Ashlea Grove Rest Home

Profile & contact details

Premises details
Premises nameAshlea Grove Rest Home
Address 41 Centennial Avenue Milton 9220
Total beds37
Service typesDementia care, Rest home care
Certification/licence details
Certification/licence namePhantom 2021 Limited - Ashlea Grove Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence22 December 2025
Certification period36 months
Provider details
Provider namePhantom 2021 Limited
Street address35 Centennial Avenue Milton 9220
Post address35 Centennial Avenue Milton 9220

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: 04 October 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.Partial Provisional: i). Ensure the proposed area is secure and the rest home area is closed off appropriately. ii). The deck is yet to be built to include planters and areas of interest and made secure. iii). A ramp and new path are yet to be built to provide access to the rest home area. iv). The existing entrance to the facility will need to be made secure. v). The manager’s office and nurses’ station are yet to be reconfigured, furnished and functional. vi). The proposed new dining room and … (this text has been trimmed due to space limits).i). – vi). Ensure all building and refurbishments are completed, and the unit is made secure. This will need to be verified by the Funder as suitable prior to occupancy. PA LowIn Progress
A medication management system shall be implemented appropriate to the scope of the service.Partial Provisional: (i). The medication room is yet to be built, furnished, fully functional with handwashing facilities and made secure. (ii). A lockable medication trolley is yet to be purchased for the reconfigured dementia unit. i). & ii). Ensure the medication room is fully functional and made secure and a lockable medication trolley is purchased. Ensure this is verified as suitable by the funder prior to occupancy. PA LowIn Progress
The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination.The two residents using restraint had no documentation to reflect that monitoring was completed in a timely manner when restraint was utilised. Ensure there is documented evidence that restraints are monitored when in use and the frequency of monitoring related to risk. PA ModerateReporting Complete24/03/2023
Each episode of restraint shall be evaluated, and service providers shall consider: (a) Time intervals between the debrief process and evaluation processes shall be determined by the nature and risk of the restraint being used; (b) The type of restraint used; (c) Whether the person’s care or support plan, and advance directives or preferences, where in place, were followed; (d) The impact the restraint had on the person. This shall inform changes to the person’s care or support plan, resulting f… (this text has been trimmed due to space limits).i). There is no documented evidence that interim restraint was evaluated daily during the time restraint was being used to manage residents with acute changes in health status. ii). The restraint register had not been updated to reflect restraints no longer in use. i). Ensure any use of short-term restraint is evaluated on a daily basis and documentation reflects this. ii). Ensure the register is updated when restraint is no longer required. PA LowReporting Complete24/03/2023
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).i). Two of the six care plans reviewed had evaluations documented that were not consistent with the residents’ goals. ii). Three of six care plans reviewed did not document progression towards meeting goals. i). & ii). Ensure evaluations reflect the current goals of residents. PA LowReporting Complete04/04/2023

Guide to table

Outcome required

The outcome required by the Health and Disability Services Standards.

Found at audit

The issue that was found when the rest home was audited.

Action required

The action necessary to fix the issue, as decided by the auditor.

Risk level

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.

Action status

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.

Audit reports

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. 

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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 reports

Audit date: 04 October 2022

Audit type:Partial Provisional Audit; Certification Audit

Audit date: 02 December 2021

Audit type:Provisional Audit

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