Bethanie Elanora Villas Nursing Home

37 HASTIE Street, SOUTH BUNBURY, WA, 6230

1. Assessment contact (performance assessment) – siteFeb 17, 2025

   Prepared by S Turner

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2. Assessment contact Performance ReportJan 23, 2025

   An assessment contact was conducted with this service on 23 January 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. Assessment Contact - SiteSep 20, 2023

   Prepared by R Beaman

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

   The performance report identifies non-compliance in Standards 3, 7, and 8. The service failed to effectively manage high impact or high prevalence risks associated with consumer care, particularly in pain management, falls prevention, and diabetes care. Staff competency was also found lacking, impacting the delivery of effective clinical care. Additionally, the risk management system and incident management practices were ineffective, leading to inadequate identification and mitigation of risks.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not effectively manage high impact or high prevalence risks associated with consumer care, specifically related to falls, pain management, and diabetes.

   • Not met (3)(b) Ensure high impact or high prevalence risks associated with care are effectively managed for each consumer. — The service did not demonstrate effective management of high impact or high prevalence risks, specifically in relation to falls and pain management. For example, Consumer A experienced significant pain due to staff's inappropriate manual handling technique and was not assessed for pain adequately post-incidents leading to fractures. Staff also failed to manage pain relief appropriately after hospital transfer. Consumers B and C had ineffective falls management plans with no alternative strategies identified. Consumer D’s diabetes care plan showed inconsistent recording of blood glucose levels, and staff did not escalate a decline in condition timely.

   Risks: Consumers A, B, C, and D experienced increased pain, delayed pain relief, fractures, and ineffective falls management due to inadequate risk management practices.; Consumer D's diabetes was not managed effectively with inconsistent monitoring of blood glucose levels.

   Recommendations: Commence daily huddles with staff to identify consumers at risk and develop actions.; Provide specialist clinical support on the floor for staff.; Review progress notes with an action plan to the site.; Educate staff on the principles of clinical risk management.

   Standard 7 Human resourcesNon-compliant

   The workforce was not competent in managing high impact risks associated with consumer care, including pain, falls, and diabetes management.

   • Not met (3)(c) Ensure the workforce is competent and have the knowledge and qualifications to perform their roles effectively, specifically in relation to managing clinical risks, including falls, pain, diabetes and incidents. — Staff did not show competency in safe manual handling processes leading to Consumer A's fracture. Clinical staff failed to identify or monitor pain effectively for Consumers A and C post-incidents. Staff also did not follow policies and procedures regarding neurological observations after falls, and they did not manage diabetes care as per directives.

   Risks: Consumers experienced increased pain, delayed pain relief, fractures, and ineffective falls management due to staff incompetence.; Consumer D's diabetes was not managed effectively with inconsistent monitoring of blood glucose levels.

   Recommendations: Monitor manual handling practices to identify any issues in staff practice.; Recruit a clinical remediation manager.; Review the competence of registered staff to use continuous infusion pumps and medications given continuously as prescribed.; Provide further education for areas including falls, manual handling, clinical deterioration, pain, diabetes management, and undertaking vital signs.

   Standard 8 Organisational governanceNon-compliant

   The service did not have an effective risk management system or incident management system to prevent recurrence of incidents and mitigate harm.

   • Not met (3)(d) Ensure the organisation’s risk management systems and practices are effective, specifically in relation to the management of high impact or high prevalence risks associated with consumer care and an incident management system that prevents recurrence and mitigates harm to consumers. — The risk management system was not effective in identifying increased pain for Consumers A and C. The incident management system did not prevent recurrence of falls for Consumer B or report incidents consistently, including a near miss incident involving Consumer A.

   Risks: Consumers experienced ineffective clinical care due to the lack of an effective risk management system.; Incidents were not reported consistently and root cause analysis was not conducted following unexpected deaths.

   Recommendations: Conduct trend and root cause analysis to identify causal factors of falls.; Review and update the clinical risk meeting template to include high impact/high prevalence risks.; Establish daily management meetings for a coordinated remediation approach.; Develop an initial remediation action plan.

   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.

4. Assessment contact Performance ReportAug 11, 2023

   An assessment contact was conducted with this service on 10 August 2023 to 11 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 decisionNov 17, 2022

   Following a site audit conducted on 03 October 2022 to 05 October 2022, the Commission made a decision on 17 November 2022 to re-accredit this service. The period of accreditation of the service will expire on 17 November 2025.

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6. Site AuditNov 17, 2022

   Prepared by James Howard

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

   The Bethanie Elanora Villas Nursing Home demonstrated compliance with most Aged Care Quality Standards, except for Standard 3 Personal care and clinical care where it was found non-compliant due to ineffective management of high impact risks associated with consumer care. The service provided safe, effective, and culturally sensitive care while supporting consumers' independence and well-being.

   Standard 1 Consumer dignity and choiceCompliant

   The service treated consumers with dignity, respect, and cultural safety, supported consumer choices and independence, communicated information clearly, and respected privacy.

   • Met Requirement 1(3)(a) — Consumers and representatives confirmed staff treated consumers with dignity and respect and valued their identities, cultures, and diversity.
   • Met Requirement 1(3)(b) — The service provided care and services that were culturally safe according to consumers and representatives.
   • Met Requirement 1(3)(c) — Consumers and representatives indicated they were supported to exercise choice and independence, make decisions, maintain personal relationships, and communicate their decisions.
   • Met Requirement 1(3)(d) — Management and staff described ways in which they supported consumers to take risks and live their best lives.
   • Met Requirement 1(3)(e) — Consumers indicated they received up-to-date information regarding the care and services provided.
   • Met Requirement 1(3)(f) — Care planning documentation outlined consumers' privacy expectations when staff provided daily care and services.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service considered individual risks to health and well-being during care planning, involved consumers in the process, communicated outcomes effectively, and reviewed plans regularly.

   • Met Requirement 2(3)(a) — The service considered individual risks to health and well-being when undertaking care planning.
   • Met Requirement 2(3)(b) — Consumers confirmed they had input into the planning of their care, including end-of-life care wishes.
   • Met Requirement 2(3)(c) — Care planning documentation demonstrated consumers and representatives were consulted throughout the assessment process.
   • Met Requirement 2(3)(d) — Consumers confirmed outcomes of assessment and planning were communicated to them, and they could access their care plans upon request.
   • Met Requirement 2(3)(e) — Care planning documentation showed staff reviewed care plans regularly and when circumstances changed or incidents occurred.

   Standard 3 Personal care and clinical careNon-compliant

   The service provided safe, effective, and tailored personal and clinical care but did not effectively manage high impact risks associated with consumer care.

   • Met Requirement 3(3)(a) — Care planning documentation showed the care and supports provided to consumers was best practice, tailored to their needs.
   • Not met Requirement 3(3)(b) — The service did not demonstrate effective management of high impact or high prevalence risks associated with consumer care at the time of the site audit.
   • Met Requirement 3(3)(c) — Staff described how they provided care to consumers that were palliating to maximize their comfort.
   • Met Requirement 3(3)(d) — Consumers indicated the service contacted them in a timely manner to discuss any deterioration in health or abilities.
   • Met Requirement 3(3)(e) — Information relating to consumers' conditions, needs and preferences was documented and communicated within the organization.
   • Met Requirement 3(3)(f) — Consumers advised timely and appropriate referrals occurred, and they had access to health care professionals when required.
   • Met Requirement 3(3)(g) — Staff were familiar with antimicrobial stewardship and described measures taken to prevent infection and reduce the prescription of antibiotics.

   Risks: A consumer with cognitive impairments experienced a fall, leading to significant delays in medical review and identification of fractures.

   Recommendations: Staff should be reminded of the importance of following falls prevention and management procedures.; Training on current processes for handling falls should be provided by the clinical nurse educator.; A digital pain assessment tool is being trialed to assist staff in identifying pain, especially among consumers with cognitive impairments.

   Standard 4 Services and supports for daily livingCompliant

   The service supported consumers' independence, well-being, community participation, and provided suitable meals and equipment.

   • Met Requirement 4(3)(a) — Consumers felt the service supported them with their daily living needs and respected their preferences.
   • Met Requirement 4(3)(b) — Staff described how they provided supports which promoted consumers' emotional, spiritual, and psychological well-being.
   • Met Requirement 4(3)(c) — Consumers felt the service assisted them to participate in their community, have social relationships, and engage in activities of interest.
   • Met Requirement 4(3)(d) — Information on consumers' conditions, needs, and preferences was effectively shared with staff and other providers of care.
   • Met Requirement 4(3)(e) — Consumers indicated timely and appropriate referrals occurred when required.
   • Met Requirement 4(3)(f) — Meals provided were varied, of suitable quality and quantity according to consumers' dietary preferences and requirements.
   • Met Requirement 4(3)(g) — Equipment for consumers was safe, clean, well-maintained, and managed through regular cleaning and maintenance schedules.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, clean, comfortable, and enabled consumers to move freely.

   • Met Requirement 5(3)(a) — Management and staff described how they made consumers feel welcome in the service.
   • Met Requirement 5(3)(b) — Consumers indicated the environment was safe, clean, well-maintained, comfortable, and supported free movement.
   • Met Requirement 5(3)(c) — Furniture and fittings were observed to be safe, clean, and well maintained.

   Standard 6 Feedback and complaintsCompliant

   Consumers felt encouraged and supported to provide feedback and make complaints; the service responded appropriately.

   • Met Requirement 6(3)(a) — Staff described processes in place to support consumers and representatives to provide feedback.
   • Met Requirement 6(3)(b) — Consumers were aware of alternative avenues for raising complaints, such as through advocacy services or the Commission.
   • Met Requirement 6(3)(c) — The service took appropriate action in response to complaints and used an open disclosure process.
   • Met Requirement 6(3)(d) — Feedback and complaints were trended, analyzed, and used to improve the quality of care and services.

   Standard 7 Human resourcesCompliant

   The workforce was planned and deployed effectively, interactions with consumers were respectful, staff were competent and supported.

   • Met Requirement 7(3)(a) — Staff advised the service was suitably staffed to support the delivery of care.
   • Met Requirement 7(3)(b) — Consumers and representatives reported that staff engaged with consumers in a respectful, kind, and caring manner.
   • Met Requirement 7(3)(c) — Staff felt competent to meet consumers' care needs according to consumers and representatives.
   • Met Requirement 7(3)(d) — Management ensured staff met minimum qualification requirements and had current criminal history checks.
   • Met Requirement 7(3)(e) — Staff confirmed their performance was monitored through observations, competencies, and mandatory training.

   Standard 8 Organisational governanceCompliant

   Consumers were engaged in care development; the governing body promoted safe, inclusive care; effective governance systems were in place.

   • Met Requirement 8(3)(a) — Consumers felt they had ongoing input into how their care and services were delivered.
   • Met Requirement 8(3)(b) — Management outlined strategies used by the governing body to promote a culture of safe, inclusive, and quality care.
   • Met Requirement 8(3)(c) — The service had effective governance systems for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback and complaint management.
   • Met Requirement 8(3)(d) — Risk management systems were in place to manage high impact risks, identify abuse or neglect, support consumers' well-being, and prevent incidents.
   • Met Requirement 8(3)(e) — Clinical care practice was governed by policies concerning antimicrobial stewardship, restrictive practices, and open disclosure principles.

   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. Site audit Performance ReportOct 5, 2022

   A site audit was conducted with this service on 03 October 2022 to 05 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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8. Exceptional CircumstancesDec 2, 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 17 July 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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9. Assessment contact Performance ReportMar 17, 2021

   An assessment contact was conducted with this service on 17 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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10. Assessment contact Performance ReportSep 9, 2020

    An assessment contact was conducted with this service on 09 September 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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11. AssessmentNov 9, 2018

    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 17 January 2022.

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12. AssessmentApr 16, 2015

    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 17 July 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 17 January 2019. The reconsideration decision and audit report is attached.

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13. AssessmentApr 16, 2015

    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 17 July 2018.

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14. AssessmentMay 3, 2012
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15. AssessmentMay 1, 2009
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No regulatory actions recorded.