Cedar Manor Rest Home & Hospital

Profile & contact details

Premises details
Premises nameCedar Manor Rest Home & Hospital
Address 30 Sixth Avenue Tauranga 3110
Total beds92
Service typesMedical, Dementia care, Rest home care, Geriatric
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - Cedar Manor Rest Home & Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence31 January 2018
Certification period36 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: 25 May 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff attendance numbers are very low meaning insufficient staff have completed required trainings. For example, (out of 100 staff), over 2015 and 2016 to date, three have attended health and safety training, two falls prevention training, six pressure injury prevention training, eleven infection control training, eleven challenging behaviour management training and six cultural safety training. Provide evidence that sufficient staff have attended compulsory and scheduled training. PA LowIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.One resident who self-administers in the rest home did not have a three monthly GP review of the consent/competency as per policy. Ensure that the GP reviews the self-medication competency three monthly. 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) One rest home level care plan contradicted itself with regard to how often the resident should be weighed. (ii) One resident in the dementia unit, with behaviours that challenge, did not have interventions documented to manage the behaviour. (iii) Ongoing pain assessments for two rest home and two hospital residents with identified pain were not documented. (i) Ensure care plans document consistent advice. (ii) Ensure care plan interventions are documented for behaviour that challenges (iii) Ensure ongoing pain monitoring is documented for resident with identified pain. PA LowIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Infection control, quality and staff meeting minutes did not document discussion around analysis of trends of accident/incident or infection control data. Ensure quality data analysis results are communicated to service providers. 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) Start and stop dates and/or a prescriber signature for short-term medication was not present for three dementia and two hospital medication charts. (ii) ‘As required’ medications did not have the time of administration documented for one rest home and two dementia charts. (iii) One hospital resident medication files reviewed evidenced two medication charts. (iv) Gaps in staff administration signatures were noted on regular medications for two rest home charts. (i) Ensure that prescribers document all medications as per direction on the chart and policy. (ii) Ensure that ‘as required’ medications have the time of administration documented. (iii) Ensure residents have only one medication chart. (iv) Ensure that staff always sign on administration. PA ModerateIn 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.Three out of the nine medication charts sampled in the dementia wing showed PRN medications that are signed as given but without times. Times were documented in the progress notes and therefore a low risk has been awarded. Ensure all PRN medications have the time given documented at the time at the time of administration PA LowReporting Cancelled
All records are legible and the name and designation of the service provider is identifiable.(i)Changes to interventions on care summaries were not always dated; (ii) follow up on incident forms by RNs were not always dated or included times. Ensure dates and times are routinely documented by the writer PA LowReporting Cancelled
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) In two out of ten permanent resident files (rest home, hospital) the evaluations were not completed within the six month time frame. (ii) In the rest home tracers file and a dementia file, progress notes continuity of care was not documented, (iii) In one of the two rest homes files sampled the resident’s MNA was not completed although the resident was underweight (i) Ensure evaluations are completed within the six month time frames or earlier as required; (ii) Ensure continuity of care is documented in all resident progress notes, (iii) Ensure risk assessments are completed on admission as per policy. 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: 25 May 2016

Audit type:Surveillance Audit

Audit date: 24 November 2014

Audit type:Certification Audit

Audit date: 26 February 2014

Audit type:Surveillance Audit

Audit date: 04 April 2013

Audit type:HealthCERT Inspection

Audit date: 27 November 2012

Audit type:Certification Audit

Audit date: 09 January 2012

Audit type:Surveillance Audit

Audit date: 15 November 2010

Audit type:Certification Audit

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