Radius Thornleigh Park
Profile & contact details
|Premises name||Radius Thornleigh Park|
|Address||25 Heta Road New Plymouth 4312|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Radius Residential Care Limited - Radius Thornleigh Park|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||05 December 2018|
|Certification period||Other months|
|Provider name||Radius Residential Care Limited|
|Street address||12 Viaduct Harbour Avenue Auckland Central Auckland 1010|
|Post address||PO Box 450 Auckland 1140|
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: 12 June 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||Two of four residents care plans sampled (from the hospital) do not have documented evidence of resident or family input.||Ensure there is documented evidence for all care plans of resident and/or family input.||PA Low||Reporting Complete||11/03/2016|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||There had been no fire drill in the past six months. The risk is low as a fire drill is booked with the New Zealand Fire Service for 9 October 2014 (email confirmation sighted).||Ensure fire drills are conducted at least six monthly.||PA Low||Reporting Complete||11/03/2016|
|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.||The InterRAI ‘assessment due’ summary documented that nine InterRAI assessments were overdue for review. This included one of the eight files sampled (from the rest home).||Ensure all InterRAI assessments are reviewed at least six monthly or when needs change.||PA Low||Reporting Complete||11/03/2016|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||In three of eight complaints reviewed the complaints register had no documented evidence of an acknowledgement letter or outcome letter being sent to the complainant.||Ensure all complaints are acknowledged within five working days and the complainant receives a documented outcome of the complaint.||PA Low||Reporting Complete||21/03/2016|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||There are three freezers and only one temperature has been recorded. One freezer has an external thermostat, which was at -7 degrees Celsius during the audit and the kitchen manager was unaware that this was outside the safe range. Temperatures were not recorded for the fridge in the kitchenette.||Ensure that individual temperatures are recorded for all fridges and freezers and that these are maintained in a safe temperature range.||PA Low||Reporting Complete||21/03/2016|
|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) controlled drug checks have not occurred weekly. (ii) Three of 16 medication charts sampled have as required medications prescribed (for midazolam and OxyContin) with no indication for use documented. (iii) Three of 16 medication administration records do not have all prescribed medications signed as administered.||(i) Ensure controlled drug-checks occur weekly. (ii) Ensure ‘indication for use’ is documented for ‘as required’ medications. (iii) Ensure that medication is administered as prescribed.||PA Moderate||Reporting Complete||24/03/2016|
|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.||None of the six residents admitted since 1 July 2015 (two to the hospital and four to the rest home), have had InterRAI assessments completed.||Ensure that an InterRAI assessment is completed for every new admission.||PA Low||Reporting Complete||24/03/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Four of the eight care plans sampled (three from the hospital and one from the rest home) did not have interventions documented for all assessed needs. Examples included falls management, use of a sliding sheet, weight management, management of hypo and hyperglycaemia and regular turns.||Ensure that care plans document interventions for all identified areas of need.||PA Moderate||Reporting Complete||24/03/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Two of the three pressure areas at the facility did not have a comprehensive assessment completed. Four of the 12 current wounds (including two of three pressure areas) have not been reviewed within the stated timeframe.||Ensure all wounds have a comprehensive assessment and are reviewed within the stated timeframe.||PA Moderate||Reporting Complete||24/03/2016|
|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 latest fire evacuation drill on 28 February 2017 occurred later than the required six-month period.||Ensure that fire evacuation drills are conducted at least six-monthly.||PA Moderate||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.||Two rest home level residents did not have an interRAI assessment within 21 days of admission. An interRAI assessment had not been completed for one rest home resident with changes to health requiring re-assessment for higher level of care.||Ensure interRAI assessments are completed within 21 days of admission. Ensure interRAI assessments are completed for residents with changes to health status.||PA Moderate||In Progress|
|Key components of service delivery shall be explicitly linked to the quality management system.||Not all facility meetings have been completed as per annual meeting calendar schedule. Required actions and resolutions have not been consistently documented, followed up or completed.||Ensure that all facility meetings are completed as per annual meeting calendar schedule and any required actions are followed up or completed.||PA Low||In Progress|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||There was no documented evidence of relative/resident input into the care plan for one younger person with a long-term chronic health condition.||Ensure there is documented evidence of resident/relative input into the resident’s care plan.||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||1) The care plan for one rest home resident had not been updated to reflect additional supports required following a hospital admission including the use of oxygen and pressure injury prevention for high risk of pressure injury. A dietitian referral had been actioned, however there was no report or dietary recommendations included in the resident file or care plan. 2) The care plan for another rest home resident did not reflect falls prevention interventions for moderate risk of falls and absc… (this text has been trimmed due to space limits).||Ensure care plans reflect the resident needs/supports and current health status.||PA Moderate||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||1) There were no weekly weights for one hospital younger person under LTCHC with unintentional weight loss. 2) Intentional rounding had not been completed half hourly for two rest home residents as per care plan instructions. 3) Neurological observations had not been completed for three residents as per protocol following unwitnessed falls.||Ensure interventions are implemented for the monitoring of a resident’s health status.||PA Moderate||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.||1) Three of four glucagon kits had expired. 2) The signing sheet for one ‘as required’ controlled drug did not align with the medication chart. 3) One discontinued medication had not been dated or signed by the GP.||1) Ensure all expiry dates of medications are checked and medication removed if out of date. 2) Ensure signing sheets align with the prescription. 3) Ensure all medications are dated and signed when discontinued.||PA Moderate||In Progress|
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: 12 June 2017
Audit type:Surveillance Audit
- Radius Thornleigh Park - Jun 2017 (docx, 34.57 KB)
- Radius Thornleigh Park - Jun 2017 (pdf, 136.05 KB)
Audit type:Certification Audit
- Radius Thornleigh Park - Sep 2015 (docx, 41.93 KB)
- Radius Thornleigh Park - Sep 2015 (pdf, 163.23 KB)
Audit type:Surveillance Audit
- Radius Thornleigh Park - May 2014 (docx, 85.18 KB)
- Radius Thornleigh Park - May 2014 (pdf, 570.92 KB)
Audit type:Certification Audit
Audit type:Surveillance Audit