Acacia Living Group Menora Gardens Aged Care Facility

51 Alexander Drive, MENORA, WA, 6050

1. Accreditation decisionJun 26, 2025

   Following a site audit conducted on 15 May 2023 to 17 May 2023, the Commission made a decision on 18 July 2023 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 26 June 2025. The period of accreditation of the service will expire on 18 January 2026.

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2. Assessment contact Performance ReportAug 13, 2024

   An assessment contact was conducted with this service on 12/08/2024 to 13/08/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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3. Exceptional CircumstancesJul 28, 2023

   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 19 February 2024. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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4. Accreditation decisionJul 18, 2023

   Following a site audit conducted on 15 May 2023 to 17 May 2023, the Commission made a decision on 18 July 2023 to re-accredit this service. The period of accreditation of the service will expire on 18 July 2025.

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5. Site AuditJul 18, 2023

   Prepared by R Beaman

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

   The performance report highlights significant non-compliance across multiple standards, particularly in areas such as consumer dignity and choice, personal care and clinical care, services and supports for daily living, organizational service environment, feedback and complaints, human resources, and organizational governance. The provider has acknowledged the findings and proposed actions to address these issues, but improvements will require time to be fully embedded.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service was found non-compliant due to issues with treating consumers with dignity and respect in personal care.

   • Not met (3)(a) — Consumers A and B were observed walking through communal areas in soiled clothing, and three consumers were assisted by staff in a rushed and undignified manner during meal service.
   • Met (3)(b) — Care and services are delivered in a culturally safe manner.
   • Met (3)(c) — Consumers confirmed they can make decisions about their care, communicate these decisions, and maintain relationships of choice.
   • Met (3)(d) — Consumers were supported to take risks to live the best life possible.
   • Met (3)(e) — Information provided was current, accurate, and communicated in a way that enabled consumers to exercise choice.
   • Met (3)(f) — Consumers' privacy is respected and personal information kept confidential.

   Risks: Consumers were treated with dignity and respect in relation to their personal hygiene and meal assistance.

   Recommendations: Discuss expectations of the organization with staff.; Commence daily rounding by senior management team.; Undertake a survey and collect feedback about dignity and respect from consumers and representatives.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service was compliant in ensuring ongoing assessments and planning considered risks, were based on partnerships with consumers, and outcomes were effectively communicated.

   • Met (3)(a) — Assessments and planning consider risks associated with care.
   • Met (3)(b) — Needs, goals, and preferences are identified in assessments and planning.
   • Met (3)(c) — Assessment and planning include ongoing partnerships with consumers and other organizations involved in care.
   • Met (3)(d) — Outcomes of assessments are effectively communicated to the consumer and documented.
   • Met (3)(e) — Care and services are reviewed regularly for effectiveness, especially when circumstances change or incidents impact needs.

   Standard 3 Personal care and clinical careNon-compliant

   The service was non-compliant due to issues with safe personal care, management of high-impact risks, recognition of deterioration, and infection control.

   • Not met (3)(a) — Consumers A, B, and D were observed in soiled clothing.
   • Not met (3)(b) — High-impact risks such as the use of restraint, pain management, and falls were not effectively managed.
   • Met (3)(c) — Needs, goals, and preferences for end-of-life care are recognized and addressed.
   • Not met (3)(d) — Deterioration or changes in condition were not recognized or responded to timely for Consumers C, E, and F.
   • Met (3)(e) — Information about the consumer’s condition is documented and communicated within the organization.
   • Met (3)(f) — Timely referrals to other organizations are made appropriately.
   • Not met (3)(g) — Infection control practices were not effective in preventing or controlling infections.

   Risks: Consumers A, B, and D were observed sitting in soiled continence aids.; Physical restraints used during meal assistance for Consumers B and D.

   Recommendations: Review of the cleaning schedule.; Provision of equipment required to ensure furniture is cleaned timely.; Collecting feedback from consumers and representatives on cleanliness.

   Standard 4 Services and supports for daily livingNon-compliant

   The service was non-compliant due to issues with services not meeting needs, lack of engagement in lifestyle activities, and meal quality.

   • Not met (3)(a) — Services for daily living did not meet the needs or optimize independence.
   • Met (3)(b) — Emotional, spiritual, and psychological well-being is promoted through services.
   • Not met (3)(c) — Consumers were not supported to participate in community activities or do things of interest.
   • Met (3)(d) — Information about the consumer’s condition is communicated within the organization.
   • Met (3)(e) — Timely referrals to other organizations are made appropriately.
   • Not met (3)(f) — Meals were not provided in a dignified manner and the dining experience was not positive.

   Risks: Consumers A, B, and D were observed sitting without engagement for extended periods.; Physical restraints used during meal assistance for Consumers B and C.

   Recommendations: Implementation of a Care Champion model of care with extra staff on the floor.; Review of consumer social and leisure profiles.

   Standard 5 Organisation’s service environmentNon-compliant

   The service was non-compliant due to issues with the welcoming nature of the environment, cleanliness, and maintenance in the memory support unit.

   • Not met (3)(a) — The service environment was not welcoming or easy to navigate for consumers.
   • Not met (3)(b) — The memory support unit was not clean, safe, well-maintained, and comfortable.
   • Met (3)(c) — Furniture, fittings, and equipment are maintained and suitable for consumers.

   Risks: The memory support unit was observed to be cold in temperature with little furnishings.; Chairs were soiled and unclean.

   Recommendations: Undertaking an environmental audit of the service.; Delivering toolbox training on hospitality standards.

   Standard 6 Feedback and complaintsNon-compliant

   The service was non-compliant due to issues with appropriate action in response to feedback or complaints, and not using open disclosure processes when incidents occur.

   • Met (3)(a) — Consumers are encouraged and supported to provide feedback.
   • Met (3)(b) — Consumers have access to advocates, language services, and methods for raising complaints.
   • Not met (3)(c) — Appropriate action was not taken in response to feedback or complaints.
   • Not met (3)(d) — Feedback and complaints were not reviewed and used to improve the quality of care and services.

   Risks: Consumers' representatives made complaints about cleanliness that went unresolved.; Consumer C's representative advised they made a complaint about an injury caused by incorrect wound care, which was not appropriately addressed.

   Recommendations: Delivery of feedback management training.; Undertaking a review of all feedback received over three months prior to the Site Audit visit.

   Standard 7 Human resourcesNon-compliant

   The service was non-compliant due to issues with workforce planning, competency, and regular assessment of staff performance.

   • Not met (3)(a) — There were not enough staff to deliver care in a way that met consumers' needs.
   • Met (3)(b) — Workforce interactions with consumers are kind, caring and respectful of each consumer’s identity, culture and diversity.
   • Not met (3)(c) — The workforce was not competent or had the qualifications to effectively perform their roles.
   • Not met (3)(d) — Workforce was not trained, equipped and supported to deliver outcomes required by standards.
   • Not met (3)(e) — Regular assessment, monitoring, and review of the performance of each member of the workforce were not undertaken.

   Risks: Consumers A and B's representatives raised concerns about staffing levels contributing to poor personal care.; Staff did not recognize signs of deterioration in Consumers C and F.

   Recommendations: Implementing a care champion model of care across the service.; Rostering extra staff.

   Standard 8 Organisational governanceNon-compliant

   The service was non-compliant due to issues with promoting safe, inclusive and quality care culture, effective organizational-wide governance systems, risk management practices, and clinical governance framework.

   • Met (3)(a) — Consumers are engaged in the development, delivery, and evaluation of care and services.
   • Not met (3)(b) — The governing body did not promote a culture of safe, inclusive, and quality care or was accountable for their delivery.
   • Not met (3)(c) — Organizational-wide governance systems were ineffective in workforce governance and feedback and complaints mechanisms.
   • Not met (3)(d) — Risk management systems did not ensure safety, specifically in managing high-impact risks to consumer care and preventing incidents.
   • Not met (3)(e) — Clinical governance framework was ineffective in antimicrobial stewardship, minimizing the use of restraint, and open disclosure.

   Risks: The governing body did not support consumers' health, safety, and well-being.; Not all complaints data is being recorded accurately.

   Recommendations: Implementing an internal timeline for improvement at the service.; Having twice weekly meetings with the organization’s quality compliance manager to monitor progress.

   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 ReportMay 17, 2023

   A site audit was conducted with this service on 15 May 2023 to 17 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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7. Exceptional CircumstancesJan 30, 2023

   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 09 August 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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8. Accreditation decisionDec 23, 2021

   Following a site audit conducted on 28 May 2019 to 30 May 2019, the Commission made a decision on 02 July 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 23 December 2021. The period of accreditation of the service will expire on 09 February 2023.

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9. Assessment contact Performance ReportApr 22, 2021

   An assessment contact was conducted with this service on 22 April 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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10. AssessmentMay 30, 2019

    Following an audit we decided that this service met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 09 August 2022.

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11. AssessmentJul 2, 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 09 October 2018.

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12. AssessmentJul 2, 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 09 October 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 09 August 2019. The reconsideration decision and audit report is attached.

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13. AssessmentAug 2, 2012
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14. AssessmentJul 10, 2009
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No regulatory actions recorded.