Aversham House

Profile & contact details

Premises details
Premises nameAversham House
Address 88 Cole Street Masterton 5810
Total beds21
Service typesRest home care
Certification/licence details
Certification/licence nameAversham House (2006) Limited - Aversham House
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence25 May 2019
Certification period36 months
Provider details
Provider nameAversham House (2006) Limited
Street address 88 Cole Street Masterton 5810
Post address

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: 03 March 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.1) Two of ten medication charts had not been reviewed three monthly by the GP. 2) Household medications had been administered for four out of ten residents as sighted on the non-packaged signing sheets. There was no evidence of verbal orders or standing orders in place for the administration of panadol, laxsol, mylanta or ural sachets. The medications had not been prescribed on the resident medication charts. 3) Discontinued medications on four medication charts were not dated and signed whe… (this text has been trimmed due to space limits).1), 2) and 3). Ensure the prescribing, review and administration of medications meets legislative requirements. 4) Ensure weekly stock-take is completed for all controlled drugs. PA ModerateReporting Complete01/08/2016
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.1) One resident admitted for permanent care does not have an interRAI assessment and long-term care plan developed within the required timeframe. 2) One resident has not had six monthly evaluations of the long-term care plan. 1) Ensure interRAI assessments and long-term care plans are developed within 21 days of admission. 2) Ensure care plans are evaluated at least six monthly. PA LowReporting Complete01/08/2016
Consumers have a right to full and frank information and open disclosure from service providers.There was no documented evidence of notification to the next of kin for five of ten accident/incidents. Ensure the next of kin are notified for all accidents/incidents unless requested otherwise. PA LowReporting Complete02/12/2016
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.(i) Four of ten accident/incident forms did not evidence RN manager sign off. (ii) Two current pressure injuries were not reported as incidents. Ensure there is RN manager sign off for all accident/incidents reported. PA LowReporting Complete02/12/2016
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i) There was no documented evidence of resident meetings between January and July 2015 and from September to December 2015. (ii) The two current pressure injuries have not been included in quality monitoring data or discussed in meetings. (i) Ensure resident meetings are held as scheduled and recorded in meeting minutes. (ii) Ensure that all pressure injuries are included in quality monitoring data and discussed in meetings. PA ModerateReporting Complete02/12/2016
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.The infection control programme has not been reviewed annually. Ensure the infection control programme is reviewed annually. PA LowReporting Complete02/12/2016
The appointment of appropriate service providers to safely meet the needs of consumers.1) Three of five staff files had no evidence of signed job descriptions. 2) Five of five staff files reviewed did not have an annual performance appraisal. 1) Ensure that signed job descriptions are in staff files. 2) Ensure staff performance appraisals are completed annually. PA LowReporting Complete02/12/2016

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: 03 March 2016

Audit type:Certification Audit

Audit date: 24 September 2014

Audit type:Surveillance Audit

Audit date: 25 March 2013

Audit type:Certification Audit

Audit date: 06 December 2011

Audit type:Surveillance Audit

Audit date: 18 March 2010

Audit type:Certification Audit

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