BaptistCare Shalom Centre

159-165 Balaclava Road, MACQUARIE PARK, NSW, 2113

1. Assessment Contact - SiteAug 30, 2023

   Prepared by T Solomon

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

   The performance report for BaptistCare Shalom Centre highlights compliance in ongoing assessment and planning with consumers, and organisational governance. However, the service is non-compliant in personal care and clinical care due to ineffective management of changing behaviours and lack of ongoing review and adjustments of strategies.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service demonstrated it is planning care and services that centre on the consumer’s needs and goals, reflecting their personal preferences.

   • Met Requirement 2(3)(b) — Information was gathered through documentation review, interviews, and observations. The service demonstrated it is planning care and services that centre on the consumer’s needs and goals and reflect their personal preferences, including end of life planning.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not demonstrate effective management of changing behaviours and ongoing review, evaluation, and adjustments of implemented strategies to address these changes.

   • Not met Requirement 3(3)(a) — The service did not demonstrate effective management of changing behaviours and did not demonstrate ongoing review, evaluation, and adjustments of implemented strategies to address changing behaviours.
   • Met Requirement 3(3)(f) — A documentation review shows timely and appropriate referrals are made for consumers where needed, and the results of assessment and recommendations made are updated in the consumer’s care plans.

   Recommendations: Ensure staff have a comprehensive understanding of restrictive practices and how to support consumers identified utilising restrictive practices.; Ensure behaviour support plans are reviewed and ineffective strategies are addressed and adjusted as required.

   Standard 8 Organisational governanceCompliant

   The service has implemented actions to address previous non-compliance, demonstrating effective organisation-wide governance systems and risk management practices.

   • Met Requirement 8(3)(c) — The Approved Provider responded with additional information and documentation. Based on the information provided by the Assessment Team and the Approved Provider, Requirement 8(3)(c) is found Compliant.
   • Met Requirement 8(3)(d) — The Approved Provider responded with additional information and documentation. Based on the information provided by the Assessment Team and the Approved Provider, Requirement 8(3)(d) is found Compliant.

   Standard 2 Ongoing assessment and planning with consumersNot applicable as not all requirements have been assessed

   Standard 8 Organisational governanceNot applicable as not all requirements have been assessed

   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.

2. Assessment contact Performance ReportJul 19, 2023

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

   source ↗
3. Accreditation decisionMar 31, 2023

   Following a site audit conducted on 13 February 2023 to 16 February 2023, the Commission made a decision on 31 March 2023 to re-accredit this service. The period of accreditation of the service will expire on 31 March 2026.

   source ↗
4. Site AuditMar 31, 2023

   Prepared by Melissa Buhagiar

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

   The service demonstrates compliance with most standards, particularly in consumer dignity and choice, services and supports for daily living, feedback and complaints, human resources. However, non-compliance was noted in ongoing assessment and planning, personal care and clinical care, and organizational governance due to issues such as insufficient documentation of individualized care plans, ineffective risk management systems, and lack of consistent information management.

   Standard 1 Consumer dignity and choiceCompliant

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

   • Met Requirement 1(3)(a) — Consumers and representatives said staff treat them with dignity and respect.
   • Met Requirement 1(3)(b) — The service provides culturally safe care, respecting each consumer's cultural identity.
   • Met Requirement 1(3)(c) — Consumers are supported to make decisions about their own care and relationships.
   • Met Requirement 1(3)(d) — The service supports consumers in taking risks for a better life.
   • Met Requirement 1(3)(e) — Information provided to consumers is current, accurate, and communicated clearly.
   • Met Requirement 1(3)(f) — The service respects consumer privacy and confidentiality.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   Care plans do not always outline current conditions, needs, or preferences.

   • Met Requirement 2(3)(a) — Assessment and planning inform the delivery of safe care.
   • Not met Requirement 2(3)(b) — Care plans do not always outline current conditions, needs, or preferences.
   • Met Requirement 2(3)(c) — Assessment and planning involve partnerships with consumers and other organizations.
   • Met Requirement 2(3)(d) — Outcomes of assessment are effectively communicated to the consumer.
   • Met Requirement 2(3)(e) — Care and services are reviewed regularly for effectiveness.

   Recommendations: Ensure care plans outline current conditions, needs, and preferences.; Improve the incorporation of specialist provider recommendations into consumer care plans.

   Standard 3 Personal care and clinical careNon-compliant

   Personal and clinical care is not always best practice or tailored to individual needs.

   • Not met Requirement 3(3)(a) — Care provided is not consistently safe, effective, and tailored to each consumer's needs.
   • Met Requirement 3(3)(b) — High impact or high prevalence risks are effectively managed.
   • Met Requirement 3(3)(c) — Needs of consumers nearing the end of life are recognized and addressed.
   • Met Requirement 3(3)(d) — Deterioration or change in a consumer’s condition is recognized and responded to timely.
   • Met Requirement 3(3)(e) — Information about the consumer's condition, needs, and preferences is documented and communicated effectively.
   • Not met Requirement 3(3)(f) — Referrals are not always timely or appropriate.
   • Met Requirement 3(3)(g) — Infection-related risks are minimized through standard and transmission-based precautions.

   Risks: Potential physical restraint during meal service.; Lack of follow-up for wound consultant referrals leading to deterioration.

   Recommendations: Ensure personal care is safe, effective, and tailored to individual needs.; Improve timely and appropriate referrals.

   Standard 4 Services and supports for daily livingCompliant

   Services support consumers' independence, well-being, and quality of life.

   • Met Requirement 4(3)(a) — Consumers receive safe services that meet their needs.
   • 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 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 other organizations are made appropriately.
   • Met Requirement 4(3)(f) — Meals provided are varied and of suitable quality and quantity.
   • Met Requirement 4(3)(g) — Equipment is safe, clean, and well-maintained.

   Standard 5 Organisation’s service environmentCompliant

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

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

   Recommendations: Ensure contractors follow safety protocols.; Address maintenance issues promptly.

   Standard 6 Feedback and complaintsCompliant

   Consumers are encouraged to provide feedback and make complaints.

   • Met Requirement 6(3)(a) — Feedback and complaint processes are in place.
   • Met Requirement 6(3)(b) — Consumers have access to advocates and language services.
   • Met Requirement 6(3)(c) — Appropriate action is taken in response to complaints.
   • Met Requirement 6(3)(d) — Feedback and complaints are reviewed for quality improvement.

   Recommendations: Ensure comprehensive monitoring of feedback systems.; Improve the completeness of the complaints register.

   Standard 7 Human resourcesCompliant

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

   • Met Requirement 7(3)(a) — Workforce planning ensures delivery of safe and quality care.
   • Met Requirement 7(3)(b) — Interactions with consumers are kind, caring, and respectful.
   • Met Requirement 7(3)(c) — Staff have the qualifications and knowledge to perform their roles effectively.
   • Met Requirement 7(3)(d) — Workforce is recruited, trained, equipped, and supported for quality care delivery.
   • Met Requirement 7(3)(e) — Regular assessment of staff performance is undertaken.

   Recommendations: Continue to recruit and train additional staff.; Ensure regular completion of staff appraisals.

   Standard 8 Organisational governanceNon-compliant

   Governance systems do not provide sufficient, consistent information for effective management.

   • Met Requirement 8(3)(a) — Consumers are engaged in care and service development.
   • Met Requirement 8(3)(b) — The governing body promotes safe, inclusive, and quality care.
   • Not met Requirement 8(3)(c) — Information management systems do not provide sufficient or consistent information for staff and management.
   • Not met Requirement 8(3)(d) — Risk management systems are not always effective in preventing incidents.
   • Met Requirement 8(3)(e) — Clinical governance framework is documented and staff understand policies.

   Risks: Ineffective risk management systems.; Insufficient information management for effective care delivery.

   Recommendations: Implement a new electronic clinical documentation system.; Ensure continuous improvement in behavior support plans and wound management.

   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 ReportFeb 16, 2023

   A site audit was conducted with this service on 13 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.

   source ↗
6. 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 18 May 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
7. Exceptional CircumstancesApr 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 until 18 November 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
8. Exceptional CircumstancesOct 27, 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 18 May 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
9. Exceptional CircumstancesApr 21, 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 18 November 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
10. AssessmentFeb 22, 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 18 May 2021.

    source ↗
11. AssessmentMar 25, 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 18 May 2018.

    source ↗
12. AssessmentMar 23, 2012
    source ↗

No regulatory actions recorded.