Profile & contact details
|Premises name||Hokianga Hospital|
|Address||Hokianga Health 163 Parnell Street RD 3 Kaikohe 0473|
|Service types||Rest home care, Geriatric, Maternity, Medical|
|Certification/licence name||Hokianga Health Enterprise Trust|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||07 September 2018|
|Certification period||36 months|
|Provider name||Hokianga Health Enterprise Trust|
|Street address||163 Parnell Street RD 3 Kaikohe 0473|
|Post address||Private Bag Kaikohe 0440|
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: 26 April 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Staffing and skill mix arrangements have not been documented.||Develop a documented process that details how staffing is planned and rostered to ensure staffing and skill mix is appropriate to provide safe service delivery.||PA Low||Reporting Complete||24/05/2016|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||There are examples of policies and procedural manuals in use which are overdue for review. Some updated policies have not yet replaced the previous version of the PDF policy located on the share file and accessible by staff. There are multiple versions of maternity policies available for staff. There are insufficient policy and procedures available that detail the organisation’s expectations related to some aspects of practice. The restraint policy does not include the full definition of restrai… (this text has been trimmed due to space limits).||Ensure policies are procedures are sufficiently detailed to guide staff practice and document control processes consistently implemented.||PA Moderate||Reporting Complete||24/05/2016|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Records to evidence that reference checks or interviews are being conducted are not present in all staff files sampled. This included the three staff employed since June 2014.||Ensure records are maintained to demonstrate that the recruitment process has been followed.||PA Low||Reporting Complete||24/05/2016|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||While staff confirm a detailed orientation is provided relevant to the staff role and responsibilities, records are not present in some staff files reviewed to demonstrate that the service/department specific component has been completed. For example, the workbooks that are to be completed by medical and nursing staff. The orientation/ongoing education programme is not sufficiently detailed in relation to the registered nurses’ responsibilities for the care of clients in the maternity unit. … (this text has been trimmed due to space limits).||Ensure records are available to verify that staff have completed any department/role specific orientation in a timely manner. Ensure the orientation and ongoing programme is sufficiently detailed in relation to the registered nurses’ responsibilities during the provision of care for clients in the maternity service.||PA Moderate||Reporting Complete||24/05/2016|
|Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.||There is currently no secure manner to maintain entry and exit information until it is retrospectively reported by the DHB and entered into the Hokianga electronic register. The process to record and track the location of records and the organisation of archived records does not ensure that clinical records can be reliably located.||Ensure that there is an accessible record of the details of entry and exit maintained from the time of admission onwards. Ensure the clinical records storage and tracking system facilitates secure management and reliable access to stored clients’ records.||PA Low||Reporting Complete||24/05/2016|
|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.||The door to treatment room in which medication is stored is repeatedly left open during the audit and is reported by staff as an ongoing problem, The ambient temperature of medication storage is not monitored. Medication prescribing is of an appropriate standards with some exceptions which are areas for improvement including: - group bracketing of dates of prescriptions - dates of discontinuation of medication is not recorded - recording of dose limits and indications for PRN medications - pres… (this text has been trimmed due to space limits).||Ensure all aspects of medicines management meet the requirements of best practice and legislation.||PA Moderate||Reporting Complete||24/05/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Medical – Care plans are not fully documented to reflect the individual needs of clients. Maternity - Plans for care and discharge are discussed but not documented. There is no system or template to facilitate robust documentation of the plan of care required for mother and infant. Goals/needs/desired outcomes are not recorded for postnatal care. Planning for assessment on admission, postnatal care (including care to be provided by the nursing staff overnight) and education is not documented. Th… (this text has been trimmed due to space limits).||Ensure that there is a system for postnatal admission, care and discharge plans in the maternity service. Ensure that plans for care in maternity and medical services are fully documented.||PA Low||Reporting Complete||24/05/2016|
|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).||The form that facilitates observation and monitoring of the client during each episode of restraint is not being used.||Ensure records are maintained to demonstrate the observations and monitoring of clients during each episode of restraint.||PA Low||Reporting Complete||24/05/2016|
|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.||Evaluations by nursing staff are poorly documented, with little or no information recorded about the times of evaluation or features of the evaluation conducted.||Ensure 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||PA Moderate||Reporting Complete||25/07/2016|
|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).||The quarterly review of restraint and enablers includes a review of the number and type of events. Some other aspects as required to meet the standards are not explicitly included.||Ensure a comprehensive review occurs of restraint practices that includes all components to meet the standards.||PA Low||Reporting Complete||25/07/2016|
|Regular auditing and monitoring of compliance with prophylactic and therapeutic antimicrobial policies shall be a component of the facility's infection control programme.||The standard requires that regular auditing and monitoring of compliance with prophylactic and therapeutic antimicrobial policy will be a component of the infection control programme. While the antimicrobial use policy states audit will be conducted for microbial prescribing compliance, no evidence is available at audit to demonstrate this.||Ensure a robust audit process is conducted to evaluate compliance with antimicrobial policy and best practice requirements||PA Low||Reporting Complete||25/07/2016|
|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.||The organisation`s policy and procedures related to pressure injury prevention and management are not sufficiently detailed to include pressure injury assessment categories (stages) and or information regarding essential notifications.||Review the current policy and procedures to include pressure injury prevention, management and the stages of pressure injuries. In addition, the policy needs to state the reporting obligations and essential notification requirements for stage 3 and stage 4 pressure injuries.||PA Low||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: 26 April 2017
Audit type:Surveillance Audit
Audit type:Certification Audit