Akooramak Care of Older Persons

269 WOOD Street, WARWICK, QLD, 4370

1. Accreditation decisionSep 18, 2024

   Following a site audit conducted on 13/08/2024 to 15/08/2024, the Commission made a decision on 18/09/2024 to re-accredit this service. The period of accreditation of the service will expire on 02/12/2027

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2. Site AuditSep 18, 2024

   Prepared by J Earnshaw

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3. Site audit Performance ReportAug 15, 2024

   A site audit was conducted with this service on 13/08/2024 to 15/08/2024. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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4. Assessment contact (performance assessment) – siteFeb 28, 2024

   Prepared by P. Sherin

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5. Assessment contact Performance ReportJan 30, 2024

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

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6. Assessment contact Performance ReportOct 17, 2023

   An assessment contact was conducted with this service on 17 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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7. Assessment Contact - SiteAug 10, 2023

   Prepared by P. Sherin

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

   The performance report for Akooramak Care of Older Persons highlights that the service has taken significant steps to address previous non-compliances, achieving compliance in several areas. However, there is a notable area of concern regarding Standard 4 (Services and supports for daily living), specifically Requirement 4(3)(f) related to meal provision, which remains non-compliant due to dissatisfaction from consumers about the variety and quantity of meals provided.

   math errorNot applicable

   Not applicable as not all requirements have been assessed.

   math errorNot applicable

   Not applicable as not all requirements have been assessed.

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   Not applicable as not all requirements have been assessed.

   math errorNon-compliant

   The service did not demonstrate that meals provided are varied and of suitable quantity based on consumers' individual needs and preferences.

   • Not met 4(3)(f) — Consumers expressed dissatisfaction with the meals provided, stating that specified menu items are frequently not available and no substitutes are offered for those they cannot eat. Some consumers also reported insufficient quantity of food being served.

   Risks: Risks to consumer satisfaction due to meal dissatisfaction and lack of variety or suitable quantity.

   Recommendations: Continue with planned actions including fortnightly consumer/representative food advisory meetings, individual consultations with consumers, review of dietary profiles, menu revisions, engagement of a new Chef, review of suppliers and processes, implementation of new processes to limit changes in the menu, and use of photograph spot checks and electronic surveys.

   math errorNot applicable

   Not applicable as not all requirements have been assessed.

   math errorNot applicable

   Not applicable as not all requirements have been assessed.

   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.

8. Assessment contact Performance ReportJul 11, 2023

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

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9. Accreditation decisionDec 2, 2022

   Following a site audit conducted on 18 October 2022 to 20 October 2022, the Commission made a decision on 02 December 2022 to re-accredit this service. The period of accreditation of the service will expire on 02 December 2024.

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10. Site AuditDec 2, 2022

    Prepared by Denise McDonald

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

    The performance report highlights that Akooramak Care of Older Persons is compliant in several areas, including services and supports for daily living, the service environment, feedback and complaints handling. However, it faces significant challenges in consumer dignity and choice, ongoing assessment and planning with consumers, personal care and clinical care, human resources management, and organizational governance. The report identifies specific risks related to inadequate risk assessments, staffing shortages, and ineffective training and monitoring processes.

    Standard 1 Consumer dignity and choiceNon-compliant

    The service was compliant in treating consumers with respect and supporting cultural safety, choices, independence, privacy, and clear communication but failed to support consumers taking risks.

    • Met 1(3)(a) — Consumers said they were treated with dignity, respect; and their identity, culture, and diversity were valued.
    • Met 1(3)(b) — Staff described how they treated consumers with respect by using their preferred names, acknowledging their choices, and knocking before entering rooms. Activities included cultural events.
    • Met 1(3)(c) — Consumers felt safe to make decisions about care and services, including intimate relationships.
    • Not met 1(3)(d) — Deficiencies in processes for supporting consumers who wished to undertake risky activities like smoking or using motorized scooters were noted. Documentation of risk discussions was incomplete.
    • Met 1(3)(e) — Consumers received information clearly and promptly, with strategies for diverse cognitive abilities.
    • Met 1(3)(f) — Staff respected privacy and confidentiality protocols were in place.

    Risks: Risks associated with activities like smoking or using motorized scooters were not discussed with consumers.

    Recommendations: Complete consumer assessments to establish risk activities.; Discuss relevant mitigation strategies with consumers.; Review all consumer care plans.

    Standard 2 Ongoing assessment and planning with consumersNon-compliant

    The service was compliant in involving consumers in the assessment process, addressing needs, goals, preferences, and communicating outcomes but failed to effectively inform safe and effective care through risk assessments.

    • Not met 2(3)(a) — Risks associated with cognitive impairments, room locking, and restrictive practices were not consistently determined or documented in care plans.
    • Met 2(3)(b) — Care planning documentation generally identified and addressed consumer needs, goals, and preferences.
    • Met 2(3)(c) — Consumers were involved in assessment and planning through regular conversations with staff.
    • Met 2(3)(d) — Outcomes of assessments were communicated to consumers, and care plans were up-to-date.
    • Met 2(3)(e) — Care was reviewed regularly for effectiveness when circumstances changed or incidents occurred.

    Risks: Risks associated with cognitive impairments and restrictive practices were not consistently assessed.

    Recommendations: Accurately identify risks in care plans.; Consult consumers and representatives where restrictive practices are used.

    Standard 3 Personal care and clinical careNon-compliant

    The service was compliant in managing high-impact risks, addressing end-of-life needs, recognizing changes in consumer conditions, documenting information, making timely referrals, and minimizing infection-related risks but failed to provide tailored personal and clinical care.

    • Not met 3(3)(a) — Toileting assistance was not as planned, resulting in incontinence and anxiety. Bedrails were used without proper documentation.
    • Met 3(3)(b) — High-impact risks like delirium and pressure injuries were managed effectively with strategies recorded.
    • Met 3(3)(c) — Staff attended to end-of-life care, prioritizing comfort and dignity.
    • Met 3(3)(d) — Deterioration in consumer conditions was recognized and responded to promptly.
    • Met 3(3)(e) — Information about consumers' conditions, needs, and preferences was documented and communicated effectively.
    • Met 3(3)(f) — Referral processes were effective with input from various health professionals.
    • Met 3(3)(g) — Infection control practices and antibiotic stewardship were managed well.

    Risks: Toileting assistance was not as planned, leading to incontinence.

    Recommendations: Appoint additional clinical staff.; Develop new monitoring documentation for restrictive practice authorizations.

    Standard 4 Services and supports for daily livingCompliant

    The service was compliant in providing safe, effective services that met consumer needs, promoting well-being, supporting independence, communication, referrals, meal quality, and equipment maintenance.

    • Met 4(3)(a) — Consumers were able to optimize their independence through services provided.
    • Met 4(3)(b) — Services promoted emotional, spiritual, and psychological well-being.
    • Met 4(3)(c) — Consumers were supported to participate in community activities and maintain relationships.
    • Met 4(3)(d) — Information about consumers' conditions, needs, and preferences was communicated effectively.
    • Met 4(3)(e) — Referral processes were effective with input from various health professionals.
    • Met 4(3)(f) — Meals were varied, of suitable quality and quantity.
    • Met 4(3)(g) — Equipment was safe, clean, well-maintained.

    Standard 5 Organisation’s service environmentCompliant

    The service was compliant in providing a welcoming and easy-to-understand environment that supported consumer independence, interaction, safety, cleanliness, and mobility.

    • Met 5(3)(a) — Consumers felt comfortable and at home in the service environment.
    • Met 5(3)(b) — The environment was safe, clean, well-maintained, and enabled free movement indoors and outdoors.
    • Met 5(3)(c) — Furniture, fittings, and equipment were safe, clean, well-maintained, and suitable for consumers.

    Standard 6 Feedback and complaintsCompliant

    The service was compliant in encouraging feedback and making complaints accessible, providing awareness of advocates and language services, taking appropriate action on complaints, and using feedback for improvement.

    • Met 6(3)(a) — Consumers felt they could make complaints without concerns.
    • Met 6(3)(b) — Information about advocacy and translation services was available.
    • Met 6(3)(c) — Appropriate action was taken in response to complaints, with an open disclosure process used.
    • Met 6(3)(d) — Feedback and complaints were reviewed and used for continuous improvement.

    Standard 7 Human resourcesNon-compliant

    The service was compliant in interactions being kind, caring, respectful of identity, culture, and diversity, and staff competence but failed to plan the workforce effectively, train staff adequately, or regularly assess performance.

    • Not met 7(3)(a) — Consumers experienced long delays for assistance due to staffing shortages.
    • Met 7(3)(b) — Staff were kind, caring, and respectful of consumers' individuality.
    • Met 7(3)(c) — Staff had the necessary skills to perform their roles.
    • Not met 7(3)(d) — Deficiencies in training and monitoring processes were noted, with staff lacking knowledge of key elements related to Quality Standards.
    • Not met 7(3)(e) — Most staff had not had their performance reviewed in the past 12 months.

    Risks: Staff shortages led to long delays for assistance.

    Recommendations: Review and extend shifts.; Investigate human resource systems for automatic training alerts.; Improve personnel filing system and electronic recording of staff data.

    Standard 8 Organisational governanceNon-compliant

    The service was compliant in promoting a culture of safe, inclusive care but failed to engage consumers in development and evaluation, maintain effective governance systems, manage risks effectively, or have a clinical governance framework.

    • Not met 8(3)(a) — Consumers were not engaged in the development and evaluation of care services.
    • Met 8(3)(b) — The governing body promoted safe, inclusive care and was accountable for its delivery.
    • Not met 8(3)(c) — Governance systems were ineffective due to staff not being trained in new systems and feeling disconnected from continuous improvement processes.
    • Not met 8(3)(d) — Risk management practices were deficient, with risks for consumers not accurately identified or assessed.
    • Not met 8(3)(e) — Clinical governance framework was still in development and policies on antimicrobial stewardship and minimizing restraints had not been developed.

    Risks: Risks for consumers were not accurately identified or assessed.

    Recommendations: Develop a risk management framework.; Establish an advisory group with consumer involvement.; Implement staff training on new systems.

    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.

11. Exceptional CircumstancesNov 28, 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 23 June 2023 The service remains subject to compliance monitoring by the Aged Care Quality and Safety Commission.

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12. Site audit Performance ReportOct 20, 2022

    A site audit was conducted with this service on 18 October 2022 to 20 October 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

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13. Assessment contact Performance ReportFeb 16, 2022

    An assessment contact was conducted with this service on 16 February 2022. The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

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14. AssessmentOct 16, 2019

    Following a site audit the Commission made a decision on 18 November 2019 that this service met all of the Aged Care Quality Standards. The service is re-accredited for three years until 23 December 2022.

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15. AssessmentSep 29, 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 23 December 2019.

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16. AssessmentOct 17, 2013
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17. AssessmentOct 7, 2010
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No regulatory actions recorded.