Bentleys Aged Care

47 Harpin Street, EAST BENDIGO, VIC, 3550

1. Assessment contact (performance assessment) – non-siteDec 11, 2023

   Prepared by L Glass

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2. Assessment contact Performance ReportOct 11, 2023

   An assessment contact was conducted with this service on 11 October 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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3. Accreditation decisionSep 20, 2023

   Following a site audit conducted on 07 August 2023 to 09 August 2023, the Commission made a decision on 20 September 2023 to re-accredit this service. The period of accreditation of the service will expire on 23 December 2026.

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4. Site AuditSep 20, 2023

   Prepared by Jeannie Miaris

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

   The performance report for Bentleys Aged Care indicates compliance with seven out of eight Quality Standards. The service demonstrated strong adherence to standards related to consumer dignity, ongoing assessment, personal and clinical care, services for daily living, the service environment, feedback and complaints, and organisational governance. However, non-compliance was noted in Standard 7 (Human Resources) due to a lack of evidence showing regular performance reviews were conducted for all staff members.

   Standard 1 Consumer dignity and choiceCompliant

   Consumers were treated with dignity and respect, their culture was considered in care delivery, and they were supported to make choices and maintain relationships.

   • Met Requirement 1(3)(a) — Consumers and representatives said consumers were treated with dignity and respect, and staff valued their identity, culture, and diversity.
   • Met Requirement 1(3)(b) — Consumers advised they were supported by the service to observe religious and cultural practices.
   • Met Requirement 1(3)(c) — Consumers reflected how they were supported to communicate their decisions, make connections with others, and maintain relationships of choice.
   • Met Requirement 1(3)(d) — Consumers advised they were supported to do things with an element of risk to live the life they chose.
   • Met Requirement 1(3)(e) — Staff explained how they communicated information in a clear, easy-to-understand manner to support consumers in making informed decisions.
   • Met Requirement 1(3)(f) — Consumers and representatives considered consumers' privacy was respected by staff and personal information was kept confidential.

   Standard 2 Ongoing assessment and planning with consumersCompliant

   Assessment and planning processes identified risks to health, addressed needs, involved consumers in care decisions, communicated outcomes effectively, and reviewed care regularly.

   • Met Requirement 2(3)(a) — Consumers and representatives considered assessment and planning processes identified risks to consumers' health and well-being.
   • Met Requirement 2(3)(b) — Consumers advised that advance care planning was discussed during admission and scheduled reviews.
   • Met Requirement 2(3)(c) — Staff explained how they partnered with consumers, representatives, and others in the care planning processes.
   • Met Requirement 2(3)(d) — Consumers advised that outcomes of assessment and planning were communicated to them and a copy of the consumer's care plan was provided.
   • Met Requirement 2(3)(e) — Staff outlined processes in place to regularly review consumers' care on a 3-monthly basis.

   Recommendations: Management advised they would implement improvements to the communication of assessment and planning outcomes through revision of policy and providing education to staff.

   Standard 3 Personal care and clinical careCompliant

   Consumers received safe, effective, and tailored personal and clinical care that addressed their needs and preferences.

   • Met Requirement 3(3)(a) — Staff described consumers' needs and preferences and how these were considered in the delivery of personal and clinical care.
   • Met Requirement 3(3)(b) — Consumers and representatives advised high impact or high prevalence risks associated with consumers’ care was effectively managed.
   • Met Requirement 3(3)(c) — Management advised medical officers and other specialists provided guidance in the delivery of palliative care.
   • Met Requirement 3(3)(d) — Consumers and representatives advised deterioration in consumers was identified and responded to in a timely manner.
   • Met Requirement 3(3)(e) — Staff described how they shared information about consumers through shift handover processes and care planning documentation.
   • Met Requirement 3(3)(f) — Consumers advised they had access to relevant health care providers and services.
   • Met Requirement 3(3)(g) — The service outlined overarching strategies in place to minimise infections such as staff training, competency checks, and audits.

   Standard 4 Services and supports for daily livingCompliant

   Services and supports met consumers' needs, promoted well-being, independence, and quality of life.

   • Met Requirement 4(3)(a) — Consumers advised they were engaged in various lifestyle activities.
   • Met Requirement 4(3)(b) — Care planning documentation reflected consumers' emotional and spiritual preferences and ways to support their well-being.
   • Met Requirement 4(3)(c) — Consumers advised they participate in activities within and outside the service, build and maintain relationships, and were supported to do things of interest to them.
   • Met Requirement 4(3)(d) — Staff demonstrated knowledge of consumers' condition and needs consistent with information reflected in documentation.
   • Met Requirement 4(3)(e) — Consumers advised timely and appropriate referrals were completed to supplement services and supports available at the service.
   • Met Requirement 4(3)(f) — Staff explained how consumers could request alternative meals if menu selections were not to their preference.
   • Met Requirement 4(3)(g) — Management and staff described processes for identifying equipment that requires maintenance and cleaning.

   Standard 5 Organisation’s service environmentCompliant

   The service environment was welcoming, safe, clean, well-maintained, and supported consumers' movement.

   • Met Requirement 5(3)(a) — Consumers and representatives said the service environment was welcoming, and consumers felt at home.
   • Met Requirement 5(3)(b) — The service environment was observed to be clean and well maintained, supporting free movement both indoors and outdoors.
   • Met Requirement 5(3)(c) — Equipment, furniture, and fittings were observed to be safe, clean, and well-maintained.

   Standard 6 Feedback and complaintsCompliant

   Consumers were encouraged and supported to provide feedback and make complaints, which were reviewed for quality improvement.

   • Met Requirement 6(3)(a) — Consumers and representatives said they were supported to provide feedback and complaints.
   • Met Requirement 6(3)(b) — Information was displayed throughout the service to inform consumers of external complaints resolution pathways.
   • Met Requirement 6(3)(c) — Consumers and representatives reflected how the service responded in a timely and appropriate manner when things went wrong or in response to complaints.
   • Met Requirement 6(3)(d) — Documentation reflected consumers' feedback was reviewed and used to improve the quality of care and services.

   Standard 7 Human resourcesNon-compliant

   The workforce was planned and managed effectively, but regular performance reviews were not conducted.

   • Met Requirement 7(3)(a) — Consumers said the service had the right number and combination of staff to deliver quality care.
   • Met Requirement 7(3)(b) — Staff described consumers' needs and preferences and were observed to be attentive and respectful in their interactions with consumers.
   • Met Requirement 7(3)(c) — Documentation demonstrated staff had the appropriate qualifications, checks, and knowledge required to effectively perform their role.
   • Met Requirement 7(3)(d) — Management described processes in place to identify training needs and monitor completion of training.
   • Not met Requirement 7(3)(e) — The service could not provide evidence of other means of regular or systematic performance evaluation being conducted for all staff.

   Recommendations: Continuous improvement activities included a review and update to the staff performance appraisal policy and processes.

   Standard 8 Organisational governanceCompliant

   Consumers were engaged in care development, management promoted safe and quality care culture, and effective governance systems were in place.

   • Met Requirement 8(3)(a) — Management described changes made in response to consumer feedback.
   • Met Requirement 8(3)(b) — A culture of safe, inclusive, and quality care was fostered through regular meetings with executive and senior management.
   • Met Requirement 8(3)(c) — Effective organisation-wide governance systems were supported by structured reporting processes, meetings, policies, procedures, training, and audits mechanisms.
   • Met Requirement 8(3)(d) — The service had an established risk management framework which was supported by policies, procedures, training, and reporting processes.
   • Met Requirement 8(3)(e) — Management advised the clinical governance framework was overseen by meetings, dedicated personnel, and reporting structures to support best practice and safe clinical care.

   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.

5. Site audit Performance ReportAug 9, 2023

   A site audit was conducted with this service on 07 August 2023 to 09 August 2023. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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6. Assessment Contact - SiteDec 15, 2022

   Prepared by L Glass

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7. Assessment contact Performance ReportNov 22, 2022

   An assessment contact was conducted with this service on 22 November 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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8. Assessment contact Performance ReportMay 18, 2022

   An assessment contact was conducted with this service on 17 May 2022 to 18 May 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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9. Assessment contact Performance ReportNov 18, 2021

   An assessment contact was conducted with this service on 18 November 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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10. Assessment contact Performance ReportMar 30, 2021

    An assessment contact was conducted with this service on 30 March 2021. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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11. Accreditation decisionDec 23, 2020

    Following a site audit conducted on 24 November 2020 to 26 November 2020, the Commission made a decision on 23 December 2020 to re-accredit this service. The period of accreditation of the service will expire on 23 December 2023.

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12. Exceptional CircumstancesDec 3, 2020

    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 28 June 2021.

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13. Site audit Performance ReportNov 26, 2020

    A site audit was conducted with this service on 24 November 2020 to 26 November 2020. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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14. Exceptional CircumstancesMay 25, 2020

    During the COVID-19 pandemic, the Aged Care Quality and Safety Commission has temporarily modified our Regulatory Program, including 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 28 December 2020. The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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15. AssessmentApr 5, 2017

    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 28 June 2020.

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16. AssessmentJun 20, 2016

    This is a new home and is accredited for one year until 28 June 2017. We made the decision on 28 June 2016.

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No regulatory actions recorded.