Carnarvon Private Hospital
Profile & contact details
|Premises name||Carnarvon Private Hospital|
|Address||20 Lincoln Road Henderson Auckland 0610|
|Service types||Geriatric, Medical|
|Certification/licence name||CHT Healthcare Trust - Carnarvon Private Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 November 2017|
|Certification period||12 months|
|Provider name||CHT Healthcare Trust|
|Street address||97 Great South Rd Market Road Auckland 1543|
|Post address||PO Box 74341 Market Road Auckland 1543|
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: 08 September 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||i) The three restraint care plans reviewed did not document when the restraint was to be initiated or frequency of monitoring required when restraint is in use, and no monitoring of the restraint was evidenced to be occurring. ii) One resident was observed during the audit using a lap belt when in a wheelchair. An incident form noted the resident had unbuckled the belt and slipped from the chair whilst being restrained two weeks prior to audit. On review of the resident file, a restraint asse… (this text has been trimmed due to space limits).||i) Ensure that all residents using a restraint have the required assessments, consents and care plans documented to manage any identified risks. ii) Following any adverse event, the use of the restraint is reviewed and any changes that are required are documented on the care plan.||PA High||Reporting Complete||21/11/2016|
|A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.||One resident was noted on the day of audit to be using a lap belt (restraint) which was not documented on the restraint register.||Ensure the restraint and enabler registers are current.||PA Low||Reporting Complete||21/11/2016|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||i) The hazard register had not been reviewed or updated since December 2014. ii) An incident report dated 23 August 2016 noted the smoke detectors might need replacing. No follow up investigation or action had been taken on the day of audit. iii) Hazard identification reporting by staff was not evidenced. iv) An audit is completed using the hazard register bi-monthly however there is no evidence the hazard register is updated if changes are required, and no evidence corrective actions are do… (this text has been trimmed due to space limits).||i-iv) Ensure that all aspects of the Health and Safety system are implemented. v) Ensure that fire exits remain clear at all times.||PA High||Reporting Complete||21/11/2016|
|The appointment of appropriate service providers to safely meet the needs of consumers.||i) One of seven staff files reviewed did not have a signed employment agreement. ii) Four of seven staff files reviewed did not have a signed job description.||Ensure that all staff have a signed employment agreement and job description on file.||PA Low||Reporting Complete||13/12/2016|
|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.||The long-term care plan for one recent admission was evidenced to have been written before the InterRAI assessment had been completed.||Ensure the InterRAI assessment is completed before the care plan is developed.||PA Low||Reporting Complete||13/12/2016|
|Service delivery plans demonstrate service integration.||A separate folder containing residents care plan summary and other care related information was kept in a folder in each wing for caregivers to read. This duplicate information was not consistently updated when changes to resident’s needs occurred, and no links to this duplicate information were detailed in the resident files. In the files sampled, the nursing assessment and nursing care plan for a respite resident has not been updated on admission to evidence recent changes to the residents’ n… (this text has been trimmed due to space limits).||Ensure that integration of resident information related to care delivery occurs.||PA Moderate||Reporting Complete||13/12/2016|
|All buildings, plant, and equipment comply with legislation.||Electrical equipment in use (one battery charger, 4 electric panel heaters and four TVs in resident bedrooms and 2 power cords) had not been tested and tagged in the required timeframes.||Ensure all electrical equipment is tested and tagged in the required timeframes.||PA Low||Reporting Complete||13/12/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) Two residents with pain had no care plan documented for pain management (wound pain and renal calculi). ii) One resident who had experienced considerable unplanned weight loss prior to admission had no weight management care plan documented. iii) One resident with a history of hallucinations related to a mental health condition had no management plan documented. iv) One resident with previous suicidal ideology reported on the resident satisfaction survey they wanted to die. No care p… (this text has been trimmed due to space limits).||i-iv) Ensure care plans are documented to reflect the residents’ current needs.||PA High||Reporting Complete||13/12/2016|
|Consumers have a right to full and frank information and open disclosure from service providers.||Six of seven incident forms reviewed did not evidence communication to families/EPOAs following an untoward event.||Ensure that communication with families/EPOA occurs following untoward events and this is clearly documented.||PA Low||Reporting Complete||08/02/2017|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||i) Currently the strategic business plan or risk management plan are not being implemented or followed. ii) There was no documented evidence to identify the 2012 – 2017 strategic business plan having had an annual review since 2014.||i) Ensure that there is a strategic business plan and a risk management plan in place and these plans are fully implemented. ii) Ensure that the strategic business plan and the risk management plan are reviewed at least annually.||PA Low||Reporting Complete||08/02/2017|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||i) The documented strategic and business plan and risk management plan are not fully implemented. ii) Previous audit history or evidence of internal audits completed could not be located on the day of audit. A new internal audit programme introduced 29 July 2016 was not fully implemented to identify actions, follow through and reporting.||i) Ensure that all aspects of the quality and risk management system are implemented. ii) Ensure that there is a system for storing and retrieving organisational data and information.||PA Moderate||Reporting Complete||08/02/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) The clinical indicator data is collected but not analysed, trended or evaluated. ii) Health and Safety inspection audits were evidenced, however these audits were not consistently dated or correction actions documented.||i) Ensure that all clinical indicator data is consistently collected, analysed and trended. ii) Ensure that the results of audits and the corrective actions required are consistently communicated to all staff.||PA Moderate||Reporting Complete||08/02/2017|
|A process to measure achievement against the quality and risk management plan is implemented.||Only one of the scheduled audits on the organisation’s scheduled audit planner had been completed since the surveillance audit in May. Other audits have been completed, however not all sections of the audit tool used were consistently completed.||Ensure that the monitoring schedule is fully implemented and all sections of the audit tool are fully completed.||PA Low||Reporting Complete||08/02/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||i) No corrective action plans were sighted or remedial actions evidenced where clinical indicator data, identified areas requiring improvement. For example, areas that were above an acceptable benchmark included falls, bruises and skin tears. ii) No corrective action plans had been developed and implemented for the deficits noted in the care documentation audits completed in July and September 2016. iii) Not all corrective action plans that had been documented, were evaluated for effectiven… (this text has been trimmed due to space limits).||i-iii) Ensure that corrective actions are documented and implemented where areas are identified requiring improvement.||PA Moderate||Reporting Complete||08/02/2017|
|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.||Two of two current pressure injuries had not had an accident and incident form completed. Not all sections of the accident incident forms were consistently completed.||Ensure that all pressure injuries are reported on an accident and incident form. Ensure incident forms are fully completed.||PA Low||Reporting Complete||08/02/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Four of seven files reviewed did not have evidence of an orientation having been completed.||Ensure that all staff complete the required orientation and that there is a record of this kept on their employment file.||PA Low||Reporting Complete||08/02/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||i) Two of two residents with pressure injuries (one stage 1 and one stage 3) did not have pressure injury prevention and management strategies fully documented. ii) Not all interventions in use (applying moisturiser to the skin and use of pressure relieving equipment) were documented for one resident with a stage three pressure injury. iii) Six of six wounds reviewed did not have a current comprehensive wound assessment documented (including the hospital tracer.) iv) Six of six wounds revie… (this text has been trimmed due to space limits).||i) Ensure that all wounds have detailed assessments documented, and that wound management plans contain sufficient detail to direct wound management. ii) Ensure that all interventions in use are documented. iii) Ensure that there is a comprehensive initial wound assessment and a wound assessment completed with each dressing change. iv) Ensure that there is a comprehensive wound management plan documented for each wound.||PA Moderate||Reporting Complete||08/02/2017|
|Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).||The duration of restraint episodes was not evidenced to be evaluated on six monthly restraint evaluation or monthly individual resident restraint audits reviewed.||Ensure that the duration of restraint episode is evaluated to ensure it is for the least amount of time required.||PA Low||Reporting Complete||08/02/2017|
|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) One recent permanent hospital admission did not have an InterRAI assessment completed within 21 days of admission. ii) Two of four files reviewed for residents who had been at the service for longer than six months did not have the InterRAI assessments reviewed six monthly.||i) Ensure InterRAI assessments are completed within the required timeframes. ii) Ensure that all InterRAI assessments are reviewed within the required timeframes.||PA Low||Reporting Complete||18/04/2017|
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: 08 September 2016
Audit type:Provisional Audit