BaptistCare The Gracewood Centre
activeOverview
Location
Kellyville - West (SA2)
2 Free Settlers Drive, KELLYVILLE, NSW, 2155
Star ratings
Latest — May 2026
Compliance findings
15 recorded
| Date | Type | Requirement | Severity | Finding | Status |
|---|---|---|---|---|---|
| 29 Apr 2025 | Site Audit | – | – | Consumer dignity and choice | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Ongoing assessment and planning with consumers | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Personal care and clinical care | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Services and supports for daily living | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Organisation’s service environment | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Feedback and complaints | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Human resources | Compliant |
| 29 Apr 2025 | Site Audit | – | – | Organisational governance | Compliant |
| 12 Oct 2023 | Assessment Contact - Site | – | – | Ongoing assessment and planning with consumers | Not applicable |
| 12 Oct 2023 | Assessment Contact - Site | – | – | Personal care and clinical care | Not applicable |
| 06 June 2023 | Assessment Contact - Site | – | – | Consumer dignity and choice | Not applicable |
| 06 June 2023 | Assessment Contact - Site | – | – | Ongoing assessment and planning with consumers | Non-compliant |
| 06 June 2023 | Assessment Contact - Site | – | – | Personal care and clinical care | Non-compliant |
| 06 June 2023 | Assessment Contact - Site | – | – | Human resources | Not applicable |
| 06 June 2023 | Assessment Contact - Site | – | – | Organisational governance | Not applicable |
Accreditation & assessment timeline
15 events · AI report insights nested where analysed
- Accreditation decision
Following a site audit conducted on 25/03/2025 to 27/03/2025, the Commission made a decision on 29/04/2025 to re-accredit this service. The period of accreditation of the service will expire on 29/06/2028.
source ↗ - Site Auditsource ↗
- Site audit Performance Report
A site audit was conducted with this service on 25 March 2025 to 27 March 2025. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.
source ↗ - Assessment Contact - Sitesource ↗
- Assessment contact Performance Report
An assessment contact was conducted with this service on 08 September 2023 to 08 September 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Assessment Contact - Sitesource ↗
AI report insightsAI-extracted · qwen2.5:32b
The service, BaptistCare The Gracewood Centre, has demonstrated compliance in treating consumers with dignity and respect and supporting them to take risks. However, it is non-compliant in ongoing assessment and planning with consumers due to gaps in reviewing care plans regularly and effectively managing incidents. Additionally, the management of high-impact or high-prevalence risks associated with personal care and clinical care is also found to be non-compliant. The service shows compliance in human resources and organizational governance, indicating sufficient staff levels and effective governance systems.
Standard 1 Consumer dignity and choiceCompliant
The service has been found compliant with requirements related to treating consumers with dignity and respect and supporting them to take risks.
- Met Requirement 1(3)(a) — The service has a diversity and inclusion policy, staff know consumers' backgrounds and culture, and cultural events are celebrated. Consumers were observed to be treated with dignity and respect.
- Met Requirement 1(3)(d) — There is a resident decision-making and risk policy supporting consumers in taking risks. Consumers confirmed they are supported to take risks, including signing consent forms for risky activities.
Standard 2 Ongoing assessment and planning with consumersNon-compliant
The service is non-compliant due to gaps in reviewing care plans regularly and effectively managing incidents.
- Not met Requirement 2(3)(e) — Care and services were not reviewed for effectiveness for some consumers, especially those with behavior support needs. There is a lack of documentation on triggers and strategies used to manage behaviors.
Risks: Consumers' care plans are not updated regularly or when circumstances change, which can lead to ineffective care planning and potential incidents.
Recommendations: Review and update care and service plans regularly for all consumers. Ensure documentation includes triggers and strategies used in behavior management.
Standard 3 Personal care and clinical careNon-compliant
The service is non-compliant due to ineffective management of high-impact risks associated with consumer behaviors.
- Not met Requirement 3(3)(b) — Effective management of behavior-related risks for two consumers is lacking. Consumers reported that verbal behavior from one consumer makes them upset.
Risks: Ineffective management of high-impact and high-prevalence risks, particularly behaviors and falls, can negatively impact emotional health and safety.
Recommendations: Implement more effective strategies to manage high-impact risks associated with consumer behavior. Ensure documentation includes triggers and the effectiveness of interventions used.
Standard 7 Human resourcesCompliant
The service is compliant, showing sufficient staff levels and respectful interactions.
- Met Requirement 7(3)(a) — There are enough staff to provide safe and quality care. Staff rosters show shifts are filled, and call bells are answered promptly.
- Met Requirement 7(3)(b) — Staff interactions with consumers are kind, caring, and respectful of each consumer’s identity, culture, and diversity. Consumers provided positive feedback on staff behavior.
Standard 8 Organisational governanceCompliant
The service is compliant with effective organizational governance systems.
- Met Requirement 8(3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback.
Standard 4 Quality of careNot applicable as not all requirements have been assessed
Standard 5 Quality of lifeNot applicable as not all requirements have been assessed
Standard 6 Leadership and 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.
- Assessment contact Performance Report
An assessment contact was conducted with this service on 02 May 2023 to 03 May 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Accreditation decision
Following a site audit conducted on 24 May 2022 to 26 May 2022, the Commission made a decision on 29 June 2022 to re-accredit this service. The period of accreditation of the service will expire on 29 June 2025.
source ↗ - Exceptional Circumstances
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 25 January 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Site audit Performance Report
A site audit was conducted with this service on 24 May 2022 to 26 May 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.
source ↗ - Exceptional Circumstances
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 25 July 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Exceptional Circumstances
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 25 January 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Exceptional Circumstances
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 25 July 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Assessment
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 25 January 2021.
source ↗ - Assessment
This is a new home and is accredited for one year until 25 January 2018. We made the decision on 25 January 2017.
source ↗
Regulatory actions
0 recorded
No regulatory actions recorded.