Bexley Care Centre

82-84 Connemarra Street, BEXLEY, NSW, 2207

1. AssessmentSep 1, 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 01/09/2025, 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) – siteNov 18, 2024

   Prepared by Micheal Cooper

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3. Assessment contact Performance ReportOct 17, 2024

   An assessment contact was conducted with this service on 17/10/2024 to 17/10/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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4. Accreditation decisionJun 28, 2023

   Following a site audit conducted on 05 June 2023 to 07 June 2023, the Commission made a decision on 28 June 2023 to re-accredit this service. The period of accreditation of the service will expire on 01 November 2026.

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5. Site AuditJun 28, 2023

   Prepared by D McDonald

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6. Site audit Performance ReportJun 7, 2023

   A site audit was conducted with this service on 05 June 2023 to 07 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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7. Assessment Contact - SiteDec 15, 2022

   Prepared by M Buhagiar

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

   The performance report for Bexley Care Centre indicates that the service has made significant improvements in several areas following previous non-compliance findings. The service is compliant with most standards, including consumer dignity and choice, ongoing assessment and planning, personal care and clinical care, organisation’s service environment, feedback and complaints, human resources, and organisational governance. However, it remains non-compliant with Standard 4 regarding services and supports for daily living due to insufficient engagement of consumers at risk of social isolation in meaningful activities.

   Standard 1 Consumer dignity and choiceCompliant

   The service has taken significant steps to ensure privacy and confidentiality are respected, including staff training and environmental changes.

   • Met Requirement 1(3)(f) — Consumers and representatives interviewed said they were satisfied the service has made improvements to reduce other consumers entering their rooms. Staff were observed to be respectful of consumer privacy during personal care.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service has implemented actions such as staff training, consultation with consumers/representatives, and the development of individualized care plans.

   • Met Requirement 2(3)(a) — Consumers were assessed for their care needs on entry to the service, and an interim plan of care is developed.
   • Met Requirement 2(3)(b) — Most consumers' files had evidence of an advanced care plan or a discussion about it in their care plan.
   • Met Requirement 2(3)(e) — Care plans and documents show care and services are being reviewed every 4 months. When the consumer's condition changes, registered nurses use a resident of the day process to regularly review consumers.

   Standard 3 Personal care and clinical careCompliant

   The service has implemented actions such as staff training on behavior management, de-escalation techniques, and documentation.

   • Met Requirement 3(3)(a) — Consumers receive safe and effective personal and clinical care that is best practice, tailored to meet individual needs.
   • Met Requirement 3(3)(b) — High-impact and high-prevalence risks are effectively managed through regular clinical data monitoring and implementation of suitable risk mitigation strategies for individual consumers.

   Standard 4 Services and supports for daily livingNon-compliant

   The service has implemented actions such as additional hours to lifestyle activities, detailed lifestyle plans, and staff training on consumer engagement.

   • Not met Requirement 4(3)(a) — There was minimal evidence that staff were effectively engaging with consumers at risk of being socially isolated and requiring one-to-one staff to be engaged in activities.

   Recommendations: Education for clinical and lifestyle staff on consumer engagement and the provision of meaningful activities.; Audit on all lifestyle activities to identify consumers who are at risk of being socially isolated including individualised one-to-one meaningful activities.; Review of lifestyle meetings to track progress and provide support and education as required.

   Standard 5 Organisation’s service environmentCompliant

   The service has implemented actions such as way-finding cues, renovations, and a sensory room to assist consumers navigate the service environment.

   • Met Requirement 5(3)(a) — Consumers were observed getting on well together with one consumer going outside independently and picked some flowers from the service garden to bring them back to give to another consumer.
   • Met Requirement 5(3)(b) — The outdoor area was clean and tidy. The fence height had been increased, and the garden looked well maintained.

   Standard 6 Feedback and complaintsCompliant

   The service has implemented actions such as staff training on open disclosure and recording of complaints.

   • Met Requirement 6(3)(c) — Consumers and representatives said that they feel listened to by management and were satisfied with improvements made in response to complaints.
   • Met Requirement 6(3)(d) — The service demonstrated it takes appropriate action in accordance with open disclosure principles in response to complaints.

   Standard 7 Human resourcesCompliant

   The service has implemented actions such as a roster review, extensive staff education program, and appointment of a clinical nurse educator.

   • Met Requirement 7(3)(a) — Consumers felt they were very well cared for by the staff and had no complaints about the care they received.
   • Met Requirement 7(3)(c) — All consumers sampled expressed satisfaction with the skills of the staff. No concerns were raised during interviews in relation to competency or knowledge of staff.
   • Met Requirement 7(3)(d) — An extensive staff education program has been developed, and participation at training sessions is almost 100% of staff rostered.

   Standard 8 Organisational governanceCompliant

   The service has implemented actions such as engagement with consumers in care planning, continuous improvement plans, and incident management systems.

   • Met Requirement 8(3)(a) — Consumers are engaged to participate in advanced care planning and various aspects of how their care and services are delivered.
   • Met Requirement 8(3)(c) — The service demonstrated feedback and complaints inform continuous improvement, and complaint trends are monitored at the regional quality level with relevant information provided to the governing body.
   • Met Requirement 8(3)(d) — A clinical risk register has been implemented, and a clinical risk meeting is established with management and the quality team at the service.

   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.

8. Assessment contact Performance ReportNov 17, 2022

   An assessment contact was conducted with this service on 17 November 2022 to 18 November 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 decisionJul 29, 2021

   Following a site audit conducted on 22 June 2021 to 24 June 2021, the Commission made a decision on 29 July 2021 to re-accredit this service. The period of accreditation of the service will expire on 01 November 2023.

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10. Site audit Performance ReportJun 24, 2021

    A site audit was conducted with this service on 22 June 2021 to 24 June 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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11. AssessmentAug 17, 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 01 November 2021.

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12. AssessmentJan 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 01 April 2018.

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13. AssessmentJan 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 01 April 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 01 November 2018. The reconsideration decision and audit report is attached.

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14. AssessmentJan 18, 2012
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15. AssessmentJan 22, 2009
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No regulatory actions recorded.