Palm Grove Rest Home
Profile & contact details
|Premises name||Palm Grove Rest Home|
|Address||8 Grove Road Narrow Neck Auckland 0624|
|Service types||Rest home care|
|Certification/licence name||Lifeline Agedcare Limited|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 August 2018|
|Certification period||36 months|
|Provider name||Lifeline Agecare Limited|
|Street address||8 Grove Road Davenport Auckland 0624|
|Post address||72 Bremner Avenue Mt Roskill Auckland 1041|
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: 01 November 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||There was no evidence of DHB notification following an absconding incident involving a police search.||Ensure the DHB is notified for all essential notifications under Section 31.||PA Moderate||Reporting Complete||27/10/2015|
|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.||One long-term care plan had not been reviewed six monthly.||Ensure that all long-term care plans are reviewed six monthly.||PA Low||Reporting Complete||27/10/2015|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||One short-term care plan did not have interventions resolved or evaluated or updated in the long term care plan. One long-term care plan had no interventions identified around a resident who is at risk of wandering. One long-term care plan did not have interventions identified to support the management of a chronic wound.||Ensure short-term care plans are evaluated with interventions resolved or documented on the long-term care plan. Ensure that long-term care plans include interventions to guide care staff in the delivery of current resident care.||PA Low||Reporting Complete||27/10/2015|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There is no documented evidence of the outcomes of internal audits discussed at meetings. The results of surveys have not been collated, feedback to participants or discussed at meetings.||Ensure staff are aware of the outcomes of internal audits. Collate survey results and ensure outcomes are feedback to staff and participants.||PA Low||Reporting Complete||27/10/2015|
|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.||There was one opened eye drops not dated. There was one expired nasal spray medication. One resident had prescribed topical medications stored on top of the drawers in the bedroom.||Ensure all eye drops are dated on opening. Ensure checks on medication are completed and expired medications are disposed of. Ensure all prescribed medications are securely stored.||PA Moderate||Reporting Complete||27/10/2015|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) Adverse event data for falls, skin tears, bruising, staff accidents, medication errors, and infections has not been consistently collated, analysed or evaluated to identify any possible trends. ii) Only six of thirty-two internal audits have been completed as per the 2016 internal audit schedule. The nurse manager reports that since she has been employed she has been the only RN (August-October 2016) and has not had time to complete internal audits. A second RN was employed in October.… (this text has been trimmed due to space limits).||i) Ensure data collected is regularly collated, analysed, and evaluated. ii) Ensure the audit schedule is completed as planned. iii) Ensure staff are kept informed regarding quality and risk management results.||PA Low||Reporting Complete||06/03/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Four of five staff files selected did not indicate reference checking had occurred.||Ensure reference checks are completed as part of the appointment process.||PA Low||Reporting Complete||06/03/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Four of the five staff files reviewed did not include documented evidence to support completion of the orientation programme.||Ensure staff files reflect documented evidence of staff completing an orientation programme.||PA Low||Reporting Complete||06/03/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There are no RNs trained in InterRAI. The nurse manager is currently undergoing training.||Ensure a minimum of one nurse is available who is trained in InterRAI.||PA Low||Reporting Complete||06/03/2017|
|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 out of five resident files have long-term care plans which are overdue for review; and ii A resident has chronic back pain and is on regular pain medication but no pain assessments have been completed.||i Ensure long-term care plans are evaluated at least six monthly; and ii Ensure residents with chronic pain and who are on regular pain medication, have pain assessments completed.||PA Moderate||Reporting Complete||06/03/2017|
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: 01 November 2016
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit