Belmore Place Care Community

35 Yerrick Road, LAKEMBA, NSW, 2195

1. Accreditation decisionMar 2, 2023

   Following a site audit conducted on 04 January 2023 to 06 January 2023, the Commission made a decision on 02 March 2023 to re-accredit this service. The period of accreditation of the service will expire on 02 March 2026.

   source ↗
2. Site AuditMar 2, 2023

   Prepared by G Cherry

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

   The performance report for Belmore Place Care Community indicates compliance across most standards with notable non-compliance in Standards 2 (Ongoing assessment and planning with consumers) and 3 (Personal care and clinical care). The main areas of concern include deficiencies in the identification and addressing of consumer needs, goals, and preferences in assessments and planning processes, as well as issues related to personal/clinical care that do not consistently meet best practices or optimize health and well-being. Recommendations for improvement are provided.

   Standard 1 Consumer dignity and choiceCompliant

   All requirements were assessed as compliant, indicating that consumers are treated with respect, provided culturally safe care, supported in exercising choices, and their privacy is respected.

   • Met Requirement 1(3)(a) — Consumers and representatives consider consumers are treated with respect and dignity. Staff demonstrate knowledge of cultural needs/preferences.
   • Met Requirement 1(3)(b) — Staff provide culturally safe care, respecting consumer preferences including diet and spiritual needs.
   • Met Requirement 1(3)(c) — Consumers receive support to exercise choice/maintain independence and maintain relationships of importance.
   • Met Requirement 1(3)(d) — Staff provide support for consumers taking risks to live their best life, with documented risk assessments and mitigation strategies.
   • Met Requirement 1(3)(e) — Consumers receive current, accurate, and easy-to-understand information in a timely manner.
   • Met Requirement 1(3)(f) — Staff consistently provide care demonstrating respect for privacy and confidentiality.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The standard is non-compliant due to a lack of consistent identification and addressing of consumer needs, goals, and preferences in the assessment and planning process.

   • Met Requirement 2(3)(a) — The service demonstrates an effective system of assessment/care planning completion for most consumers, including consideration of risks to consumer health and well-being.
   • Not met Requirement 2(3)(b) — Assessment and planning processes did not consistently identify needs, goals, and preferences. Generic strategies in Behaviour Support Plans (BSPs) do not include individualized non-pharmacological alternatives.
   • Met Requirement 2(3)(c) — Partnership with consumers and other organizations is demonstrated, including engagement of advocacy services where required.
   • Met Requirement 2(3)(d) — Outcomes of assessment and planning are effectively communicated to the consumer and documented in care plans.
   • Met Requirement 2(3)(e) — Care and services are reviewed regularly for effectiveness, with reassessments occurring when circumstances change or incidents impact needs.

   Risks: Generic strategies in Behaviour Support Plans (BSPs) do not include individualized non-pharmacological alternatives to trial prior to administration of psychotropic medications.

   Recommendations: Review/revise relevant behaviour support plans to ensure details relating to triggers/contributing factors to changed behaviours include effective strategies which are person-centred and individualised to guide staff in care provision.

   Standard 3 Personal care and clinical careNon-compliant

   The standard is non-compliant due to deficiencies in the identification of a pressure injury/wound for one consumer, leading to significant tissue loss. Additionally, there are issues with the use of restrictive practices.

   • Not met Requirement 3(3)(a) — Deficiencies in non-identification of a pressure injury/wound for one consumer, leading to significant tissue loss. Documentation does not demonstrate consistent assessment and documentation of medications used as chemical restraint.
   • Met Requirement 3(3)(b) — High impact/high prevalence risks are managed effectively with staff demonstrating knowledge of monitoring and management processes.
   • Met Requirement 3(3)(c) — End-of-life care maximizes comfort and preserves dignity, with staff providing individualized wishes such as oral care, repositioning, pain medication, and aromatherapy.
   • Met Requirement 3(3)(d) — Deterioration or change in consumer’s mental health, cognitive function, capacity, or condition is recognized and responded to timely with appropriate reassessments.
   • Met Requirement 3(3)(e) — Information about the consumer's condition, needs, and preferences is documented and communicated within the organization and with others involved in care delivery.
   • Met Requirement 3(3)(f) — Timely and appropriate referrals to individuals, other organizations, and providers of other care and services are made as required.
   • Met Requirement 3(3)(g) — Infection-related risks are minimized through standard and transmission-based precautions, with staff demonstrating understanding of infection control protocols.

   Risks: Non-identification of a pressure injury/wound for one consumer leading to significant tissue loss.; Documentation does not demonstrate consistent assessment and documentation of medications used as chemical restraint.

   Recommendations: Implement and maintain processes to assess, determine, and document when a treatment or intervention constitutes a restrictive practice. Review and revise understanding of chemical restraint to ensure practices align with the Quality of Care Principles 2014 definition and requirements for use of a restrictive practice.

   Standard 4 Services and supports for daily livingCompliant

   All requirements were assessed as compliant, indicating that consumers receive safe and effective services and supports for daily living that meet their needs, goals, and preferences.

   • Met Requirement 4(3)(a) — Consumers receive effective services and supports for daily living with staff engaging and assisting consumers in activities.
   • Met Requirement 4(3)(b) — Support is provided to promote emotional, spiritual, and psychological well-being through individualized care needs.
   • Met Requirement 4(3)(c) — Consumers receive support to participate in community activities, do things of interest, and be involved in relationships of choice.
   • Met Requirement 4(3)(d) — Information about the consumer's condition, needs, and preferences is communicated within the organization and with external care providers.
   • Met Requirement 4(3)(e) — Timely and appropriate referrals to individuals and other organizations are made when required.
   • Met Requirement 4(3)(f) — Meals provided are varied, of suitable quality and quantity, with consideration for dietary needs/preferences.
   • Met Requirement 4(3)(g) — Equipment is safe, suitable, clean, and well-maintained, with staff demonstrating knowledge of hazard identification processes.

   Standard 5 Organisation’s service environmentCompliant

   All requirements were assessed as compliant, indicating that the service environment is welcoming, safe, clean, and well-maintained.

   • Met Requirement 5(3)(a) — The living environment optimizes consumer independence/function with positive feedback from consumers and representatives.
   • Met Requirement 5(3)(b) — Service environment is clean, well-maintained, and enables consumers to move freely both indoors and outdoors.
   • Met Requirement 5(3)(c) — Furniture, fittings, and equipment are safe, suitable, clean, and well-maintained with adequate tables and seating in dining/lounge areas.

   Standard 6 Feedback and complaintsCompliant

   All requirements were assessed as compliant, indicating that consumers are encouraged to provide feedback and make complaints, with appropriate action taken in response.

   • Met Requirement 6(3)(a) — Consumers feel safe raising matters with staff and management through various methods including direct engagement, meeting forums, surveys, and online options.
   • Met Requirement 6(3)(b) — Consumers are made aware of advocacy groups, language services, and other methods for raising/resolving feedback/complaints.
   • Met Requirement 6(3)(c) — Appropriate action is taken in response to complaints with principles of open disclosure practiced when things go wrong.
   • Met Requirement 6(3)(d) — Feedback and complaints are reviewed and used for continuous improvement, with examples provided such as changes to laundry processes.

   Standard 7 Human resourcesCompliant

   All requirements were assessed as compliant, indicating that the workforce is planned and deployed effectively to deliver safe and quality care.

   • Met Requirement 7(3)(a) — Sufficient suitably skilled staff are available, with monitoring processes ensuring timely response to consumer requests.
   • Met Requirement 7(3)(b) — Staff interactions with consumers are kind, caring, and respectful of each consumer’s identity, culture, and diversity.
   • Met Requirement 7(3)(c) — The workforce is competent with staff having the qualifications and knowledge to effectively perform their roles.
   • Met Requirement 7(3)(d) — Staff are recruited, trained, equipped, and supported to deliver required outcomes.
   • Met Requirement 7(3)(e) — Regular assessment, monitoring, and review of staff performance is undertaken with completion of performance appraisals.

   Standard 8 Organisational governanceCompliant

   All requirements were assessed as compliant, indicating that the organization promotes a culture of safe and quality care with effective governance systems.

   • Met Requirement 8(3)(a) — Consumers are engaged in development, delivery, and evaluation of care/services through various mechanisms including regular meeting forums and feedback/complaints processes.
   • Met Requirement 8(3)(b) — The governing body promotes a culture of safe, inclusive quality care with accountability for delivery demonstrated through reporting structures.
   • Met Requirement 8(3)(c) — Effective organization-wide governance systems are in place including information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback/complaints.
   • Met Requirement 8(3)(d) — Risk management systems and practices are effective with multidisciplinary approaches taken for identification and management of clinical risks.
   • Met Requirement 8(3)(e) — Clinical governance framework is demonstrated with antimicrobial stewardship discussed at medication advisory committee meetings, staff trained in minimizing antibiotic usage, and principles of open disclosure practiced.

   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.

3. Site audit Performance ReportJan 6, 2023

   A site audit was conducted with this service on 04 January 2023 to 06 January 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

   source ↗
4. Exceptional CircumstancesSep 23, 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 25 April 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
5. Exceptional CircumstancesMar 22, 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 25 October 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
6. Exceptional CircumstancesSep 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 25 April 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

   source ↗
7. AssessmentAug 1, 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 25 October 2021.

   source ↗
8. AssessmentAug 12, 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 25 October 2018.

   source ↗
9. AssessmentAug 15, 2012
   source ↗
10. AssessmentAug 26, 2009
    source ↗

No regulatory actions recorded.