Profile & contact details
|Premises name||Mitchell Court|
|Address||Mitchell Court 228C Levers Road Matua Tauranga 3110|
|Service types||Rest home care|
|Certification/licence name||Mitchell Court (Tauranga) Limited|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||31 May 2018|
|Certification period||36 months|
|Provider name||Mitchell Court (Tauranga) Limited|
|Street address||228C Levers Road Matua Tauranga 3110|
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: 22 November 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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 of five resident files had not had the initial interRAI assessments completed within 21 days of admission. ii) Two of five resident files had not had the interRAI assessment completed at last six-monthly. iii)One respite resident who was regularly admitted for periods of respite, had not had an initial assessment completed for the current admission or the short-term care plan on file updated to reflect the recent change in health condition.||i-ii) Ensure that all interRAI assessments are completed within the required timeframes. iii)Ensure that an initial assessment and an initial care plan is documented (based on the assessment information) for all respite residents for each admission.||PA Low||Reporting Complete||23/11/2017|
|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.||Three of five long-term care plans reviewed were not evaluated against the stated goals and not all sections of the care plan had been evaluated.||Ensure that care plans are evaluated against the stated goals and all sections of the care plan are evaluated at least six-monthly.||PA Low||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Interventions were not documented in sufficient detail to guide care staff for i) one resident with postural hypotension, chronic pain, short-term memory loss and at risk of malnutrition ii) one resident with mental health needs, Meniere’s disease and hearing loss, iii) one resident with short-term memory loss, back pain, macular degeneration and visual disturbance.||Ensure that interventions are documented in sufficient detail to guide the care staff.||PA Low||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Four of four activity plans had been reviewed six-monthly but the activity care plan review had not occurred at the same time as the review of the long-term care plan (ARC 16.5ciii).||Ensure that activity plans are reviewed as part of the review of the long-term care plan.||PA Low||In Progress|
|Advance directives that are made available to service providers are acted on where valid.||Two of the five resident files sampled contain a clinically indicated not for resuscitation order signed by the GP but there is no evidence of this being discussed with the family.||Ensure that when the GP completes a clinically indicated not for resuscitation order that there is documented evidence that this has been discussed with the family or EPOA.||PA Low||Reporting Cancelled|
|Consumers have a right to full and frank information and open disclosure from service providers.||It was not always documented on the accident/incident reporting forms that family had been informed.||For those clients who have not specifically requested that family are not to be notified, ensure family are kept informed following an adverse event. For those clients where family are not to be informed, ensure the accident/incident form reflects this.||PA Low||Reporting Cancelled|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||While data is collected and there were examples of data being analysed and evaluated. There were shortfalls around documentation to reflect this was routinely completed.||Ensure documented evidence is available to verify that quality improvement data is analysed and evaluated with results communicated to staff.||PA Low||Reporting Cancelled|
|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) The short term resident and a new resident have transcribed lists that staff are using to administer medication (this was rectified on audit day for the new resident). (ii) Two of 10 medication charts sampled had prescribed medications that have not always been signed as administered. (iii) One of three open eye drops had not been dated when they were opened.||(i) Ensure transcribing does not occur. (ii) Ensure administration sheets document that all medications are administered as prescribed. (iii) Ensure that all eye drops are dated when they are opened.||PA Moderate||Reporting Cancelled|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||There is no documented evidence that previous activities plans have been evaluated and reviewed.||Ensure that activities plans have a documented evaluation at the time the care plan is reviewed.||PA Low||Reporting Cancelled|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i)Corrective actions have been implemented to reduce the incidence of falls and chest infections. The corrective actions that have been implemented have not been consistently documented, evaluated or signed off. ii) Where scheduled monitoring has identified, areas requiring improvement (charting of prn medication, interRAI assessments, replacement of curtains) corrective action plans have not been consistently documented and the results of the monitoring have not been communicated to staff … (this text has been trimmed due to space limits).||i-ii) Where areas of improvements are identified, ensure that corrective plans are documented and once implemented, the plan is evaluated and signed off. Ensure the results of monitoring and the corrective action plans implemented are communicated to staff.||PA Low||Reporting Complete||23/11/2017|
|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.||One of five resident files evidenced the initial assessment and the initial care plan were not completed and documented by a registered nurse.||Ensure that all initial assessments and initial care plans are completed by a registered nurse or enrolled nurse under the direction of the RN.||PA Moderate||Reporting Complete||23/11/2017|
|Advance directives that are made available to service providers are acted on where valid.||i)Two of the five resident files sampled contain a clinically indicated ‘not for resuscitation’ order signed by the GP but there is no evidence of this being discussed with the family. ii)One ‘not for resuscitation’ order for a competent resident has been signed by the GP and the EPOA.||i) Ensure when the GP completes a clinically indicated not for resuscitation order that there is documented evidence that this has been discussed with the family or EPOA. ii) Ensure that the advanced directives are signed in accordance with all the legislative requirements.||PA Moderate||Reporting Complete||23/11/2017|
|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)Standing orders in use do not comply with organisational policy or MOH guidelines for the use of standing orders. (ii)Seven of ten medication charts sampled did not have indications for use documented for ‘as required’ medication (iii)One of ten signing sheets reviewed evidenced that over the counter preparations were being regularly administered that had not been prescribed by a medical practitioner||(i)Ensure that standing orders in use comply with all guidelines and legislative requirements. (ii)Ensure that ‘indications for use’ are charted for all ‘as required’ medication. (iii) Ensure that all medications and over the counter preparations to be administered to a resident are prescribed correctly.||PA Moderate||Reporting Complete||23/11/2017|
|Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.||A resident who was admitted for regular periods of respite had not signed an admission agreement and had no other documented evidence of consent.||Ensure that all residents admitted for care have a signed admission agreement and all relevant consents are documented.||PA Low||Reporting Complete||23/11/2017|
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: 22 November 2016
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit; Verification Audit
Audit type:Provisional Audit