Profile & contact details
|Premises name||Eversleigh Hospital|
|Address||12 Coronation Street Belmont Auckland 0622|
|Service types||Rest home care, Geriatric|
|Certification/licence name||Golden Concept E Limited - Eversleigh Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 May 2019|
|Certification period||36 months|
|Provider name||Golden Concept E Limited|
|Street address||44 Montgomery Crescent Cockle bay Auckland 2014|
|Post address||12 Coronation Street Belmont Auckland 0622|
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: 22 February 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Not all areas for improvement identified through the internal audit and monitoring process had corrective action plans documented or where corrective actions had been noted, the plan/interventions were not specific.||Ensure that corrective action plans are developed with specific interventions for all areas requiring improvements.||PA Low||Reporting Complete||02/08/2016|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Essential notifications were not completed for one incident referred to the coroner in June 2015 and one incident referred to the police in November 2015.||Ensure that all the contractual and legal reporting requirements are met.||PA Low||Reporting Complete||18/07/2016|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Two new staff recently recruited had not had the mandatory police vet checks completed.||Ensure that the organisational requirement for all new staff to have police vet checks is followed.||PA Low||Reporting Complete||18/07/2016|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||i) Two of two new staff had no evidence that they had completed the organisations orientation requirements. ii) Three of seven staff files sampled do not have signed job descriptions on file.||i) Ensure that all new staff complete the orientation/induction process. ii) Ensure that all staff have a signed job description.||PA Low||Reporting Complete||18/07/2016|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||Two of four residents using bed rails as enablers were incorrectly classified and the bedrails were being used as restraints.||Ensure that all enablers and restraints being used comply with the definitions in the organisational policy and the Restraint Minimisation and Safe Practice Standards NZS 8134.0.||PA Low||Reporting Complete||18/07/2016|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||For six residents using restraint and four residents using enablers, the potential risks associated with the use of restraint and enablers was not documented and discussed, as part of the assessment and consent process.||Ensure that all assessments for restraint use identify and document the risks associated with the use of the restraint or enabler and these risks are discussed with the resident and family/whānau.||PA Low||Reporting Complete||18/07/2016|
|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 restraint and enabler care plans do not document the risks associated with the use of the restraint or enabler and no interventions were documented to manage the identified risk (ii) One resident currently using a restraint has no restraint care plan in place. (iii) Two hourly monitoring of the resident whilst using a restraint was not consistently evidenced in four of six residents using a restraint.||(i-ii) Ensure that all residents using a restraint or enabler have a care plan documented that outlines interventions to cover the assessed care needs and identified risks. (iii) Ensure that all monitoring required is implemented and consistently documented.||PA Low||Reporting Complete||18/07/2016|
|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).||An annual review of the restraint minimisation and safe practice programme has not been completed as required by the organisational policy.||Ensure that the restraint minimisation programme is reviewed in accordance with the organisational policy.||PA Low||Reporting Complete||18/07/2016|
|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.||There is no evidence of the neurological observations (PERL) noted on the incident form as being completed for four hospital residents, following an unwitnessed fall and there were no timeframes specified for the neurological assessments to be continued.||Ensure that neurological assessments are completed as required by the organisations falls policy.||PA Low||Reporting Complete||02/08/2016|
|Professional qualifications are validated, including evidence of registration and scope of practice for service providers.||Three of five staff files reviewed that should have had an annual performance review completed, had no evidence a performance review had been completed in the past 12 months.||Ensure that all staff have an annual performance review.||PA Low||Reporting Complete||02/08/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) Education has not been provided in the past 12 months for chemical safety training, abuse and neglect prevention, wound management and pressure injury prevention, infection control, and challenging behaviour, and restraint minimisation. ii) Education has not been provided in the past 2 years for advocacy, resident rights, and cultural awareness. iii) Staff attendance numbers have been low at the education sessions provided. Where staff have not attended, no follow-up education or traini… (this text has been trimmed due to space limits).||i) Ensure that the education schedule is fully implemented and education is provided to cover all contractual and legal requirements. ii) Ensure that a process is put in place to ensure that all staff attend mandatory education and where attendance is low an education follow-up plan is implemented.||PA Moderate||Reporting Complete||02/08/2016|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||The amendments made in 2015 to clause D13.3 of the ARRC contract, regarding refund timeframes are not included in the admission agreement currently in use by the service.||Ensure that the current admission agreement aligns fully to the ARRC contract.||PA Low||Reporting Complete||02/08/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Not all internal audits and monitoring identified on the organisation audit planner have been completed.||Ensure that all scheduled audits and monitoring is completed.||PA Low||Reporting Complete||07/11/2016|
|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.||Three of the six files reviewed were new residents since July 2015. All three had InterRAI assessments completed but none were within 21 days of admission.||Ensure all InterRAI assessments are completed within required timeframes.||PA Low||Reporting Complete||07/11/2016|
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.