Orewa Beach View Retirement Home & Hospital
Profile & contact details
|Premises name||Orewa Beach View Retirement Home & Hospital|
|Address||163 Hibiscus Coast Highway Red Beach 0932|
|Service types||Geriatric, Dementia care|
|Certification/licence name||Orewa Beach View Retirement Home & Hospital Limited - Orewa Beach View Retirement Home & Hospital|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||14 June 2018|
|Certification period||12 months|
|Provider name||Orewa Beach View Retirement Home & Hospital Limited|
|Street address||53B Sentinel Road Herne Bay Auckland 1011|
|Post address||PO Box 147096 Ponsonby Auckland 1144|
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: 27 March 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||The last recorded fire evacuation drill was dated the 31 May 2016. No documentation was sighted related to the false alarm which occurred in December 2016. (A drill was undertaken on the request of the auditor on the 28 March 2017).||Provide evidence that six monthly fire drills are maintained, documented and embedded into practice.||PA Low||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Not all corrective actions are documented. For example, the challenging behaviour audit which had three recommendations for follow up have not been written up as a corrective action and no documented evidence could be found at the time of audit to show any actions had been taken to address the audit findings. A significant challenging behaviour incident which occurred in January 2017 has no corrective actions identified.||Provide evidence that corrective action data is documented to show that improvements are acknowledged and implemented by the service||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Three of the six files reviewed did not have evidence of completed orientation.||Provide evidence that all new staff orientation documentation is complete to identify what tasks/items have been covered.||PA Low||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Staff appraisals are not up to date. There is no system in place to alert management when staff appraisals are due.||Provide evidence that staff appraisals are undertaken annually to meet contractual requirements.||PA Low||In Progress|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The last recorded complaint documented in the complaints register is dated August 2016. Two recent complaints are not identified in the complaints register, one of which is related to a serious issue and remains open under police investigation.||Provide evidence that all complaints are entered into the complaints register.||PA Low||In Progress|
|Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).||No evidence could be found that the facility required three monthly individual resident evaluation of restraint has occurred since July 2016.||Provide evidence that policies and procedures are followed to include three monthly evaluations of all restraint in use.||PA Low||In Progress|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||The organisation’s strategic and business plan was last reviewed in February 2015. The current owner/director stated they were unaware that they were required to monitor the set objectives and goals.||Provide evidence that the organisational planning processes are overseen by the governing body and regularly reviewed to allow monitoring of planned, coordinated and appropriate service delivery to meet the needs of residents.||PA Moderate||In Progress|
|During a temporary absence a suitably qualified and/or experienced person performs the manager's role.||There is no mechanism in place to ensure that during a temporary absence of the facility manager role and be undertaken.||Provide evidence that there is a process in place to allow cover for temporary absence for the facility manager by a suitable qualified and/or experienced person.||PA Moderate||In Progress|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||The facility manager is new to the role and they have no established localised networks or support from the current owner. The current owner had very limited knowledge of what is expected as the owner of an aged care facility. There are no formalised lines of communication between the facility manager and the current owner.||Provide evidence that the facility manager is supported into their role to allow them to gain confidence and experience to complete all required tasks.||PA Low||In Progress|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The audit schedule is not up to date. No audits were undertaken in November or December 2016 and there is no plan in place to ensure the missed audits will be undertaken in the near future. The audit schedule does not include pressure injury management.||Provide evidence that all quality and risk management systems as described in policy are implemented in a timely manner.||PA Low||In Progress|
|All buildings, plant, and equipment comply with legislation.||Electrical safety checks show a due date of August 2015. There is no documented evidence of the procedure to be undertaken to ensure all toilet equipment is cleaned to comply with infection control standards. Oxygen bottles are not secured. Numerous items as listed above are not listed in the maintenance book for repair.||Provide evidence that all electrical equipment is regularly checked by an approved person to indicate it is safe for use. There is a documented procedure in place for staff to follow to ensure all equipment is correctly cleaned. Ensure all maintenance issues are reported, recorded and addressed. Oxygen bottles are secured.||PA Moderate||In Progress|
|The organisation plans to ensure Māori receive services commensurate with their needs.||A resident whom affiliates with their Maori culture does not have a Maori Health plan||Ensure all residents who affiliate with their Maori culture are supported by a Maori Health plan.||PA Low||In Progress|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||The service does not follow the document control management policy. Approximately 50% of the policies and procedures sighted on the days of audit were out of date and there is no system in place to show when updates are due. Obsolete forms are not always removed to prevent ongoing use.||Provide evidence that there is a system is in place to ensure the most up to date policies, procedures and documents are in use.||PA Low||In Progress|
|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.||Not all residents had identified needs documented in the support care plan.||Ensure the needs of all residents are identified in the service delivery planning.||PA Low||In Progress|
|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.||There is no documentation on incident and accident forms to show what corrective actions are to be put in place to improve services. There are shortfalls identified in the adverse event which occurred and was reported to the Ministry, however no opportunities to improve service delivery as a result had been documented at the time of audit. A significant challenging behaviour incident which occurred in January 2017 has no corrective actions identified.||Provide evidence that all data is documented to a level of detail that identifies the shortfalls, so it can be used an opportunity to improve service as required.||PA Low||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.||Not all residents had an up to date interRAI assessment or GP admission.||Ensure that all residents have an interRAI assessment and are admitted by a GP to meet contractual requirements and time frames.||PA Low||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Documentation related to evaluation and analysis of quality data is not complete. Staff meeting minutes for February did not show any numbers related to the data collected. There is no documented evaluation for the resident or food satisfaction surveys carried out in August 2016.||Provide evidence that quality improvement data is consistently analysed and evaluated and results communicated to staff, and where relevant, residents/families.||PA Low||In Progress|
|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.||Safe medication management and disposal of sharps processes as per policy and procedure are not being followed.||Ensure all medication is administered safely as prescribed and sharps are disposed of appropriately.||PA High||Reporting Complete||24/05/2017|
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: 27 March 2017
Audit type:Provisional Audit