Hillsborough Hospital

Profile & contact details

Premises details
Premises nameHillsborough Hospital
Address 109 Frederick Street Hillsborough Auckland 1042
Total beds47
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - Hillsborough Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence31 October 2017
Certification period36 months
Provider details
Provider nameBupa Care Services NZ Limited
Street addressLevel 2 109 Carlton Grove Road Newmarket Auckland 1023
Post addressPO Box 113054 Newmarket Auckland 1149
Websitewww.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: 30 March 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) There is no short term care plan in place for a sacral pressure area for one resident. A sacral pressure area for another resident is not linked to the care summary. The dressing frequency for a sacral pressure area does not align with the dressing frequency on the wound evaluation form (however documentation does reflect the pressure area is improving and being managed). (ii) There is no documented diabetic management plan for an insulin dependent diabetic resident. (iii) There is no do… (this text has been trimmed due to space limits).Ensure interventions are documented and implemented to reflect the resident’s current needs PA LowReporting Complete17/12/2014
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) Five out of 14 medications charts did not have an indication for use of PRN medication (tramadol, zopiclone, oxynorm, sevredol, morphine sulphate). 2) Dittos are used for the dose of controlled drug on the signing sheets of two of four residents on controlled drugs. 1) Ensure PRN medications have an indication for use. 2) Ensure the signing of medication meets legislative requirements. PA LowReporting Complete17/12/2014
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.There were no documented interventions to reflect the resident’s current health status for: (i) one resident identified as high risk of pressure injury. An appropriate pressure injury prevention plan was not recorded. The same resident did not have early warning signs and symptoms for a known illness and there were no interventions for altered behaviour; (ii) the care summary had not been updated to reflect the residents current skin integrity (link tracer 1.3.3); (iii) there was no documented … (this text has been trimmed due to space limits).(i), (ii) and (iii) ensure interventions are documented to reflect the resident’s current health status. (iv) Ensure neurological observations are completed as per protocol. PA ModerateReporting Complete27/07/2016
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 out of three files reviewed did not identify the use of an enabler in the care plan/care summary Ensure the use of an enabler is linked to the care plan and care summary PA LowReporting Complete27/07/2016

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: 30 March 2016

Audit type:Partial Provisional Audit; Surveillance Audit

Audit date: 22 July 2014

Audit type:Certification Audit

Audit date: 30 October 2012

Audit type:Surveillance Audit

Audit date: 02 September 2010

Audit type:Certification Audit

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