Profile & contact details
|Premises name||Glencoe Resthome|
|Address||64 Kolmar Road Papatoetoe Auckland 2025|
|Service types||Rest home care|
|Certification/licence name||Udian Holdings Limited - Glencoe Resthome|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||25 February 2019|
|Certification period||36 months|
|Provider name||Udian Holdings Limited|
|Street address||64 Kolmar Road Papatoetoe Auckland 2025|
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: 02 December 2015
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.||Security cameras have being recently installed and monitor external and internal communal areas including the lounge, dining room, staff office, kitchen and hallway areas. Not all residents and family interviewed are aware of these cameras. Security camera footage is archived for up to one month. One resident is unable to open the external gate without staff assistance. The resident has diminished cognitive capacity. The resident’s family member interviewed is happy the resident is unable to… (this text has been trimmed due to space limits).||Ensure residents and family are informed of the use of security cameras and records are retained to demonstrate this. Ensure that in the event a resident is unable to independently leave the premises without assistance that informed consent is able to be demonstrated.||PA Low||Reporting Complete||30/05/2016|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||While new staff advise they have been provided with an orientation to the facility and residents, records of this process have not been maintained for the two new staff/managers.||Ensure records are retained to demonstrate that staff and managers complete the orientation programme.||PA Low||Reporting Complete||29/08/2016|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||The registered nurse medication competency was last completed in August 2014.||Ensure that all staff responsible for medication management undergo competency assessments on at least an annual basis.||PA Low||Reporting Complete||29/08/2016|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||The six monthly care plan evaluations do not consistently evidence linkages with information obtained via the incident reporting process. As an example three of five residents’ files reviewed did not include in the evaluation that the resident had fallen in the preceding six month period. One resident had had three falls.||Ensure that relevant information from incidents and accidents is included in the resident’s evaluations.||PA Low||Reporting Complete||29/08/2016|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register does not include details of the most recent complaint (November 2015) and actions undertaken in response to the complaint, although an acknowledgment letter was sent to the complainant.||Ensure the complaints register is maintained and includes all required documentation.||PA Low||Reporting Complete||29/08/2016|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Records are not available to demonstrate that all staff involved with food preparation/cooking have completed food safety training.||Ensure that staff involved with food services have completed approved food safety training and records are available to demonstrate this.||PA Low||Reporting Complete||29/08/2016|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||Records are not available to demonstrate that the owner has attended eight hours of education relevant to managing an aged care service in the last 12 months as required to meet the aged related residential care (ARRC) contract with Counties Manukau District Health Board (CMDHB).||Ensure records are available to demonstrate that the person responsible for managing (as detailed in the ARRC contract) completes at least 8 hours of relevant education every year.||PA Low||Reporting Complete||29/08/2016|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Two events that required essential notification had not been reported to the DHB or HealthCert (Ministry of Health).||Ensure all events that require reporting to the Ministry of Health, District Health Board or other governmental agencies / departments are notified in a timely manner.||PA Moderate||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: 02 December 2015
Audit type:Certification Audit
Audit type:Provisional Audit