Profile & contact details
|Premises name||Lara Lodge|
|Address||4 Pegasus Drive Sunnybrook Rotorua 3015|
|Service types||Rest home care|
|Certification/licence name||Lara Lodge 2017 Limited - Lara Lodge|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||31 March 2018|
|Certification period||12 months|
|Provider name||Lara Lodge 2017 Limited|
|Street address||Lara Lodge 4 Pegasus Drive Sunnybrook Rotorua 3015|
|Post address||4 Pegasus Drive Sunnybrook Rotorua 3015|
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: 07 September 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date 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.||The service has bulk supply of medication but is assessed as rest home level of care.||Dispose of the bulk supply of medicines.||PA Low||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Employee files do not include evidence of criminal vetting and referee checks.||Ensure that all employees have documentation on file including criminal vetting and referee checks.||PA Low||In Progress|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||A review of the menu by a dietitian is not able to be sighted.||Ensure that there is a review of the menu and resident dietary needs by the diet||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Staff files sampled do not evidence of completion of the required orientation programme.||Ensure there is documentation of completion of orientation.||PA Low||In Progress|
|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.||Two of the files reviewed do not include a six-monthly evaluation and review of the care plan.||Ensure that an evaluation and updating of the care plan is completed six monthly.||PA Moderate||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Performance appraisals are not completed annually as per policy.||Ensure that staff have a performance appraisal at least annually as per policy.||PA Low||In Progress|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Not all care plans have been updated in response to changes in care.||Ensure that care plans are updated as changes are identified.||PA Moderate||In Progress|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||Agreements are not able to be sighted for all residents including one new resident who has been admitted under the new management. The agreement does not align with the ARRC agreement. The improvement required at the previous audit remains.||i) Ensure that each resident has an agreement. ii) Ensure that the agreement aligns with the ARRC agreement.||PA Moderate||In Progress|
|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 first interRAI assessment for a new resident is not completed within three weeks of entry to the service.||Ensure that the first interRAI assessment for a new resident is not completed within three weeks of entry to the service.||PA Low||In Progress|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||Hot water temperatures are not within 45 Degrees Celsius. The risk rating has been raised from low to moderate. The hoist has not been checked annually as planned.||Ensure that the hot water temperature is maintained within 45 degrees Celsius. Ensure that the hoist is checked annually.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality improvement data is not consistently reviewed for trends with analysis providing opportunities for improvement. The improvement required at the previous audit remains. There is a lack of documented evidence to reflect quality improvement data being communicated to staff. The improvement required at the previous audit remains. There has been no review of the 2016 quality and risk management plan as required by the organisational policy. The improvement required at the previous audit rema… (this text has been trimmed due to space limits).||Analyse quality improvement data to identify opportunities for improvement. Document evidence to reflect quality improvement data being communicated to staff. Review the 2016 quality and risk management plan as required by the organisational policy.||PA Moderate||In Progress|
|Consumers have a right to full and frank information and open disclosure from service providers.||Six of eleven incident/accident forms reviewed (and a review of the progress notes), did not evidence that families/whānau were notified following an adverse event.||Ensure that family/whānau are notified following an adverse event||PA Low||Reporting Complete||11/01/2018|
|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.||(i) An anticoagulant drug was signed as administered twice a day instead of once a day. There was no medication error reporting following this incident. The RN interviewed and the RN was unable to determine if this was a signing error or if the medicine was administered twice. (ii) Anticoagulant drug charts were faxed to the service from the GP’s clinic according to the blood results. An anticoagulant drug chart was missing at one time and another time, the RN had a verbal order but this was… (this text has been trimmed due to space limits).||(i) Ensure safe administration of anticoagulant drugs and that this is reflected in documentation. (ii) Ensure documented evidence of RN input in PRN medication administration.||PA Moderate||Reporting Complete||11/01/2018|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||A resident was assessed as competent to administer her own insulin, but there was no documentation to reflect what was being administered. According to Lara Lodge policy, the RN is required to monitor the resident’s competency on a weekly basis, this was also not documented.||Ensure that self-medication administration is monitored.||PA Moderate||Reporting Complete||11/01/2018|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i) Frozen meat was not stored correctly. Packaging was open and the meat was discoloured. (ii) Two meat products were taken out of the original packaging and re- packaged in small portions but the date was not recorded on the new package.||Ensure that food is stored correctly.||PA Low||Reporting Complete||11/01/2018|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Three of five files sampled (Interim manager, cleaner and activities) had no evidence of completion of the required orientation programme.||Ensure that the required orientation/induction programme is completed by all staff and evidence of this is kept on staff files.||PA Low||Reporting Complete||11/01/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) Three of three staff files sampled that were due for an annual review had not had their performance review completed. ii) The restraint coordinator has not attended or received training on the Restraint Minimisation and Safe Practice standard. (iii) Evidence of staff attendance at training in relation to the Restraint Minimisation and Safe Practice standard and management of challenging behaviours could not be located.||i) Ensure that all staff have at least an annual performance review. ii) Ensure that the restraint coordinator attends training on the Restraint Minimisation and Safe Practice Standard (2008). 111) Ensure that the service can evidence staff training in relation Restraint Minimisation and Safe Practice Standard (2008) and the management of challenging behaviours.||PA Low||Reporting Complete||11/01/2018|
|Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made: (a) Only as a last resort to maintain the safety of consumers, service providers or others; (b) Following appropriate planning and preparation; (c) By the most appropriate health professional; (d) When the environment is appropriate and safe for successful … (this text has been trimmed due to space limits).||i) One of two residents using restraint did not have the risks associated with the use of the restraint documented in the assessment and consent process. ii) Two of two residents using restraint did not have interventions documented in the care plan to manage the risks associated with the use of the restraint.||i) Ensure that the risks associated with the use of restraint are documented in the assessment and consent process. ii) Ensure that interventions are documented in the care plan to manage the risks associated with the use of restraint.||PA Low||Reporting Complete||11/01/2018|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||The admission agreement does not align with the ARRC contract such as, the payment schedule around re-payment after discharge is not included in the contract.||Ensure that resident admission agreement aligns with the ARRC contract.||PA Low||Reporting Complete||11/01/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Two of eleven residents did not have the RN assessment fully documented following an unwitnessed fall and the neurological observations were not completed as required by the organisational policy.||Ensure that all RN assessments are fully documented and neurological observations are completed following an unwitnessed fall according to the organisational policy.||PA Low||Reporting Complete||11/01/2018|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i) Hot water temperature fluctuates around 45 to 51 degrees Celsius. This was recorded as part of the quality system including follow-up requirements around contacting a plumber to rectify the situation; however outcome of this was not documented. Furthermore, there was no documented evidence that hot water temperatures are within acceptable range. (ii) The facility has a sling hoist to be used as required; however it has not been serviced since 2013. (iii) Meeting minutes identified concern … (this text has been trimmed due to space limits).||(i) Ensure that hot water temperature is maintained within 45 degrees Celsius. (ii) Ensure that the hoist is serviced. (iii) Ensure that there are adequate numbers of wheelchairs available for resident use.||PA Low||Reporting Complete||11/01/2018|
|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.||(i) In one file, a resident with several wandering episodes out of the facility were documented in the progress notes but care plan evaluations did not include this and effectiveness of current interventions were not documented in the progress notes. (ii) One care plan evaluation was completed before the InterRAI assessment, and care plan evaluations have not been completed following this assessment.||(i) Ensure care plan evaluations include reviewing interventions outcomes. (ii) Ensure InterRAI re-assessments are completed before the care plan evaluation.||PA Low||Reporting Complete||11/01/2018|
|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.||(i) One resident’s InterRAI assessment was overdue 35 days and another InterRAI assessment was completed four weeks after admission. (ii) One care plan evaluation was overdue.||(i) Ensure that InterRAI assessments are completed in a timely manner. (ii) Ensure that care plan evaluations are completed at least six monthly.||PA Low||Reporting Complete||11/01/2018|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||An annual review of the IC programme has not been completed in 2016. Advised this was due to the receivership.||Ensure that annual review of the IC programme occurs.||PA Low||Reporting Complete||11/01/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) Quality improvement data is not consistently trended and analysed to identify opportunities for improvement. Corrective action plans are not consistently documented where opportunities for improvements are identified. (ii) There is a lack of documented evidence to reflect quality improvement data being communicated to staff. (iii) There has been no monthly review of the 2016 quality and risk management plan as required by the organisational policy.||i-iii) Ensure that all quality improvement data is trended and analysed and the results communicated to staff and residents where appropriate.||PA Low||Reporting Complete||12/01/2018|
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.