Ultimate Care Lakewood

Profile & contact details

Premises details
Premises nameUltimate Care Lakewood
Address 31 Horseshoe Lake Road Shirley Christchurch 8061
Total beds36
Service typesDementia care
Certification/licence details
Certification/licence nameThe Ultimate Care Group - Ultimate Care Lakewood
Current auditorCentral Region's Technical Advisory Services Limited
End date of current certificate/licence17 April 2024
Certification period12 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: 01 March 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation.i) Not all staff files had evidence of a signed job description. ii) Criminal record-checks had not been completed on staff. Ensure that a: i) Signed copy of a current job description is retained on staff files. ii) Update the human resource policy to require criminal record-checking and ensure that these are completed on staff. PA LowReporting Complete26/07/2023
Service providers shall evaluate progress against quality outcomes.The resident/whānau survey results have not been collated, analysed, or shared with staff, residents, or family/whānau. Ensure survey results are collated, analysed, or shared with staff, residents, or whānau. PA LowReporting Complete26/07/2023
Governance bodies shall demonstrate commitment toward eliminating restraint.There is no evidence to demonstrate that the governance body are committed to maintaining a restraint free environment. The governance body is to demonstrate their commitment to eliminating restraint. PA LowReporting Complete26/07/2023
Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings.Accident, incident forms do not consistently identify strategies to minimise the risk of reoccurrence. Ensure strategies to minimise the risk of reoccurrence are identified and implemented. PA LowReporting Complete26/07/2023
Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.The emergency evacuation drill has not been undertaken six-monthly Ensure trial evacuations occur six monthly PA LowReporting Complete26/07/2023
Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi… (this text has been trimmed due to space limits).The cleaning trolley containing chemicals and cleaning products was not stored securely when unattended. Ensure secure storage of chemicals at all times. PA ModerateReporting Complete26/07/2023
Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.The facility manager has not completed professional development relevant to the role Ensure that the facility manager completes role specific professional development PA LowReporting Complete26/07/2023
My service provider shall work in partnership with iwi and Māori organisations within and beyond the health sector to allow for better service integration, planning, and support for Māori.Partnerships with Māori iwi are yet to be formalised. Establish and develop partnerships and linkages with Māori organisations. PA LowReporting Complete12/03/2024
My service provider shall work in partnership with Pacific communities and organisations, within and beyond the health and disability sector, to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes.Partnerships with Pacific communities and organisations are not yet developed. Establish partnerships with Pacific communities and organisations. PA LowReporting Complete12/03/2024
Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies.There is no Māori representation at an organisational level. Ensure meaningful Māori representation at organisational level. PA LowReporting Complete12/03/2024
During the initial engagement prior to service entry, service providers shall ensure: (a) There is accurate information about the service available in a variety of accessible formats; (b) There are documented entry criteria that are clearly communicated to people, whānau, and, where appropriate, local communities and referral agencies. Not all admission agreements sighted were signed or fully completed. Ensure all resident admission documentation is completed in full. PA LowReporting Complete12/03/2024

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.

Audit reports

Audit date: 01 March 2023

Audit type:Provisional Audit

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