Ropata Lodge

Profile & contact details

Premises details
Premises nameRopata Lodge
Address 57 Ropata Crescent Boulcott Lower Hutt 5010
Total beds33
Service typesRest home care
Certification/licence details
Certification/licence nameRopata Lodge Limited - Ropata Lodge
Current auditorThe DAA Group Limited
End date of current certificate/licence27 October 2019
Certification period36 months
Provider details
Provider nameRopata Lodge Limited
Street addressN/A 57 Ropata Crescent Boulcott Lower Hutt 5010
Post address57 Ropata Crescent Boulcott Lower Hutt 5010

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: 17 August 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A process to measure achievement against the quality and risk management plan is implemented.A process that links all the quality data collected to enable regular measurement of progress against the quality plan has not yet been developed to reflect the actual positive activity that is occurring. Provide evidence of a formalised process that enables measurement of actual achievement and progress against all the elements included in the plan. Refer also 1.2.3.6. PA LowIn 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.Long term care plans and interRAI assessments are not always completed within three weeks of admission. Provide evidence long term care plans and interRAI assessments are undertaken within three weeks of admission PA LowIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.While there is a quality improvement and risk management plan developed, this is not being formally implemented into a process that clearly links all the data collected, with relevant analysis, into a consistent way to enable robust reporting and evaluation of all quality improvement data. Develop and implement a system that will collect all data into a format that enables reporting on trends, corrective action reporting and evaluation across all quality indicators which will also support reporting and measuring achievement against the quality and risk plan (see also 1.2.3.7). PA LowIn Progress
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.Documentation, observation and interview verifies an infection control programme is operating however it has not been reviewed annually and the programme sighted has not been reviewed to determine its relevance to the facility. Provide evidence that the infection control programme reflects the ICP operating at Ropata and is reviewed annually. PA ModerateReporting Complete14/10/2016
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.There is a lack of specific annual goals, objectives or any service related planning included in the business planning cycle that can provide direction for the management of the delivery of services. Further develop the business planning process to include service specific goals and objectives to provide clear direction to support and provide guidance to the service management team. PA LowReporting Complete11/11/2016
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.Eye drops being used, had no evidence to verify their use by dates, since opening, had not expired. There is no documented evidence of controlled drugs being checked six monthly. Ensure eye drops are used within their use by dates and the controlled drug register has the required six monthly checks. PA ModerateReporting Complete11/11/2016
The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation.There is no formal IC surveillance programme operating as evidenced by documentation, interviews and observation. Evidence is provided that an IPC surveillance programme is operating, with the results of findings and analysis acted on. PA ModerateReporting Complete11/11/2016
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).There is no formalised risk register developed to identify actual and potential risks and then, where appropriate, communicate these to relevant stakeholders. Identify and document all potential and actual service provision risks, with relevant analysis, monitoring and review, and then develop and implement a process that addresses/treats those risks. Where appropriate, communicate these to relevant stakeholders. PA ModerateReporting Complete01/05/2017
The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.The responsibility for infection control is not clearly defined with no job description, no formal training in ICP provided and no clear lines of accountability for infection control matters as evidenced by documentation and interviews with the IPC coordinator. Provide evidence the responsibility for IPC is clearly defined, and formal IPC training provided to the ICP co-ordinator PA ModerateReporting Complete28/08/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Interview with the facility manager and sighted documentation verified long term care plans did not always describe the required support identified in the assessment process. Provide evidence long term care plans describe the required support identified in the assessment process. PA ModerateReporting Complete30/10/2017

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. 

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 reports

Audit date: 17 August 2016

Audit type:Certification Audit

Audit date: 07 October 2015

Audit type:Partial Provisional Audit

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