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How Anchor Excellence enabled a sanctioned and heavily non-compliant aged care home to return to compliance.

The Organisation

A medium-sized residential aged care facility, sanctioned for not complying with its responsibilities under Part 4.1, 4.2 and  4.3 of the Specify Aged Care Act. The sanction was applied by the Department of Health in November 2018 as a consequence of 22/44 Standards (per Schedule 2 of the Quality of Care Principles) and identification of 5 critical deficiencies:

  • Specialised nursing care needs
  • Continence management
  • Emotional support
  • Infection control and
  • Human resource management

The Challenge

As part of the sanction, the approved provider was required to appoint both an Advisor and Administrator for the period of the sanction. Anchor Excellence’s Cynthia Payne (Advisor) and John Engeler (Administrator) commenced appointment on 8 December 2018.

These statutory appointments are obliged on the approved provider as part of its requirements to return the home to compliance. In addition to the Sanction for Accreditation Standards, the home also was provided with a notice of non-compliance for ACFI (breach of records principles) and a notice of non-compliance for Prudential (breach of permitted uses).

At the time of Anchor Excellence’s commencement, the home had a newly appointed GM. The organisation itself is privately owned by a family-owned business, with a board consisting of four directors.

Anchor Excellence rapidly improved the distressed organisation by utilising its leadership team, frameworks and programs.

The Result

The home was supported using the signature Anchor Compliance Remediation Framework. With the home’s leadership team relatively new and inexperienced, support was delivered at board and at the home level.

Remedying all critical deficiencies was a fundamental priority. A Daily Report template was implemented, and a stakeholder communication plan deployed, in order to engage the home’s active communities in our appointment and highlight what was involved in the sanction. Anchor Excellence offered vital support through weekly meetings with the leadership team (including calls with case managers from the Department of Health), as well as providing coaching/mentoring across the whole team; from the Board, Senior Executives and Managers to the Care Team, Lifestyle, Kitchen and Maintainance.

During our time with the home:

  • Together with the home’s quality manager, we project planned the implementation of the QPS quality audit systems
  • Assisted the home to implement Altura online education tools,  enabling staff competencies in key areas of focus
  • We realised performance with the leadership team to design and implement a comprehensive HR management system (together with HR Advisor firm)
  • The home moved from 30% utilisation of MANAD care systems to 90%
  • The CI plan was fully integrated into the homes clinical management systems
  • Provided the home Clinical team training on High Impact risk and deployed the signature HIRA-E risk tool
  • Attendance at Resident and Relative meetings increased by 60%
  • New care programs and initiatives were implemented (See below – Living Well)
  • Anchor Excellence’s (Cynthia and John) attended monthly board meetings to ensure AP direct engagement and education.

As part of the transformation process, the ‘Living Well‘ project was implemented by Anchor Excellence’s Dr Maggie Haertsch to address the behavioural support neighbourhood. This project successfully established a relationship-based model of care to the home. Anchor Excellence leader, Claire Ward, worked in tandem to ensure a consumer-centric culture and was the project lead for the implementation of QPS; transitioning the policies and procedures to reflect the new quality standards.


The home successfully returned to compliance before the Time For Improvement deadline (TFI).


The Anchor Excellence Team transitioned the distressed organisation out of sanction, which in turn enabled it to take admissions and focus on a quality ‘lived experience’ for its residents. The ACFI matters were verified back to compliance together with Prudential compliance. Anchor Excellence continues to support the home with its monthly ‘AnchorAssure Home Review’ to give the Board and the executive the ongoing coaching and advice to sustain its new performance.

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