Bethanie Waters
activeOverview
Location
Port Kennedy (SA2)
18 Olivenza Crescent, PORT KENNEDY, WA, 6172
Star ratings
Latest — May 2026
Compliance findings
12 recorded
| Date | Type | Requirement | Severity | Finding | Status |
|---|---|---|---|---|---|
| 08 Apr 2025 | Assessment contact (performance assessment) – site | – | – | Ongoing assessment and planning with consumers | Not applicable |
| 08 Apr 2025 | Assessment contact (performance assessment) – site | – | – | Personal care and clinical care Not | Compliant |
| 08 Apr 2025 | Assessment contact (performance assessment) – site | – | – | Organisational governance Not | Compliant |
| 14 Aug 2024 | Assessment contact (performance assessment) – site | – | – | Personal care and clinical care Not | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Consumer dignity and choice | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Ongoing assessment and planning with consumers | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Personal care and clinical care | Non-compliant |
| 27 Mar 2024 | Site Audit | – | – | Services and supports for daily living | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Organisation’s service environment | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Feedback and complaints | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Human resources | Compliant |
| 27 Mar 2024 | Site Audit | – | – | Organisational governance | Compliant |
Accreditation & assessment timeline
22 events · AI report insights nested where analysed
- Assessment
The Aged Care Quality and Safety Commission (the Commission) has monitored the provider’s progress in implementing improvements in the service to ensure compliance with the Aged Care Quality Standards. Based on the information submitted by the provider, as of 03/09/2025, the Commission is satisfied actions have been taken to address the non-compliance with the Aged Care Quality Standards. The Commission will continue to monitor the provider’s performance.
source ↗ - Assessment contact (performance assessment) – sitesource ↗
- Assessment contact Performance Report
An assessment contact was conducted with this service on 05/02/2025 to 06/02/2025. 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 07/11/2024 to 07/11/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
source ↗ - Assessment contact (performance assessment) – sitesource ↗
- Assessment contact Performance Report
An assessment contact was conducted with this service on 18/07/2024 to 18/07/2024. 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 05 February 2024 to 08 February 2024, the Commission made a decision on 27 March 2024 to re-accredit this service. The period of accreditation of the service will expire on 13 November 2026.
source ↗ - Site Auditsource ↗
AI report insightsAI-extracted · qwen2.5:32b
The service was found to be compliant with most standards, except for Standard 3 Personal care and clinical care due to non-compliance in requirement (3)(d). The report highlights the need for improvements in recognizing and responding to changes in consumers' conditions.
Standard 1 Consumer dignity and choiceCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — Staff are kind and respectful when interacting with consumers, and care is provided in line with consumer preferences.
- Met (3)(b) — Care and services are culturally safe.
- Met (3)(c) — Consumers receive care that is right for them, and staff support consumers' choices about when care is provided.
- Met (3)(d) — Staff support consumers in taking risks to live the way they choose.
- Met (3)(e) — Information is provided to consumers via emails, newsletters, and meetings, ensuring it is clear and easy to understand.
- Met (3)(f) — Consumers' privacy is respected, with staff knocking on doors before entering rooms and conducting handovers in private areas.
Standard 2 Ongoing assessment and planning with consumersCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — Staff are knowledgeable of processes to assess and identify consumers' risks.
- Met (3)(b) — Consumers' preferences, current care needs, people important to them, and end-of-life wishes are documented.
- Met (3)(c) — Care conferences are undertaken annually with consumers choosing who they would like involved in the discussion.
- Met (3)(d) — Consumers and representatives have seen care plans or had them discussed with them, and changes are communicated at handovers.
- Met (3)(e) — Care plans are updated when incidents occur and reviewed regularly to reflect changing needs.
Standard 3 Personal care and clinical careNon-compliant
The standard is non-compliant due to requirement (3)(d) not being met.
- Met (3)(a) — Care and services are tailored to consumers' needs.
- Met (3)(b) — Strategies in place to manage risks were observed.
- Met (3)(c) — Comfort and dignity are prioritized for consumers nearing the end of life.
- Not met (3)(d) — Consumers with changes in their condition were not recognized or responded to in a timely manner, leading to issues such as weight loss and pressure injuries.
- Met (3)(e) — Information about consumers' conditions is documented and communicated effectively.
- Met (3)(f) — Referrals to external care providers are made in a timely manner.
- Met (3)(g) — Infection-related risks are minimized through appropriate practices and antibiotic stewardship principles.
Risks: Consumers with changes in their condition were not recognized or responded to in a timely manner, leading to issues such as weight loss and pressure injuries.
Recommendations: The service should implement strategies to ensure timely recognition and response to changes in consumers' conditions.
Standard 4 Services and supports for daily livingCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — Consumers are supported in optimizing their independence and well-being.
- Met (3)(b) — Staff provide emotional and spiritual support to consumers.
- Met (3)(c) — Consumers are supported in participating in community activities and engaging in things of interest.
- Met (3)(d) — Information about consumers' conditions is communicated effectively within the organization.
- Met (3)(e) — Referrals to external services are made in a timely manner.
- Met (3)(f) — Meals provided are varied and of suitable quality and quantity.
- Met (3)(g) — Equipment is safe, clean, well-maintained, and suitable for consumers.
Standard 5 Organisation’s service environmentCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — The service environment is welcoming, easy to understand, and optimizes consumers' sense of belonging.
- Met (3)(b) — The service environment is safe, clean, well-maintained, and comfortable, enabling free movement for consumers.
- Met (3)(c) — Furniture, fittings, and equipment are safe, clean, well-maintained, and suitable for consumers.
Standard 6 Feedback and complaintsCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — Consumers are encouraged and supported to provide feedback and make complaints.
- Met (3)(b) — Information about advocates and other methods for raising complaints is available, and annual Advocare sessions are held.
- Met (3)(c) — Appropriate action is taken in response to complaints, and open disclosure principles are used when things go wrong.
- Met (3)(d) — Feedback and complaints are reviewed and used for continuous improvement.
Standard 7 Human resourcesCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — There are enough staff rostered to provide quality care and services.
- Met (3)(b) — Staff interactions with consumers are kind, caring, and respectful of each consumer's identity, culture, and diversity.
- Met (3)(c) — The workforce is competent and has the qualifications to perform their roles effectively.
- Met (3)(d) — Staff are recruited, trained, equipped, and supported to deliver required outcomes.
- Met (3)(e) — Regular assessment, monitoring, and review of staff performance is undertaken.
Standard 8 Organisational governanceCompliant
All requirements were found to be compliant with the standard.
- Met (3)(a) — Consumers are engaged in the development, delivery, and evaluation of care and services.
- Met (3)(b) — The governing body promotes a culture of safe, inclusive, and quality care and services.
- Met (3)(c) — Effective governance systems are in place for information management, continuous improvement, financial governance, workforce governance, regulatory compliance, and feedback and complaints.
- Met (3)(d) — Risk management systems ensure consumers are supported to live the best life they can.
- Met (3)(e) — A clinical governance framework is in place, including antimicrobial stewardship and open disclosure 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.
- Site audit Performance Report
A site audit was conducted with this service on 05 February 2024 to 08 February 2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.
source ↗ - Assessment contact Performance Report
An assessment contact was conducted with this service on 11 August 2022. 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 01 March 2022 to 03 March 2022, the Commission made a decision on 04 May 2022 to re-accredit this service. The period of accreditation of the service will expire on 13 May 2024.
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 13 November 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Site audit Performance Report
A site audit was conducted with this service on 01 March 2022 to 03 March 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.
source ↗ - Assessment contact Performance Report
An assessment contact was conducted with this service on 14 September 2021 to 15 September 2021. 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 08 March 2021 to 10 March 2021, the Commission made a decision on 13 May 2021 to re-accredit this service. The period of accreditation of the service will expire on 13 May 2022.
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 October 2021. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.
source ↗ - Site audit Performance Report
A site audit was conducted with this service on 08 March 2021 to 10 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.
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 April 2021.
source ↗ - Assessment contact Performance Report
An assessment contact was conducted with this service on 16 July 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.
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 October 2020.
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 October 2017.
source ↗ - Assessmentsource ↗
Regulatory actions
0 recorded
No regulatory actions recorded.