Adina Care Cootamundra

121 Mackay Street, COOTAMUNDRA, NSW, 2590

1. AssessmentMay 7, 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 07/05/2025, 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. Accreditation decisionAug 12, 2024

   Following a site audit conducted on 02 July 2024 to 05 July 2024, the Commission made a decision on 12 August 2024 to re-accredit this service. The period of accreditation of the service will expire on 04 October 2025.

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3. Site AuditAug 12, 2024

   Prepared by Therese Solomon

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4. Site audit Performance ReportJul 5, 2024

   A site audit was conducted with this service on 02/07/2024 to 05/07/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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5. Assessment contact (performance assessment) – siteJan 31, 2024

   Prepared by M Wyborn

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6. Assessment contact Performance ReportDec 12, 2023

   An assessment contact was conducted with this service on 12 December 2023 to 12 December 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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7. Accreditation decisionApr 4, 2023

   Following a site audit conducted on 10 January 2023 to 12 January 2023, the Commission made a decision on 04 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 04 October 2024.

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8. Site AuditApr 4, 2023

   Prepared by Katrina Platt

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

   The performance report highlights significant areas for improvement across several Quality Standards, particularly in consumer dignity and choice, ongoing assessment and planning, personal care and clinical care, services and supports for daily living, human resources, and organizational governance. The service needs to address deficiencies in staff competencies, timely referrals, comprehensive assessments, and effective risk management systems.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service was found to be non-compliant due to issues with treating consumers with dignity, respecting their privacy, and supporting them in exercising choice and independence.

   • Not met 1(3)(a) — Consumers were not consistently treated with dignity and respect. Management references to consumers were not always respectful.
   • Met 1(3)(b) — Care and services were culturally safe, supporting consumers' individual cultures.
   • Not met 1(3)(c) — Consumers were not always consulted about personal care preferences. Decision-making processes were not documented clearly.
   • Not met 1(3)(d) — Consumers were not supported to take risks to live the best life they can, and risk assessments did not address key interventions required for safety.
   • Not met 1(3)(e) — Information provided was not always current or communicated in a way that enabled choice. Monthly newsletters lacked key information.
   • Not met 1(3)(f) — Consumer privacy and confidentiality were not demonstrated, with personal information displayed in public areas.

   Risks: Consumers felt disrespected after sustaining a fall.; Privacy breaches due to undignified practices such as displaying consumer files in public areas.

   Recommendations: Ensure consumers are treated with dignity and respect, including addressing the use of mobility equipment that impacts on consumer dignity.; Document decision-making processes clearly and ensure staff awareness about consumer choices.; Improve communication methods to provide clear information to consumers.; Secure personal information properly at all times.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The service was non-compliant due to deficiencies in comprehensive assessments, care plans, and regular reviews of services for effectiveness.

   • Not met 2(3)(a) — Comprehensive assessment and planning were not demonstrated. Risks to consumer health and well-being were not considered.
   • Not met 2(3)(b) — Care plans did not capture measurable care goals, preferences for personal care provision, or management of pressure injuries and mobility needs.
   • Not met 2(3)(c) — Consumers were not involved in assessment and planning processes. Information from external providers was not consistently placed in care plans.
   • Not met 2(3)(d) — Outcomes of assessments were not effectively communicated to consumers, and access to care plans was not provided when requested.
   • Not met 2(3)(e) — Regular reviews for effectiveness were not conducted as required by policy. Formal review processes were lacking.

   Risks: Incomplete care plans and assessments led to ineffective management of consumer needs.; Consumers were not involved in the planning process, leading to unmet needs.

   Recommendations: Ensure comprehensive assessment and planning that considers all aspects of consumer health and well-being.; Include consumers in the planning process and ensure their preferences are documented.; Regularly review care plans for effectiveness and document these reviews.

   Standard 3 Personal care and clinical careNon-compliant

   The service was non-compliant due to issues with best practice personal and clinical care, management of high-impact risks, and timely referrals.

   • Not met 3(3)(a) — Care was not always tailored to consumer needs. Staff practices were deficient in wound classification and grading.
   • Not met 3(3)(b) — High-impact risks such as falls, pressure injuries, and weight loss were not effectively managed. Behaviour support plans were lacking.
   • Met 3(3)(c) — Needs of consumers nearing the end of life were recognized and addressed with appropriate care.
   • Met 3(3)(d) — Deterioration or changes in consumer conditions were recognized and responded to timely.
   • Met 3(3)(e) — Information about the consumer’s condition, needs, and preferences was documented and communicated effectively.
   • Not met 3(3)(f) — Timely referrals for wound management and behavior management were delayed.

   Risks: Deficiencies in staff clinical competencies impacted care quality.; Untimely recognition of skin deterioration led to late-stage pressure injuries.

   Recommendations: Ensure personal and clinical care is best practice, tailored to consumer needs.; Effectively manage high-impact risks through comprehensive behavior support plans.; Improve timely referrals for specialized services.

   Standard 4 Services and supports for daily livingNon-compliant

   The service was non-compliant due to deficiencies in meeting consumer needs, promoting well-being, and providing suitable meals.

   • Not met 4(3)(a) — Services did not meet all consumer needs, goals, and preferences. Feedback about laundry service deficiencies was noted.
   • Not met 4(3)(b) — Emotional and psychological well-being were not adequately promoted despite some activities being provided.
   • Met 4(3)(c) — Consumers participated in community activities and maintained social relationships.
   • Met 4(3)(d) — Information about consumer conditions, needs, and preferences was communicated effectively within the organization.
   • Met 4(3)(e) — Timely referrals to other organizations were demonstrated.
   • Not met 4(3)(f) — Meals were not always varied or tailored to individual dietary needs and preferences. Consumers with swallowing difficulties received inappropriate food textures.

   Risks: Deficiencies in the laundry service impacted consumer satisfaction.; Limited meal choices did not meet all consumers' nutritional needs.

   Recommendations: Ensure services for daily living are tailored to individual consumer needs and preferences.; Promote emotional and psychological well-being through more personalized interactions with staff.; Improve meal variety and ensure meals are suitable for each consumer's dietary requirements.

   Standard 5 Organisation’s service environmentCompliant

   The service was compliant as the environment was safe, clean, and maintained well, promoting a sense of belonging among consumers.

   • Met 5(3)(a) — The environment was welcoming and promoted consumer independence and interaction.
   • Met 5(3)(b) — Common areas were safe, clean, and well-maintained. Consumers could move freely indoors and outdoors.
   • Met 5(3)(c) — Furniture, fittings, and equipment were safe, clean, well maintained, and suitable for consumers.

   Standard 6 Feedback and complaintsCompliant

   The service was compliant as it encouraged feedback and supported the resolution of complaints.

   • Met 6(3)(a) — Consumers were encouraged to provide feedback and make complaints.
   • Met 6(3)(b) — Information about advocates, language services, and methods for raising and resolving complaints was available.
   • Met 6(3)(c) — Appropriate action was taken in response to complaints using an open disclosure process.
   • Met 6(3)(d) — Feedback and complaints were reviewed and used for quality improvement.

   Standard 7 Human resourcesNon-compliant

   The service was non-compliant due to deficiencies in staff competencies, training, and performance reviews.

   • Met 7(3)(a) — Workforce planning enabled the delivery of safe and quality care.
   • Met 7(3)(b) — Staff interactions were kind, caring, and respectful of consumer identity, culture, and diversity.
   • Not met 7(3)(c) — Deficiencies in staff clinical competencies were noted. Training needs were not always met.
   • Not met 7(3)(d) — Staff recruitment, training, and support did not fully align with the Quality Standards.
   • Not met 7(3)(e) — Regular performance reviews were not conducted for all staff members.

   Risks: Staff shortages impacted care quality.; Training needs were not always addressed, leading to deficiencies in clinical competencies.

   Recommendations: Ensure workforce competencies align with the Quality Standards and provide regular training.; Conduct annual performance reviews for all staff members.

   Standard 8 Organisational governanceNon-compliant

   The service was non-compliant due to deficiencies in consumer engagement, organizational culture, and risk management systems.

   • Not met 8(3)(a) — Consumers were not always engaged in the development and evaluation of care services.
   • Not met 8(3)(b) — The governing body did not promote a culture of safe, inclusive quality care. Information on incidents was not provided to board meetings.
   • Not met 8(3)(c) — Effective governance systems were lacking in information management and regulatory compliance.
   • Not met 8(3)(d) — Risk management systems did not effectively manage high-impact risks or report incidents under the Serious Incident Response Scheme.
   • Not met 8(3)(e) — The clinical governance framework was incomplete, with deficiencies in antimicrobial stewardship and minimizing use of restraints.

   Risks: Consumers were not involved in care planning processes.; Ineffective communication to the governing body impacted decision-making on safe care provision.

   Recommendations: Engage consumers more actively in the development, delivery, and evaluation of care services.; Promote a culture of safety through effective governance systems and risk management practices.; Ensure compliance with legislative requirements for reporting incidents under the Serious Incident Response Scheme.

   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 ReportJan 12, 2023

   A site audit was conducted with this service on 10 January 2023 to 12 January 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 27, 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 06 May 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Exceptional CircumstancesApr 27, 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 06 November 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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12. 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 06 May 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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13. 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 06 November 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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14. AssessmentFeb 7, 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 06 May 2021.

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15. AssessmentFeb 11, 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 06 May 2018.

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16. AssessmentFeb 15, 2012
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No regulatory actions recorded.