Lester Heights Hospital
Profile & contact details
|Premises name||Lester Heights Hospital|
|Address||93 Fourth Avenue Woodhill Whangarei 0110|
|Service types||Physical, Rest home care, Geriatric, Medical|
|Certification/licence name||Lester Heights Hospital Limited - Lester Heights Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||15 November 2017|
|Certification period||12 months|
|Provider name||Lester Heights Hospital Limited|
|Street address||41A Millen Avenue Pakuranga Auckland 2010|
|Post address||41A Millen Avenue Pakuranga Auckland 2010|
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: 03 April 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A process to measure achievement against the quality and risk management plan is implemented.||i) Seven of twelve audits scheduled from September through to March have not been completed (laundry, staff satisfaction, staff education, building compliance, resident admission process, resident file check and infection control).||Ensure that the monitoring schedule is fully implemented.||PA Moderate||Reporting Complete||30/08/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i) End cooked food temperatures are not being consistently documented. (ii) Fridge and freezer temperatures are not being consistently documented.||i-ii) Ensure that end cooked food temperatures and fridge and freezer temperatures are consistently documented.||PA Low||In Progress|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||In one rest home respite file, there was no documentation kept in the resident’s file of the care provided by the district nursing service or of the assessments and consultations completed by the medical staff. The rest home respite resident was accepted for admission from the DHB with a PICC line that was to be managed by the district nursing service. There was no evidence that the registered nurses at Lester Heights had received any training in the monitoring required for the PICC line. The… (this text has been trimmed due to space limits).||Ensure that a record is kept in the resident’s file of all assessments and care provided by the allied health care team and the medical officers. Ensure that assessments and care plans are documented in a timely manner and the requirements noted in the hospital discharge summaries are completed in the timeframes stipulated.||PA High||Reporting Complete||26/06/2017|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||i) Six of eight complaints received from residents or families (2017 year to date) were not responded to within the required timeframes and the complainants were not advised on how to contact the Health and Disability Commissioner. ii) Two resident complaints (one documented in the resident meeting minutes for January and one reported verbally to staff) were not documented on the complaints register and these complaints were not investigated or responded to. iii) There was no record kept of t… (this text has been trimmed due to space limits).||i-iii) Ensure that all aspects of complaints management comply with the requirements of Right 10 of the Code.||PA Moderate||Reporting Complete||30/08/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There was no evidence that quality data (infection surveillance data, incidents and accidents, complaints, clinical indicator data) were being consistently analysed and trended and the results communicated to staff.||Ensure that all quality improvement data is trended and analysed and the results communicated to staff and residents where appropriate.||PA Low||Reporting Complete||30/08/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||i) Corrective action plans are not being consistently documented where the quality data is identifying areas requiring improvement. ii) Where corrective action plans have been documented, the corrective action plans are not being consistently evaluated, communicated to staff or signed out. iii) There was no evidence that the corrective action forms that are part of the service’s quality management system are being used.||i-iii) Ensure that corrective actions plans are documented where opportunities for improvement are noted and the corrective action plans are then implemented, reviewed and signed off once completed.||PA Low||Reporting Complete||30/08/2017|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||There is no evidence that the hazard register has been reviewed in the past 12 months.||Ensure that the hazard register is reviewed at least annually.||PA Low||Reporting Complete||30/08/2017|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||The non-facility acquired pressure injury was not documented on an accident and incident form or captured in the clinical indicator data.||Ensure that all pressure injuries are reported on an accident and incident form.||PA Low||Reporting Complete||30/08/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) Six of the nine scheduled education sessions between September 2016 and February 2017 have not been delivered. ii) Education has not been provided to staff on the needs of the younger person with a disability. iii) Six of six staff files sampled could not evidence completion of an annual performance review.||i) Ensure that the education planner is fully implemented. ii) Ensure that staff are provided with education on the needs of the younger person with a disability. iii) Ensure that all staff have an annual performance review.||PA Low||Reporting Complete||30/08/2017|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||i) One rest home resident (respite) had a) the same dose of anticoagulation therapy charted twice- one charting was not signed and the other charting was not dated and; b) the Paracetamol charted QID on one chart and Paracetamol PRN up to QID on the second chart. ii)Standing orders in use do not comply with Ministry of Health 2016 Standing Order Guidelines (2nd edition).||i-ii) Ensure that all medication is charted in accordance with all professional guidelines and legislative requirements.||PA Moderate||Reporting Complete||30/08/2017|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.||(i) One of five wound care plans sampled for a hospital resident, was documented by a student nurse and had not been reviewed or countersigned by a registered nurse. (ii) One rest home respite resident and two hospital residents had changes in health condition (pain, red skin areas, behaviours) reported in the progress notes by healthcare assistants. However, there was no documented evidence of follow up or follow up in a timely manner by a registered nurse.||(i) Ensure that a registered nurse reviews and signs off all assessments and care plans. (ii) Ensure that issues reported by healthcare assistants are followed up in a timely manner by registered nurses.||PA Moderate||Reporting Complete||30/08/2017|
|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) Two of two subsidised residents (one hospital and one rest home) admitted for long-term care did not have the interRAI assessment completed within 21 days of admission. ii) Four of four long-term residents (two hospital including one young person with disability, one long term chronic and one rest home) did not have the long-term care plan developed within 21 days of admission (completed between 2- 3 months). The YPD resident admitted with co-morbidities in January still did not have a LTC… (this text has been trimmed due to space limits).||i-ii) Ensure that all interRAI assessments and long-term care plans are documented within the required timeframes.||PA Moderate||Reporting Complete||30/08/2017|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||(i) Four of four residents (two rest home- including one respite and two hospital- including one resident admitted under a long term chronic contract) documented episodes of pain in the progress notes, but there was no evidence of any pain assessments being completed. (ii) One YPD resident (hospital) and one LTCH resident (hospital) did not have all required assessments completed on admission.||(i)-(ii) Ensure that risk assessments including screening for PI risk and pain are completed where indicated.||PA Moderate||Reporting Complete||30/08/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||i) Two residents (one rest home and one hospital- long term chronic) on behaviour monitoring charts did not have all sections of the monitoring form completed and did not evidence review of the monitoring by a registered nurse. ii) Four of four residents (two rest home and two hospital) did not have neurological observations completed or completed for the required timeframes. iii) Four of eight hospital residents using a restraint did not have interventions to manage the risks documented in suf… (this text has been trimmed due to space limits).||i) Ensure that all sections of the behaviour monitoring form are fully completed and the behaviour monitoring form is reviewed by a registered nurse. ii) Ensure that all residents following an unwitnessed fall, have neurological observations completed in accordance with the organisations falls management policy. iii) Ensure that all residents using a restraint have interventions documented in sufficient detail to guide the care staff.||PA Moderate||Reporting Complete||30/08/2017|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Two of three (hospital) care plans sampled were not updated with a change in care needs including a) an increase in the assistance required with meals; b) the removal of a restraint; and c) the development of a chronic infection.||Ensure that the care plan is evaluated and updated with all changes in care needs.||PA Low||Reporting Complete||30/08/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) One respite resident (rest home) admitted to the service on the 24 March, had no care plan documented and no evidence of a discharge planning process for the three previous admissions. (ii) One YPD hospital resident with co-morbidities admitted in January 2017 had an initial care plan documented but did not have a long-term care plan documented. The initial care plan for the YPD resident did have sufficient interventions to cover all current needs. (iii) Three of three long-term care plan… (this text has been trimmed due to space limits).||(i) Ensure care plans are documented for all respite residents. Ensure that all interventions noted by allied health are transferred to the care plan. (ii) Ensure that all residents have a long-term care plan documented to support current needs. iii-vi) Ensure that care plans are documented for all assessed care needs and updated as needs change.||PA High||Reporting Complete||11/09/2017|
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: 03 April 2017
Audit type:Surveillance Audit
- Lester Heights Hospital - Apr 2017 (docx, 40.08 KB)
- Lester Heights Hospital - Apr 2017 (pdf, 160.3 KB)
Audit type:Provisional Audit