delivery, particularly in the management of skin integrity and diabetes for two consumers.

   • Not met 3(3)(a) — Skin integrity assessment was not reviewed timely and safe care delivery was not delivered in accordance with a named consumer’s changed needs between mid-May and mid-June 2023, contributing to the development of a suspected deep tissue pressure injury. A second named consumer continued to receive diabetic medication that had been ceased for 4 days as staff were unaware of the medication regimen change.

   Risks: Development of a suspected deep tissue pressure injury due to ineffective care delivery.; Continued administration of discontinued diabetic medication, though no adverse impact was reported.

   Recommendations: Embed improvements into usual practice and sustain the improvement to ensure all consumers receive consistent safe and effective skin, wound, and pressure injury care.; Ensure effective communication process on medication change and safe monitoring process on medication administration.

   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 ReportAug 15, 2023

   An assessment contact was conducted with this service on 15 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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5. Site AuditApr 20, 2023

   Prepared by J Renna

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

   The service is compliant with most standards but non-compliant in Standard 3 Personal care and clinical care due to issues related to the inappropriate use of chemical restraints without informed consent or personalized interventions. The report highlights areas for improvement, particularly around ensuring staff have the necessary skills and knowledge to manage restraints appropriately.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers are treated with respect, provided culturally safe care, supported to make choices, informed about their care, and their privacy is respected.

   • Met (3)(a) — Consumers said they are treated with dignity and respect. Staff were observed to engage consumers in a friendly manner.
   • Met (3)(b) — Staff make consumers feel safe, respecting their cultural identity.
   • Met (3)(c) — Consumers can decide how and when they receive care and who is involved in decision-making.
   • Met (3)(d) — The service supports consumer choice, including consideration of risk to enable living the best life possible.
   • Met (3)(e) — Consumers are provided information via various mechanisms that enables them to exercise choice.
   • Met (3)(f) — The service maintains consumers' privacy, including educating staff on the importance of privacy and confidentiality.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Assessment and planning processes are in place to inform safe care, address consumer needs, involve partners, communicate outcomes effectively, and review regularly.

   • Met (3)(a) — The service has processes for risk identification and mitigation strategies.
   • Met (3)(b) — Care plans include consumers' needs, goals, and preferences.
   • Met (3)(c) — Consumers, representatives, and other providers are involved in the delivery of care.
   • Met (3)(d) — Care plans are accessible to consumers and staff.
   • Met (3)(e) — Care plans are reviewed regularly for effectiveness, especially when circumstances change or incidents occur.

   Standard 3 Personal care and clinical careNon-compliant

   The service failed to provide safe and effective personal and clinical care that is best practice and tailored to consumers' needs, particularly in the use of chemical restraint.

   • Not met (3)(a) — For two sampled consumers, non-pharmacological interventions were not personalized or evaluated for effectiveness. Informed consent was not obtained prior to the use of chemical restraint.
   • Met (3)(b) — Effective management of high impact risks associated with care is demonstrated, including wound and pain management.
   • Met (3)(c) — Consumers nearing the end of life are provided comfort and dignity.
   • Met (3)(d) — Deterioration or changes in a consumer's condition are recognized and responded to timely.
   • Met (3)(e) — Information about the consumer’s condition, needs, and preferences is documented and communicated effectively.
   • Met (3)(f) — Timely referrals are made to other organizations and providers of care.
   • Met (3)(g) — Infection-related risks are minimized through appropriate use of antibiotics and infection control practices.

   Risks: Serious risk to consumers due to the improper use of chemical restraint without informed consent or personalized non-pharmacological interventions.

   Recommendations: Ensure staff have skills and knowledge to identify and manage restraints appropriately, obtain informed consent, implement behavior management strategies, and monitor effectiveness.

   Standard 4 Services and supports for daily livingCompliant

   Consumers receive services that meet their needs, promote well-being, assist in community participation, and are supported to do things of interest.

   • Met (3)(a) — Consumers' needs, goals, and preferences are considered.
   • Met (3)(b) — Services support emotional, spiritual, and psychological well-being.
   • Met (3)(c) — Consumers are supported to participate in community activities and maintain relationships.
   • Met (3)(d) — Information about the consumer’s condition, needs, and preferences is communicated effectively.
   • Met (3)(e) — Timely referrals are made to other organizations and providers of care.
   • Met (3)(f) — Meals provided are varied, suitable in quality and quantity.
   • Met (3)(g) — Equipment is safe, clean, well-maintained, and appropriate for consumers' needs.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is welcoming, safe, clean, and enables consumer independence and interaction.

   • Met (3)(a) — Consumers feel a sense of belonging and can move freely.
   • Met (3)(b) — The environment is safe, clean, well-maintained, and comfortable.
   • Met (3)(c) — Furniture, fittings, and equipment are safe, clean, well-maintained, and suitable for consumers.

   Standard 6 Feedback and complaintsCompliant

   Consumers are encouraged to provide feedback and make complaints. Complaints are reviewed and used to improve care.

   • Met (3)(a) — Consumers feel supported to raise concerns.
   • Met (3)(b) — Information about advocacy and external complaints services is accessible.
   • Met (3)(c) — Appropriate action is taken in response to complaints, including open disclosure when things go wrong.
   • Met (3)(d) — Feedback and complaints are reviewed and used for continuous improvement.

   Standard 7 Human resourcesCompliant

   The workforce is planned, trained, equipped, and supported to deliver safe and quality care.

   • Met (3)(a) — Workforce planning ensures sufficient staff to meet consumer needs.
   • Met (3)(b) — Staff interactions are kind, caring, and respectful of each consumer’s identity, culture, and diversity.
   • Met (3)(c) — The workforce is competent with appropriate qualifications and knowledge to perform roles effectively.
   • Met (3)(d) — Staff are recruited, trained, equipped, and supported appropriately.
   • Met (3)(e) — Regular assessment, monitoring, and review of staff performance is undertaken.

   Standard 8 Organisational governanceCompliant

   Consumers are engaged in care development. The governing body promotes safe, inclusive care with effective governance systems.

   • Met (3)(a) — Consumers are engaged through feedback mechanisms.
   • Met (3)(b) — The governing body promotes a culture of safe, inclusive care and is accountable for its delivery.
   • Met (3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, feedback, and complaints.
   • Met (3)(d) — Risk management systems identify and respond to abuse and neglect, manage high impact risks, and prevent incidents.
   • Met (3)(e) — Clinical governance framework includes antimicrobial stewardship, minimizing restraint use, and open disclosure principles.

   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.

6. Accreditation decisionMar 2, 2023

   Following a site audit conducted on 28 February 2023 to 02 March 2023, the Commission made a decision on 20 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 08 June 2026.

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7. Site audit Performance ReportMar 2, 2023

   A site audit was conducted with this service on 28 February 2023 to 02 March 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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8. Assessment Contact - SiteDec 22, 2022

   Prepared by J Renna

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

   The performance report for Baptistcare Moonya highlights non-compliance with Standards 2, 3, and 4 due to ineffective assessment and planning processes, unmanaged high impact risks, and inadequate support for daily living activities. The service was compliant with Standard 7 regarding workforce planning and deployment, and Standard 8 concerning governance systems and risk management practices.

   2Non-compliant

   The service was unable to demonstrate that ongoing assessment and planning processes effectively identified risks to consumers' health and well-being, leading to safe and effective care.

   • Not met (3)(a) — The service was unable to demonstrate that assessments included consideration of risks associated with swallowing and sexual assault for two consumers. Assessments were not undertaken, and interventions were not documented to guide staff in providing safe care.

   Risks: Consumers A and B experienced unmanaged pain during personal care.; Consumer A had a sacral pressure injury that was not effectively managed until two weeks after identification.

   Recommendations: Ensure staff have the skills and knowledge to initiate assessments, develop and/or update care plans, and regularly review consumers’ care and service needs.; Monitor staff compliance with the service’s policies, procedures and guidelines in relation to assessment, care planning and review.

   3Non-compliant

   The service was unable to demonstrate effective management of high impact or high prevalence risks associated with the care of each consumer.

   • Not met (3)(b) — There were no documented interventions for Consumer A's pressure injury until two weeks after identification. Pain management strategies were not effectively implemented for Consumers A and B.

   Risks: Consumer A had a sacral pressure injury that was not managed effectively.; Consumers A and B experienced unmanaged pain during personal care.

   Recommendations: Ensure staff have the skills and knowledge to provide appropriate care relating to wounds and skin integrity, develop and/or implement appropriate pain management strategies, and document information related to consumers’ personal and clinical care needs.; Monitor staff compliance with the service’s policies, procedures and guidelines in relation to management of high impact or high prevalence risks.

   4Non-compliant

   The service was unable to demonstrate that services and supports for daily living assist each consumer to participate in their community within and outside the organisation's service environment.

   • Not met (3)(c) — Consumers A and B were not participating in activities of interest, despite documented preferences.

   Recommendations: Ensure consumers’ services and supports for daily living are reflective of their current condition and needs.

   7Compliant

   The service demonstrated that the workforce is planned to enable, and the number and mix of members of the workforce deployed enables, the delivery and management of safe and quality care and services.

   • Met (3)(a) — Consumers and representatives were satisfied with staffing numbers. Call bell data showed a majority of call bells are responded to within five minutes.

   8Compliant

   The service demonstrated effective organisation-wide governance systems and risk management practices.

   • Met (3)(c) — Staff confirmed they have access to the information needed for their roles. Management reported opportunities for improvement are identified following incidents and near misses.
   • Met (3)(d) — Validated assessments and standardised tools were used to identify risks, and these risks and associated management strategies were discussed at Clinical team meetings. Documentation showed all incidents were reviewed to identify areas for improvement.

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   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. Assessment contact Performance ReportNov 9, 2022

   An assessment contact was conducted with this service on 08 November 2022 to 09 November 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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10. Accreditation decisionJun 8, 2021

    Following a site audit conducted on 22 February 2021 to 25 February 2021, the Commission made a decision on 08 June 2021 to re-accredit this service. The period of accreditation of the service will expire on 08 June 2023.

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11. Site audit Performance ReportFeb 25, 2021

    A site audit was conducted with this service on 22 February 2021 to 25 February 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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12. Exceptional CircumstancesDec 16, 2020

    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 04 July 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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13. AssessmentNov 30, 2017

    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 04 January 2021.

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14. AssessmentOct 23, 2014

    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 04 January 2018.

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15. AssessmentNov 4, 2011
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No regulatory actions recorded.