Redroofs Rest Home
Profile & contact details
| Premises name | Redroofs Rest Home |
|---|---|
| Address | 15 Dunblane Street Maori Hill Dunedin 9010 |
| Total beds | 50 |
| Service types | Rest home care |
| Certification/licence name | Heritage Lifecare (BPA) Limited - Redroofs Rest Home |
|---|---|
| Current auditor | The DAA Group Limited |
| End date of current certificate/licence | 03 April 2025 |
| Certification period | 36 months |
| Provider name | Heritage Lifecare (BPA) Limited |
|---|---|
| Street address | 16 Johnsonville Road Johnsonville Wellington 6037 |
| Post address | PO Box 13223 Johnsonville Wellington 6440 |
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: 05 July 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| The facilitation of safe self-administration of medicines by consumers where appropriate. | The process of safe administration for three residents choosing to administer some of their own medications is not occurring according to the organisation’s medication policy. | The policy for safe administration of medication by residents is implemented and documented. | PA Moderate | Reporting Complete | 26/05/2022 |
| Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers. | Eye protection and face shields are not cleaned and sanitised after use. | Provide evidence that eye protection and face shields are cleaned and sanitised after each use. | PA Moderate | Reporting Complete | 29/06/2022 |
| The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. | The documentation on the daily cleaning schedules did not evidence that all tasks had been consistently completed. | Provide evidence that the documentation on the daily cleaning schedules is completed as required by the facility. | PA Low | Reporting Complete | 29/06/2022 |
| The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed. | The 2022 business plan has not yet been developed. The review of the 2021 goals has not taken place. | Provide evidence that the 2022 Business Plan has been developed, and that the 2021 goals have been reviewed. | PA Low | Reporting Complete | 21/07/2022 |
| 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. | Files reviewed showed care planning was occurring, however none of the files reviewed had the long term care plan developed within the required time frame of three weeks. This varied between four and nine weeks. | All long term care plans are developed within three weeks of admission. | PA Low | Reporting Complete | 21/07/2022 |
| 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. | Twelve percent (12%) of policies and procedures were not current at the time of audit. The provider was not able to provide an employment policy. | Provide evidence that the policies and procedures are current. Provide evidence that an employment policy has been developed and implemented in accordance with good employment practice to meet the requirements of legislation. | PA Moderate | Reporting Complete | 06/09/2022 |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | An annual education plan is in place which outlines the competency requirements of staff. There is no record in place to confirm that staff have completed the required competencies specific to their role. | For all staff complete the required competencies specific to their role, as outlined in the organisation’s training plan, and have these recorded onto the competency register. | PA Low | Reporting Complete | 25/03/2024 |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | An education plan is in place which outlines the training requirements of staff. There is no record in place to confirm that all staff have completed the training requirements specific to their role. | All staff complete the specified training requirements, specific to their role, as outlined in the organisation’s training plan. | PA Low | Reporting Complete | 25/03/2024 |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Redroofs have a required orientation process in place, but not all staff files had records to evidence that the employee had completed the orientation process. | All staff to have completed the orientation process relevant to their role, in line with the organisation’s requirements, and that a record of their orientation is held on each employee’s file. | PA Low | Reporting Complete | 25/03/2024 |
| Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits). | Not all residents had short-term care plans in place when clinically indicated, and reassessment of one person’s changing support needs, and their level of care had not occurred. | All resident files are reviewed, and short-term care plans completed as appropriate. The resident with complex needs to have an updated interRAI assessment completed and a referral made to the Needs Assessment and Service Coordination (NASC) service for level of care assessment. | PA Moderate | Reporting Complete | 25/03/2024 |
Guide to table
Outcome required
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
Action required
The action necessary to fix the issue, as decided by the auditor.
Risk level
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.
Action status
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.
Audit reports
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.
From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.
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 Ngā Paerewa Health and Disability Services Standard.
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 reports
Audit date: 05 July 2023Audit type:Surveillance Audit
Audit date: 01 February 2022Audit type:Certification Audit
Audit date: 27 November 2020Audit type:Surveillance Audit
Audit date: 14 February 2019Audit type:Certification Audit
Audit date: 20 February 2018Audit type:Provisional Audit