Ultimate Care Kensington Court

Profile & contact details

Premises details
Premises nameUltimate Care Kensington Court
Address 18 McMahon Street Stoke Nelson 7011
Total beds81
Service typesMedical, Rest home care, Geriatric
Certification/licence details
Certification/licence nameThe Ultimate Care Group Limited - Ultimate Care Kensington Court
Current auditorCentral Region's Technical Advisory Services Limited
End date of current certificate/licence03 June 2024
Certification period36 months
Provider details
Provider nameThe Ultimate Care Group Limited
Street addressLevel 2 111 Johnsonville Road Johnsonville Wellington 6037
Post addressPO Box 425 Waterloo Quay Wellington 6140
Websitewww.ultimatecare.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: 08 September 2022

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.Not all medications received from pharmacy were checked against the medication profile prior to administration. Ensure that all medications received from pharmacy are checked before administration and the check is recorded. PA ModerateReporting Complete31/08/2021
The facilitation of safe self-administration of medicines by consumers where appropriate.Self-administration of PRN medications is not consistently recorded, and competency assessments are not always in place for residents who self-administer medications. Ensure that self-administration of medications is carried out in accordance with policy. PA ModerateReporting Complete31/08/2021
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Not all aspects of the quality management processes are documented when implemented. (i) Responsibilities, timeframes and sign-off for quality actions were not always documented in meeting minutes. (ii) Staff meeting minutes did not always document quality discussions that were conducted. (iii) Not all incidents reports had documented evidence of close-out when completed. Ensure that: (i) All meeting minutes show responsibilities, timeframes and sign-off for quality and corrective actions. (ii) All quality items on the staff meeting agenda are recorded in the meeting minutes. (iii) Incidents reports evidence sign off when completed. PA LowReporting Complete28/09/2021
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Annual performance appraisals are overdue for completion. Ensure all staff undergo an annual performance appraisal. PA LowReporting Complete28/09/2021
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.Long-term care plans are not consistently developed within the first three weeks after admission to the facility. Ensure long-term care plans are completed within the required timeframes. PA LowReporting Complete28/09/2021
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.The facility does not have 24/7 RN cover as required under the ARRC agreement. Ensure there is 24/7 RN cover. PA ModerateReporting Complete15/05/2023

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.

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