Aldersgate Aged Care Services

160 OG Road, FELIXSTOW, SA, 5070

1. Assessment contact (performance assessment) – siteNov 18, 2024

   Prepared by J Wilson

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2. Assessment contact Performance ReportOct 24, 2024

   An assessment contact was conducted with this service on 24/10/2024 to 24/10/2024. 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 (performance assessment) – siteMay 30, 2024

   Prepared by M Roach

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

   The performance report identifies non-compliance with Standards 3, 7, and 8. The service faces challenges in delivering safe and effective personal care and clinical care, ensuring workforce competency, and maintaining effective organizational governance and risk management practices. While the provider has initiated improvement actions, these have not yet been fully embedded into normal processes.

   Standard 3 Personal care and clinical careNon-compliant

   The service is not delivering effective and best practice personal and clinical care that optimizes consumers' health and well-being, particularly in managing high-impact or high-prevalence risks.

   • Not met 3(3)(a) — Consumers expressed dissatisfaction with delayed or missed personal care, and staff showed unfamiliarity with personalized behaviour support strategies. Non-pharmacological interventions were not trialled before administering medication for behavior management.
   • Not met 3(3)(b) — Consumers with pressure injuries did not receive care according to their assessed repositioning frequency, and pain monitoring charting was incomplete despite severe pain. Wound deterioration was not timely escalated.

   Risks: Delayed or missed personal care affecting consumer well-being; Ineffective management of high-impact risks such as pressure injuries and pain

   Recommendations: Ensure staff have access to full care plans including behavior support strategies.; Implement consistent monitoring and documentation for all consumers' behaviors.

   Standard 7 Human resourcesNon-compliant

   The workforce lacks the necessary competency in delivering consumer care, particularly in behaviour management and clinical documentation.

   • Not met 7(3)(c) — Staff showed lack of confidence in managing consumers' behaviors and were not equipped with knowledge to identify pressure injuries early or manage pain effectively.

   Recommendations: Develop a formalized training structure for staff.; Ensure all mandatory training is completed within the required timeframe.

   Standard 8 Organisational governanceNon-compliant

   The service lacks effective organization-wide governance systems and risk management practices, particularly in information management and workforce governance.

   • Not met 8(3)(c) — Inconsistent completion of consumer care documentation and monitoring charting. Processes for continuous improvement have not been effective in improving the quality of care.
   • Not met 8(3)(d) — Risk management systems were ineffective in managing high-impact or high-prevalence risks, including behavior management and pressure area care. Staff did not document ongoing incidents of consumer aggressive behaviors.

   Risks: Inconsistent documentation affecting accurate data collection for risk evaluation

   Recommendations: Implement continuous monitoring tools to support clinical leaders.; Ensure effective incident reporting and management systems are in place.

   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.

4. Assessment contact Performance ReportApr 18, 2024

   An assessment contact was conducted with this service on 17/04/2024 to 18/04/2024. 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 decisionAug 9, 2023

   Following a site audit conducted on 27 June 2023 to 30 June 2023, the Commission made a decision on 09 August 2023 to re-accredit this service. The period of accreditation of the service will expire on 09 August 2026.

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6. Site AuditAug 9, 2023

   Prepared by A. Douglas

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

   The performance report for Aldersgate Aged Care Services indicates compliance with all Quality Standards except Standard 8 Organisational governance, where there were issues related to regulatory compliance. The service demonstrated effective care delivery, consumer engagement, and feedback mechanisms but needs to improve its governance systems.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers reported being treated with respect and their cultural needs were met. They felt supported in making decisions about their care.

   • Met Requirement 1(3)(a) — Consumers said they were treated with dignity and respect.
   • Met Requirement 1(3)(b) — Staff demonstrated an awareness of consumers’ identities, diversity, and culture.
   • Met Requirement 1(3)(c) — Consumers said the service supported them to make decisions about their care.
   • Met Requirement 1(3)(d) — Staff provided examples of risks taken by consumers and described how they supported consumers to undertake these risks.
   • Met Requirement 1(3)(e) — Consumers said the service provided them with information in a way they could understand.
   • Met Requirement 1(3)(f) — Consumers said the service protected their privacy and confidentiality.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Assessment and care plans were based on consumer needs, preferences, and included advance care planning.

   • Met Requirement 2(3)(a) — Consumers and representatives confirmed assessment and planning was based upon consumers’ needs and preferences.
   • Met Requirement 2(3)(b) — Staff said advance care planning and end of life (EOL) care was discussed with consumers and representatives on admission, or as care needs changed.
   • Met Requirement 2(3)(c) — Consumers and representatives reported they were involved in assessment and planning on an ongoing basis.
   • Met Requirement 2(3)(d) — The Assessment Team observed the service used an electronic care management system (ECMS) to record all care planning and progress notes.
   • Met Requirement 2(3)(e) — Consumers and representatives confirmed care and services were reviewed regularly for effectiveness and when circumstances changed.

   Standard 3 Personal care and clinical careCompliant

   Personal and clinical care was tailored to individual needs, with effective management of risks.

   • Met Requirement 3(3)(a) — Consumers and representatives expressed satisfaction with how the service managed high impact or high prevalence risks associated with care and services.
   • Met Requirement 3(3)(b) — Staff recognised high prevalence and high impact risks and were able to specify individual consumer risks and mitigation strategies which were in place.
   • Met Requirement 3(3)(c) — Consumers and representatives confirmed advance care planning, including consumers’ EOL wishes, were discussed with them.
   • Met Requirement 3(3)(d) — Staff described the ways in which they responded to a change in a consumer’s condition.
   • Met Requirement 3(3)(e) — Consumers and representatives said they were satisfied that their care needs and preferences were documented and communicated between staff.
   • Met Requirement 3(3)(f) — Consumers confirmed the service had referred them to appropriate providers, organisations, or individuals to meet their needs.
   • Met Requirement 3(3)(g) — The service had policies and procedures which underpinned their infection, prevention and control processes related to antimicrobial stewardship (AMS) and infection control management.

   Standard 4 Services and supports for daily livingCompliant

   Daily living services were tailored to individual needs, promoting independence and well-being.

   • Met Requirement 4(3)(a) — Consumers said the service supported them to access and participate in daily living activities that met their needs.
   • Met Requirement 4(3)(b) — Staff described strategies they used to support consumers’ emotional and psychological well-being.
   • Met Requirement 4(3)(c) — Consumers confirmed they participated in activities within and outside of the service.
   • Met Requirement 4(3)(d) — During the Site Audit, staff used the service’s ECMS to relay information between other staff at the service and external providers.
   • Met Requirement 4(3)(e) — Consumers confirmed they were supported by other organisations, support services and providers of other care and services.
   • Met Requirement 4(3)(f) — Consumers expressed satisfaction with the quality, quantity, and variety of meals.
   • Met Requirement 4(3)(g) — The Assessment Team observed equipment was clean, safe, and suitable for use.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, and well-maintained.

   • Met Requirement 5(3)(a) — Consumers and representatives said the service was welcoming and easy to navigate.
   • Met Requirement 5(3)(b) — The Assessment Team observed consumers had personalised their rooms with their own furnishings, photos, and mementos.
   • Met Requirement 5(3)(c) — Consumers said the service’s furniture, fittings, and equipment were safe, suitable, clean, and well-maintained.

   Standard 6 Feedback and complaintsCompliant

   Feedback mechanisms were in place and consumers felt supported to make complaints.

   • Met Requirement 6(3)(a) — Consumers demonstrated an awareness of different options for raising complaints, including advocacy services and external complaint mechanisms.
   • Met Requirement 6(3)(b) — Staff could describe how they accessed language and advocacy services on behalf of the consumer.
   • Met Requirement 6(3)(c) — Consumers and representatives said management promptly responded to and sought to resolve their concerns after they made a complaint.
   • Met Requirement 6(3)(d) — Consumer meeting minutes and the plan for continuous improvement (PCI) demonstrated complaints, feedback and suggestions are generally documented and changes at the service are communicated with consumers.

   Standard 7 Human resourcesCompliant

   The workforce was planned to meet consumer needs, interactions were respectful, and staff were competent.

   • Met Requirement 7(3)(a) — Consumers said they were satisfied with the quantity of staff at the service.
   • Met Requirement 7(3)(b) — Staff demonstrated they were familiar with consumer's individual needs and preferences.
   • Met Requirement 7(3)(c) — All staff had the relevant qualifications to perform the duties outlined in their position descriptions.
   • Met Requirement 7(3)(d) — Staff confirmed they received ongoing training and support to perform their roles.
   • Met Requirement 7(3)(e) — Consumers confirmed staff were performing well and raised no concerns with their overall performance.

   Standard 8 Organisational governanceNon-compliant

   While consumers felt engaged in service development, the service could not demonstrate effective regulatory compliance systems.

   • Met Requirement 8(3)(a) — Consumers said they felt involved in the design, delivery, and evaluation of services.
   • Met Requirement 8(3)(b) — Management outlined systems and reporting processes in place through which the governing body monitored the service’s compliance with the Quality Standards.
   • Not met Requirement 8(3)(c) — The Assessment Team recommended this Requirement as Not Met, as it considered the service could not demonstrate effective organisation wide governance systems in relation to regulatory compliance.
   • Met Requirement 8(3)(d) — Staff confirmed they analysed incidents to identify issues and trends, and these were reported at governance committee meetings.
   • Met Requirement 8(3)(e) — The service demonstrated there was a clinical governance framework in place, including antimicrobial stewardship, minimising the use of restraint, and open disclosure.

   Risks: Two named consumers who were subject to environmental restraint did not have the appropriate assessments, informed consent, and reviews in place.

   Recommendations: The service will be introducing an improved access control mechanism through the service’s secure perimeter gate by approximately October 2023.; A call bell system featuring a real-time location function that operates within the service grounds is being trialed to monitor consumers’ movements into and out of the service.

   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.

7. Exceptional CircumstancesJul 28, 2023

   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 21 February 2024. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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8. Site audit Performance ReportJun 30, 2023

   A site audit was conducted with this service on 27 June 2023 to 30 June 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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9. Exceptional CircumstancesJan 30, 2023

   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 21 August 2023. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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10. Accreditation decisionDec 23, 2021

    Following a site audit conducted on 03 June 2019 to 05 June 2019, the Commission made a decision on 27 June 2019 to re-accredit this service. The decision on the service’s accreditation period was varied following reconsideration on own initiative on 23 December 2021. The period of accreditation of the service will expire on 21 February 2023.

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11. Assessment contact Performance ReportAug 19, 2021

    An assessment contact was conducted with this service on 19 August 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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12. AssessmentJun 5, 2019

    Following an audit we decided that this service met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 21 August 2022.

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13. AssessmentMay 18, 2016

    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 21 August 2019.

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14. AssessmentJun 12, 2013
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15. AssessmentJun 2, 2010
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No regulatory actions recorded.