Aspen

Profile & contact details

Premises details
Premises nameAspen
Address 27 McLean Street Tauranga 3110
Total beds54
Service typesMedical, Rest home care, Geriatric
Certification/licence details
Certification/licence nameAspen Lifecare Limited
Current auditorThe DAA Group Limited
End date of current certificate/licence23 September 2018
Certification period36 months
Provider details
Provider nameAspen Lifecare Limited
Street addressLevel 2 111 Johnsonville Johnsonville Wellington 6037
Post addressPO Box 13223 Johnsonville Wellington 6440

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: 01 March 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.While some improvement has been made, corrective action plans are still not being created which specifically describe the required improvement, identify a specific plan for addressing the noted deficits, and enable monitoring the plan through to completion. The organisation has a ‘quality improvement plan’ form. This document is to be used for both corrective action plans and quality improvement initiatives. Start using this document whenever a corrective action plan is required. PA ModerateIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Review of this spreadsheet identifies that approximately one third of staff have not completed all required topics over the whole year. This includes challenging behaviours training both for people with dementia and due to other causes. Kitchen staff in charge of cooking and kitchen management have completed the required unit standards (167 and 168), this was more than five years ago for the main cooks. There has not been any recent training / refresher education in these topics. See also CAR 1… (this text has been trimmed due to space limits).Keep an overview of staff completing required, ongoing training and education. Ensure that staff attend the required training and that the training programme incorporates additional topics when these are identified. PA LowIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.Two of three residents had an initial assessment to assess for safe self-administration of medicines, however there is no evidence to support the required three monthly ongoing competency assessments to meet contractual requirements. To ensure that the facility meets the contractual requirements for residents whom are self-administrating medications. PA LowIn Progress
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.All information about assessed and support needs was evident in residents’ files reviewed, however not all information was identified specifically in the long-term care plans for each resident. All information and required interventions pertaining to the resident is identified in the resident’s care plan and meets the individual’s needs and contractual requirements. PA LowIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.While some improvement has been made not all interventions undertaken are identified in residents’ care plans. Provide evidence that care plans describe all the required support and interventions to achieve each resident’s desired outcome. PA LowIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.There is limited analysis of quality improvement data. Other than analysis of infections, other ‘Clinical indicator’ data is only being analysed on a monthly basis and at a simplistic level. Trends in the data for individual residents are potentially being overlooked and issues are possibly not being identified. See also CAR 1.2.3.8 There is no analysis of data for individual residents over longer periods of time or consideration of all the factors involved in all the events for an individual.… (this text has been trimmed due to space limits).Quality improvement data is analysed so that meaningful conclusions can be drawn and risks managed effectively. The data is reviewed over longer periods of time than one month. PA ModerateIn Progress
There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.The specific forms required in policy to be completed related to the use/need of antibiotics have not been completed for residents who require them. Provide evidence that all infection control policies and procedures are implemented. PA LowReporting Cancelled
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Not all interventions undertaken are identified in residents’ care plans, for example, one resident with a specific religious belief did not have this identified on their care plan, and there are no specific requirements about how this will be managed in the care planning process documentation. No wound care information is shown on the care plans to identify required support and or interventions. One of the six residents’ files had a behaviour monitoring chart but the behavioural issues were n… (this text has been trimmed due to space limits).Provide evidence that care plans describe all the required support and interventions to achieve each resident’s desired outcome. PA LowReporting Cancelled
The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.One of six resident files did not have any completed assessments and one file had partially completed assessments. Two of the six residents’ files reviewed had wounds but no wound care assessments were completed. Provide evidence that appropriate assessment tools are completed to serve as the basis for service delivery planning. PA LowReporting Cancelled
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Education has not been presented to match the organisational educational calendar. Limited education has been presented on-site since November 2014 as identified in staff education records. Provide evidence that the expected education, as shown on the 2015-2016 education calendar, is presented as a minimum to maintain staff knowledge and skills. PA LowReporting Cancelled
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.The evaluations undertaken are not always completed for all aspects of care and do not always identify the degree of achievement towards meeting set goals. Provide evidence of care plan evaluations that indicate the degree of achievement toward meeting the goals set. PA ModerateReporting Cancelled
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Documentation was not sighted for all corrective actions. The facility manager confirms corrective actions have not been specifically documented and therefore no evidence was available that corrective action follow up was completed. Provide evidence that corrective action planning is consistently documented to an auditable level to identify how areas identified for improvement are being met. PA LowReporting Cancelled

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. 

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 reports

Audit date: 01 March 2017

Audit type:Surveillance Audit

Audit date: 06 August 2015

Audit type:Certification Audit

Audit date: 16 July 2014

Audit type:Provisional Audit

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