Abbey House Aged Care

300 Range Road, MITTAGONG, NSW, 2575

1. Assessment contact (performance assessment) – siteSep 4, 2024

   Prepared by G Cherry

   source ↗
2. Assessment contact Performance ReportJul 31, 2024

   An assessment contact was conducted with this service on 30/07/2024 to 31/07/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

   source ↗
3. Assessment contact (performance assessment) – siteNov 30, 2023

   Prepared by Therese Solomon

   source ↗
4. Assessment contact Performance ReportOct 5, 2023

   An assessment contact was conducted with this service on 04 October 2023 to 05 October 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

   source ↗
5. Assessment Contact - SiteJul 20, 2023

   Prepared by G Cherry

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

   The performance report for Abbey House Aged Care highlights non-compliance with Standard 3 Personal care and clinical care due to deficiencies in the system ensuring safe, effective personal/clinical care. The service is compliant with Standard 7 Human resources, showing improvements in staffing levels and workforce planning. Other standards were not assessed.

   Standard 3 Personal care and clinical careNon-compliant

   The service did not demonstrate an effective system to ensure staff adherence to organisational expectations, resulting in consumers not receiving personal/clinical care as per assessed needs, goals, and preferences.

   • Not met 3(3)(a) — The service did not demonstrate an effective system to ensure staff adherence to organisational expectations resulting in consumers not receiving personal/clinical care (in particular medications) as per assessed needs, goals, and preferences.

   Risks: Deficiencies relating to lack of timely identification/staging of pressure injury/wound care, lack of appropriate clinical assessment, and photographic evidence not detailing consistent measurements nor strategies to minimise further deterioration.

   Recommendations: Implement a system to ensure incidents are reported in a timely manner.; Review consumers' skin integrity and escalate issues to registered nurses.; Provide education/training to staff on wound care identification/descriptors/evaluation and pain assessment.

   Standard 7 Human resourcesCompliant

   The service demonstrated active recruitment of clinical, care, and general service staff with notable changes in staffing levels across all areas.

   • Met 7(3)(a) — All sampled consumers consider a notable change in staffing levels across all areas in recent months, giving examples of improved response times when requesting assistance.

   Recommendations: Continue to provide additional education/training for new care staff regarding identification of changes in consumer condition including incident management procedure.

   Standard 1, Standard 2, Standard 4, Standard 5, Standard 6, Standard 8Not applicable

   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.

6. Assessment contact Performance ReportJun 28, 2023

   An assessment contact was conducted with this service on 28 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

   source ↗
7. Accreditation decisionOct 19, 2022

   Following a site audit conducted on 06 September 2022 to 08 September 2022, the Commission made a decision on 19 October 2022 to re-accredit this service. The period of accreditation of the service will expire on 11 January 2026.

   source ↗
8. Site AuditOct 19, 2022

   Prepared by James Howard

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

   The service was compliant with most standards but faced challenges in providing safe and effective personal and clinical care (Standard 3) and ensuring adequate staffing levels to deliver quality services (Standard 7). The report highlights areas for improvement, particularly around medication management and workforce planning.

   1Compliant

   Consumers felt staff were kind, caring, and treated them with dignity and respect. Care planning documentation identified consumers' backgrounds, preferences, identities, and cultural practices.

   • Met 1(3)(a) — Consumers and representatives felt staff were kind, caring and treated consumers with dignity and respect.
   • Met 1(3)(b) — The service had policies and procedures in place which guided the provision of care in accordance with consumers’ cultural needs.
   • Met 1(3)(c) — Consumers and representatives considered they were supported to exercise choice and independence, could make their own decisions and maintain personal relationships.
   • Met 1(3)(d) — Consumers indicated staff supported them to take risks and live the best lives they can.
   • Met 1(3)(e) — The Assessment Team observed information regarding menu options, activities calendar, meetings and church services on display throughout the service.
   • Met 1(3)(f) — Consumers and representatives felt respected within the service and were confident their information was kept confidential.

   2Compliant

   Staff demonstrated an understanding of relevant risks to consumers' health and well-being, and strategies in place to mitigate these risks. Consumers were involved in the assessment and planning process.

   • Met 2(3)(a) — Staff demonstrated an understanding of the relevant risks to the health and well-being of each consumer and the strategies in place to mitigate these risks.
   • Met 2(3)(b) — The service demonstrated assessment and planning identified and addressed consumers’ current needs, goals, and preferences, including advance care planning if consumers wished.
   • Met 2(3)(c) — Management and staff described how they held end-of-life and advance care planning conversations with consumers during the admission process, at case conferences and as consumers’ needs changed.
   • Met 2(3)(d) — Care planning documentation reflected outcomes of assessment and planning were communicated with consumers and representatives.
   • Met 2(3)(e) — Representatives indicated they were regularly informed if consumers’ care needs changed or when incidents occurred.

   3Non-compliant

   The service could not demonstrate each consumer received safe and effective clinical care that was best practice, tailored to their needs, and optimized their health and well-being.

   • Not met 3(3)(a) — Feedback from consumers and representatives indicated staff did not provide medication on time as prescribed by medical officers.
   • Met 3(3)(b) — Representatives expressed satisfaction with the care received in relation to the management of high impact or high prevalence risks.
   • Met 3(3)(c) — Management and staff described changes made to the delivery of care for consumers requiring end-of-life care.
   • Met 3(3)(d) — Deterioration or changes in consumers’ health was recognized and responded to in a timely manner, as confirmed by care planning documents reviewed by the Assessment Team.
   • Met 3(3)(e) — Consumers and representatives were confident consumers’ information was well documented and shared between staff and other services involved in providing care.
   • Met 3(3)(f) — The service demonstrated it had a referral process in place which ensured timely and appropriate referrals were sent to individuals, other organizations, and providers of health care services to guide best practice.
   • Met 3(3)(g) — The service communicated regularly with consumers’ families regarding COVID-19 outbreak information and visitation restrictions.

   Risks: Delayed medication management had a significant impact on the health and well-being of some consumers.

   Recommendations: Address delays in medication administration.; Ensure care is aligned with consumer preferences as documented in their care plans.; Monitor staffing levels to ensure they meet consumer needs.

   4Compliant

   Consumers were satisfied that services and supports met their needs, goals, and preferences, enabling them to maintain independence and quality of life.

   • Met 4(3)(a) — Consumers were satisfied they received services and supports that met their needs, goals and preferences and enabled them to maintain their independence and quality of life.
   • Met 4(3)(b) — The Assessment Team observed consumers involved in activities within the service and noted staff encouraged other consumers to engage in the activities.
   • Met 4(3)(c) — Consumers indicated they were supported to participate in activities both within and outside the service environment.
   • Met 4(3)(d) — Staff advised information about consumers’ condition, needs and preferences was shared via the handover process and recorded on the electronic care management system.
   • Met 4(3)(e) — The service had policies and procedures which supported referrals to allied health professionals, organizations and volunteers.
   • Met 4(3)(f) — Consumers indicated the provided meals were varied and of suitable quality and quantity.
   • Met 4(3)(g) — The Assessment Team observed equipment used to support consumers to engage in activities of daily living and lifestyle activities was safe, suitable, clean and well maintained.

   5Compliant

   Consumers felt at home within the service environment which was welcoming, easy to understand, and promoted belonging and interaction.

   • Met 5(3)(a) — The service contained multiple communal areas which consumers could access at any given time, promoting belonging and interaction between consumers.
   • Met 5(3)(b) — The Assessment Team observed the service environment was safe, clean, and well maintained and allowed consumers to move freely both indoors and outdoors.
   • Met 5(3)(c) — Furniture, fittings and equipment at the service were safe, clean and well maintained.

   6Compliant

   Consumers felt encouraged to provide feedback and make complaints. The service took appropriate action in response to complaints.

   • Met 6(3)(a) — Management and staff described the processes in place to encourage and support feedback and complaints.
   • Met 6(3)(b) — The Assessment Team observed the consumer handbook included information about advocacy services and other methods of raising and resolving complaints.
   • Met 6(3)(c) — Consumers and representatives indicated the service took appropriate action in response to complaints and staff understood and utilized an open disclosure process in dealing with complaints.
   • Met 6(3)(d) — The service demonstrated feedback and complaints were trended, analyzed, and used to improve the quality of care and services.

   7Non-compliant

   Consumers and representatives indicated there were insufficient staffing levels which impacted the care consumers received.

   • Not met 7(3)(a) — Consumers and representatives indicated there were insufficient staffing levels, which impacted the care consumers received.
   • Met 7(3)(b) — Staff interactions with consumers were kind and caring and staff were respectful of each consumer’s identity, culture, and diversity.
   • Met 7(3)(c) — Consumers and representatives expressed confidence with the ability of staff to perform their roles and meet their care needs.
   • Met 7(3)(d) — The service demonstrated staff were recruited, trained, and equipped to support and deliver care and services in line with the Quality Standards.
   • Met 7(3)(e) — Staff confirmed performance appraisals were regularly completed and outlined the performance appraisal process.

   Risks: Insufficient staffing levels impacted care, including delays in medication administration, toileting, and showering.

   Recommendations: Review current contingency plans to ensure staff are equally distributed.; Recruit additional staff through a recruitment, retention, and award program.

   8Compliant

   Consumers were engaged in the development, delivery, and evaluation of care and services. The organization had effective governance systems and risk management practices.

   • Met 8(3)(a) — Consumers and representatives considered the organisation was well run and confirmed they were aware of opportunities to participate in the development, delivery, and evaluation of services.
   • Met 8(3)(b) — Management showed the organization’s governance structure included direct feeding of information to the organisational management team from the front-line managers of each service.
   • Met 8(3)(c) — There were organisation-wide governance systems to support effective information management, continuous improvement, financial governance, workforce governance, regulatory compliance and feedback and complaint management.
   • Met 8(3)(d) — Management confirmed incidents and trends were identified and analyzed, and reported to various committees and to the board, leading to care and service improvements for consumers.
   • Met 8(3)(e) — Staff demonstrated a shared understanding of policies pertaining to antimicrobial stewardship, restrictive practices 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.

9. Site audit Performance ReportSep 8, 2022

   A site audit was conducted with this service on 06 September 2022 to 08 September 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

   source ↗
10. Accreditation decisionJun 7, 2021

    Following a site audit conducted on 07 November 2018 to 09 November 2018, the Commission made a decision on 12 December 2018 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 07 June 2021. The period of accreditation of the service will expire on 11 January 2023.

    source ↗
11. Assessment contact Performance ReportDec 2, 2020

    An assessment contact was conducted with this service on 02 December 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

    source ↗
12. 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 11 January 2022.

    source ↗
13. AssessmentFeb 25, 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 11 May 2018.

    source ↗
14. AssessmentFeb 25, 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 11 May 2018. This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 11 January 2019. The reconsideration decision and audit report is attached.

    source ↗
15. AssessmentFeb 29, 2012
    source ↗
16. AssessmentFeb 25, 2009
    source ↗

No regulatory actions recorded.