St Clair Park Residential Centre

Profile & contact details

Premises details
Premises name	St Clair Park Residential Centre
Address	287 Middleton Road Corstorphine Dunedin 9012
Total beds	41
Service types	Dementia care, Psychiatric, Rest home care

Certification/licence details
Certification/licence name	St Clair Park Residential Centre Limited - St Clair Park Residential Centre
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	22 September 2024
Certification period	36 months

Provider details
Provider name	St Clair Park Residential Centre Limited
Street address	287 Middleton Road Corstorphine Dunedin 9012
Post address

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: 14 June 2023

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.	i) The internal audit programme has not consistently been completed as per the audit schedule. ii) Complaints, resident survey results, and corrective actions are not consistently documented in the meeting minutes to evidence staff are kept informed.	i) Ensure the internal audit programme is completed as planned. with quality results communicated to staff. ii) Ensure that documented evidence indicates staff are kept informed regarding corrective actions required.	PA Low	Reporting Complete	01/03/2022
The service demonstrates consumer participation in the planning, implementation, monitoring, and evaluation of service delivery.	Residents do not have input at all levels of service delivery as per policy.	Ensure residents have participation in planning, implementation, and monitoring of service delivery.	PA Low	Reporting Complete	01/03/2022
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.	Bio-medical equipment was overdue for calibration.	Ensure the bio-medical equipment is calibrated as per policy requirements.	PA Low	In Progress
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	(i). Internal audits that had been completed for 2022 included an action plan; however, there was no documentation to evidence the action plans were followed up or signed off when completed. (ii). The annual resident and family/whānau surveys have not been completed since 2021.	(i). Ensure internal audits are fully implemented and documentation reflects implementation and sign off of corrective action plans. (ii). Ensure annual resident and family/whānau audits are implemented.	PA Low	In Progress
Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan.	An approved fire evacuation plan was not verified on the audit day.	Ensure there is an approved fire evacuation plan for the building.	PA Low	In Progress
A medication management system shall be implemented appropriate to the scope of the service.	(i). Documentation of PRN medicine’s effectiveness was not being consistently completed. (ii). Three blister packs of expired PRN medication were found in the PRN folder. (iii). Eye-drops were not dated when opened.	(i). Ensure effectiveness of PRN medications are documented. (ii). Ensure all expired medications are returned to the pharmacy. (iii). Ensure all eye drops are dated on opening.	PA Moderate	In Progress
Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably.	Files and documentation reviewed did not evidence all annual competencies have been completed in 2022 or 2023 year to date. On interview, staff confirmed annual medication competencies where required and completion of orientation competencies; however, could not confirm competencies for moving and handling, restraint, or hand hygiene.	Ensure staff competencies are renewed annually as per policy.	PA Moderate	In Progress
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.	There was little evidence of training being provided in 2022. There has been no documented training for mandatory training, including cultural training; medication training; falls prevention; dementia and challenging behaviour; pain management; wound management; complaint management; and infection control.	Ensure the training schedule is implemented and includes all required mandatory training requirements.	PA Moderate	In Progress
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).	(i). Four out of seven residents long-term care plans reviewed were not linked to interRAI assessments, and outcome scores were not consistently identified. (ii). Four out of seven care plans had not been reviewed following interRAI reassessments. (iii). Unwitnessed falls did not have neurological observations fully completed as per policy requirements.	(i). & (ii). Ensure all outcome scores of interRAI assessments are included in care planning and care plans are reviewed following interRAI reassessments. (iii). Ensure all neurological observations are consistently completed post unwitnessed falls or head injuries, as per policy requirements.	PA Moderate	In Progress
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.	The service is not currently including ethnicity data in infection surveillance.	Ensure ethnicity is incorporated into infection surveillance reporting.	PA Low	In Progress
Information held about health care and support workers shall be accurate, relevant, secure, and confidential. Ethnicity data shall be collected, recorded, and used in accordance with Health Information Standards Organisation (HISO) requirements.	The service is not collating or reporting ethnicity data.	Ensure ethnicity data is collated and reported to quality and governance.	PA Low	In 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.

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: 14 June 2023

Audit type:Surveillance Audit

Audit date: 12 July 2021

Audit type:Certification Audit

Audit date: 07 November 2019

Audit type:Surveillance Audit

Audit date: 28 March 2019

Audit type:Surveillance Audit

Audit date: 19 July 2018

Audit type:Partial Provisional Audit; Certification Audit

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