Bethanie Subiaco
activeOverview
Location
Subiaco - Shenton Park (SA2)
45 Bishop Street, JOLIMONT, WA, 6014
Star ratings
Latest — May 2026
Compliance findings
13 recorded
| Date | Type | Requirement | Severity | Finding | Status |
|---|---|---|---|---|---|
| 29 Sept 2023 | Assessment Contact - Site | – | – | Consumer dignity and choice | Not applicable |
| 29 Sept 2023 | Assessment Contact - Site | – | – | Feedback and complaints | Not applicable |
| 29 Sept 2023 | Assessment Contact - Site | – | – | Organisational governance | Not applicable |
| 03 July 2023 | Site Audit | – | – | Consumer dignity and choice | Non-compliant |
| 03 July 2023 | Site Audit | – | – | Ongoing assessment and planning with consumers | Compliant |
| 03 July 2023 | Site Audit | – | – | Personal care and clinical care | Compliant |
| 03 July 2023 | Site Audit | – | – | Services and supports for daily living | Compliant |
| 03 July 2023 | Site Audit | – | – | Organisation’s service environment | Compliant |
| 03 July 2023 | Site Audit | – | – | Feedback and complaints | Non-compliant |
| 03 July 2023 | Site Audit | – | – | Human resources | Compliant |
| 03 July 2023 | Site Audit | – | – | Organisational governance | Non-compliant |
| 14 Mar 2023 | Assessment Contact - Site | – | – | Ongoing assessment and planning with consumers | Not applicable |
| 14 Mar 2023 | Assessment Contact - Site | – | – | Personal care and clinical care | Non-compliant |
Accreditation & assessment timeline
16 events · AI report insights nested where analysed
- Accreditation decision
Following a site audit conducted on 16 May 2023 to 18 May 2023, the Commission made a decision on 03 July 2023 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 26 June 2025. The period of accreditation of the service will expire on 03 January 2026.
source ↗ - Assessment Contact - Sitesource ↗
- Assessment contact Performance Report
An assessment contact was conducted with this service on 04 September 2023 to 04 September 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Accreditation decision
Following a site audit conducted on 16 May 2023 to 18 May 2023, the Commission made a decision on 03 July 2023 to re-accredit this service. The period of accreditation of the service will expire on 03 July 2025.
source ↗ - Site Auditsource ↗
AI report insightsAI-extracted · qwen2.5:32b
The performance report highlights that Bethanie Subiaco meets most of the Aged Care Quality Standards but faces challenges in supporting consumers' risk-taking safely (Standard 1), managing feedback and complaints effectively (Standard 6), and ensuring robust risk management systems for incidents and consumer well-being (Standard 8). The service is compliant with standards related to ongoing assessment, personal care, services for daily living, the service environment, human resources, and organizational governance.
Standard 1 Consumer dignity and choiceNon-compliant
The service supports consumers' dignity, culture, and independence but falls short in supporting them to take risks safely.
- Met (3)(a) — Consumers are treated with dignity and respect.
- Met (3)(b) — Care is culturally safe.
- Met (3)(c) — Consumers are supported to exercise choice and independence.
- Not met (3)(d) — Risk mitigation strategies for consumers who leave the service independently have not been effectively implemented.
- Met (3)(e) — Information provided to consumers is clear and enables them to exercise choice.
- Met (3)(f) — Consumers' privacy is respected, and personal information is kept confidential.
Risks: Four consumers who regularly leave the service independently are at risk of falls or other harm due to lack of implemented risk mitigation strategies.
Recommendations: Review processes for supporting consumers to take risks safely.; Implement and document risk mitigation strategies for consumers leaving the service independently.
Standard 2 Ongoing assessment and planning with consumersCompliant
The service effectively assesses and plans care in partnership with consumers, addressing their needs, goals, and preferences.
- Met (3)(a) — Assessment and planning inform the delivery of safe and effective care.
- Met (3)(b) — Needs, goals, and preferences are identified and addressed in assessment and planning.
- Met (3)(c) — Assessment and planning involve ongoing partnership with consumers and other organizations involved in care.
- Met (3)(d) — Outcomes of assessment and planning are effectively communicated to the consumer and documented.
- Met (3)(e) — Care is reviewed regularly for effectiveness, especially when circumstances change or incidents occur.
Standard 3 Personal care and clinical careCompliant
The service provides safe and effective personal and clinical care that meets consumers' needs and optimizes their health.
- Met (3)(a) — Personal and clinical care is best practice, tailored to individual needs.
- Met (3)(b) — High impact or high prevalence risks are effectively managed.
- Met (3)(c) — Needs of consumers nearing the end of life are recognized and addressed.
- Met (3)(d) — Deterioration or changes in mental health, cognitive function, capacity, or condition are promptly recognized and responded to.
- Met (3)(e) — Information about the consumer’s condition is documented and communicated within the organization.
- Met (3)(f) — Timely referrals to other organizations and providers are made as needed.
- Met (3)(g) — Infection-related risks are minimized through appropriate practices.
Standard 4 Services and supports for daily livingCompliant
The service provides safe, effective services that meet consumers' needs and promote their independence and well-being.
- Met (3)(a) — Services for daily living meet consumer needs.
- Met (3)(b) — Emotional, spiritual, and psychological well-being is promoted.
- Met (3)(c) — Consumers are supported to participate in community activities and maintain relationships.
- Met (3)(d) — Information about the consumer’s condition is communicated within the organization.
- Met (3)(e) — Timely referrals to other organizations and providers are made as needed.
- Met (3)(f) — Meals provided are varied, of suitable quality, and quantity.
- Met (3)(g) — Equipment is safe, clean, well-maintained, and suitable for consumer use.
Standard 5 Organisation’s service environmentCompliant
The service environment is welcoming, safe, clean, and promotes consumers' sense of belonging.
- Met (3)(a) — Environment optimizes each consumer’s sense of belonging.
- Met (3)(b) — The environment is safe, clean, well-maintained, and enables consumers to move freely.
- Met (3)(c) — Furniture, fittings, and equipment are safe, clean, well-maintained, and suitable for consumer use.
Standard 6 Feedback and complaintsNon-compliant
The service encourages feedback but does not consistently document or act on complaints effectively.
- Met (3)(a) — Consumers are encouraged and supported to provide feedback.
- Met (3)(b) — Consumers have access to advocates, language services, and other methods for raising complaints.
- Not met (3)(c) — Appropriate action is not consistently taken in response to complaints.
- Not met (3)(d) — Feedback and complaints are not reviewed effectively for quality improvement.
Risks: Consumers and representatives are not confident that the organization acts promptly and appropriately in response to feedback and complaints.
Recommendations: Review processes to ensure all feedback and complaints are captured.; Ensure open disclosure processes are applied where required.
Standard 7 Human resourcesCompliant
The service has adequate staffing levels, staff interactions with consumers are respectful, and the workforce is competent and supported.
- Met (3)(a) — Workforce planning enables safe and quality care.
- Met (3)(b) — Staff interactions are kind, caring, and respectful of each consumer’s identity.
- Met (3)(c) — The workforce is competent with the qualifications needed to perform their roles.
- Met (3)(d) — Staff are recruited, trained, equipped, and supported effectively.
- Met (3)(e) — Regular assessment, monitoring, and review of staff performance is undertaken.
Standard 8 Organisational governanceNon-compliant
The service engages consumers in care development but lacks effective risk management systems for supporting consumer risks and preventing incidents.
- Met (3)(a) — Consumers are engaged in the development, delivery, and evaluation of care.
- Met (3)(b) — The governing body promotes a culture of safe, inclusive, and quality care.
- Met (3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback and complaints.
- Not met (3)(d) — Risk management systems for supporting consumers to live their best life and managing incidents are not effective.
- Met (3)(e) — A clinical governance framework is in place, including antimicrobial stewardship, minimizing use of restraint, and open disclosure.
Risks: Consumers who choose to partake in risky activities are not effectively supported with risk mitigation strategies.; Incident investigations do not consistently identify root causes or implement preventive actions.
Recommendations: Review the organization’s risk management processes for supporting consumers to live their best life and managing incidents.; Implement changes to the incident management system to document investigation, corrective actions, and outcomes effectively.
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.
- Site audit Performance Report
A site audit was conducted with this service on 16 May 2023 to 18 May 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 assesses Bethanie Subiaco against the Aged Care Quality Standards. Standard 2 is compliant with ongoing assessment and planning, while Standard 3 is non-compliant due to ineffective management of high impact or high prevalence risks associated with personal care and clinical care.
Standard 2 Ongoing assessment and planning with consumersCompliant
The service demonstrated that care and services are reviewed regularly for effectiveness, when circumstances change or incidents impact the needs of the consumer.
- Met (3)(e) Care and services are reviewed regularly for effectiveness, and when circumstances change or when incidents impact on the needs, goals or preferences of the consumer. — Care plans included evidence of assessment and care planning on a regular basis, or with changes in circumstances such as falls, hospitalisation, wounds, low mood, or deterioration. Representatives said following incidents they were contacted to advise and discuss preferred treatment and strategies.
Standard 3 Personal care and clinical careNon-compliant
The service did not demonstrate effective management of high impact or high prevalence risks associated with the use of chemical restraint.
- Not met (3)(b) Effective management of high impact or high prevalence risks associated with the care of each consumer. — The service did not demonstrate effective management of high impact or high prevalence risks for consumers subject to restrictive practices. Behaviour support plans were not individualised, and there was insufficient documentation regarding non-pharmacological strategies before medication use.
Risks: Use of chemical restraint without sufficient documentation on the behavior of concern and evaluation of effectiveness or monitoring for adverse effects.; Lack of restraint authorities for all consumers subject to chemical restraint.
Recommendations: Update behaviour support plans, medication charts with indications for use, staff education, and updating the psychotropic register.; Increase oversight of the use of psychotropic medications and ensure completion of all restraint authority forms.
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 16 February 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Exceptional Circumstances
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 26 August 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Assessment contact Performance Report
An assessment contact was conducted with this service on 09 March 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Assessment contact Performance Report
An assessment contact was conducted with this service on 04 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Assessment contact Performance Report
An assessment contact was conducted with this service on 17 November 2020 to 18 November 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Accreditation decision
Following a site audit conducted on 7 January 2020 to 9 January 2020, the Commission made a decision on 19 February 2020 to re-accredit this service. The period of accreditation of the service will expire on 26 February 2023. The Performance Report is attached.
source ↗ - Assessment
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 26 February 2020.
source ↗ - Assessmentsource ↗
- Assessmentsource ↗
Regulatory actions
0 recorded
No regulatory actions recorded.