Adventist Residential Care

31 Webb Street, ROSSMOYNE, WA, 6148

1. Assessment contact (performance assessment) – siteApr 12, 2024

   Prepared by M Glenn

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2. Assessment contact Performance ReportMar 26, 2024

   An assessment contact was conducted with this service on 26 March 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. Assessment Contact - SiteOct 10, 2023

   Prepared by R Beaman

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

   The performance report details the Commissioner’s assessment of Adventist Residential Care against the Aged Care Quality Standards. The service is compliant with Standard 2, but non-compliant with Standards 3 and 8 due to issues related to managing risks associated with care and minimising the use of restraint.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service has implemented a system to ensure consumer care management plans are updated where there is a change in clinical status, including updating those following incidents.

   • Met (3)(b) Assessment and planning identifies and addresses the consumer’s current needs, goals and preferences, including advance care planning and end of life planning if the consumer wishes. — Consumer care plans were reflective of consumers' current needs, goals, and preferences. Documentation confirmed where there had been a change in condition or incident, care was reviewed and the care plan for consumers updated to reflect their current needs.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not effectively manage high impact or high prevalence risks associated with the care of each consumer, including in relation to the administration and monitoring of psychotropic medications.

   • Not met (3)(b) Effective management of high impact or high prevalence risks associated with the care of each consumer. — The service did not demonstrate it effectively managed the high impact or high prevalence risks associated with consumer care specifically in relation to restrictive practices.

   Risks: Consumers A, B, C, D, and E have been prescribed psychotropic medications without consistent consideration of risk, evaluation for effectiveness, or trial of reduction.

   Recommendations: Education to be delivered to medical officers regarding expectations of psychotropic review and best practice.; Development of a process to ensure the correct procedure is followed in reviewing consumers' psychotropic medication.

   Standard 8 Organisational governanceNon-compliant

   The service did not demonstrate its clinical governance framework was effective in minimising the use of restraint, specifically in relation to the use of psychotropic medications.

   • Not met (3)(e) Where clinical care is provided—a clinical governance framework, including but not limited to the following: antimicrobial stewardship; minimising the use of restraint; open disclosure. — The service did not demonstrate it was effectively minimising the use of restraint, specifically chemical and environmental restraint.

   Risks: Consumers are subject to an environmental restraint through the removal of access cards for exiting the facility.

   Recommendations: Review medical officer reasons for administration and apply a chemical restraint restrictive practice form if required.; Implementing a procedure where medical officers will document the reason for prescription and administration of psychotropic medications for consumers.

   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.

4. Assessment contact Performance ReportAug 16, 2023

   An assessment contact was conducted with this service on 16 August 2023 to 16 August 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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5. Accreditation decisionApr 20, 2023

   Following a site audit conducted on 07 March 2023 to 09 March 2023, the Commission made a decision on 20 April 2023 to re-accredit this service. The period of accreditation of the service will expire on 20 April 2026.

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6. Site AuditApr 20, 2023

   Prepared by M Glenn

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

   The service meets most standards, but faces challenges in ongoing assessment and planning with consumers, personal care and clinical care, and organizational governance. Areas for improvement include ensuring care plans reflect current needs and preferences, effective management of high impact risks, and a robust clinical governance framework to minimize the use of restrictive practices.

   Standard 1 Consumer dignity and choiceCompliant

   The service treats consumers with respect, supports their choices, and ensures privacy.

   • Met (3)(a) — Consumers said they are treated with dignity and respect.
   • Met (3)(b) — Care files demonstrated consumers' cultural safety needs are assessed on entry and ongoing.
   • Met (3)(c) — Consumers were satisfied they can make decisions about their care and maintain relationships of choice.
   • Met (3)(d) — Processes support consumers to take risks for a better life.
   • Met (3)(e) — Information is provided in a timely and understandable manner.
   • Met (3)(f) — Privacy is respected, and personal information is kept confidential.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   Care plans are not always reflective of current needs or preferences.

   • Met (3)(a) — Assessments inform safe and effective care.
   • Not met (3)(b) — Care files did not demonstrate an effective process for capturing current needs in plans.
   • Met (3)(c) — Partnership with consumers and others is demonstrated.
   • Met (3)(d) — Outcomes are communicated to the consumer and documented in care plans.
   • Met (3)(e) — Care is reviewed regularly for effectiveness.

   Recommendations: Ensure care plans reflect current needs, preferences, and management strategies.

   Standard 3 Personal care and clinical careNon-compliant

   Management of high impact risks is not effective.

   • Met (3)(a) — Personal and clinical care are tailored to needs.
   • Not met (3)(b) — No evidence of restraint authorisation or informed consent in care files for consumers subject to restrictive practice.
   • Met (3)(c) — End-of-life needs are recognized and addressed.
   • Met (3)(d) — Deterioration or changes in function are recognized and responded to timely.
   • Met (3)(e) — Information about condition, needs, and preferences is documented and communicated.
   • Met (3)(f) — Timely referrals to other care providers are made.
   • Met (3)(g) — Infection-related risks are minimized through appropriate practices.

   Recommendations: Ensure staff have skills to support consumers in understanding the use of chemical restraint and implement non-pharmacological strategies.

   Standard 4 Services and supports for daily livingCompliant

   Services meet needs, goals, and preferences.

   • Met (3)(a) — Needs, goals, and preferences are met.
   • Met (3)(b) — Emotional, spiritual, and psychological well-being is promoted.
   • Met (3)(c) — Consumers are supported to engage in community activities.
   • Met (3)(d) — Information about condition, needs, and preferences is communicated.
   • Met (3)(e) — Timely referrals are made to other care providers.
   • Met (3)(f) — Meals provided are varied and of suitable quality.
   • Met (3)(g) — Equipment is safe, clean, and well-maintained.

   Standard 5 Organisation’s service environmentCompliant

   The environment is welcoming and enables independence.

   • Met (3)(a) — Environment encourages a sense of community.
   • Met (3)(b) — Service environment is safe, clean, and enables free movement.
   • Met (3)(c) — Furniture and equipment are safe, clean, and well-maintained.

   Standard 6 Feedback and complaintsCompliant

   Consumers can provide feedback and make complaints.

   • Met (3)(a) — Feedback and complaint mechanisms are accessible.
   • Met (3)(b) — Consumers have access to advocates and language services.
   • Met (3)(c) — Appropriate action is taken in response to complaints.
   • Met (3)(d) — Feedback and complaints are reviewed for improvement.

   Standard 7 Human resourcesCompliant

   The workforce is planned, trained, and supported.

   • Met (3)(a) — Workforce planning ensures quality care.
   • Met (3)(b) — Interactions with consumers are respectful and caring.
   • Met (3)(c) — Staff have qualifications and knowledge for their roles.
   • Met (3)(d) — Recruitment, training, and support are provided.
   • Met (3)(e) — Performance is regularly assessed and reviewed.

   Standard 8 Organisational governanceNon-compliant

   Governance systems are effective except for clinical governance.

   • Met (3)(a) — Consumers engage in care and service development.
   • Met (3)(b) — Governing body promotes safe, inclusive care.
   • Met (3)(c) — Effective governance systems are in place.
   • Met (3)(d) — Risk management systems and practices are effective.
   • Not met (3)(e) — Clinical governance framework for minimizing restraint use is not demonstrated.

   Recommendations: Review the clinical governance framework to minimize restrictive practices.

   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. Site audit Performance ReportMar 9, 2023

   A site audit was conducted with this service on 07 March 2023 to 09 March 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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8. Exceptional CircumstancesOct 28, 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 20 May 2023 The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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9. AssessmentAug 30, 2019

   Following a site audit the Commission made a decision on 26 September 2019 that this service met all of the Aged Care Quality Standards. The service is re-accredited for three years until 20 November 2022.

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10. AssessmentAug 11, 2016

    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 20 November 2019.

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11. AssessmentAug 14, 2013
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12. AssessmentSep 15, 2010
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No regulatory actions recorded.