Abberfield Aged Care Facility

376-380 Bluff Road, SANDRINGHAM, VIC, 3191

1. AssessmentAug 18, 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 18/08/2025, 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. Accreditation decisionJul 4, 2025

   Following a site audit conducted on 22 November 2022 to 25 November 2022, the Commission made a decision on 14 February 2023 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 04 July 2025. The period of accreditation of the service will expire on 14 February 2026.

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3. Assessment contact (performance assessment) – siteOct 25, 2024

   Prepared by N Chahal

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4. Assessment contact Performance ReportSep 24, 2024

   An assessment contact was conducted with this service on 24 September 2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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5. Assessment Contact - SiteJun 30, 2023

   Prepared by D. Fekonja

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6. Assessment contact Performance ReportJun 9, 2023

   An assessment contact was conducted with this service on 09 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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7. Accreditation decisionFeb 14, 2023

   Following a site audit conducted on 22 November 2022 to 25 November 2022, the Commission made a decision on 14 February 2023 to re-accredit this service. The period of accreditation of the service will expire on 14 August 2025.

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8. Site AuditFeb 14, 2023

   Prepared by G. Hope-Simpson

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

   The performance report for Abberfield Aged Care Facility indicates compliance with most standards, but non-compliance in Personal care and clinical care (Standard 3) and Human resources (Standard 7). The main issues identified were insufficient staffing levels leading to substandard personal care and extended wait times for assistance. Recommendations include further staff training and recruitment of additional care staff.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers were generally treated with dignity and respect, but some feedback indicated substandard personal care due to staff shortages.

   • Met Requirement 1(3)(a) — Consumers and representatives said they were treated with dignity and respect by staff, and their identity and culture valued.
   • Met Requirement 1(3)(b) — Staff described ways in which consumers’ identities, cultures, and diversity were valued. Consumers' care planning documentation showed individual cultural needs identified.
   • Met Requirement 1(3)(c) — Consumers stated they were supported to exercise choice and independence regarding how their care and services were delivered and maintained connections and relationships.
   • Met Requirement 1(3)(d) — Staff described how they supported consumers to take risks and assist them in understanding the benefits and potential harm when making decisions concerning risk.
   • Met Requirement 1(3)(e) — Consumers said they were provided with information which was current, accurate, relevant, and assisted them to make choices about their care and service delivery.
   • Met Requirement 1(3)(f) — The Assessment Team observed staff practices respectful of consumer privacy.

   Risks: Two named consumers provided feedback regarding substandard personal care needs due to lack of staff and long waits for assistance.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Consumers' current needs, goals, and preferences were considered in the care planning process.

   • Met Requirement 2(3)(a) — Consumers and representatives said consumers’ current needs and preferences were considered in the care planning and risk assessments process.
   • Met Requirement 2(3)(b) — Consumers and representatives stated they had discussed their current care needs, goals, and preferences, including advance care planning and end-of-life care.
   • Met Requirement 2(3)(c) — The service partnered with consumers/representatives, allied health professionals, GPs, and other specialist practitioners/services to carry out assessment and planning.
   • Met Requirement 2(3)(d) — Most consumers and representatives were aware of care planning documentation and some stated they have a copy or sighted the documentation.
   • Met Requirement 2(3)(e) — Consumers and representatives said they were satisfied that staff made post-incident changes to care and services delivered.

   Risks: One sampled consumer’s skin care plan had not been updated to reflect their current pressure injury management needs after skin deterioration occurred.

   Standard 3 Personal care and clinical careNon-compliant

   Consumers did not receive safe and effective personal or clinical care due to staff shortages.

   • Not met Requirement 3(3)(a) — The Assessment Team found consumers were not receiving safe and effective personal and clinical care, particularly in falls management, skincare, continence care, and medication management.
   • Met Requirement 3(3)(b) — Consumers and representatives said they felt that the service was adequately managing risks to consumers' health, particularly for behavior management and COVID-19.
   • Met Requirement 3(3)(c) — Staff described how they care for and support consumers through end-of-life phases. Care plans contained end-of-life wishes and included religious intervention and comfort care measures.
   • Met Requirement 3(3)(d) — Care planning documentation demonstrated adequate information to support effective and safe care.
   • Met Requirement 3(3)(e) — Consumers reported permanent staff knew them well, and information about their condition, needs, and preferences were communicated within the organization.
   • Met Requirement 3(3)(f) — Some consumers said the service supported them with referrals to specialist care providers outside of the organization.
   • Met Requirement 3(3)(g) — Consumers and representatives interviewed were satisfied with the service’s management of COVID-19 precautions and other infection control practices.

   Risks: Consumers reported extended wait times for meals, being directed by staff to urinate in their continence aid, receiving only second daily showers, and feeling rushed in the shower.; A consumer sustained a fracture following a fall after attempting to use the bathroom unaided due to no staff on hand to assist.

   Recommendations: Further staff training is provided in areas such as personal care, skin care, pressure injury prevention, falls management, and continence care.; Staff practice, including agency staff practice, should be monitored for alignment with best practices.

   Standard 4 Services and supports for daily livingCompliant

   Consumers were satisfied they received services and supports that met their needs, goals, and preferences.

   • Met Requirement 4(3)(a) — Consumers stated their independence and quality of life were optimized.
   • Met Requirement 4(3)(b) — Staff demonstrated they planned and provided for consumers’ emotional, spiritual, and psychological needs in the lifestyle program.
   • Met Requirement 4(3)(c) — Consumers were satisfied that the service supported them to participate in their community within and outside the service environment if they chose.
   • Met Requirement 4(3)(d) — Care plans carried information needed to support shared care, and staff outlined how information is shared throughout the service.
   • Met Requirement 4(3)(e) — Consumers reported permanent staff knew them well, and information about their condition, needs, and preferences were communicated within the organization.
   • Met Requirement 4(3)(f) — Most consumers said that meals provided were varied and of suitable quality and quantity.
   • Met Requirement 4(3)(g) — Staff described how they ensure equipment is kept clean as per infection control processes.

   Risks: One consumer’s personal wheelchair was observed to be visibly unclean.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, clean, and well-maintained.

   • Met Requirement 5(3)(a) — Consumers said they feel the service is homely and comfortable.
   • Met Requirement 5(3)(b) — The Assessment Team observed the service environment to be welcoming, reflecting dementia-enabling principles of design.
   • Met Requirement 5(3)(c) — Staff understood how to report maintenance issues and infection control processes with all shared equipment.

   Risks: The Assessment Team observed various areas of the service to be unclean, but management had these issues rectified by cleaning contractors during the site audit.

   Standard 6 Feedback and complaintsCompliant

   Consumers were encouraged and supported to provide feedback and make complaints.

   • Met Requirement 6(3)(a) — Consumers and representatives said they were encouraged and supported to provide feedback and make complaints.
   • Met Requirement 6(3)(b) — While the service had information on advocacy services displayed, staff did not know how to utilize an accredited translation service for non-English speaking consumers.
   • Met Requirement 6(3)(c) — Consumers and representatives generally said management resolved complaints and incidents and apologized when things went wrong.
   • Met Requirement 6(3)(d) — Staff described how information from feedback and complaints was used to improve the quality of care and services.

   Risks: One representative raised concern about repeated instances where a consumer’s call bell was out of reach despite previous complaints.

   Standard 7 Human resourcesNon-compliant

   The workforce planning did not enable the delivery and management of safe and quality care due to insufficient staffing.

   • Not met Requirement 7(3)(a) — Consumers provided examples of being left unattended for long periods, experiencing extended call bell wait times resulting in an impact on their care and well-being.
   • Met Requirement 7(3)(b) — All consumers and representatives said staff were kind, gentle, and caring when providing care.
   • Met Requirement 7(3)(c) — Most consumers and representatives said staff performed their duties effectively and were skilled to meet consumers’ care needs.
   • Met Requirement 7(3)(d) — Staff confirmed the service had probationary and ongoing performance review systems, with relevant policies and procedures in place.
   • Met Requirement 7(3)(e) — Management said this was due to a change in management, had a plan to address the backlog, and demonstrated other ways staff performance was monitored.

   Risks: Consumers reported extended wait times for assistance from care staff.; Some staff with DECT phones had ringtone volumes low so call bells could not always be heard.

   Recommendations: The service recruits more care staff and ensures a timely response when call bells are activated.

   Standard 8 Organisational governanceCompliant

   Consumers were engaged in the development, delivery, and evaluation of care and services.

   • Met Requirement 8(3)(a) — Most consumers and representatives said they were engaged in development, delivery, and evaluation of care and services.
   • Met Requirement 8(3)(b) — The service demonstrated it had central policies and procedures with the governing body promoting a culture of safe, inclusive, and quality care and services.
   • Met Requirement 8(3)(c) — The service demonstrated effective governance systems in place for information management, financial governance, feedback and complaints, and continuous improvement.
   • Met Requirement 8(3)(d) — Management stated they will review the reporting guidelines again to ensure all reportable incidents were reported in a timely manner.
   • Met Requirement 8(3)(e) — The service demonstrated a clinical governance framework in place, including policies concerning antimicrobial stewardship, minimising the use of restraint and open disclosure.

   Risks: Two instances were noted which had not been reported within legislative requirements.

   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.

9. Site audit Performance ReportNov 25, 2022

   A site audit was conducted with this service on 22 November 2022 to 25 November 2022. 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 CircumstancesSep 27, 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 12 April 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Accreditation decisionMar 5, 2021

    Following a site audit conducted on 16 July 2018 to 17 July 2018, the Commission made a decision on 27 August 2018 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 05 March 2021. The period of accreditation of the service will expire on 12 October 2022.

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12. AssessmentJul 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 12 October 2021.

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13. AssessmentJul 22, 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 12 October 2018.

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14. AssessmentJul 24, 2012
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15. AssessmentJul 21, 2009
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No regulatory actions recorded.