San Michele Home and Hospital

Profile & contact details

Premises details
Premises nameSan Michele Home and Hospital
Address 175 College Street Te Awamutu 3800
Total beds30
Service typesMedical, Rest home care, Geriatric
Certification/licence details
Certification/licence nameStanthom Properties Limited - San Michele Home and Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence02 November 2019
Certification period24 months
Provider details
Provider nameStanthom Properties Limited
Street address 31 Pukehana Avenue Epsom Auckland 1023
Post addressPO Box 28853 Remuera Auckland 1541

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: 23 August 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.The registered nurse with the title of infection control nurse has no evidence of having completed any formal training in infection prevention and control. Ensure that the registered nurse who holds the title of infection control nurse, has formal training in infection prevention and control. PA LowIn Progress
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.The food menu has not been reviewed by a dietitian within the last three years. Ensure that the menus are reviewed by the dietician to meet recognised nutritional guidelines. PA LowIn Progress
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 civil defence kit has not been checked since 2014, a list of required items was not available and the contents doesn’t have all essential supplies as per civil defence guidelines. Provide evidence that the civil defence kit has the required items in the event of an emergency, a list of contents is available and is checked on a regular basis. PA ModerateIn Progress
The appointment of appropriate service providers to safely meet the needs of consumers.There was no evidence in staff files of reference checks and police vetting. The staff who are the coordinators for restraint and infection control have no evidence of position descriptions on file. An agreement for the contracting of RNs from a local bureau was not evidenced until a replacement was requested during the audit. Provide evidence that: (i) reference checks and police vetting is completed for all potential employees and documentation held on file; (ii) the nurse manager has position descriptions on file for coordinator of restraint and infection control; (iii) the agreement between the bureau and the facility is available and kept on file. PA ModerateIn 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.Short term care plans did not show evidence of evaluations. Ensure that all short-term care plans are evaluated. PA ModerateIn Progress
New service providers receive an orientation/induction programme that covers the essential components of the service provided.The nurse manager has not received an orientation to the new position of nurse manager and there is no evidence on file of one having been completed. Provide evidence that an orientation has been completed for the nurse manager and documentation relating to this is kept on the nurse manager’s file. PA LowIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective actions, who is responsible and timeframes for the action to be completed is not evidenced in the staff and RN meeting minutes. The 2016 satisfaction survey was unable to be located including any corrective actions. Where action plans have been developed and implemented, review of the action plan for effectiveness is not evidenced. Provide evidence that corrective actions are developed, implemented and reviewed where deficits are identified. PA ModerateIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Medication competency assessments for bureau staff were not evidenced. There was no evidence on the cook’s file of a certificate relating to food handling. Provide evidence that (i) bureau staff have current medication competencies and (ii) the cook has completed training in food handling. PA ModerateIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.No evidence of an assessment was provided to show that the resident was competent to self-administer medication. Ensure that residents are assessed as safe to self-administer medication. PA LowIn Progress
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.A complaints register was not evidenced. Provide evidence that a complaints register has been developed implemented and maintained. PA LowIn 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 date is not evidenced and/or reported and discussed at staff meetings (refer to criterion 1.2.3.8). Ensure that results of monthly surveillance and reduction and prevention of infections and outcomes are evidenced in surveillance reports, discussion and minutes of staff meetings. PA LowIn Progress
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.Although a mission statement and organisational objectives were evidenced, it was not clear as to when the objectives were developed and if they had been reviewed. There was evidence that a business plan had existed, however, the area in the filing cabinet was empty and the nurse manager could not recall having seen a business plan. Provide evidence, such as a business plan, that the purpose, values, scope, direction and goals of the organisation are clearly identified and reviewed on a regular basis. PA LowIn 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.Not all residents have ongoing assessments to support changes in their health status and to support service delivery planning Ensure that all residents have assessments to highlight appropriate service delivery required and to serve as the basis for service delivery planning PA ModerateIn Progress
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.Not all residents with changes in health status are seen by their GP and/or relevant allied staff. Ensure that when there is a change in status that residents are seen by their GP and/or allied health person and this is documented along with any required/prescribed interventions. PA ModerateIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Not all documentation reflected daily care provided to residents by care staff. Ensure that the care provided to residents is reflected in the documentation completed daily. PA ModerateIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.(i) Privacy for residents nearest the door in room nine and 11 is compromised. (ii) Flooring in the laundry has lifted showing the concrete. (iii) Paper towel dispenses are rusty. (iv) The seal around the wash hand basin in the passage way is damaged and mouldy with water is leaking through. (v) The shower wall in hospital B side is damaged and water is leaking through. (vi) The exterior of the building has areas of dry rot and the building is dirty. Provide evidence that: (i) the residents nearest the door in rooms nine and eleven are provided with privacy; (ii) the vinyl in the laundry has been replaced or repaired; (iii) the paper towel dispensers that are rusty have been replaced; (iv) the seal around the wash hand wash is replaced; (v) the weather boards that have dry rot are replaced and exterior of the building is cleaned. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Not all care plans identified specific and accurate interventions related to the resident Ensure that all delivery plans describe accurately the required support and/or intervention PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Quality data is not consistently analysed to identify trends. Although staff reported they discuss trends and actions at the staff meetings, there was little evidence to support this in the minutes of meetings. Provide evidence that quality data is consistently and comprehensively analysed to identify trends and the results provided to staff are documented in the staff and RN meeting minutes. PA ModerateIn Progress
Professional qualifications are validated, including evidence of registration and scope of practice for service providers.Copies of practising certificates for allied health professional and the GP were not current. Provide evidence that copies of practising certificates for allied health professional and the GP are current. PA LowIn Progress

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: 23 August 2017

Audit type:Certification Audit

Audit date: 23 March 2016

Audit type:Surveillance Audit

Audit date: 09 September 2014

Audit type:Certification Audit

Audit date: 08 May 2013

Audit type:Surveillance Audit

Audit date: 26 September 2011

Audit type:Certification Audit

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