St Basil's Miranda

29 H Wandella Road, MIRANDA, NSW, 2228

1. Site AuditFeb 28, 2025

   Prepared by Paramdeep Singh

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2. Site audit Performance ReportFeb 6, 2025

   A site audit was conducted with this service on 04/02/2025 to 06/02/2025. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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3. Assessment Contact - SiteAug 30, 2023

   Prepared by B Bassett

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4. Assessment contact Performance ReportJul 26, 2023

   An assessment contact was conducted with this service on 25 July 2023 to 26 July 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 decisionNov 2, 2022

   Following a site audit conducted on 04 October 2022 to 07 October 2022, the Commission made a decision on 02 November 2022 to re-accredit this service. The period of accreditation of the service will expire on 30 May 2025.

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6. Site AuditNov 2, 2022

   Prepared by E Woodley

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

   The performance report indicates that St Basil's Miranda is compliant with Standards 2, 5, 6 and partially compliant with Standard 8. However, the service was found to be non-compliant with Standards 1, 3, 4, and 7 due to issues related to consumer dignity and privacy, personal care and clinical care practices, services for daily living, and workforce planning.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service was not able to consistently demonstrate all consumers are treated with dignity and respect due to delays in call bell response and privacy issues.

   • Not met Requirement 1(3)(a) — Delays in call bell response compromised consumer dignity while waiting for staff assistance, including sitting in soiled continence aids.
   • Not met Requirement 1(3)(f) — Staff did not always knock before entering rooms and privacy was negatively impacted when handover discussions were conducted near other consumers within earshot.

   Risks: Consumers' dignity compromised due to delays in call bell response.; Privacy concerns as staff do not always knock before entering consumer's room.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service demonstrated effective ongoing assessment and planning that considers risks to health and well-being, reflects consumer goals and preferences, and involves partnerships with consumers.

   • Met Requirement 2(3)(a) — Assessment and planning considered risks to health and well-being including falls, skin integrity, pressure injuries, co-morbidities.
   • Met Requirement 2(3)(b) — Advance care directives and end-of-life discussions were in place for several consumers sampled.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not consistently provide best practice personal and clinical care tailored to consumer needs, particularly regarding restrictive practices and behavior management.

   • Not met Requirement 3(3)(a) — Inconsistent identification, assessment, and management of consumers prescribed chemical restrictive practice.

   Standard 4 Services and supports for daily livingNon-compliant

   The service did not meet all consumer needs in services and supports for daily living, particularly regarding meal temperatures.

   • Not met Requirement 4(3)(a) — Consumers with limited ability to participate due to mobility, hearing or vision impairments were unable to attend most activities.
   • Not met Requirement 4(3)(f) — Eleven consumers interviewed expressed dissatisfaction with the temperature of meals provided at the service.

   Standard 5 Organisation’s service environmentCompliant

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

   • Met Requirement 5(3)(a) — Consumers reported satisfaction with the service environment which feels like home.
   • Met Requirement 5(3)(b) — The service demonstrated a safe, clean and well maintained environment that enables consumers to move freely.

   Standard 6 Feedback and complaintsCompliant

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

   • Met Requirement 6(3)(a) — Consumers could describe various methods available for providing feedback and making complaints.
   • Met Requirement 6(3)(b) — Posters promoting external complaints mechanisms, advocacy services, language services were observed.

   Standard 7 Human resourcesNon-compliant

   The service did not consistently deploy a sufficient workforce to deliver safe and quality care.

   • Not met Requirement 7(3)(a) — Consumers reported delays in call bell response due to insufficient staff.

   Standard 8 Organisational governanceNon-compliant

   The service demonstrated effective governance systems except for regulatory compliance regarding restrictive practices and behavior support plans.

   • Not met Requirement 8(3)(c) — Service did not demonstrate effective governance relating to regulatory compliance for restrictive practices.

   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.

7. 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 30 May 2023 The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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8. Site audit Performance ReportOct 7, 2022

   A site audit was conducted with this service on 04 October 2022 to 07 October 2022. 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 decisionOct 28, 2021

   Following a site audit conducted on 11 February 2019 to 13 February 2019, the Commission made a decision on 15 March 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 28 October 2021. The period of accreditation of the service will expire on 30 November 2022.

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10. AssessmentFeb 13, 2019

    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 30 May 2022.

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11. AssessmentMar 10, 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 30 May 2019.

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12. AssessmentMar 14, 2013
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13. AssessmentFeb 25, 2010
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No regulatory actions recorded.