Bethsalem Care

10 Education Road, HAPPY VALLEY, SA, 5159

1. Assessment Contact - SiteJul 26, 2023

   Prepared by M Glenn

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2. Assessment contact Performance ReportJul 6, 2023

   An assessment contact was conducted with this service on 06 July 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 - SiteMay 1, 2023

   Prepared by J Renna

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

   The performance report for Bethsalem Care indicates non-compliance in Standard 2 Ongoing assessment and planning with consumers due to issues in care plan reviews following incidents or changes in condition. The report highlights areas where improvements must be made to ensure compliance with the Quality Standards, particularly around staff skills and knowledge, updating consumer care plans, and monitoring staff compliance.

   Standard 1 Consumer dignity and choiceNot applicable

   The standard is not applicable as not all requirements have been assessed.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   Non-compliant due to issues in care plan reviews following incidents or changes in condition.

   • Met Requirement 2(3)(a) — The service demonstrated assessment and planning, including consideration of risks to the consumer’s health and well-being, informs the delivery of safe and effective care and services. Nine consumers and one representative were satisfied with staff knowledge of individual risks.
   • Not met Requirement 2(3)(e) — Care plans were not consistently reviewed following falls or behavioural incidents, and there was no evidence that existing strategies had been reviewed. One consumer's care plan did not reflect changes in condition after a fall.

   Risks: One consumer’s risk of pressure injuries was not reassessed and new interventions were not implemented following the development of a new pressure injury.; A Physiotherapist assessment was not undertaken following a fall, and pain management strategies were not implemented despite mild pain being charted.

   Recommendations: Ensure staff have skills and knowledge to initiate assessments and update care plans where changes in consumers’ health are identified or when incidents occur.; Ensure consumer care plans are updated and reflective of current needs and preferences.; Monitor staff compliance with the service’s policies, procedures, and guidelines.

   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 4, 2023

   An assessment contact was conducted with this service on 04 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. Accreditation decisionDec 5, 2022

   Following a site audit conducted on 07 November 2022 to 09 November 2022, the Commission made a decision on 05 December 2022 to re-accredit this service. The period of accreditation of the service will expire on 17 February 2026.

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6. Site AuditDec 5, 2022

   Prepared by Denise McDonald

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

   Bethsalem Care was found compliant in all standards except Standard 1 (Consumer dignity and choice), where non-compliance related to supporting consumers to take risks. The service demonstrated effective governance, human resources management, feedback mechanisms, and safe environments. However, there were identified areas for improvement, particularly around updating the dignity of risk policy and ensuring timely completion of annual performance appraisals.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service did not support two named consumers to safely take risks related to smoking and alcohol consumption.

   • Met Requirement 1(3)(a) — Consumers said staff treat them with dignity and respect and felt valued as an individual.
   • Met Requirement 1(3)(b) — Care planning documentation evidenced that consumers’ culture, diversity, identity, and personal preferences are acknowledged.
   • Met Requirement 1(3)(c) — Consumers confirmed they were kept informed and supported to make choices and decisions about the things they liked to do.
   • Not met Requirement 1(3)(d) — The service did not support two named consumers to safely take risks related to smoking and alcohol consumption.
   • Met Requirement 1(3)(e) — Consumers confirmed they were kept informed and supported to make choices and decisions about the things they liked to do.
   • Met Requirement 1(3)(f) — Staff were observed to respect consumers’ privacy.

   Risks: The service did not support two named consumers to safely take risks related to smoking and alcohol consumption.

   Recommendations: Update the dignity of risk policy to include a process for regular monitoring and review or risk-taking behaviors.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service has implemented improvements to address previous non-compliance, now compliant.

   • Met Requirement 2(3)(a) — Care planning documentation recorded assessments of consumers’ needs and risks to their health and well-being.
   • Met Requirement 2(3)(b) — Consumers confirmed the service recognised and respected their cultural background and provided care that was consistent with their cultural preferences.
   • Met Requirement 2(3)(c) — Management described partnering with consumers in care planning and processes for making referrals to allied health professionals.
   • Met Requirement 2(3)(d) — Consumers and representatives felt the service effectively kept them up to date and informed about the consumers’ care planning and assessments.
   • Met Requirement 2(3)(e) — Care planning documentation demonstrated deterioration or changes to consumers’ condition were identified and responded to.

   Standard 3 Personal care and clinical careCompliant

   Consumers received safe, effective, and tailored personal and clinical care.

   • Met Requirement 3(3)(a) — Management and clinical staff described process which ensured clinical and personal care is aligned to best practice.
   • Met Requirement 3(3)(b) — Care planning documentation demonstrated high impact and high prevalence risks were identified and monitored.
   • Met Requirement 3(3)(c) — Consumers and representatives said when a consumer needed end of life cares, the service supported them to be as free from pain as possible.
   • Met Requirement 3(3)(d) — Staff explained how deterioration was reported and assessed by clinical staff.
   • Met Requirement 3(3)(e) — Consumers and representatives expressed satisfaction with the communication of consumers’ needs, preferences, and changes to condition.
   • Met Requirement 3(3)(f) — Consumers confirmed they are provided support by other organisations and services.
   • Met Requirement 3(3)(g) — The service had documented policies and procedures which guided staff in relation to antimicrobial stewardship, infection control, and the management of a COVID-19 outbreak.

   Standard 4 Services and supports for daily livingCompliant

   Consumers received safe and effective services that met their needs.

   • Met Requirement 4(3)(a) — Consumers confirmed they were supported to participate in activities they like.
   • Met Requirement 4(3)(b) — The Assessment Team observed consumers of varying levels of ability engaged in daily living activities during the site audit.
   • Met Requirement 4(3)(c) — Consumers felt supported to participate in activities both within the service and in the outside community.
   • Met Requirement 4(3)(d) — Staff described how information about consumers’ condition, needs, and preferences are shared.
   • Met Requirement 4(3)(e) — Consumers confirmed they are provided support by other organisations and services.
   • Met Requirement 4(3)(f) — Consumers expressed the variety, quantity, and quality of the meals provided met their needs.
   • Met Requirement 4(3)(g) — Staff confirmed access to equipment and explained how equipment is kept safe, clean, and well-maintained.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, and well maintained.

   • Met Requirement 5(3)(a) — Consumers and representatives confirmed they find the service environment to be welcoming and easy to understand.
   • Met Requirement 5(3)(b) — Management and staff described how the service is cleaned in accordance with a daily cleaning schedule.
   • Met Requirement 5(3)(c) — The Assessment Team observed furniture and equipment to be clean and in good condition.

   Standard 6 Feedback and complaintsCompliant

   Consumers felt comfortable providing feedback or making a complaint.

   • Met Requirement 6(3)(a) — Management and staff described avenues for consumers to provide feedback and complaints.
   • Met Requirement 6(3)(b) — Consumers and representatives said they were aware of, and have access to, advocates, language services, and other methods for raising and resolving complaints.
   • Met Requirement 6(3)(c) — The service’s feedback and complaints register demonstrated appropriate action was taken and an open disclosure process was followed.
   • Met Requirement 6(3)(d) — Consumers and representatives felt their feedback is used to improve services.

   Standard 7 Human resourcesCompliant

   The workforce was planned, trained, and supported effectively.

   • Met Requirement 7(3)(a) — Management described how the service ensured adequate staff.
   • Met Requirement 7(3)(b) — Consumers and representatives said staff are kind, caring and gentle when providing cares.
   • Met Requirement 7(3)(c) — Position descriptions included key competencies and qualifications required for each role.
   • Met Requirement 7(3)(d) — Staff said the service provided mandatory and supplementary training to support them to provide quality care.
   • Met Requirement 7(3)(e) — The Assessment Team identified that a large number of annual performance appraisals were overdue, however, management described how staff performance was being managed for individuals identified to be underperforming.

   Recommendations: Ensure timely completion of annual performance appraisals.

   Standard 8 Organisational governanceCompliant

   The service demonstrated effective governance systems and practices.

   • Met Requirement 8(3)(a) — Management described how consumers were engaged in the development, delivery and evaluation of care and services.
   • Met Requirement 8(3)(b) — The Assessment Team reviewed documentation which demonstrated the involvement of the board in quality, clinical governance, and risk management matters.
   • Met Requirement 8(3)(c) — Management said they were subscribed to a range of newsletters, industry alerts and said they regularly browse the Commission’s website to monitor changes to aged care laws.
   • Met Requirement 8(3)(d) — The service demonstrated all staff had received the required COVID-19 vaccinations and had current police checks and professional registrations.
   • Met Requirement 8(3)(e) — Clinical staff demonstrated an understanding of strategies to minimise the use of antibiotics and restrictive practices, and open disclosure.

   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.

7. Accreditation decisionNov 9, 2022

   Following a site audit conducted on 07 November 2022 to 09 November 2022, the Commission made a decision on 05 December 2022 to re-accredit this service. The period of accreditation of the service will expire on 17 February 2026.

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8. Assessment contact Performance ReportMay 4, 2022

   An assessment contact was conducted with this service on 04 May 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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9. Accreditation decisionDec 23, 2021

   Following a site audit conducted on 28 May 2019 to 30 May 2019, the Commission made a decision on 27 June 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 23 December 2021. The period of accreditation of the service will expire on 17 February 2023.

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10. AssessmentMay 30, 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 17 August 2022.

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11. AssessmentJun 8, 2016

    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 17 August 2019.

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12. AssessmentJun 5, 2013
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13. AssessmentJun 9, 2010
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No regulatory actions recorded.