Bethanie Dalyellup
activeOverview
Location
Dalyellup (SA2)
114 Norton Promenade, DALYELLUP, WA, 6230
Star ratings
Latest — May 2026
Compliance findings
11 recorded
| Date | Type | Requirement | Severity | Finding | Status |
|---|---|---|---|---|---|
| 17 Jan 2024 | Site Audit | – | – | Organisational governance | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Organisation’s service environment | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Feedback and complaints | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Human resources | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Consumer dignity and choice | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Ongoing assessment and planning with consumers | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Personal care and clinical care | Compliant |
| 17 Jan 2024 | Site Audit | – | – | Services and supports for daily living | Compliant |
| 12 Sept 2023 | Assessment Contact - Site | – | – | Human resources | Not applicable |
| 12 Sept 2023 | Assessment Contact - Site | – | – | Organisational governance | Non-compliant |
| 12 Sept 2023 | Assessment Contact - Site | – | – | Ongoing assessment and planning with consumers | Not applicable |
Accreditation & assessment timeline
6 events · AI report insights nested where analysed
- Accreditation decision
Following a site audit conducted on 27 November 2023 to 30 November 2023, the Commission made a decision on 17 January 2024 to re-accredit this service. The period of accreditation of the service will expire on 08 March 2027.
source ↗ - Site Auditsource ↗
- Site audit Performance Report
A site audit was conducted with this service on 27 November 2023 to 30 November 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.
source ↗ - Assessment Contact - Sitesource ↗
AI report insightsAI-extracted · qwen2.5:32b
The performance report for Bethanie Dalyellup highlights compliance with Standards 2 and 7, but identifies non-compliance with Standard 8 due to ineffective clinical governance related to minimising the use of restraints. The report recommends improvements in policies, training, and monitoring to ensure safe and quality care.
Standard 2 Ongoing assessment and planning with consumersCompliant
The service has recently commenced but was able to demonstrate effective ongoing assessment and planning for sampled consumers.
- Met Requirement 2(3)(a) — Documentation showed a clinical admission checklist is commenced at pre-admission, and a detailed interim care plan is created on admission. Three consumers sampled had a range of assessments completed with relevant strategies developed.
Standard 7 Human resourcesCompliant
The service demonstrated the workforce was planned and deployed to enable safe and quality care.
- Met Requirement 7(3)(a) — Consumers were satisfied with the provision of care, and staff observed providing care in a respectful manner. Allocation sheets showed unfilled shifts filled with agency staff.
Standard 8 Organisational governanceNon-compliant
The service was non-compliant due to ineffective clinical governance in minimising the use of restraint.
- Met Requirement 8(3)(d) — Policies and procedures are in place for managing risks, identifying abuse/neglect, supporting consumers to live their best life, and incident management.
- Not met Requirement 8(3)(e) — The service was unable to demonstrate an effective clinical governance framework specifically in relation to minimising the use of restraint. Consumers were prescribed psychotropic medication without clear evidence of informed consent or consideration as restrictive practices.
Risks: Use of chemical and mechanical restraints without appropriate assessment, planning, and informed consent.
Recommendations: Review clinical governance framework and relevant policies and procedures to minimise the use of restraint.; Ensure staff are trained in restrictive practices and behaviour support.; Monitor and minimise restraint usage within the service.
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.
- Assessment contact Performance Report
An assessment contact was conducted with this service on 19 July 2023 to 20 July 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Accreditation decision
Following an application for accreditation, the Commission made a decision on 08 March 2023 to accredit this commencing service. The period of accreditation of the service will expire on 08 March 2024.
source ↗
Regulatory actions
0 recorded
No regulatory actions recorded.