St Annes Nursing Home

238 Piper Street, BROKEN HILL, NSW, 2880

1. Assessment contact (performance assessment) – non-siteMar 7, 2025

   Prepared by M Glenn

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2. Assessment contact Performance ReportFeb 17, 2025

   An assessment contact was conducted with this service on 17/02/2025 to 17/02/2025. 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 decisionSep 18, 2024

   Following a site audit conducted on 13/08/2024 to 15/08/2024, the Commission made a decision on 18/09/2024 to re-accredit this service. The period of accreditation of the service will expire on 25/11/2026.

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4. Site AuditSep 13, 2024

   Prepared by J Wilson

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5. Site audit Performance ReportAug 15, 2024

   A site audit was conducted with this service on 13 August 2024 to 15 August 2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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6. Accreditation decisionMar 31, 2023

   Following a site audit conducted on 07 February 2023 to 09 February 2023, the Commission made a decision on 31 March 2023 to re-accredit this service. The period of accreditation of the service will expire on 25 November 2024.

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7. Site AuditMar 31, 2023

   Prepared by M Glenn

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

   The performance report indicates significant non-compliance across all eight Aged Care Quality Standards at St Annes Nursing Home. The service faces challenges in ensuring consumers are treated with dignity, respect, and choice; effective ongoing assessment and planning processes; safe and tailored personal and clinical care; services that support daily living goals; a supportive service environment; feedback mechanisms that capture consumer concerns; adequate staffing levels and skills; and governance systems that promote quality care. The report highlights the need for comprehensive improvements to ensure compliance with the Quality Standards.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service did not ensure each consumer was treated with dignity and respect, and information provided to consumers was not clear or easy to understand.

   • Not met (3)(a) — Consumers reported feeling uncomfortable due to other consumers entering their rooms at night, and staff were dismissive of these concerns.
   • Met (3)(b) — Care files included information about cultural backgrounds and strategies to support them had been developed.
   • Met (3)(c) — Consumers were able to make decisions about their care, including personal preferences for activities and meals.
   • Met (3)(d) — Consumers are supported to take risks to live the best life they can.
   • Not met (3)(e) — Activity schedules were not available in consumers' rooms, and communication about activities was not clear or accessible.
   • Met (3)(f) — Processes to ensure privacy and confidentiality of personal information are in place.

   Risks: Consumers feel unsafe due to other consumers' behaviors, such as entering their rooms at night.; Representatives experienced bullying and harassment when raising concerns about care.

   Recommendations: Acknowledge and resolve consumer feedback/notifications.; Review all consumer assessments and care plans with the consumer.; Provide education on dignity, respect, customer service, bullying, harassment, risk management, and new Aged Care Code of Conduct requirements.

   Standard 2 Ongoing assessment and planning with consumersNon-compliant

   Assessment and planning processes did not effectively inform the delivery of safe and effective care and services.

   • Not met (3)(a) — Essential safety strategies for high-risk activities were not included in assessments, and staff were unaware of these strategies.
   • Not met (3)(b) — Entry assessments had not been completed for some consumers, and care plans did not reflect current needs or preferences.
   • Not met (3)(c) — Representatives were not contacted about reviews of assessments or care plan updates.
   • Not met (3)(d) — Consumers and representatives stated they are not informed when assessments are undertaken or outcomes communicated to them.
   • Not met (3)(e) — Care plans were not reviewed for effectiveness following incidents or changes in circumstances, such as falls.

   Risks: Consumers' care and service needs are not consistently addressed due to incomplete assessments.; Representatives feel excluded from the assessment and planning process.

   Recommendations: Review all consumer care plans.; Implement environmental restrictive practices, consents, authorities, and assessments as a priority.; Provide ongoing coaching, mentoring, and training for management and staff.

   Standard 3 Personal care and clinical careNon-compliant

   Consumers did not receive safe and effective personal or clinical care tailored to their needs.

   • Not met (3)(a) — Diabetes management directives were not followed, wound treatments were inconsistent, and weight loss was not effectively managed.
   • Not met (3)(b) — High impact or high prevalence risks such as falls and behaviors were not effectively managed.
   • Met (3)(c) — End-of-life care needs are recognized and addressed, with comfort maximized and dignity preserved.
   • Not met (3)(d) — Changes or deterioration in Consumer K's condition were not effectively recognized or responded to in a timely manner.
   • Not met (3)(e) — Information about consumers' conditions, needs, and preferences was not consistently documented or communicated within the organization.
   • Not met (3)(f) — Timely referrals to appropriate Allied health professionals were not made in response to changes in consumer condition.

   Risks: Consumers' diabetes and wound management needs are not consistently met.; Behavioral issues impact other consumers' safety and well-being.

   Recommendations: Review the management of diabetes, wounds, and weight loss by a Clinical nurse consultant.; Provide training on specialized nursing safe work practices.; Recruit for the Clinical support nurse position to oversee care in line with assessments and policies.

   Standard 4 Services and supports for daily livingNon-compliant

   Services and supports were not consistently tailored to consumers' goals, needs, and preferences.

   • Not met (3)(a) — Consumers' personal care preferences are not always respected due to staffing shortages.
   • Not met (3)(b) — Care files did not capture consumers' current interests and abilities.
   • Not met (3)(c) — Activity programs were not always reflective of consumer preferences, and engagement levels were not monitored effectively.

   Risks: Consumers do not consistently receive personal care in line with their preferences.; Activity programs may not meet consumers' current interests or abilities.

   Recommendations: Review the activity schedule in consultation with consumers and representatives.; Monitor consumer satisfaction of the program on an ongoing basis and initiate changes based on feedback.

   Standard 5 Organisation’s service environmentNon-compliant

   The service environment did not consistently support free movement for consumers both indoors and outdoors.

   • Not met (3)(b) — All external doors were locked, restricting access to courtyards.
   • Not met (3)(c) — Monitoring processes related to the service environment and safety of equipment were not regularly undertaken.

   Risks: Consumers' free movement is restricted by locked doors.; Safety issues with furniture, fittings, and equipment may go unaddressed.

   Recommendations: Review processes to ensure consumers can move freely both indoors and outdoors.; Regularly monitor the service environment for safety and address any identified issues promptly.

   Standard 6 Feedback and complaintsNon-compliant

   Feedback and complaint management systems were not effectively capturing all feedback or ensuring appropriate action was taken.

   • Not met (3)(a) — The complaints management system did not facilitate easy provision of feedback and making complaints.
   • Not met (3)(c) — Feedback forms were not easily identifiable, and consumers were unaware of them.

   Risks: Consumers may not feel supported to provide feedback or make complaints.; Emerging trends from feedback are not being identified for improvement opportunities.

   Recommendations: Review the complaints management system to ensure it supports consumers and representatives in providing feedback.; Ensure appropriate action is taken in response to feedback, including using an open disclosure approach when necessary.

   Standard 7 Human resourcesNon-compliant

   Staffing levels and skills were not adequate to deliver care and services tailored to consumers' needs.

   • Not met (3)(a) — Adequate staffing levels, particularly clinical staff, are not maintained.
   • Not met (3)(b) — Workforce interactions with consumers were not monitored effectively to ensure respectful treatment.
   • Not met (3)(c) — Staff competency and skills are not regularly tested or monitored.

   Risks: Consumers may receive care from staff who lack the necessary skills or knowledge.; Poor interactions between staff and consumers can negatively impact consumer experience.

   Recommendations: Ensure appropriate staffing levels and skill mix are maintained to deliver care in line with consumers' needs.; Monitor workforce interactions with consumers and take actions where poor interactions are identified.; Provide training to address deficiencies across all Quality Standards.

   Standard 8 Organisational governanceNon-compliant

   Governance systems did not effectively support the delivery of safe, inclusive, and quality care.

   • Not met (3)(a) — Consumers are not consistently supported in developing and evaluating their care.
   • Not met (3)(b) — A culture of safe, inclusive, and quality care is not promoted at the governing body level.
   • Not met (3)(c) — The governing body is not fully aware or accountable for the delivery of care through communication processes.

   Risks: Consumers may feel excluded from decisions about their care.; Governing bodies are not adequately informed about service-level issues affecting quality care.

   Recommendations: Review governance systems to ensure they support safe, inclusive, and quality care delivery.; Ensure the governing body is aware of and accountable for the delivery of care through effective communication processes.; Implement a clinical governance framework that minimizes restrictive practices and ensures open disclosure.

   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.

8. Site audit Performance ReportFeb 9, 2023

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

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9. Accreditation decisionMay 25, 2021

   Following a site audit conducted on 15 March 2021 to 18 March 2021, the Commission made a decision on 25 May 2021 to re-accredit this service. The period of accreditation of the service will expire on 25 May 2023.

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10. Exceptional CircumstancesMay 24, 2021

    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 04 December 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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11. Site audit Performance ReportMar 18, 2021

    A site audit was conducted with this service on 15 March 2021 to 18 March 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. Exceptional CircumstancesNov 30, 2020

    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 04 June 2021.

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13. Compliance monitoring updateJan 16, 2019

    An assessment contact was conducted by the Aged Care Quality and Safety Commission (Commission) on 16 January 2019 at St Anne's Nursing Home to monitor the service’s progress in meeting the Accreditation Standards. The Commission found the service complies with all Accreditation Standards.

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14. AssessmentSep 20, 2018

    Following an audit we decided that this home met 41 of the 44 expected outcomes of the Accreditation Standards and would be accredited for two years until 04 December 2020.

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15. AssessmentSep 1, 2017

    Following an audit we decided that this home met 38 of the 44 expected outcomes of the Accreditation Standards and would be accredited for one year until 04 December 2018.

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16. AssessmentSep 3, 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 04 December 2017.

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17. AssessmentSep 21, 2011
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No regulatory actions recorded.