Fergusson Rest Home & Hospital

Profile & contact details

Premises details
Premises name	Fergusson Rest Home & Hospital
Address	654 Fergusson Drive Trentham Upper Hutt 5018
Total beds	112
Service types	Dementia care, Rest home care, Geriatric, Medical

Certification/licence details
Certification/licence name	Bupa Care Services NZ Limited - Fergusson Rest Home & Hospital
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	11 July 2025
Certification period	36 months

Provider details
Provider name	Bupa Care Services NZ Limited
Street address	Level 2 109 Carlton Grove Road Newmarket Auckland 1023
Post address	PO Box 113054 Newmarket Auckland 1149
Website	www.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: 14 December 2023

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits).	(i). Two hospital and one rest home resident assessed as high falls risk did not have detailed interventions in the care plan to manage the risk. (ii). Three residents (two hospital and one rest home) on anticoagulants did not have associated risks documented in the care plan. (iii). One hospital level care resident with ongoing pain did not have complex medical conditions did not have detailed interventions to manage their pain. (iv). There were no interventions documented in a care plan for… (this text has been trimmed due to space limits).	(i-vi) Ensure care plans have detailed interventions documented to provide guidance to staff on care management and are updated to reflect changes to resident needs and management plan.	PA Low	In Progress
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	i) Satisfaction survey results, internal audit results and clinical indicator data are collected (and trended where applicable) but are not consistently shared with either residents (where applicable) (resident/family meeting minutes sighted) or with staff (quality meeting minutes, staff meeting minutes and staff notice boards sighted). ii) There is a lack of documented evidence to indicate that a corrective action plan was developed to address areas for improvements identified in either the 202… (this text has been trimmed due to space limits).	i) Ensure quality data (e.g. satisfaction survey results, clinical indicator data) are shared with residents/family (where applicable) and with staff. ii) Ensure corrective action plans are developed for areas that identify a need for improvement. iii) Ensure corrective actions plans that are developed are shared with staff.	PA Low	Reporting Complete	17/07/2023
Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings.	Twenty-eight accident incident reports reviewed during the month of April indicated that the investigation process had commenced but not been closed. The sample size was extended to March and indicated a significant number of adverse events were still open. The clinical manager stated that relevant documentation related to the adverse event must be uploaded before sign-off can take place.	Ensure all documentation relating to accident and incident reports are uploaded and signed off by the clinical manager to indicate that the adverse event is closed.	PA Low	Reporting Complete	15/08/2023
Service providers shall evaluate progress against quality outcomes.	The Bupa health check completed in November 2021 indicated there were 21 criteria requiring action ranging from low to high risk. Eleven findings (clinical) have been signed off as being met. Ten corrective actions remain open (nine designated high risk and one designated moderate risk). There is no evidence documented to indicate progress being made.	Ensure progress is evaluated and documented against measurable outcomes (e.g. Bupa health check) with priority given to high and moderate risk areas.	PA Moderate	Reporting Complete	15/08/2023
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.	i) Three of 10 staff files reviewed failed to indicate that staff had completed their orientation programme and therefore orientation competencies are not assessed. A spreadsheet in the care home manager’s office and review of meeting minutes reflects this as an ongoing issue. ii) There is no documented evidence to indicate hospitality contractors, assisting caregivers during staff shortages, are orientated. iii) Only two health and safety orientations were sighted for external contractors s… (this text has been trimmed due to space limits).	i) Ensure that there is documented evidence to indicate staff have completed their orientation programme which includes competencies. ii) Ensure hospitality contractors who are assisting caregivers with low-risk activities undergo an orientation programme. iii) Ensure all contractors are orientated to health and safety.	PA Moderate	Reporting Complete	15/08/2023
Service providers shall maintain quality records that comply with the relevant legislation, health information standards, and professional guidelines, including in terms of privacy.	All ten residents’ files audited (progress notes, family communication records) failed to indicate the designation of the service provider.	Ensure all hard copy documentation stored in residents’ files include the signatory’s designation.	PA Low	Reporting Complete	15/08/2023
Service providers shall ensure health care and support workers are able to provide a level of first aid and emergency treatment appropriate for the degree of risk associated with the provision of the service.	Only one staff holds a current first aid/CPR certificate.	Ensure there is a minimum of one staff trained in first aid/ CPR 24 hours a day, seven days a week.	PA Moderate	Reporting Complete	11/09/2023
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Six of eight staff files reviewed of staff who have been employed for over one year are missing evidence of a performance appraisal being completed. This has also been identified as an issue in meeting minutes.	Ensure all staff have an annual performance appraisal completed annually.	PA Low	Reporting Complete	11/09/2023
Service providers shall ensure there are implemented fire safety and emergency management policies and procedures identifying and minimising related risk.	Water stores in the event of a civil emergency do not meet Hutt Valley DHB requirements.	Ensure there are adequate water stores as per Hutt Valley DHB requirements (15,680 litres) in the event of a civil emergency.	PA Moderate	Reporting Complete	27/09/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	(i). Internal audits and meetings have not been completed as scheduled. (ii). There is no evidence of corrective actions being followed up and signed off in the meeting minutes.	(i). Ensure that internal audits and meetings are completed as scheduled. (ii). Ensure that where corrective actions are identified; follow-up and sign off is completed as per quality programme policy.	PA Moderate	In Progress
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.	(i). One initial interRAI assessment has not been completed for a resident who has been a permanent placement for over six weeks. (ii). Two initial interRAI assessments were not completed within three weeks. (iii). Three residents who had been at the facility longer than three weeks did not have long term care plans and a further two were completed late. (iv). Six monthly evaluations had not been completed for one resident who had been at the service over six months and a further two evaluation… (this text has been trimmed due to space limits).	(i-iv). Ensure that all assessments care planning and reviews are completed in line with policy and legislative requirements. (v). Ensure care plan requirements are updated following a change in care needs.	PA Low	In Progress
Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered.	Staff working in the dementia unit have not completed the required NZQA unit standards as per ARRC agreement E4.5f	Ensure that staff working in the dementia unit have completed the required unit standards.	PA Low	In Progress
A medication management system shall be implemented appropriate to the scope of the service.	(i). Medication room temperatures are recorded at the beginning of the morning shift. Temperatures were not recorded consistently as per policy for two (hospital and rest home) of three treatment rooms. (ii). Seven of seven eye drops in current use in the hospital did not evidence opening dates. iii). The respite resident did not have a signed medication chart, photo identification or indications for as required medications documented. (iv). The controlled drug register in the rest home did no… (this text has been trimmed due to space limits).	(i). Ensure that medication room temperature monitoring is completed daily and is consistently recorded. (ii). Ensure eye drops are dated on opening. iii). Ensure respite residents medications are charted as per policy. (iv). Ensure controlled drugs medications are checked weekly.	PA Moderate	In Progress
Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings.	(i). No incident forms were completed for resident who was admitted for hospital level care in June 2023 with x 3 grade three and above pressure injuries. (ii). No section 31 notification was completed for same hospital level care resident in June 2023 with x 3 grade three and above pressure injuries. (iii). Where there is a resident behaviour incident there is no corresponding incident form completed for the other resident or staff involved in the incident including where injuries where sustain… (this text has been trimmed due to space limits).	(i)-(ii). Ensure event reports are completed for residents presenting with a reportable adverse event, including incident forms and section 31 reports where indicated. (iii). Ensure incident forms are completed for all staff and residents affected with resident behaviour related incidents.	PA Moderate	In Progress
Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.	Not all nightshifts evidenced a first aid trained staff member on duty.	Ensure there is a minimum of one staff trained in first aid/ CPR 24 hours a day, seven days a week.	PA Moderate	In Progress
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).	(i). One repositioning chart for a hospital level resident did not have monitoring completed as per care plan timeframes. (ii). Four of four restraint monitoring charts reviewed did not have monitoring completed as per care plan or policy timeframes.	(i). – (ii). Ensure monitoring records are completed as per care plan and policy requirements.	PA Low	In Progress
Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.	The annual education programme since last audit has not been fully implemented.	Provide evidence that education and training is being conducted for all staff as per annual education and training plan.	PA Low	In Progress
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.	There is no evidence of completed orientation for two of seven staff files reviewed.	Ensure the orientation and induction process is completed as per policy requirements	PA Low	In Progress
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Performance reviews have not been completed for four of five staff who have been employed for more than 12 months.	Ensure that performance appraisals are completed annually as scheduled.	PA Moderate	In Progress

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.

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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: 14 December 2023

Audit type:Surveillance Audit

Audit date: 25 May 2022

Audit type:Certification Audit

Audit date: 16 March 2021

Audit type:Surveillance Audit

Audit date: 02 March 2020

Audit type:Certification Audit

Audit date: 15 October 2018

Audit type:Surveillance Audit

Audit date: 07 March 2017

Audit type:Certification Audit

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