Glenbrae Resthome and Hospital

Profile & contact details

Premises details
Premises nameGlenbrae Resthome and Hospital
Address 22 Hilda Street Fenton Park Rotorua 3010
Total beds41
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameGlenbrae Resthome and Hospital Limited - Glenbrae Resthome and Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence11 May 2019
Certification period36 months
Provider details
Provider nameGlenbrae Resthome and Hospital Limited
Street address 22 Hilda Street Fenton Park Rotorua 3010
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: 07 March 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate 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.(1) Three of twelve medication charts sampled had gaps on the signing sheet; (i) one hospital resident prescribed Vitamin B 12 monthly was not signed as administered in December, (ii) one hospital resident prescribed three monthly Zoladex was last signed for as administered in September 2015. (2) One hospital resident was on continuous oxygen that was not prescribed by the GP, (3) One rest home resident was prescribed both regular and “as required” morphine (PRN). (i) The administration of the … (this text has been trimmed due to space limits).(1) Ensure all medication is given as prescribed. (2) Ensure that oxygen is prescribed; (3) Ensure that PRN medication is signed for on a separate signing sheet to the regular medication and that there is a regular review of PRN medication administered. Ensure that all medication is administered at the time prescribed. PA ModerateReporting Complete14/11/2016
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. i) One of six files reviewed (hospital level care) for a resident admitted in December did not have an interRAI assessment completed within 21 days of admission. ii) One of six (rest home level care) did not have the long-term care plan completed within 21 days of admission. iii) Three of five files (one hospital and two rest home) did not have an interRAI assessment completed at the time of the long-term care plan review. iv)Two of five files sampled (one hospital and one rest home) had not be… (this text has been trimmed due to space limits).i) Ensure that all interRAI assessments are completed within the required timeframes. ii) Ensure that all long-term care plans are documented within 21 days of admission. iii) Ensure that the interRAI assessments are completed to inform the review of the long-term care plan. iv) Ensure that all new admissions are seen by the GP within the required timeframes. PA LowReporting Complete14/11/2016
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) Three of six files reviewed (one hospital (tracer) and two rest home - including the rest home tracer) had interventions documented in the progress notes that were not transferred to a care plan for acute changes in health conditions (for infections and weight loss). ii) Interventions were not documented for all identified care needs in five of six files reviewed (three hospital and two rest home). Intervention shortfalls were identified around manual handling requirements, pressure injury ri… (this text has been trimmed due to space limits).i) Ensure that interventions documented in the progress notes are transferred to a care plan for all acute changes in health status. ii) Ensure that care plans include all current interventions for care. PA LowReporting Complete14/11/2016
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).The site specific centralised hazard register has not been updated or reviewed since 2010. Ensure regular review of the hazard register. PA LowReporting Complete28/04/2017
Advance directives that are made available to service providers are acted on where valid.The ‘do not resuscitate’ form in use for those residents deemed not competent does not meet current legislation Ensure that EPOA’s and next of kin do not make a do not resuscitate decision on behalf of their relative PA LowReporting Complete28/04/2017

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.

Audit reports

Audit date: 07 March 2016

Audit type:Certification Audit

Audit date: 03 November 2014

Audit type:Surveillance Audit

Audit date: 15 October 2013

Audit type:Verification Audit

Audit date: 13 March 2013

Audit type:Certification Audit

Audit date: 12 March 2012

Audit type:Surveillance Audit

Audit date: 14 March 2011

Audit type:Certification Audit

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