Eltham Care Rest Home
Profile & contact details
|Premises name||Eltham Care Rest Home|
|Address||54 Maata Road Eltham 4398|
|Service types||Dementia care, Rest home care|
|Certification/licence name||Sound Care Limited - Eltham Care Rest Home|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||08 February 2018|
|Certification period||12 months|
|Provider name||Sound Care Limited|
|Street address||The Theatre Royal 486 New North Road Kingsland Auckland 1021|
|Post address||PO Box 41344 Kingsland Auckland 1021|
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: 04 September 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|All buildings, plant, and equipment comply with legislation.||Clinical equipment checks were due in October 2015. One window in one of the dementia care resident lounges has a missing window catch. Wall heaters throughout the facility are rusting. The bathroom vinyl in one bathroom is separating and poses a tripping hazard and cannot be cleaned to meet infection control cleaning standards.||Provide evidence that all buildings, plant and equipment comply with legislative requirements, is safe and fit for purpose||PA Moderate||Reporting Complete||24/05/2017|
|An appropriate 'call system' is available to summon assistance when required.||One bedroom which has two beds in it only has one working call bell.||Ensure all required call bells are in working order.||PA Low||Reporting Complete||15/03/2017|
|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.||Evidence of updated interRAI assessments for a backlog of reviews recently completed by NASC are not available on site to guide care planning. A RN is still to complete interRAI training to address the eleven reviews due in December 2016 and January 2017||Ensure all interRAI reviews are completed within the required timeframes||PA Moderate||Reporting Complete||28/03/2017|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||Inaccurate and poorly integrated assessment and planning information in the guiding care documents is seen in more than half the files sampled. The likelihood and consequence of this creates a high level of risk for care delivery to residents in the facility.||Implement effective systems which enables a coordinated approach in the documentation of care delivery in a manner that promotes continuity of care and a team approach where appropriate.||PA High||Reporting Complete||28/03/2017|
|Consumers are provided with safe and accessible external areas that meet their needs.||Furnishings used in one of the outdoor areas used by rest home residents has inappropriate furnishings which are in a poor state of repair. Cracked and uneven concrete, an open drain beside the walking ramp and cigarette butts are littered around the area. Incomplete plumbing work in the dementia care outdoor area has left an exposed hole in the ground which is covered over by an easily removed wooden pallet.||Provide evidence that the outdoor areas are safe and fit for purpose for residents to use.||PA Moderate||Reporting Complete||24/04/2017|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||Comments sighted on the August 2016 fire evacuation drill indicated that the drill was not well done and that it was a “waste of time”. Staff on duty on the day of the August 2016 drill did not know what actions to take and a recommendation for further staff education and the training of fire wardens was noted. This is yet to be followed up. Key padlocks on two doors in the rest home area may restrict resident movement. (No environmental restraint is documented).||Ensure staff knowledge and training allows safe management of emergency situations and can be demonstrated during fire evacuations. Ensure rest home level care residents areas are not restricted.||PA Moderate||Reporting Complete||24/04/2017|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||One complaint received related to two issues (one issue is about the pot-holes in the drive and the other is about food services). No evidence could be found that the issue related to food had been addressed nor was it acknowledged in the response letter sent to the person who made the complaint. No evidence was available related to the complaints leading to the DHB issues based audit.||Provide evidence that all complaint documentation is completed and that all issues identified in a complaint are responded too.||PA Low||Reporting Complete||24/05/2017|
|The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.||Resident privacy and dignity in the dementia unit is compromised in that three male residents were observed to be shaved by staff in the lounge, with other residents and visitors present.||Maintain resident privacy and dignity during personal care activities.||PA Low||Reporting Complete||24/05/2017|
|All records are legible and the name and designation of the service provider is identifiable.||The name and designation of staff making entries in organisational records is not in accordance with policy or legal requirements.||Ensure all staff entries in clinical records and organisational documents are in accordance with policy or legal requirements.||PA Low||Reporting Complete||24/05/2017|
|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.||The controlled drug register balance for a liquid medicine does not match the stock on hand.||Complete actions to ensure the controlled drug register entries are accurately recorded.||PA Low||Reporting Complete||24/05/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Not all aspects of food procurement, storage and delivery, comply with current legislation and guidelines. There are limited food pantry stocks on hand at the end of the ordering cycle to provide suitable food items in an emergency. Chilled and frozen food is not temperature checked on arrival from the supplier; the evening meal reheated by care staff is not temperature checked prior to serving; and records of the kitchen fridge temperature monitoring could not be located. The kitchen has a bu… (this text has been trimmed due to space limits).||Ensure all aspects of the food service comply with current legislation, and guidelines.||PA Moderate||Reporting Complete||24/05/2017|
|Advance directives that are made available to service providers are acted on where valid.||Documentation in relation to resuscitation wishes and advance directives is confusing. Status of the resident to make a valid decision is unclear in the current documentation formats.||Review the current documentation and update this to ensure advance directive and resuscitation decisions are clearly documented.||PA Moderate||Reporting Complete||19/07/2017|
|Consumers have a right to full and frank information and open disclosure from service providers.||A sample of incident data for October 2016 (13 resident related incidents) recorded that family members had been contacted on four occasions. The remaining nine incidents have no indication of family contact being made, or the reason why this did not occur.||Ensure the system for open disclosure following a resident adverse event is sufficiently detailed and completed (eg, incident reports have the open disclosure section completed and includes the reasons that family were not contacted, as applicable).||PA Low||Reporting Complete||26/07/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Procedures set out in policy regarding employment are not followed. Reference checking is not consistently undertaken, incomplete employment data is contained within staff files and performance appraisals are not all up to date. One staff member’s file contained none of the required items.||Provide evidence that the appointment of service providers is undertaken according to current good practice requirements to safely meet the residents’ needs. Annual staff appraisals are kept current to meet contractual requirements||PA Low||Reporting Complete||26/07/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||No documented evaluation of data was sighted. Infection control data collected identifies the number of infections that occur but analysis is limited and does not clearly identify trends, possible causative factors or required actions. Not all the internal audits listed to occur have been completed for 2016.||Provide evidence that quality data evaluated to identify trends and that internal audits are up to date.||PA Low||Reporting Complete||29/08/2017|
|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.||As the data sighted on accident and accident forms is not always completed there is insufficient documented data to show if the information is used as an opportunity to improve service delivery.||Provide evidence of how service shortfalls are used as opportunities to improve service delivery.||PA Low||Reporting Complete||29/08/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Documentation related to corrective actions was difficult to trace to specific incidents and not all issues identified have a documented corrective action, such as complaints follow up (refer criterion 18.104.22.168) and the results of the resident satisfaction survey (November 2015).||Provide evidence that all issues identified have a corrective action put in place to show what actions are to be taken and by whom and by when||PA Low||Reporting Complete||14/09/2017|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The one resident who self-administers a medicated spray has no evidence to verify this is managed safely.||Provide evidence that the facilitation of safe self-administration of medicines is maintained to reflect policy and legislative requirements.||PA Moderate||In Progress|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The fridge in the secure unit has no records to verify temperatures are monitored and the ice box is iced up. Food in this fridge is not dated to indicate use by dates. Decanted dry goods in the kitchen have no documentation to verify use by dates and the cleaning schedule documentation to verify compliance with this schedule was not located at the time of audit.||All aspects of food storage, production and preparation complies with current legislation and guidelines.||PA Moderate||In Progress|
|The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.||Resident’s privacy was observed to be compromised during a medication round.||Ensure residents privacy and dignity is maintained at all times.||PA Low||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Documentation is not consistently reflective of residents’ assessed needs and desired outcome.||Documentation is consistent with meeting residents’ assessed needs and desired outcomes.||PA Low||In Progress|
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: 04 September 2017
Audit type:Surveillance Audit
Audit type:Provisional Audit