Adventist Nursing Home

56 Elsom Street, KINGS LANGLEY, NSW, 2147

1. Accreditation decisionJul 17, 2024

   Following a site audit conducted on 12 June 2024 to 14 June 2024, the Commission made a decision on 17 July 2024 to re-accredit this service. The period of accreditation of the service will expire on 05 September 2027.

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2. Site AuditJul 17, 2024

   Prepared by Katherine Richards

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3. Site audit Performance ReportJun 14, 2024

   A site audit was conducted with this service on 12/06/2024 to 14/06/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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4. Assessment contact (performance assessment) – siteNov 29, 2023

   Prepared by M Wyborn

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5. Assessment contact Performance ReportSep 19, 2023

   An assessment contact was conducted with this service on 19 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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6. Assessment Contact - SiteJul 8, 2023

   Prepared by G Cherry

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

   The performance report for Adventist Nursing Home highlights non-compliance with Standard 3 Personal care and clinical care due to ineffective management of high impact/prevalence risks and timely response to consumer deterioration. Standards 6 Feedback and complaints, 7 Human resources, and 8 Organisational governance are compliant where assessed. Other standards were not fully assessed.

   Standard 3 Personal care and clinical careNon-compliant

   The service has made some improvements but still lacks effective management of high impact/prevalence risks and timely response to consumer deterioration.

   • Not met Requirement 3(3)(b) — The service has introduced a risk register, staff training, and some improvements in managing clinical risks. However, monitoring/recording documentation does not accurately detail all consumers identified at risk, and there are ongoing issues with the management of pressure injuries, diabetes, and behavioral needs.
   • Not met Requirement 3(3)(d) — The service has implemented changes such as discussions in clinical governance meetings and staff training. However, there are still issues with timely identification and response to consumer deterioration or change in condition.

   Risks: Ongoing negative outcomes for consumers due to inappropriate management of pain and unmet behavioral needs.; Ineffective monitoring following unwitnessed falls and possible head injuries.; Deterioration not identified/responded to in a timely manner, leading to ongoing unmet needs.

   Recommendations: Implement an effective system for managing high impact/prevalence risks.; Ensure deterioration or change in consumers' health is recognized and responded to promptly.

   Standard 6 Feedback and complaintsCompliant

   The service has implemented a process for recording, classifying, and utilizing feedback and complaints effectively.

   • Met Requirement 6(3)(d) — An effective method to capture, review, and implement improvements based on feedback and complaints has been established. Consumers/representatives express satisfaction with responses leading to improved outcomes.

   Standard 7 Human resourcesCompliant

   The service demonstrates appropriate workforce planning, including sufficient staff numbers and timely response to consumer requests.

   • Met Requirement 7(3)(a) — Workforce is planned and deployed effectively with evidence of adequate staffing levels, staff training, and timely response to consumer requests.

   Standard 8 Organisational governanceCompliant

   The service has effective organisational governance systems in place for information management, continuous improvement, financial governance, workforce governance, and regulatory compliance.

   • Met Requirement 8(3)(c) — Effective organisational governance systems are demonstrated with documented policies and procedures guiding staff expectations.
   • Met Requirement 8(3)(d) — The service has a risk management framework, policies for high impact/prevalence risks, abuse/neglect identification, and an incident management system. Staff are trained in these areas.

   Standard 1 Quality of care

   Standard 2 Choice

   Standard 4 Dignity and respect

   Standard 5 Health, safety and wellbeing

   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.

7. Assessment contact Performance ReportJun 9, 2023

   An assessment contact was conducted with this service on 08 June 2023 to 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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8. Accreditation decisionDec 15, 2022

   Following a site audit conducted on 08 November 2022 to 10 November 2022, the Commission made a decision on 15 December 2022 to re-accredit this service. The period of accreditation of the service will expire on 05 September 2024.

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9. Site AuditDec 15, 2022

   Prepared by Denise McDonald

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

   The performance report indicates that Adventist Nursing Home is compliant with most standards but faces challenges in managing high-impact risks, ensuring adequate staffing levels, and effectively using feedback for continuous improvement. The service has made some improvements since previous audits but still requires further action to fully comply with the Aged Care Quality Standards.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers reported being treated with respect and their cultural backgrounds were valued. Staff supported consumers in exercising choices and maintaining independence.

   • Met Requirement 1(3)(a) — Consumers said they were treated with respect and their identity, culture, and diversity were valued.
   • Met Requirement 1(3)(b) — The service had a diversity and inclusion policy guiding the practice of promoting inclusivity.
   • Met Requirement 1(3)(c) — Consumers confirmed they were given choice about when and how care was provided.
   • Met Requirement 1(3)(d) — Staff described risks taken by consumers and explained the strategies in place to support risk-taking.
   • Met Requirement 1(3)(e) — Consumers described how they were informed of how to exercise choice, and described the information as easy to understand.
   • Met Requirement 1(3)(f) — Consumers explained how their privacy was respected by staff and they felt their boundaries were observed.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service has implemented improved processes to ensure risks are identified and inform care planning. Consumers' needs, goals, and preferences were addressed.

   • Met Requirement 2(3)(a) — The service has introduced revised assessment and care planning processes to ensure risks are identified.
   • Met Requirement 2(3)(b) — Consumers' current needs, goals, and preferences were identified through discussions at entry.
   • Met Requirement 2(3)(c) — The service partnered with consumers and others in the assessment and planning of care.
   • Met Requirement 2(3)(d) — Care plans were accessible, made sense to consumers, and staff explained things clearly.
   • Met Requirement 2(3)(e) — The service regularly updates consumers on care outcomes over the telephone or through emails.

   Standard 3 Personal care and clinical careNon-compliant

   While some improvements were made, high-impact risks such as choking and falls were not effectively managed. Deterioration in consumer conditions was also not timely recognized.

   • Met Requirement 3(3)(a) — Consumers and representatives indicated consumers were receiving the personal and clinical care which met their individual needs.
   • Not met Requirement 3(3)(b) — Deficiencies in managing high-impact risks such as choking and falls were noted.
   • Met Requirement 3(3)(c) — Consumers nearing end of life had their needs recognized, comfort maximized, and dignity preserved.
   • Not met Requirement 3(3)(d) — Deterioration in a consumer's condition was not responded to in a timely manner.
   • Met Requirement 3(3)(e) — Information about the consumer’s condition, needs and preferences is documented and communicated within the organisation.
   • Met Requirement 3(3)(f) — Timely and appropriate referrals to individuals, other organisations and providers of other care and services were made.
   • Met Requirement 3(3)(g) — Infection control practices were observed, including a thorough visitor and staff COVID-19 screening process.

   Risks: Choking risks associated with texture-modified diets not effectively managed.; Falls out of bed not recognized as falls, leading to injuries.

   Recommendations: Improve management of high impact or high prevalence risks such as choking and falls.; Ensure deterioration in consumer conditions is promptly recognized and responded to.

   Standard 4 Services and supports for daily livingCompliant

   Consumers felt supported to participate in activities that met their interests, promoting independence and quality of life.

   • Met Requirement 4(3)(a) — Consumers reported feeling supported to optimize their independence and quality of life.
   • Met Requirement 4(3)(b) — The service encouraged consumers to access pastoral support for emotional, spiritual, and psychological needs.
   • Met Requirement 4(3)(c) — Consumers participated in community activities within and outside the organization’s environment.
   • Met Requirement 4(3)(d) — Information about consumers' conditions, needs, and preferences was communicated effectively.
   • Met Requirement 4(3)(e) — Timely referrals to other organizations and providers of care were made as needed.
   • Met Requirement 4(3)(f) — The service planned a monthly barbecue in response to consumer feedback about the vegetarian diet.
   • Met Requirement 4(3)(g) — Consumers and representatives confirmed equipment was safe, suitable, clean, and well maintained.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, easy to navigate, and supported consumers' sense of belonging.

   • Met Requirement 5(3)(a) — Consumers confirmed the service’s environment was welcoming and easy to understand.
   • Met Requirement 5(3)(b) — The service environment was observed to be clean, safe, well-maintained, and allowed consumers to move freely.
   • Met Requirement 5(3)(c) — Furniture, fittings, and equipment were checked, cleaned, and maintained regularly.

   Standard 6 Feedback and complaintsNon-compliant

   While mechanisms for feedback and complaints existed, the service did not effectively use this information to improve care.

   • Met Requirement 6(3)(a) — Consumers felt comfortable raising concerns directly with staff or through email.
   • Met Requirement 6(3)(b) — Staff described training delivered by clinical educators on access to advocacy and translation services.
   • Met Requirement 6(3)(c) — The service took action in response to feedback and complaints made, with elements of open disclosure when things went wrong.
   • Not met Requirement 6(3)(d) — Feedback and complaints were not collated or used to prompt improvement actions.

   Recommendations: Improve the use of feedback and complaints to inform quality care improvements.

   Standard 7 Human resourcesNon-compliant

   Despite some training improvements, staffing levels were insufficient at night, impacting consumer care.

   • Not met Requirement 7(3)(a) — Consumers and representatives provided negative feedback concerning the current staffing levels.
   • Met Requirement 7(3)(b) — Staff were observed to treat consumers kindly and respectfully.
   • Met Requirement 7(3)(c) — Consumers felt staff were competent and skilled to meet their care needs.
   • Met Requirement 7(3)(d) — Staff had participated in training modules, including manual handling and serious incident reporting.
   • Met Requirement 7(3)(e) — Annual appraisal processes were used to review performance and identify training needs for staff.

   Recommendations: Ensure adequate staffing levels, especially at night, to meet consumer care needs.

   Standard 8 Organisational governanceNon-compliant

   Governance systems were ineffective in managing high-impact risks and ensuring regulatory compliance.

   • Met Requirement 8(3)(a) — Consumers were engaged in the development, delivery, and evaluation of care and services.
   • Met Requirement 8(3)(b) — The governing body promoted a culture of safe, inclusive, and quality care and was accountable for its delivery.
   • Not met Requirement 8(3)(c) — Governance systems were ineffective in managing information, continuous improvement, regulatory compliance, feedback, and complaints.
   • Not met Requirement 8(3)(d) — Risk management systems were not effective in identifying and responding to high-impact risks or incidents.
   • Met Requirement 8(3)(e) — The service had documented policies and procedures relating to restrictive practice, antimicrobial stewardship, and open disclosure.

   Risks: Ineffective management of high-impact risks such as choking and falls.; Underreporting of incidents including alleged abuse.

   Recommendations: Improve governance systems for information management, continuous improvement, regulatory compliance, feedback, and complaints.; Ensure effective risk management practices are in place to identify and respond to high-impact risks.

   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.

10. Accreditation decisionJul 15, 2021

    Following a site audit conducted on 25 May 2021 to 28 May 2021, the Commission made a decision on 15 July 2021 to re-accredit this service. The period of accreditation of the service will expire on 05 March 2023.

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11. Site audit Performance ReportMay 28, 2021

    A site audit was conducted with this service on 25 May 2021 to 28 May 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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12. Assessment contact Performance ReportOct 30, 2020

    An assessment contact was conducted with this service on 30 October 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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13. Compliance updateFeb 14, 2020

    Following an assessment contact conducted on 14 February 2020, the Commission made a decision that improvements have been made to the service to ensure that the Aged Care Quality Standards are complied with.

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14. Non-compliance updateNov 12, 2019

    Following an assessment contact conducted on 12 November 2019, the Commission made a decision that the approved provider of the service is non-compliant with one requirement of the Aged Care Quality Standards.

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15. AssessmentJun 28, 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 05 September 2021.

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16. AssessmentJun 11, 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 05 September 2018.

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17. AssessmentJun 14, 2012
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18. AssessmentJun 26, 2009
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19. Site audit Performance Report—

    A site audit was conducted with this service on 08 November 2022 to 10 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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No regulatory actions recorded.