BeachHaven Hospital

Profile & contact details

Premises details
Premises nameBeachHaven Hospital
Address 249 Birkdale Road Beach Haven Auckland 0626
Total beds99
Service typesPhysical, Intellectual, Psychogeriatric, Medical
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - BeachHaven Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence02 July 2019
Certification period48 months
Provider details
Provider nameBupa Care Services NZ Limited
Street addressLevel 2 109 Carlton Grove Road Newmarket Auckland 1023
Post addressPO Box 113054 Newmarket Auckland 1149
Websitewww.bupa.co.nz/

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: 29 May 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The appointment of appropriate service providers to safely meet the needs of consumers.i) Three of thirty-eight caregivers who have been at the service longer than twelve months, have not completed the required dementia standards. Two are in progress and one who has been employed since 2010 has not yet started. ii)Annual competencies could not be evidenced for all staff that require competencies in relation to: manual handing; nebuliser use; oxygen usage; peg feeds; restraint; subcutaneous fluids; and syringe drivers. i-ii) Ensure that all staff who work at the service have completed the training and annual competencies required to meet all organisational contractual and legal requirements. PA LowIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective action plans are being implemented but not consistently documented where the quality data is identifying areas requiring improvement. Not all audits with low results (e.g.: activities, restraint, multidisciplinary reviews, care planning and medication) were re- audited to determine the effectiveness of corrective actions Ensure that the corrective actions implemented are documented where opportunities for improvement are noted. Ensure internal audits are re-audited following corrective actions where results are below expected percentage PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i)Falls prevention strategies documented for three residents (one hospital and two psychogeriatric) did not reflect the assessed high falls risk; (ii) Monitoring forms had not been implemented following accident/incidents for three psychogeriatric residents (two for behaviours and one for two-hourly turns); (iii) There had been no RN follow up post ‘found medication’ error for one psychogeriatric resident; (iv) Interventions had not been updated for one hospital resident – long term chronic hea… (this text has been trimmed due to space limits).(i) Ensure falls risk strategies reflect the level of falls risk; (ii) Ensure monitoring forms are implemented as per accident/incident corrective action plans; (iii) Ensure ‘medication found’ errors are investigated and recommendations implemented; (iv) and (v) Ensure interventions are documented and implemented for changes in health status. (vi) Ensure restraint risks are interventions are documented. PA ModerateIn Progress
Consumers have a right to full and frank information and open disclosure from service providers.Three of nine incident and accident forms reviewed (psychogeriatric) did not evidence that family were notified of the adverse event. Ensure that families are advised of all adverse events unless families have indicated otherwise. PA LowIn Progress
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.i)Creams and lotions were sighted on three bedside cabinets (one in East wing – hospital and two in Tui – psychogeriatric unit) and in one bathroom (East wing – hospital); and (ii) One hospital resident had been administered oxygen in an emergency. The policy was followed. However, Oxygen had not been prescribed or on the standing orders. (i)Ensure all medications are stored safely; and (ii) Ensure oxygen is prescribed as required prior to administration. PA ModerateIn Progress
Service providers responsible for medicine management are competent to perform the function for each stage they manage.Annual medication competencies have not been completed for the clinical manager, one RN (completed on day of audit), one enrolled nurse and one senior caregiver. Ensure annual medication competencies are completed and the person assessing medication competencies has also completed the required competency assessments. PA ModerateReporting Complete04/09/2017

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: 29 May 2017

Audit type:Surveillance Audit

Audit date: 13 April 2015

Audit type:Certification Audit

Audit date: 25 March 2014

Audit type:Surveillance Audit

Audit date: 01 May 2012

Audit type:Certification Audit

Audit date: 15 March 2011

Audit type:Surveillance Audit

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