The Birches 3554

Assessment contact Performance Report

An assessment contact was conducted with this service on 10 October 2023 to 10 October 2023.

The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the assessment contact.

Accreditation decision

Following a site audit conducted on 03 May 2022 to 06 May 2022, the Commission made a decision on 07 June 2022 to re-accredit this service.

The period of accreditation of the service will expire on 07 June 2025.

Site audit Performance Report

A site audit was conducted with this service on 03 May 2022 to 06 May 2022.

The attached Performance Report details the assessment of performance against the Aged Care Quality Standards following the site audit.

Exceptional Circumstances

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 30 September 2022.

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

Exceptional Circumstances

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 01 March 2022.

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

Compliance monitoring update

An assessment contact was conducted by the Aged Care Quality and Safety Commission (Commission) on 13 August 2019 at The Birches to monitor the service’s progress in meeting the Accreditation Standards. The Commission found the service complies with all Accreditation Standards.

Following an audit we decided that this service met 38 of the 44 expected outcomes of the Accreditation Standards and would be accredited for two years until 30 August 2021.

Serious risk decision

Following a Site Audit conducted on 7 to 8 May 2019, a delegate of the Aged Care Quality and Safety Commissioner made a decision that Western District Health Service failed to meet five expected outcomes in the Accreditation Standards in relation to The Birches.

On 11 June 2019 a decision was made that failure to meet one of these expected outcomes has placed the safety, health or wellbeing of a consumer of the service at serious risk. The Department of Health has been notified of the risk.

Serious risk is not an ongoing state; it is a statutory decision based on evidence at a point in time.

The Aged Care Quality and Safety Commission will continue to monitor the performance of the service including through unannounced visits.

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 30 October 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 30 October 2018.

This decision has been reconsidered and as a result the period of accreditation for this home will now expire on 30 August 2019.  The reconsideration decision and audit report is attached.