Alexander Campbell House

51 Cook Street, FORESTVILLE, NSW, 2087

1. Accreditation decisionFeb 15, 2023

   Following a site audit conducted on 10 January 2023 to 12 January 2023, the Commission made a decision on 14 February 2023 to re-accredit this service. The period of accreditation of the service will expire on 14 February 2026.

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2. Site AuditFeb 14, 2023

   Prepared by E. Blance

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

   The service generally provides safe and effective care that meets consumers' needs, goals, and preferences. However, there are areas for improvement in supporting consumers to take risks, particularly around smoking safety, and ensuring the designated smoking area is adequately supervised and equipped with firefighting equipment.

   Standard 1 Consumer dignity and choiceNon-compliant

   The service treats consumers with dignity and respect, supports their cultural needs, and maintains privacy. However, there are deficiencies in supporting consumers to take risks, particularly for those who choose to smoke.

   • Met 1(3)(a) — Consumers and their representatives confirmed they are treated with dignity and respect.
   • Met 1(3)(b) — Staff demonstrated sound knowledge of consumers' background and preferences which was consistent with consumers’ goals and well-being needs.
   • Met 1(3)(c) — Consumers were supported to nominate who they would like involved in their care, communicate their decisions, make connections with others and maintain relationships of choice.
   • Not met 1(3)(d) — Not all smoking-related risks had been adequately assessed for one named consumer. The consumer was observed to have burn holes in their clothing and was smoking unsupervised in a garden area of the service.
   • Met 1(3)(e) — Consumers advised they received up-to-date information they needed to make informed choices.
   • Met 1(3)(f) — Staff were observed respecting consumers' personal space and privacy.

   Risks: Consumers who choose to smoke are not adequately supported in understanding the risks associated with smoking, leading to potential harm such as burns or falls.

   Recommendations: Tailor risk mitigation strategies for consumers who choose to smoke, ensuring they understand all benefits and possible harms of their decisions.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   The service effectively assesses and plans care based on ongoing partnerships with consumers, addressing current needs, goals, and preferences.

   • Met 2(3)(a) — Consumers felt safe and confident that staff knew what they were doing.
   • Met 2(3)(b) — Care documentation included the consumer’s current needs, goals and preferences, including advance care planning which was identified on entry to the service and reviewed regularly.
   • Met 2(3)(c) — Documentation showed evidence of care conferences, and involvement of a diverse range of external providers and services.
   • Met 2(3)(d) — Care documentation demonstrated review on a regular basis and when circumstances changed.
   • Met 2(3)(e) — Staff described how incident reporting processes may trigger reassessment or review.

   Standard 3 Personal care and clinical careCompliant

   The service provides safe, effective, and tailored personal and clinical care that optimizes health and well-being.

   • Met 3(3)(a) — Consumers and their representatives were positive about the clinical care they received from the service.
   • Met 3(3)(b) — The service demonstrated timely identification, effective assessment, management and evaluation of consumers’ restrictive practices, skin integrity and pain.
   • Met 3(3)(c) — Care documents reflected consumer’s care needs including end-of-life needs and wishes.
   • Met 3(3)(d) — If deterioration or change of a consumer’s mental, cognitive or physical function, capacity or condition occurred, this was recognized and responded to in a timely manner.
   • Met 3(3)(e) — Care documents contained adequate information to support effective and safe sharing of the consumer’s information in providing care.
   • Met 3(3)(f) — Staff described how the input of other health professionals informed care and services.
   • Met 3(3)(g) — Staff provided examples of practices to prevent and control infections.

   Risks: The service was unable to demonstrate that each consumer receives safe and effective personal and clinical care in relation to diabetes management for two named consumers.

   Standard 4 Services and supports for daily livingCompliant

   Consumers receive services and supports that meet their needs, goals, and preferences, promoting independence and well-being.

   • Met 4(3)(a) — Consumers said the service provided lifestyle activities that met their needs and preferences.
   • Met 4(3)(b) — Consumers confirmed there was a range of activities supporting emotional, spiritual, and psychological well-being.
   • Met 4(3)(c) — Consumers were confident appropriate referrals were made to ensure they receive the service and support for daily living.
   • Met 4(3)(d) — Care documentation listed consumers’ condition and preferences for activities, personal care, and things of interest to them.
   • Met 4(3)(e) — Staff described how they sought consumer feedback to customise activities to optimise their health and well-being.
   • Met 4(3)(f) — Consumers said meals were satisfying, varied, and of suitable quality and quantity.
   • Met 4(3)(g) — Consumers said they were satisfied with the equipment provided.

   Standard 5 Organisation’s service environmentNon-compliant

   The service environment is welcoming and safe, but there are deficiencies in ensuring a safe smoking area.

   • Met 5(3)(a) — Consumers confirmed the environment was welcoming, easy to understand, and optimised each consumer’s sense of belonging.
   • Not met 5(3)(b) — The designated smoking area did not allow for consumers to be supervised by the service or have firefighting equipment accessible in the area.
   • Met 5(3)(c) — Consumer’s rooms and common areas were clean and well maintained.

   Risks: The designated smoking environment did not allow for consumers to be supervised by the service or have firefighting equipment accessible in the area, posing a fire risk.

   Recommendations: Construct a shelter and implement a fire blanket, suitable receptacle for extinguishment and disposal of cigarettes, and a fire extinguisher to ensure safe smoking within the designated area.

   Standard 6 Feedback and complaintsCompliant

   Consumers are encouraged and supported to provide feedback and make complaints, with appropriate action taken in response.

   • Met 6(3)(a) — Consumers and their representatives said they were encouraged and supported to provide feedback.
   • Met 6(3)(b) — Management acknowledged complaints and sought resolution to achieve an outcome which satisfied the consumer and their representative.
   • Met 6(3)(c) — Staff described the organisation’s open disclosure policy and process when complaints are received.
   • Met 6(3)(d) — The service trended and analysed complaints and used this information to inform continuous improvement activities.

   Standard 7 Human resourcesCompliant

   The workforce is planned, competent, and supported to deliver safe and quality care.

   • Met 7(3)(a) — Consumers confirmed there were adequate staff to provide care and services in accordance with consumers’ needs.
   • Met 7(3)(b) — Staff interactions with consumers were kind, caring, and respectful of each consumer’s identity, culture, and diversity.
   • Met 7(3)(c) — Consumers confirmed the service had qualified staff with the knowledge and skills to provide safe and quality care and services that met consumers’ needs and preferences.
   • Met 7(3)(d) — Staff were observed interacting with consumers respectfully in a kind and caring manner.
   • Met 7(3)(e) — Feedback received through complaints and surveys monitored staff behavior to ensure interactions between staff and consumers meet the organisation’s expectations.

   Standard 8 Organisational governanceCompliant

   The service has effective governance systems for safe, inclusive, and quality care.

   • Met 8(3)(a) — Consumers advised they considered the service was well run and could provide feedback and suggestions to management.
   • Met 8(3)(b) — The governing body promoted a culture of safe, inclusive, and quality care and services.
   • Met 8(3)(c) — Effective governance systems were in place for information management, continuous improvement, financial governance, workforce governance, feedback, and complaints.
   • Met 8(3)(d) — The service had implemented risk management systems to monitor and assess high impact or high prevalence risks associated with care of consumers.
   • Met 8(3)(e) — A clinical governance framework supported staff in areas such as antimicrobial stewardship, minimizing the use of restraint, and open disclosure.

   Generated by qwen2.5:32b on 11 June 2026 from the published Performance Report. AI output — may contain errors; verify against the source document and the official findings above.

3. Site audit Performance ReportJan 12, 2023

   A site audit was conducted with this service on 10 January 2023 to 12 January 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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4. Exceptional CircumstancesAug 17, 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 29 March 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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5. Exceptional CircumstancesFeb 25, 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 until 29 September 2022. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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6. AssessmentJan 17, 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 29 March 2022.

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7. AssessmentMay 20, 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 29 July 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 29 March 2019. The reconsideration decision and audit report is attached.

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8. AssessmentMay 20, 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 29 July 2018.

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9. AssessmentMay 23, 2012
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10. AssessmentMay 15, 2009
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No regulatory actions recorded.