Rosaria Rest Home
Profile & contact details
|Premises name||Rosaria Rest Home|
|Address||23 Roberton Road Avondale Auckland 1026|
|Service types||Rest home care|
|Certification/licence name||Rosaria Rest Home 2006 Limited|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||08 November 2017|
|Certification period||36 months|
|Provider name||Rosaria Rest Home 2006 Limited|
|Street address||23 Roberton Road Avondale Auckland 1026|
|Post address||2/7 Henry Street Avondale Auckland 1026|
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: 19 April 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||There was no evidence of the complaints process, for example, no complaint forms were available, no public information about the complaints process, and there was nowhere to deposit a completed complaint form. The provider was not responding to verbal complaints within five working days. A minor complaints book was available that captured some complaints issues. There was no complaints register, and no evidence of complaint management since the last audit. There is no evidence of complaints and… (this text has been trimmed due to space limits).||Ensure an up to date complaints register is maintained and correct process followed as per the policy.||PA Moderate||Reporting Complete||29/08/2016|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||The manager was unable to provide evidence of at least 8 hours annually of professional development related to the management of a rest home.||Ensure the manager is able to show at least 8 hours annually of professional development related to the management of a rest home.||PA Negligible||Reporting Complete||06/07/2016|
|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.||The medication room door is not securely locked and medication is accessible to anyone who enters the room. The medication folders are kept on top of the fridge and not in one of the locked cupboards in the room. The director/owner stated the medication folders used to be kept in the cupboards but this practice has ceased. During interview with the RN and the manager/director they stated that the medication door was not locked so the room could be easily accessed by all staff during the day. The… (this text has been trimmed due to space limits).||Ensure the medication room is secure at all times.||PA High||Reporting Complete||16/08/2016|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||The only activity plan located was dated August 2015. Contracted activities are undertaken 4.5 hours per week and there is no nominated staff member responsible for activities.||Provide evidence that there is a suitable qualified staff member who is responsible for undertaking and overseeing activities and who ensures there is a plan for activities undertaken to meet resident identified needs.||PA Moderate||Reporting Complete||29/08/2016|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The food stored in the cupboard and in the fridges does not have an expiry date or best by date shown. There is no documented cleaning schedule for the kitchen area.||Provide evidence that food storage is undertaken to meet best practice guidelines and meets current legislative guidelines. This includes the introduction of a documented regular cleaning schedule||PA Moderate||Reporting Complete||29/08/2016|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||The information related to residents’ dislikes could not be found and nutritional requirement documentation located in the kitchen was out of date.||Ensure information related to residents who have additional or modified diets are kept up to date and that all residents’ likes and dislikes are catered for.||PA Moderate||Reporting Complete||29/08/2016|
|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.||Adverse events are recorded as incidents and accidents but not used to improve service delivery or to identify and manage risk. An example is one resident who knocked their head was not observed for neuro observations and now is in hospital.||Ensure use of adverse event data is used to improve service delivery and to identify and manage identified risks. Ensure each incident is reported and reviewed to ensure changes are part of the quality system.||PA High||Reporting Complete||29/08/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Following any residents’ falls documentation could not be found regarding actions taken and interventions required to monitor the resident’s condition. Refer comments 184.108.40.206||Provide evidence that all required interventions are documented to monitor resident change in status.||PA Moderate||Reporting Complete||28/09/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Staff annual appraisals are completed but no evidence of clinical input or staff signoff could be sighted. There is currently no staff member with suitable qualifications undertaking appraisals which require a clinical assessment two yearly. Education programme is sighted but no evidence is seen of content or evaluation. Staff report on interview they attend education as part of the monthly staff meetings but are not aware of evaluations or handouts with content of the session.||Ensure appraisals are undertaken by an appropriate staff member and that staff input is identified. Ensure education has documented content and sessions are evaluated. Ensure the clinical requirements of the appraisal are completed and signed by a relevant clinician.||PA Low||Reporting Complete||28/09/2016|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The service does not provide safe staffing to meet legislative requirements. To meet DHB contractual requirements there is to be one staff member on each shift with a first aid certificate. The employee detailed above is the only person with a First aid certificate.||Ensure safe staffing levels are implemented at all times as identified in policy and required by the DHB.||PA High||Reporting Complete||28/09/2016|
|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.||Three of three recent admissions (covering 2015 and 2016) do not meet the requirements of the DHB contract for admission within two working days. Examples sighted: 1. admission date 14 November 2015 GP admission 23 November 20155 2. admission date 11 February 2016 GP admission 17 February 2016 3. admission date 09 July 2015 GP admission 19 August 2015 This was discussed with the RN who stated she was unaware of the two working days’ post admission requirement so she has never asked the GP to m… (this text has been trimmed due to space limits).||Provide evidence that newly admitted residents are seen by a GP within the required timeframes. Ensure management and staff with responsibility are aware of and comply with standards and contract requirements.||PA High||Reporting Complete||28/09/2016|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||Menus have not been approved to show they meet recognised nutritional guidelines for an aged care environment.||Provide evidence that menus have been approved a suitable for aged care.||PA Low||Reporting Complete||09/11/2016|
|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).||The quality system is not part the meetings with families or residents. The includes results of audits or incidents forms||Implement the process to ensure consumers are aware of any risks identified as part of the quality process.||PA High||Reporting Complete||18/11/2016|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||No corrective action plans sighted for any areas identified for improvement. This includes adverse event reporting, and infection control audit results||Implement corrective action plans as part of the quality risk management programme. Ensure feedback is given to staff as part of the education and quality programme.||PA High||Reporting Complete||18/11/2016|
|A process to measure achievement against the quality and risk management plan is implemented.||Since the last audit there have been no process implemented to measure quality and risk. Only building compliance audits are completed and no evidence is seen of assessment and any quality improvement measures. Staff interviewed using an interpreter were not able to report on any discussions at meetings or education.||To re implement quality and risk processes which meet the policy and legislative requirements.||UA High||Reporting Complete||18/11/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Some data is collected but not evaluated or analysed as part of the quality system. Staff interviewed using an interpreter reported no knowledge of discussions at staff meetings.||Ensure data collected analysed as part of the quality and risk programme.||UA High||Reporting Complete||18/11/2016|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||Since certification audit in 2014 the Quality Consultant has been unwell and the RN has resigned. The quality processes since that time show no evidence of ongoing quality and risk management being part of this organisations practice. The new RN on interview does not report to have an understanding of the quality systems. The director/ owner also has limited knowledge of quality and risk management however has completed audits regarding building compliance. No other areas have been maintained. … (this text has been trimmed due to space limits).||Re-establish the structure, process and reporting systems for quality and risk management. Ensure there is a staff member, or Quality Consultant who has relevant knowledge of quality systems and the audit process.||PA High||Reporting Complete||18/11/2016|
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: 19 April 2016
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit