Allanvale Private Nursing Home

38-40 Ascot Street South, ALTONA MEADOWS, VIC, 3028

1. Accreditation decisionSep 12, 2024

   Following a site audit conducted on 06/08/2024 to 09/08/2024, the Commission made a decision on 12/09/2024 to re-accredit this service. The period of accreditation of the service will expire on 17/12/2027

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2. Site AuditSep 12, 2024

   Prepared by N Chahal

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3. Site audit Performance ReportAug 9, 2024

   A site audit was conducted with this service on 06/08/2024 to 09/08/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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4. Accreditation decisionNov 1, 2023

   Following a site audit conducted on 25 July 2023 to 27 July 2023, the Commission made a decision on 01 November 2023 to re-accredit this service. The period of accreditation of the service will expire on 17 December 2024.

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5. Site AuditNov 1, 2023

   Prepared by J. Howard

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

   The performance report indicates that Allanvale Private Nursing Home was found to be non-compliant across all eight Aged Care Quality Standards. The primary areas of concern include ineffective consumer engagement, poor risk management practices, inadequate workforce planning and training, insufficient support for daily living needs, and an unsafe service environment. The Approved Provider has acknowledged these deficiencies and proposed a series of actions aimed at addressing the identified issues.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service was non-compliant with requirements related to supporting consumers in taking risks and respecting privacy.

   • Not met 1(3)(d) — Consumers were observed taking risks of which staff were unaware, such as having electrical appliances in their rooms without a safety assessment. Care plans showed staff had not conducted risk assessments for activities consumers wished to pursue.
   • Not met 1(3)(f) — Consumers' privacy was not respected and personal information was not kept confidential, as evidenced by staff entering rooms without consent, shift handovers in dining areas where consumer information was shared within earshot of consumers, unlocked nurses’ stations with visible personal information, and insecure storage of files.

   Risks: Consumers were taking risks of which staff were unaware.; Personal information was not kept confidential.

   Recommendations: Conduct risk assessments for consumers wishing to take risks.; Ensure privacy and dignity authorisation forms are included in care plans.; Implement staff education on privacy and dignity, place signs on doors, and remind staff about consumer privacy practices.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   The service was non-compliant due to incomplete assessments, lack of consumer involvement in care planning, ineffective communication of care plans, and inadequate review processes.

   • Not met 2(3)(a) — Assessments were incomplete, risks to individual consumers were only partially documented, and behavior support plans were absent.
   • Not met 2(3)(c) — Consumers and representatives were not consistently involved in the assessment and planning of care. Evidence of other service providers' input was scarce.
   • Not met 2(3)(d) — Care plans were not readily available to consumers or their representatives, despite management stating they could be requested.
   • Not met 2(3)(e) — Consumers' care and services were not regularly reviewed for effectiveness when incidents impacted on their needs, goals, and individual preferences.

   Risks: Incomplete risk assessments.; Lack of consumer involvement in planning.

   Recommendations: Conduct a review of restrictive practice and behavior management care plans.; Assign a registered nurse to oversee care plan evaluations.; Develop reporting templates for clinical issues.; Ensure all care plan evaluations are conducted regularly.

   Standard 3 Personal care and clinical careNon-compliant

   The service was non-compliant due to deficiencies in personal and clinical care, ineffective management of risks, poor documentation, untimely referrals, and inadequate infection control.

   • Not met 3(3)(a) — Care plans reflected safe care but deficiencies were identified in restrictive practices, behavior support plans, and medication management.
   • Not met 3(3)(b) — High-impact risks such as falls and unexpected weight loss were not effectively managed. Consumers experienced cold temperatures during a heating outage without adequate response from staff.
   • Not met 3(3)(e) — Information about consumers' conditions, needs, and preferences was poorly documented and communicated within the organization.
   • Not met 3(3)(f) — Referrals to medical officers were not timely, impacting consumers' health and well-being.
   • Not met 3(3)(g) — Infection control protocols were inadequate. Staff were not adequately trained in infection control and antimicrobial stewardship.

   Risks: High-impact risks such as falls and unexpected weight loss.; Poor documentation of care plans.

   Recommendations: Review restrictive practice and behavior management care plans.; Develop a new restrictive practice policy.; Train staff in infection control and antimicrobial stewardship.

   Standard 4 Services and supports for daily livingNon-compliant

   The service was non-compliant due to insufficient support for emotional well-being, ineffective communication of care preferences, poor meal quality, and poorly maintained equipment.

   • Not met 4(3)(b) — Staff were too busy to provide meaningful emotional or psychological support.
   • Not met 4(3)(d) — Consumers' daily care and living preferences were not effectively communicated between staff, particularly nursing agency staff.
   • Not met 4(3)(f) — Meals offered by the service lacked variety, quality, and quantity. Consumers often had no input into the menu.
   • Not met 4(3)(g) — Equipment such as mobility aids were not clean or well maintained.

   Risks: Poor emotional and psychological support.; Inadequate communication of care preferences.

   Recommendations: Review the leisure and lifestyle calendar.; Train staff in providing consumers with emotional and psychological support.; Improve meal quality and quantity through consumer focus groups.

   Standard 5 Organisation’s service environmentNon-compliant

   The service was non-compliant due to an unsafe, unsanitary environment and poorly maintained furniture and equipment.

   • Not met 5(3)(b) — The service environment was observed to be unsafe, unsanitary, and consumers could not move freely indoors or outdoors.
   • Not met 5(3)(c) — Furniture and equipment were unclean, soiled with food, and poorly maintained. Maintenance requests were not actioned in a timely manner.

   Risks: Unsafe service environment.; Poorly maintained furniture and equipment.

   Recommendations: Review open maintenance requests and attend to urgent entries.; Install a keypad for entry and exit to the building and balconies.; Develop a register for monitoring the cleanliness of equipment.

   Standard 6 Feedback and complaintsNon-compliant

   The service was non-compliant due to ineffective feedback processes, lack of awareness about advocacy services, poor complaint management, and failure to review feedback for improvement.

   • Not met 6(3)(a) — Consumers were discouraged from providing feedback due to a lack of response from management.
   • Not met 6(3)(b) — Consumers were generally unaware of how to access interpreter services, advocates, and other methods for raising complaints.
   • Not met 6(3)(c) — Appropriate action was not taken in response to complaints and open disclosure was not used when things went wrong.
   • Not met 6(3)(d) — Feedback and complaints were not reviewed or used to improve the quality of care and services.

   Risks: Lack of consumer awareness about advocacy services.; Poor complaint management.

   Recommendations: Train staff in feedback and complaints processes.; Ensure information on advocacy and interpreter services is available at reception and nurse stations.; Develop a report to include complaints analysis and trends for continuous improvement.

   Standard 7 Human resourcesNon-compliant

   The service was non-compliant due to workforce planning issues, staff shortages, lack of competency, inadequate training, and failure to conduct performance appraisals.

   • Not met 7(3)(a) — Daily staff shortages and high use of agency staff led to poor response times for call bells.
   • Not met 7(3)(c) — Staff were not competent or effective in their roles, often working with ill-equipped agency staff.
   • Not met 7(3)(d) — The workforce was inadequately trained and equipped to deliver quality care. Training records could not be verified.
   • Not met 7(3)(e) — Staff performance appraisals were not conducted, nor was there evidence of staff training needs being identified.

   Risks: Daily staff shortages.; Inadequate workforce competency and training.

   Recommendations: Ongoing recruitment efforts for the service’s own staff.; Review staff roles and responsibilities, issue clear position descriptions.; Implement a new learning system with mandatory training within four months.

   Standard 8 Organisational governanceNon-compliant

   The service was non-compliant due to ineffective consumer engagement, lack of accountability for care delivery, poor governance systems, inadequate risk management, and absence of a clinical governance framework.

   • Not met 8(3)(a) — Consumers were not engaged in the development, delivery, and evaluation of care and services.
   • Not met 8(3)(b) — The governing body did not promote a culture of safe, inclusive, and quality care or demonstrate accountability for their delivery.
   • Not met 8(3)(c) — Governance systems were ineffective in areas such as information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback and complaints.
   • Not met 8(3)(d) — Risk management systems and practices were inadequate, including managing high-impact risks and responding to abuse and neglect of consumers.
   • Not met 8(3)(e) — A clinical governance framework was absent, particularly in areas such as antimicrobial stewardship and minimizing the use of restraint.

   Risks: Ineffective consumer engagement.; Poor risk management systems.

   Recommendations: Engage consumers in care planning through resident meetings and surveys.; Promote a culture of safe, inclusive, and quality care.; Develop effective governance systems for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback and complaints.

   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.

6. Site audit Performance ReportJul 28, 2023

   A site audit was conducted with this service on 25 July 2023 to 28 July 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. Accreditation decisionDec 14, 2020

   Following a site audit conducted on 10 November 2020 to 11 November 2020, the Commission made a decision on 14 December 2020 to re-accredit this service. The period of accreditation of the service will expire on 17 December 2023.

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8. Exceptional CircumstancesNov 30, 2020

   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 17 June 2021.

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9. Site audit Performance ReportNov 11, 2020

   A site audit was conducted with this service on 10 November 2020 to 11 November 2020. 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 CircumstancesMay 25, 2020

    During the COVID-19 pandemic, the Aged Care Quality and Safety Commission has temporarily modified our Regulatory Program, including 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 17 December 2020. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. AssessmentMar 29, 2017

    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 17 June 2020.

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12. AssessmentOct 14, 2015

    Following an audit we decided that this home met 41 of the 44 expected outcomes of the Accreditation Standards. This home remains accredited until 17 June 2017.

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13. AssessmentMar 26, 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 three years until 17 June 2017.

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No regulatory actions recorded.