Arbor House Rest Home
Profile & contact details
|Premises name||Arbor House Rest Home|
|Address||48 Main Street Greytown 5712|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Arbor House Trust - Arbor House Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||17 August 2018|
|Certification period||24 months|
|Provider name||Arbor House Trust|
|Street address||48 Main Street Greytown 5712|
Progress on issues from the last audit
What’s on this page?
This rest home has been audited against the Health and Disability Services Standards. During the last audit, the auditors identified some areas for improvement.
Issues from their last audit are listed in the corrective actions table below, along with the action required to fix the issue, its risk level, and whether or not the issue has been reported as fixed.
A guide to the table is available below.
Details of corrective actions
Date of last audit: 14 June 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) 13 out of 28 internal audits reviewed, did not have corrective actions signed off when completed; ii) Staff and quality/RN meeting minutes lack documented evidence around discussions and required corrective actions; iii) Corrective actions have not been developed for all identified issues.||i) Ensure that all action plans are signed off when completed; ii)) Ensure that staff and quality/RN meeting minutes include discussions around quality data or any other issues and that the follow-up process is identified and completed; iii) Ensure that corrective actions are developed and completed for all identified issues.||PA Low||Reporting Complete||28/11/2016|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||(i) Oxygen had not been prescribed on the electronic medication system for a hospital resident on continuous oxygen. (ii) Three of seven medication charts on the electronic medication system did not have indications for the use of ‘as required’ medications. (iii) The standing orders format did not include the maximum dose, frequency or dosage for all medications prescribed on the standing orders format.||Ensure the prescribing of all medications meets legislative requirements.||PA Moderate||Reporting Complete||13/09/2016|
|The responsibility for restraint process and approval is clearly defined and there are clear lines of accountability for restraint use.||No job description defined the role and responsibilities of the restraint coordinator.||Ensure that a job description for the restraint coordinator is in place||PA Low||Reporting Complete||13/09/2016|
|All buildings, plant, and equipment comply with legislation.||Hot water temperatures in resident areas have not been monitored monthly.||Ensure hot water temperatures in resident areas are monitored monthly.||PA Low||Reporting Complete||11/10/2016|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Of the twelve resident related incident forms reviewed, documentation following incidents evidenced the following: Five incidents did not have documented RN assessment or sign off. Five incidents did not document if next of kin had been informed.||Ensure that there is documented RN assessment and sign-off of incident forms, including documented evidence of family notification.||PA Moderate||Reporting Complete||11/10/2016|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||(i) In the four restraint files reviewed, there were no documented assessments that meet criteria (a) to (h). (ii) Risks identified with the use of restraint had not been identified in the long-term care plans for two residents on restraint. (iii) The use of restraint had not been identified in the long-term care plan of one resident on restraint.||(i) Ensure that all restraint assessments are completed prior to the use of restraint. (ii) and (iii) Ensure the use of restraint and the risks associated with the use of restraint is documented in the resident’s long-term care plan.||PA Moderate||Reporting Complete||08/11/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i) Four staff files out of six reviewed did not have up-to-date annual staff performance appraisal; (ii) The staff have not completed pressure injury prevention training in the last two years.||Ensure that staff performance appraisals are completed annually.||PA Low||Reporting Complete||28/11/2016|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The self-medication competency had not been reviewed three monthly.||Ensure self-medication competencies are reviewed three monthly.||PA Low||Reporting Complete||28/11/2016|
|All records are legible and the name and designation of the service provider is identifiable.||Records overall within resident files were signed, however progress notes reviewed did not have recorded time of entry.||Ensure all progress note records have recorded time of entry.||PA Low||Reporting Complete||28/11/2016|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||ARC D16.12c Initial assessments and initial care plan had not been completed for one rest home and one hospital resident on admission (within 24 hours).||Ensure all residents have an initial assessment and initial care plan completed on admission to cover a period of up to 21 days.||PA Low||Reporting Complete||28/11/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) There were no documented interventions for three hospital level residents with unintentional weight loss. (ii) Fortnightly weights had not been completed as per short-term care plan for one rest home resident (tracer) with weight loss and the short-term care plan had not been reviewed to reflect current weight loss.||Ensure interventions for changes to health status are documented and implemented.||PA Low||Reporting Complete||28/11/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||The long-term care plans did not reflect the resident’s current needs for: (i) A hospital level resident with changes to care following a hospital admission. (ii) A hospital resident with changes to mobility and at high risk of a pressure injury (tracer resident). (iii) A rest home resident identified at high risk of falls. (iv) No diabetic management plan for two insulin dependent residents (one rest home and one hospital).||Ensure care plans reflect the resident’s current health status.||PA Moderate||Reporting Complete||28/11/2016|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||There is no documented evidence of an annual review of the infection control programme.||Ensure the infection control programme is reviewed at least annually.||PA Low||Reporting Complete||28/11/2016|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||(i) Three out of ten medication charts did not document evidence of GP three monthly reviews (ii) Three of ten medication charts reviewed did not document the indication for use of ‘as required’ medications.||(i) Ensure that medication charts are reviewed by a GP three monthly (ii) Ensure medication charts document the indication for use of prescribed ‘as required’ medications.||PA Moderate||In Progress|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||i) Two of three hospital files reviewed did not have a long-term care plan completed (both residents had been residing at the facility for more than 21 days). (ii) InterRAI assessments were not completed within 21 days of admission in four of five (three hospital and one rest home) resident files reviewed.||Ensure interRAI assessments and long-term care plans are completed within 21 days of admission.||PA Low||In Progress|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Of the eleven resident-related incident forms and progress notes reviewed three incidents did not have documented RN assessment following a fall.||Ensure that RN assessment following an incident is documented.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||The long-term care plans did not reflect the interventions to support all residents’ current needs for three residents: (i) A hospital level resident identified with a chronic wound and insulin dependent diabetes had no pain management, no pressure area care prevention and management, no diabetes management or nutrition management documented (link to tracer 188.8.131.52); (ii) A rest home level resident identified with current behavioural issues had no behavioural management plan (link to tracer 1.3.… (this text has been trimmed due to space limits).||Ensure that care plans reflect the required support or interventions to meet the resident’s needs.||PA Moderate||In Progress|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
Whether the required outcome was partially attained (PA) or unattained (UA), and what the risk level of the issue is.
The outcome is partially attained when:
- there is evidence that the rest home has the appropriate process in place, but not the required documentation
- when the rest home has the required documentation, but is unable to show that the process is being implemented.
The outcome is unattained when the rest home cannot show that they have the needed processes, systems or structures in place.
The risk level is determined by two things: how likely the issue is to happen and how serious the consequences of it happening would be.
The risk levels are:
- negligible – this issue requires no additional action or planning.
- low – this issue requires a negotiated plan in order to fix the issue within a specified and agreed time frame, such as one year.
- moderate – this issue requires a negotiated plan in order to fix the issue within a specific and agreed time frame, such as six months.
- high – this issue requires a negotiated plan in order to fix the issue within one month or as agreed between the service and auditor.
- critical – This issue requires immediate corrective action in order to fix the identified issue including documentation and sign off by the auditor within 24 hours to ensure consumer safety.
The risk level may be downgraded once the rest home reports the issue is fixed.
Whether the necessary action is still in progress or if it is complete, as reported by the rest home to the relevant district health board.
Date action reported complete
The date that the district health board was told the issue was fixed.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
Full audit reports are provided for audits processed and approved after 29 August 2013. Note that the format for the full audit reports was streamlined from 16 December 2014. Full audit reports between 29 August 2013 and 16 December 2014 are therefore in a different format.
Prior to 29 August 2013, only audit summaries are available.
Both the recent full audit reports and previous audit summaries include:
- an overview of the rest home’s performance, and
- coloured indicators showing how well the rest home performed against the different aspects of the Health and Disability Services Standards.
Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reportsAudit date: 14 June 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Surveillance Audit
Audit type:Certification Audit; Verification Audit
Audit type:Surveillance Audit