Roseneath Care Services
Profile & contact details
|Premises name||Roseneath Care Services|
|Address||227 High Street South Carterton 5713|
|Service types||Geriatric, Rest home care|
|Certification/licence name||Roseneath Care Services Limited|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||15 January 2016|
|Certification period||36 months|
|Provider name||Roseneath Care Services Limited|
|Street address||227 High Street South Carterton 5713|
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: 24 October 2012
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Services conduct comprehensive reviews regularly, of all restraint practice in order to determine:(a) The extent of restraint use and any trends;(b) The organisation's progress in reducing restraint;(c) Adverse outcomes;(d) Service provider compliance with policies and procedures;(e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice;(f) If individual plans....||There is no restraint approval group that reviews the restraint practice for the facility to identify trends, the progress towards reducing restraint, compliance with policies and procedures, education and training needs and whether or not any changes are required to the policies and procedures||Provide evidence that a restraint approval group is established that conducts comprehensive regular reviews of restraint practices for the facility including: the identification of trends, the progress towards reducing restraint usage, compliance with the organisation’s policies and procedures, identification of education and training needs for staff, and identifies whether or not any changes are required to the policies and procedures||PA Low||In Progress|
|The service is able to demonstrate that written consent is obtained where required.||There is no evidence of consent to receiving residential aged care services in six of eight residents’ files reviewed.||There is evidence that all residents consent to receiving aged residential care services.||PA Moderate||In Progress|
|Advance directives that are made available to service providers are acted on where valid.||In one of three files of residents receiving Stage III dementia care, a family member with Enduring Power of Attorney has completed the advance directive on behalf of the resident.||Only residents will make decisions related to their advance directive.||PA Low||In Progress|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register: (i) does not include all of the complaints that have been received prior to 15 December 2013; and (ii) does not document the actions taken.||Provide documented evidence that the complaints register includes all complaints received and documents all actions taken.||PA Low||In Progress|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||There is no documented evidence that the strategic plan for 2010 – 2012 has been reviewed and it is past the documented review date.||Provide documented evidence that the strategic plan has been reviewed.||PA Low||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality improvement data is not being comprehensively analysed and evaluated to identify trends. There is no documented evidence that quality improvement data is being reported to quality, clinical and/or staff meetings.||Provide documented evidence that quality improvement data is being comprehensively analysed to identify trends, and that quality improvement data is being reported to staff.||PA Moderate||In Progress|
|A process to measure achievement against the quality and risk management plan is implemented.||(i)There is no up-to-date quality and risk management plan available; (ii) There is minimal documented evidence available to indicate that the quality and risk management plan was maintained throughout 2013. (iii) There is no documented evidence available indicating that a resident satisfaction survey has been completed.||Provide documented evidence that (i) an up-to-date quality and risk management plan is available and is fully implemented; and (ii) a resident / family satisfaction survey is completed as part of the quality improvement programme.||PA Low||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||(i)Corrective action plans are not being developed, implemented and monitored to address areas identified as requiring improvement following internal audits and adverse events and in meeting minutes. (ii) Meeting minutes reviewed do not consistently provide evidence that responsibilities and timeframes for corrective actions are documented.||Provide documented evidence that: (i) corrective action plans addressing areas requiring improvement are being developed, monitored, evaluated and signed off as having been completed; and (ii) meeting minutes clearly document who is responsible for developing and implementing the corrective action/s and the timeframes for this.||PA Moderate||In Progress|
|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 ...||The ‘Health and Safety Register’ is not comprehensive and does not include all actual and potential risks associated with providing the service, for example human resources management, governance, business continuity risks are not identified and documented.||Provide documented evidence that actual and potential risks are identified, documented, monitored, analysed, evaluated and reviewed on a regular basis.||PA Moderate||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Eight staff files reviewed and there is no documented evidence of (i) criminal vetting having been completed on any of the eight staff files; (ii) reference checking has been completed on five of the staff files; (iii) job descriptions on six of the staff files; and (iv) the restraint co-ordinator and the infection control co-ordinator do not have job descriptions for these roles on their personal files.||Provide evidence that: (i) all new staff have criminal vetting and reference checking completed; (ii) all staff have job descriptions on their files; and (iii) the restraint co-ordinator and infection control co-ordinator have job descriptions for these roles.||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||i)There is no documented evidence on seven of the eight staff files reviewed to indicate that an orientation has been completed. (ii) The care manager has not had any management training and has not completed an orientation to the role of care manager.||Provide evidence that: (i) all new staff receive an orientation to their role; and (ii) the clinical manager receives an orientation to the role of care manager.||PA Moderate||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i)There are no documented in-service education programmes available for 2013 and 2014.(ii) Core in-service education sessions have not been provided on a regular basis, for example, medication management, infection control, management of challenging behaviours, chemical safety, cultural awareness, the principles of informed consent, open disclosure, fire safety training, and emergency and security management education.(iii) Medication competencies are not current for all staff who...||Provide evidence that: (i) an in-service education programme covering all of the core education sessions is developed and implemented for 2014 and beyond; (ii) staff involved in medicine management complete medication competencies on at least an annual basis and that records of these are kept; (iii) all staff have current performance appraisals; (iv) that all staff working in the dementia unit commence and complete the dementia specific unit standards as identified in the district..||PA Moderate||In Progress|
|All records are legible and the name and designation of the service provider is identifiable.||Staff are not recording their full names when making entries in resident’s progress notes.||Provide confirmation that staff are documenting their first and last names and their designation when making entries in records.||PA Low||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.||(i)Standing orders do not include contraindications for administration(ii) There is no evidence that the temperature of the medication fridge is being monitored(iii) There are missing entries in two of sixteen medication administration records (iv) There is no evidence that medications are checked on arrival from the pharmacy.||(i)Standing orders include contraindications for administration.(ii)Provide evidence that the temperature of the medication fridge is monitored daily.(iii)Provide evidence that medication administration records are complete.(iv)Provide evidence that medications are checked on arrival from the pharmacy.||PA Moderate||In Progress|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||There is no evidence that staff involved in the administration of medicines have been assessed as competent to undertake this role.||Provide evidence that all staff involved in medication management have been assessed as competent to undertake this role.||PA Moderate||In Progress|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||(i)There is no evidence that resident’s weight is monitored regularly. (ii) There is no evidence that a registered dietician has reviewed the menu.||(i)Provide evidence that residents are weighed on a regular basis. (ii) Provide evidence that the menu is reviewed by a registered dietician.||PA Moderate||In Progress|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Although there is documented evidence of daily kitchen cleaning being completed as scheduled, the documentation related to weekly and monthly cleaning is more sporadic. There is also no evidence that the dishwasher machine is checked regularly.||Provide evidence that all cleaning is undertaken in accordance with the cleaning schedule.||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.||Service delivery plans do not describe the required support and interventions. (Refer to Tracers 1, 2 and 3 for examples).Service delivery plans for residents receiving specialist dementia care do not include all of the information required under section E4.3 ii and iii (care planning) in the age related residential care services agreement.||(a)There is evidence that all care plans describe the required support and interventions necessary to achieve desired resident outcomes.(b) There is evidence that the care plans of all residents in the Stage III dementia unit comply with the requirements of the age related residential care services agreement.||PA Moderate||In Progress|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||There is no evidence that evaluations are being undertaken in a comprehensive and timely manner.||Provide evidence that service delivery plans are evaluated in a timely and comprehensive manner.||UA Moderate||In Progress|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||There is limited evidence that service delivery plans are changed when progress is different from expected.||Provide evidence that service delivery plans are updated when progress is different from expected.||PA Moderate||In Progress|
|Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.||The Infection Control Coordinator has not undertaken any training related to infection control management.||Provide evidence that the Infection Control Coordinator has completed appropriate education in infection control management.||PA Moderate||In Progress|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||Infection surveillance is not being analysed in a comprehensive manner, and there is no evidence of actions arising from the data that is being collected.||Provide evidence that infection surveillance data is analysed and appropriate actions are taken as required.||PA Moderate||In Progress|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to:(a) Details of the reasons for initiating the restraint, including the desired outcome;(b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint;(c) Details of any advocacy/support offered...||(i) Monitoring Forms for the hospital tracer are not comprehensive and do not include the time the restraint (lap belt) is applied and released. (ii) The care plan does not include the risks associated with the restraint used (lap belt) including the duration the restraint should be used for (Refer also criterion 22.214.171.124.)||Provide evidence that (i) comprehensive monitoring of restraint use is occurring, including the actual time the restraint is applied and released and the duration of restraint use; and (ii) the care plans identify the risks associated with the restraint being used.||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.
Full audit reports
Full audit reports are available if they were processed and approved after 29 August 2013. Visit Full audit reports to find out more.
What’s on this page?
Summaries of this rest home’s latest audit reports can be downloaded below.
The summaries include:
- an overview of the rest home’s performance
- a table showing how well the rest home does against the Health and Disability Services Standards – standards covering more than 200 aspects of quality and safety.
Before you read the audit summaries, please read our guide to rest home certification and audits.
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 summariesAudit date: 24 October 2012
Audit type:Certification Audit
Audit type:Verification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit