Devonport Palms Retirement Complex

Profile & contact details

Premises details
Premises nameDevonport Palms Retirement Complex
Address 194 Devonport Road, Tauranga 3110
Total beds30
Service typesRest home care
Certification/licence details
Certification/licence nameDevonport Palms Retirement Limited - Devonport Palms Retirement Complex
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence18 October 2018
Certification period36 months
Provider details
Provider nameDevonport Palms Retirement Limited
Street address 194 Devonport Road Tauranga 3110
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: 15 May 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.A trial fire evacuation has not been held six-monthly. The last trial fire evacuation was in May 2016 Ensure that trial fire evacuations are held at least six-monthly PA ModerateIn Progress
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.The standing orders in use do not comply with the Standing Orders Guidelines 2016. Ensure that the standing orders in use comply with the Standing Orders Guidelines 2016. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) Five of five care plans sampled do not have the interRAI assessment outcomes/scores transferred to the long-term care plans in relation to falls risk, pressure injury risk, and undernutrition and bowel management. ii) Five of five care plans sampled do not document care plan interventions for all assessed needs. Where care plan interventions were documented, they did not fully describe all support required. Examples include; management of: behaviours, an indwelling catheter, mobility, high… (this text has been trimmed due to space limits).i) Ensure that all relevant assessment scores/outcomes are transferred to the long-term care plan. ii-iii) Ensure that care plan interventions are documented for all assessed care needs and in sufficient detail to guide the care staff. iv) Ensure that all sections of the template care plan are completed fully. PA ModerateIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.i) The food preparation bench top is made of formica and pieces of formica have broken off leaving exposed wood. ii) The cupboards under the kitchen sink have chipped paint on the edges leaving exposed wooden surfaces. ii) The lino is cracked and peeling. Ensure that all outstanding maintenance in the kitchen is completed. PA ModerateIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.i) Two of five residents with a previous history of constipation have no evidence of monitoring of bowel activity documented. ii) Five of five residents following an unwitnessed fall do not have the clinical monitoring required by the organisations falls policy documented. I-ii) Ensure that all required monitoring is documented. PA LowIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Three of four activity care plans due for review, have not been reviewed in the required timeframes, or reviewed in conjunction with a review of the long-term care plan or reviewed against the resident’s stated goals. Ensure all activity care plans are reviewed at least six-monthly and are reviewed at the same time as a review of the long-term care plan and reviewed against the resident’s stated goals. 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) There was no evidence of weekly mandatory drug checks being completed. ii) One of one eye drops in use were expired. i) Ensure all required medication checks are completed as required by contractual and legal requirements. ii) Ensure all medication in use has not expired. 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.There is no signing sheet or evidence of administration of a dietary supplement prescribed for one resident. Ensure prescribed dietary supplements are signed for as administered on a signing sheet. PA LowReporting Cancelled
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.The InterRAI assessment for one resident with known depression included a risk assessment for cognitive loss/mood. The outcome of the assessment and supports required were not included in the service long-term care plan. Ensure the outcome of the InterRAI risk assessments (as triggers), are included in the service long-term care plan. 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.

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