Aubrey Downer Aged Care Home

23 Sunnyside Avenue, POINT CLARE, NSW, 2250

1. Assessment contact (performance assessment) – siteNov 9, 2023

   Prepared by G Cherry

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2. Assessment contact Performance ReportSep 14, 2023

   An assessment contact was conducted with this service on 14 September 2023 to 14 September 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. Accreditation decisionJun 21, 2023

   Following a site audit conducted on 17 May 2023 to 19 May 2023, the Commission made a decision on 21 June 2023 to re-accredit this service. The period of accreditation of the service will expire on 29 September 2026.

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4. Site AuditJun 21, 2023

   Prepared by A. Douglas

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

   Aubrey Downer Aged Care Home was compliant with most standards but non-compliant with Standard 4 due to inadequate services for daily living, emotional well-being support, community engagement, and referrals. The service has taken steps to address these issues but requires more time to fully implement improvements.

   Standard 1 Consumer dignity and choiceCompliant

   The service valued each consumer's identity, culture, and diversity, supported their choices and independence, and respected their privacy.

   • Met Requirement 1(3)(a) — Consumers said staff valued their identity, culture, and diversity. Care documents contained information about each consumer’s identity and culture.
   • Met Requirement 1(3)(b) — The service had policies to guide staff in delivering culturally safe care.
   • Met Requirement 1(3)(c) — Consumers said the service supported them to maintain relationships and make decisions about how their care is delivered.
   • Met Requirement 1(3)(d) — Consumers said the service supported them to take risks and exercise choice.
   • Met Requirement 1(3)(e) — Consumers said the service communicated information which was timely and easy to understand.
   • Met Requirement 1(3)(f) — Consumers said staff respected their privacy, and the service kept their information confidential and secured.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service effectively assessed and planned care based on consumer needs, preferences, and risks.

   • Met Requirement 2(3)(a) — Consumers said the service’s assessment and planning processes considered risks to their health and well-being.
   • Met Requirement 2(3)(b) — Staff commenced conversations about advance care and end of life (EOL) planning during the service’s admission assessments.
   • Met Requirement 2(3)(c) — Consumers said they were actively involved in the assessment, planning and review of their care.
   • Met Requirement 2(3)(d) — Care documents included the outcomes of assessment and care planning, and this information had been communicated with consumers.
   • Met Requirement 2(3)(e) — Consumers said the service regularly communicated with them when circumstances changed or incidents occurred.

   Standard 3 Personal care and clinical careCompliant

   The service provided safe, effective personal and clinical care tailored to consumer needs.

   • Met Requirement 3(3)(a) — Consumers said they received effective personal and clinical care that was tailored to their needs, and optimised their health and well-being.
   • Met Requirement 3(3)(b) — The service had a ‘clinical risk committee’ that helped to ensure the service delivered care consistent with best practice.
   • Met Requirement 3(3)(c) — Consumers said they were confident the service would support them with EOL care when required.
   • Met Requirement 3(3)(d) — The service had an effective process in place to regularly monitor each consumer for deterioration.
   • Met Requirement 3(3)(e) — Consumers said staff communicated information about their condition, needs and preferences adequately.
   • Met Requirement 3(3)(f) — Consumers said staff referred them to external providers promptly and appropriately to meet their care needs.
   • Met Requirement 3(3)(g) — The service had an infection prevention and control lead who was responsible for infection control practices at the service.

   Standard 4 Services and supports for daily livingNon-compliant

   The service did not provide adequate services and supports to meet consumer needs, promote well-being, or facilitate community engagement.

   • Not met Requirement 4(3)(a) — Consumers were not receiving effective services and supports for daily living that met their needs, goals, and preferences.
   • Not met Requirement 4(3)(b) — The service did not adequately provide services and supports for daily living which promoted each consumer’s emotional, spiritual, and psychological well-being.
   • Not met Requirement 4(3)(c) — Consumers felt it was their responsibility to initiate and coordinate their own daily living activities and communications with people important to them.
   • Met Requirement 4(3)(d) — Staff captured information about changes to consumers’ needs and preferences in care documents and shared these updates during handover processes.
   • Not met Requirement 4(3)(e) — The service could not provide evidence of referrals to advocacy support services.

   Recommendations: Recruit additional lifestyle staff members and develop a comprehensive lifestyle program.; Engage with local spiritual and religious services to offer more activities.; Facilitate community bus outings and form connections with local organizations for activities.; Provide information about external support services and engage volunteer services.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, clean, well-maintained, and enabled consumer independence and interaction.

   • Met Requirement 5(3)(a) — Consumers said the service was welcoming and easy to navigate.
   • Met Requirement 5(3)(b) — The service was clean, with adequate lighting and signage to optimise consumers’ navigation.
   • Met Requirement 5(3)(c) — Consumers said the service’s equipment was clean, well-maintained, and suitable.

   Standard 6 Feedback and complaintsCompliant

   The service encouraged feedback and complaints, provided access to advocates, and used feedback for continuous improvement.

   • Met Requirement 6(3)(a) — Consumers said they felt comfortable raising their concerns and providing feedback.
   • Met Requirement 6(3)(b) — The service displayed information regarding its escalation pathways around the facility, including information about advocacy services.
   • Met Requirement 6(3)(c) — Consumers said the service responded to feedback and addressed their concerns.
   • Met Requirement 6(3)(d) — The service used consumer feedback to improve care and services.

   Standard 7 Human resourcesCompliant

   The workforce was planned, competent, trained, and supported to deliver safe and quality care.

   • Met Requirement 7(3)(a) — Consumers said there were enough staff at the service.
   • Met Requirement 7(3)(b) — Staff interacted with consumers in a kind and caring manner.
   • Met Requirement 7(3)(c) — Consumers said they felt staff were effective in their roles and competent.
   • Met Requirement 7(3)(d) — The service provided various types of training, including orientation and annual mandatory training.
   • Met Requirement 7(3)(e) — Staff completed performance reviews every second year with high levels of engagement between management and staff.

   Standard 8 Organisational governanceCompliant

   The service engaged consumers in care development, had a governing body promoting quality care, and maintained effective governance systems.

   • Met Requirement 8(3)(a) — Consumers said they felt involved in the design, delivery, and evaluation of services.
   • Met Requirement 8(3)(b) — Management advised that all feedback or suggestions made by consumers were included in the service’s PCI.
   • Met Requirement 8(3)(c) — The service had effective governance systems for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback and complaints.
   • Met Requirement 8(3)(d) — Staff demonstrated an awareness of risk management practices including incident reporting and antimicrobial stewardship.
   • Met Requirement 8(3)(e) — The service had a clinical governance framework in place, including antimicrobial stewardship 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.

5. Site audit Performance ReportMay 19, 2023

   A site audit was conducted with this service on 17 May 2023 to 19 May 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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6. Accreditation decisionFeb 10, 2022

   Following a site audit conducted on 16 January 2019 to 17 January 2019, the Commission made a decision 20 February 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 10 February 2022. The period of accreditation of the service will expire on 29 September 2023.

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7. AssessmentJan 17, 2019

   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 29 March 2022.

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8. AssessmentMay 21, 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 29 July 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 29 March 2019. The reconsideration decision and audit report is attached.

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9. AssessmentMay 21, 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 29 July 2018.

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10. AssessmentMay 24, 2012
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11. AssessmentMay 15, 2009
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No regulatory actions recorded.