Tuapeka Community Health

Profile & contact details

Premises details
Premises nameTuapeka Community Health
Address 43 Whitehaven Street Lawrence 9532
Total beds7
Service typesRest home care, Medical
Certification/licence details
Certification/licence nameTuapeka Community Health Company Limited - Tuapeka Community Health
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence24 June 2025
Certification period36 months
Provider details
Provider nameTuapeka Community Health Company Limited
Street address 43 Whitehaven Street Lawrence 9532
Post address

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: 19 October 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented.There is no RN currently competent to complete interRAI assessments. Ensure there is at least one RN competent in completing interRAI assessments. PA LowReporting Complete28/06/2022
Service providers shall evaluate progress against quality outcomes.i) Internal audits have not been completed according to schedule from July 2021 to February 2022. ii) Corrective action plans have been identified, however, not reviewed/signed off as completed, or evidenced as discussed at staff meetings since April 2021. iii) Infection control data has not been documented as being discussed at the quarterly staff meetings. i) Ensure internal audits are completed as scheduled. ii) Ensure corrective plans are reviewed, signed off when completed. iii) Ensure there is evidence in the meeting minutes of discussion of all quality data including infection control rates and internal audit outcomes. PA LowReporting Complete14/09/2022
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 service does not provide 24/7 registered nurse cover, however advised they do provide 24/7 cover when they have patients in the hospital level beds. Ensure there is 24/7 registered nurse cover with the admission of patients under the hospital-medical component of the certificate. PA LowReporting Complete14/09/2022
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 staff had completed fire, infection control, first aid, challenging behaviour/ restraint, Te Tiriti O Waitangi, EOL care, and medication competencies in 2021, however no evidence could be located of training held in the last two years around abuse and neglect, care planning and documentation, health and safety/hazard management, nutrition and hydration, pain management and continence. Ensure all compulsory education topics are held as per policy. PA LowReporting Complete14/09/2022
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.i) Three of the five care plans did not have an interRAI assessment completed within the required timeframes. ii) One resident had no long-term care plan in place. iii) Two of the five long-term care plans have not been updated within the required timeframes. i) Ensure all residents have an interRAI assessment completed within 21 days of admission. ii) Ensure all residents have a care plan documented within required timeframes. iii) Ensure all residents have a care plan review conducted at least six-monthly. PA LowReporting Complete13/10/2022
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).Two of the five long-term care plans have no evaluations of the care provided since September 2021 and one resident who has been in the facility for six months does not have a long-term care plan. In the files where there were initial care plans, they were also used as short-term interventions for acute changes. Where the initial care plan was used for short term interventions, these were not consistently signed off following the resolution of the issue. Ensure all care plans are used developed and reviewed at least six monthly or when residents condition changes. Ensure all short-term care plans are signed off as acute conditions resolve, or interventions are added to the long-term care plan accordingly. PA ModerateReporting Complete13/10/2022
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.i). Initial assessments were not documented for two respite residents. ii). Initial care plan of one respite resident had not been updated with the current admission. . iii). One of the three long-term care plans did not have an initial interRAI assessment completed within the required timeframes. iv). Two initial long-term care plans were not documented within required timeframes and the date of one initial long-term care plan could not be confirmed. v) Three interRAI reassessments were not c… (this text has been trimmed due to space limits).i). Ensure respite residents have initial assessments completed within 24 hours of admission. ii). Ensure respite initial care plans reflect the current admission. iii). Ensure all residents have an interRAI assessment completed within 21 days of admission. iv). Ensure all residents have a long-term care plan completed with 21 days of admission. v). Ensure all residents have an interRAI reassessment documented within required timeframes. PA ModerateIn Progress
A medication management system shall be implemented appropriate to the scope of the service.Effectiveness of ‘as required’ medications were not completed in the files or medication notes of three residents who had received ‘as required’ medications Ensure effectiveness of ‘as required’ medication is documented as per policy. PA ModerateIn Progress
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits).i) . One respite resident identified as a high falls risk with a history of three recent falls, did not have interventions documented around falls prevention. The same resident had minimal interventions documented to address short-term memory loss, activities of daily living and mobility. ii). One resident assessed with a medium falls risk and fragile skin had no interventions documented to minimise risks. iii). Three of three long-term files reviewed did not document the residents’ values, beli… (this text has been trimmed due to space limits).i)-iv). Ensure care plans fully inform care staff or the interventions required to meet resident needs. PA ModerateIn Progress
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).Two of four adverse event forms related to unwitnessed falls did not have neurological observations completed as per policy. Ensure staff complete neurological observations within the stated frequencies for unwitnessed falls with or without suspected head injuries. PA LowIn Progress
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).i). The evaluations of two long-term care reviews did not evidence all required review dates. ii). Evaluation documentation does not evidence progress towards the goals. i). Ensure evaluations documentation is maintained to confirm six-monthly evaluations. ii). Ensure evaluation documentation evidence progress towards goals. PA ModerateIn Progress
Service providers shall facilitate safe self-administration of medication where appropriate.(i). One self-medicating resident did not have a competency review completed three-monthly. (ii). One resident did not have a competency review completed. (i).& (ii). Ensure all self-medicating residents have a competency completed three-monthly as per policy. PA ModerateIn Progress

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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