Elizabeth Knox Home and Hospital
Profile & contact details
|Premises name||Elizabeth Knox Home and Hospital|
|Address||10 Ranfurly Road Epsom Auckland 1023|
|Service types||Physical, Rest home care, Geriatric, Medical|
|Certification/licence name||Knox Home Trust Board|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||09 June 2018|
|Certification period||36 months|
|Provider name||Knox Home Trust Board|
|Street address||10 Ranfurly Road Epsom Auckland 1023|
|Post address||PO Box 74060 Market Rd 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: 14 November 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date 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.||Four of the 28 medicine charts reviewed did not indicate if the GP had conducted a three monthly review. Eight of the medicine charts signing sheets had no staff specimen signature. Standing orders being used at the time of audit do not indicate contra-indications or who can administer the medications shown in the standing orders. A completed updated standing order form with all correct instructions was sighted but is awaiting sign off by all four GPs.||Ensure that the GP documents the three monthly reviews on the medication chart and that the newly developed standing orders are signed off. Staff who administer medicines must complete their specimen signature on each medication sheet.||PA Low||Reporting Complete||02/02/2016|
|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).||There is insufficient evidence that monthly restraint review meetings include a full evaluation of all episodes of restraint.||Maintain sufficient evidence that monthly restraint review meetings include a full evaluation of each episode of restraint.||PA Low||Reporting Complete||02/02/2016|
|Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).||Current systems do not include the process for, or implementation of, a regular quality review of restraint practice.||Define the process for conducting a quality review of restraint practice, and implement same.||PA Low||Reporting Complete||02/02/2016|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||InterRAI assessments are not always completed and/or reviewed in the required time frames. New deficits identified at reassessment have not been consistently incorporated into the long-term care plans. Coordination of care is not ensured, with discrepancies in information between the electronic and hard copy systems in use. Specific plans in relation to residents with a known infection such as MRSA and ESBL are not included in the plans reviewed where alerts about infections are included on the… (this text has been trimmed due to space limits).||Undertake further development of the care planning system to ensure care planning information is complete with effective linkages maintained between all elements of the electronic and manual systems. Implement processes which ensure all interRAI assessments and evaluation of residents’ needs is completed within the contractual timeframes.||PA Moderate||Reporting Complete||07/11/2017|
|The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.||At the time of audit there are around 50% of the approximate 600 policies and other documents overdue for review in the electronic data base. There are also paper version of policies available for use in the clinical areas that are overdue for review and/or are redundant.||The service establishes the exact number of overdue policies and procedures and implements a process to ensure these are reviewed at regular intervals, aligned with current good practice and document controlled.||PA Moderate||Reporting Complete||07/11/2017|
|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.||Pro re nata medications do not consistently state the indications for use for three commonly used medicines.||Ensure prescribing for pro re nata medicines (PRN) includes the indications for use.||PA Low||Reporting Complete||07/11/2017|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Updating of the care plan is not always evident when the resident’s condition changes, nor the current plan made available to care partners in its most current version to guide residents’ care.||Initiate a process which ensures that where resident progress is different from expected, the service makes necessary changes and makes available the most current plan of care.||PA Moderate||Reporting Complete||07/11/2017|
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: 14 November 2016
Audit type:Surveillance Audit
- Elizabeth Knox Home and Hospital - Nov 2016 (docx, 41.88 KB)
- Elizabeth Knox Home and Hospital - Nov 2016 (pdf, 161.98 KB)
Audit type:Certification Audit
- Elizabeth Knox Home and Hospital - Mar 2015 (docx, 51.64 KB)
- Elizabeth Knox Home and Hospital - Mar 2015 (pdf, 205.65 KB)
Audit type:Partial Provisional Audit
- Elizabeth Knox Home and Hospital - Jun 2014 (docx, 65.71 KB)
- Elizabeth Knox Home and Hospital - Jun 2014 (pdf, 439.98 KB)
Audit type:Surveillance Audit
- Elizabeth Knox Home and Hospital - Nov 2013 (docx, 111.51 KB)
- Elizabeth Knox Home and Hospital - Nov 2013 (pdf, 409.7 KB)
Audit type:Certification Audit