Alwyndor Aged Care

52 Dunrobin Road, HOVE, SA, 5048

1. AssessmentJul 8, 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 08 July 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) – siteFeb 6, 2025

   Prepared by M Glenn

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3. Assessment contact Performance ReportJan 14, 2025

   An assessment contact was conducted with this service on 14/01/2025 to 14/01/2025. 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) – siteFeb 2, 2024

   Prepared by M Glenn

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5. Assessment contact Performance ReportJan 9, 2024

   An assessment contact was conducted with this service on 09 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. Accreditation decisionApr 28, 2023

   Following a site audit conducted on 14 March 2023 to 16 March 2023, the Commission made a decision on 28 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 28 April 2026.

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7. Exceptional CircumstancesApr 28, 2023

   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 14 November 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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8. Site AuditApr 28, 2023

   Prepared by K. Richards

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

   The service is compliant with most standards, but non-compliant in Standards 2 (Ongoing assessment and planning), 3 (Personal care and clinical care), and 8 (Organisational governance). Key areas for improvement include effective risk management practices, tailored personal and clinical care, and consistent recording of incidents.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers are treated with respect, their culture is valued, they have choices over care and relationships, risks are discussed, information is communicated clearly, and privacy is respected.

   • Met (3)(a) — Consumers and representatives said consumers are treated with dignity and respect.
   • Met (3)(b) — Care planning documentation demonstrated consumers’ culture and identity is captured within their care plans.
   • Met (3)(c) — Consumers indicated they enjoyed the social relationships they have developed at the service and were encouraged to maintain these connections.
   • Met (3)(d) — Staff could describe mitigating strategies used in response to risks consumers wished to take, with information captured in risk assessments.
   • Met (3)(e) — Consumers and representatives confirmed information is communicated through emails, messages, and verbally, enabling them to make choices.
   • Met (3)(f) — Personal information was observed to be stored in the electronic care system which requires password access.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   Assessment and planning did not sufficiently guide safe and effective care, especially in relation to restrictive practices and wound management. Reviews of care were not always conducted following incidents.

   • Not met (3)(a) — Assessment and planning did not provide sufficient information to guide staff in the delivery of safe and effective care.
   • Met (3)(b) — Consumers and representatives said they have been provided the opportunity to discuss consumers’ current care needs, goals and preferences.
   • Met (3)(c) — Care planning documentation included input from Allied health professionals and external specialist providers.
   • Met (3)(d) — Consumers and representatives said they are satisfied with the delivery of care, including communication of outcomes.
   • Not met (3)(e) — Care and services were not reviewed regularly for effectiveness following incidents.

   Risks: Risks associated with chemical restraint use without adequate behavior support plans.; Ineffectiveness of falls management strategies.

   Recommendations: Ensure assessments and planning include consideration of risks to the consumer’s health and well-being, and are undertaken in a timely manner.; Develop behaviour support plans for consumers using chemical restraints.; Review care and services regularly for effectiveness following incidents or changes in circumstances.

   Standard 3 Personal care and clinical careNon-compliant

   Personal and clinical care was not always best practice, tailored to needs, or optimised health and well-being. Management of high-impact risks was inadequate.

   • Not met (3)(a) — The service did not demonstrate provision of safe and effective personal and/or clinical care that is best practice, tailored to consumer needs.
   • Not met (3)(b) — Management of high impact or high prevalence risks associated with the care of each consumer was inadequate.
   • Met (3)(c) — Care files included details of end-of-life preferences and choices during end-of-life care.
   • Met (3)(d) — A review of care planning documents, progress notes, and charting demonstrated identification and actions taken in response to deterioration.
   • Met (3)(e) — Consumer documentation identified adequate and accurate information to support safe and effective sharing of consumers’ care.
   • Met (3)(f) — Staff described the process for referring consumers to health professionals and Allied health services.
   • Met (3)(g) — The service has a nominated Infection prevention and control (IPC) lead, and guidance material available for staff includes policies and an infection control flowchart on testing and antibiotic use.

   Risks: Inadequate wound management and documentation.; Use of chemical restraints without adequate behavior support plans.

   Recommendations: Ensure personal care is tailored to individual needs and optimises health and well-being.; Implement effective strategies for managing high-impact risks, such as falls and pressure injuries.

   Standard 4 Services and supports for daily livingCompliant

   Services and supports met consumers' needs, goals, and preferences, promoting independence, health, well-being, and quality of life.

   • Met (3)(a) — Consumers and representatives were satisfied with services and supports for daily living.
   • Met (3)(b) — Services include church services, pastoral visits, and one-on-one visits from lifestyle staff.
   • Met (3)(c) — Consumers confirmed they felt supported to participate in activities within the service and in the community.
   • Met (3)(d) — Staff described involvement of other providers and individuals to support consumers’ care and needs.
   • Met (3)(e) — Staff described the process for referring consumers to health professionals and Allied health services.
   • Met (3)(f) — The service implemented a dining program in January 2023, with lifestyle staff dining with consumers during the week.
   • Met (3)(g) — Equipment was observed to be clean and well-maintained.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is welcoming, safe, clean, well maintained, and enables consumers' movement.

   • Met (3)(a) — Consumers felt safe in the service and it was described as a home-like environment.
   • Met (3)(b) — The environment was well-maintained and clean, with staff observed cleaning communal areas several times during the day.
   • Met (3)(c) — Lounge areas and outdoor furniture settings appeared suitably furnished, well maintained, and equipment was clean and safe.

   Standard 6 Feedback and complaintsCompliant

   Consumers are encouraged to provide feedback and make complaints. Complaints are reviewed and used for improvement.

   • Met (3)(a) — Consumers and representatives said they were aware of mechanisms to provide feedback.
   • Met (3)(b) — Information on complaints pathways and language and advocacy services were displayed on noticeboards.
   • Met (3)(c) — Staff were familiar with the concept of open disclosure, describing the importance of transparency and providing an apology when things go wrong.
   • Met (3)(d) — Consumers and representatives could identify changes made in response to feedback and said improvements to care and services are communicated directly by staff.

   Standard 7 Human resourcesCompliant

   The workforce is planned, kind, caring, respectful, competent, trained, equipped, supported, and performance is regularly reviewed.

   • Met (3)(a) — Consumers and representatives were satisfied with staffing skills and numbers.
   • Met (3)(b) — Staff demonstrated familiarity of consumer needs, preferences and cultural requirements in line with care planning.
   • Met (3)(c) — Consumers and representatives were generally satisfied with the skills and knowledge of staff and have confidence in them to deliver care and services.
   • Met (3)(d) — The service has an orientation process to ensure the workforce is competent and to maintain a required standard of knowledge during their employment through training opportunities.
   • Met (3)(e) — Staff stated they participate in reviews where they can discuss their performance and identify areas for further training or support.

   Standard 8 Organisational governanceNon-compliant

   Consumers are engaged, the governing body promotes safe care, governance systems are effective, but risk management practices need improvement.

   • Met (3)(a) — Consumers described being involved in the development and delivery of care and services.
   • Met (3)(b) — The organisation’s strategic plan describes the Board, executive and management team’s commitment to creating an environment where consumers are actively supported to partner in care.
   • Met (3)(c) — There are a range of reporting mechanisms to ensure the Board and sub-committees are aware and accountable for the delivery of care and services.
   • Not met (3)(d) — Incident reports were not consistently being completed for two sampled consumers following acts of aggression towards staff or other consumers.
   • Met (3)(e) — The framework includes the management of antimicrobial stewardship, minimising the use of restraint and open disclosure policies.

   Risks: Inadequate recording of incidents in the incident management system.; Deficiencies identified through audits without effective action to address them.

   Recommendations: Ensure all incidents are recorded within the incident management system.; Implement continuous improvement activities to improve wound management and documentation following audit results.

   Generated by qwen2.5:32b on 11 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

9. Site audit Performance ReportMar 16, 2023

   A site audit was conducted with this service on 14 March 2023 to 16 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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10. 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 14 May 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Assessment contact Performance ReportDec 17, 2021

    An assessment contact was conducted with this service on 17 December 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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12. Assessment contact Performance ReportSep 1, 2021

    An assessment contact was conducted with this service on 01 September 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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13. Compliance monitoring updateFeb 12, 2020

    An assessment contact was conducted by the Aged Care Quality and Safety Commission (Commission) on 12 February 2020 at Alwyndor Aged Care - City of Holdfast Bay to monitor the service’s progress in meeting the Aged Care Quality Standards. The Commission found the service complies with all Aged Care Quality Standards.

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14. AssessmentSep 17, 2019

    Following a site audit the Commission made a decision on 11 October 2019 that this service met seven of the eight Aged Care Quality Standards. The service is re-accredited for three years until 14 November 2022.

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15. AssessmentAug 10, 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 14 November 2019.

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16. AssessmentAug 13, 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 two years until 14 November 2016.

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17. AssessmentOct 28, 2013
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No regulatory actions recorded.