Aruma Lodge

Beryl Street, BROKEN HILL, NSW, 2880

1. Assessment contact (performance assessment) – siteDec 7, 2023

   Prepared by M Glenn

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2. Assessment contact Performance ReportNov 15, 2023

   An assessment contact was conducted with this service on 15 November 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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3. Accreditation decisionJul 11, 2023

   Following a site audit conducted on 23 May 2023 to 25 May 2023, the Commission made a decision on 11 July 2023 to re-accredit this service. The period of accreditation of the service will expire on 11 July 2026.

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4. Site AuditJul 11, 2023

   Prepared by M Glenn

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

   The service at Aruma Lodge is compliant with all Aged Care Quality Standards except for Standard 8 Organisational governance. The main area for improvement identified is the need to review risk management systems, particularly in managing incidents and responding to abuse or neglect of consumers.

   Standard 1 Consumer dignity and choiceCompliant

   The service supports consumers' cultural backgrounds, respects their privacy, and promotes independence and risk-taking to enhance quality of life.

   • Met (3)(a) — Staff support consumers to celebrate significant events and could describe consumers’ cultural backgrounds, identity and religious beliefs.
   • Met (3)(b) — Consumers confirmed staff are knowledgeable and respectful about what is important to them and provide services that are culturally safe.
   • Met (3)(c) — Care plans documented individual consumer choices around when care and services are delivered, who is involved in care and how they are supported to maintain relationships.
   • Met (3)(d) — Consumers said they are supported to engage in risky activities of their choosing to enable them to live the best life they can.
   • Met (3)(e) — Documentation showed care plans to be reflective of consumers’ current needs and staff were knowledgeable of the strategies used to ensure effective communication with all consumers.
   • Met (3)(f) — Care documentation was identified to be only accessible to authorised personnel and staff were observed not discussing consumers’ personal information in communal areas to maintain consumers’ privacy.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service conducts ongoing assessments that consider risks, involve consumer partnerships, and are effectively communicated.

   • Met (3)(a) — Assessment and planning processes identify risks to consumers’ health and well-being, and outline management strategies to inform care and services.
   • Met (3)(b) — Consumers and representatives confirmed consumers’ needs, goals and preferences are identified and addressed.
   • Met (3)(c) — Documentation showed assessment and planning is conducted in collaboration with consumers and their representatives.
   • Met (3)(d) — Staff have access to care plans and assessments on the electronic care system and confirmed outcomes are communicated at daily handovers, huddles and via a ‘Read and Sign’ book where all staff are required to confirm knowledge of changes.
   • Met (3)(e) — Consumers are reassessed and care plans updated when circumstances change or incidents occur.

   Standard 3 Personal care and clinical careCompliant

   The service provides safe, effective, and tailored personal and clinical care that maximises consumer health and well-being.

   • Met (3)(a) — Risk assessments are conducted to identify personal and/or clinical care needs and preferences individualised care plans are developed aimed at optimising health and well-being.
   • Met (3)(b) — High impact or high prevalence risks are screened on entry, with interventions and recommendations from specialists incorporated into care plans.
   • Met (3)(c) — Staff described how they maximise comfort and preserve dignity during end-of-life and work closely with consumers, their families, the medical officer, and local palliative care team to ensure high quality care is provided.
   • Met (3)(d) — Deterioration or changes to a consumer’s condition, function and capacity are documented, recognised, and responded to in a timely manner.
   • Met (3)(e) — Key risks and changes about consumers communicated effectively within the organisation.
   • Met (3)(f) — Consumers and representatives confirmed consumers are referred to members of allied health and other external organisations as appropriate and in a timely manner.
   • Met (3)(g) — The service demonstrated processes, such as infection reports to log and monitor treatment of infections and use of antimicrobial treatment.

   Standard 4 Services and supports for daily livingCompliant

   The service provides safe and effective services that support consumers' independence, well-being, and quality of life.

   • Met (3)(a) — A lifestyle program is developed in consultation with consumers to meet their needs, goals, and preferences.
   • Met (3)(b) — Observations of staff interactions with consumers were kind, caring and thoughtful.
   • Met (3)(c) — Consumers were observed participating in group activities and individual activities of interest to them.
   • Met (3)(d) — Information about consumers’ condition are communicated daily through handovers after each shift.
   • Met (3)(e) — Staff said referrals are made in consultation with consumers and/or their representative as required or indicated by assessment.
   • Met (3)(f) — Consumers said they enjoy most meals and are supported to provide feedback for meal options.
   • Met (3)(g) — Observations confirmed staff were knowledgeable about consumers’ needs and preferences and could describe how they seek feedback regarding menu changes through consumer meeting forums.

   Standard 5 Organisation’s service environmentCompliant

   The service environment is welcoming, safe, clean, well-maintained and promotes consumers' sense of belonging.

   • Met (3)(a) — Consumers said they like where they live and find the environment easy to navigate.
   • Met (3)(b) — Regular maintenance and cleaning processes ensure the environment remains clean, safe, and well maintained.
   • Met (3)(c) — Maintenance records confirmed the regular servicing of furniture, fittings, and equipment by either onsite staff or contracted services.

   Standard 6 Feedback and complaintsCompliant

   The service encourages feedback and complaints from consumers and ensures appropriate action is taken.

   • Met (3)(a) — Consumers and representatives were aware of mechanisms available to make complaints and provide feedback.
   • Met (3)(b) — Consumers have access to language services, advocates and other external complaint agencies with written materials and contact information readily available.
   • Met (3)(c) — Staff have undertaken training in open disclosure and understood the importance of adhering to it when things go wrong.
   • Met (3)(d) — All feedback and complaints are captured, analysed, trended, and reviewed for areas of improvement.

   Standard 7 Human resourcesCompliant

   The service has a competent workforce that is planned, trained, equipped, and supported to deliver safe and quality care.

   • Met (3)(a) — Rosters are regularly reviewed based on staff experience and the needs of consumers.
   • Met (3)(b) — Consumers and representatives spoke positively of staff and observations confirmed staff are kind, caring and respectful when interacting with consumers.
   • Met (3)(c) — Policies and procedures ensure staff have the appropriate qualifications and registrations required for their role.
   • Met (3)(d) — Staff felt supported by management and have sufficient training to undertake their roles and have opportunities for additional training if requested.
   • Met (3)(e) — Management described their framework for monitoring and reviewing staff performance, which includes an annual performance review, analysing complaint data, daily progress note reviews and observation of practices.

   Standard 8 Organisational governanceNon-compliant

   The service has effective governance systems for safe care but lacks an effective risk management system.

   • Met (3)(a) — Consumers felt they are actively involved in the development and delivery of their care.
   • Met (3)(b) — The organisation’s mission, values and strategic directions are promoted and communicated throughout the service.
   • Met (3)(c) — Information management systems ensure staff have access to relevant information to perform their role.
   • Not met (3)(d) — No incident reports were completed for Consumer A and B, despite multiple incidents of aggression and allegations of abuse. Management acknowledged each of these behaviours should have been recorded as an incident but did not demonstrate a sound knowledge of Serious Incident Response Scheme reporting requirements.
   • Met (3)(e) — Clinical processes support the management of antimicrobial stewardship, minimising the use of restraint and open disclosure.

   Risks: Incidents are not consistently reported through the service’s processes, which does not enable sufficient oversight or effective analysis to identify trends and opportunities for improvement.

   Recommendations: Review the organisation’s risk management systems and practices, specifically in relation to managing and preventing incidents and responding to abuse and neglect of consumers.

   Generated by qwen2.5:32b on 12 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

5. Site audit Performance ReportMay 25, 2023

   A site audit was conducted with this service on 23 May 2023 to 25 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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6. Exceptional CircumstancesFeb 27, 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 30 September 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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7. Accreditation decisionJan 9, 2020

   Following a site audit conducted on 7 to 9 January 2020, the Commission made a decision on 31 January 2020 to re-accredit this service. The period of accreditation of the service will expire on 31 March 2023. The Performance Report is attached.

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8. AssessmentJan 10, 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 31 March 2020.

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9. AssessmentJan 8, 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 31 March 2017.

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10. AssessmentJan 4, 2012
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No regulatory actions recorded.