St Patrick's Home and Hospital

Profile & contact details

Premises details
Premises nameSt Patrick's Home and Hospital
Address 3 Wilding Avenue Epsom Auckland 1023
Total beds60
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameSt Patrick's Home and Hospital Limited - St Patrick's Home and Hospital
Current auditorCentral Region's Technical Advisory Services Limited
End date of current certificate/licence03 May 2018
Certification period24 months
Provider details
Provider nameSt Patrick's Home and Hospital Limited
Street address 3 Wilding Avenue Epsom Auckland 1023
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: 19 April 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.Policies have not been reviewed, two yearly, as required in policy. Hard copy manuals of policies are not up to date. At times, there are two versions of the same policy available to staff. Review policies at least two yearly as scheduled and ensure that policies reflect legislation and best and evidence based guidelines. Keep up to date policy manuals available for staff. Ensure that the most recent version of the policy is available for staff. PA ModerateReporting Complete28/02/2017
Service providers responsible for medicine management are competent to perform the function for each stage they manage.Not all staff who administer medicines have current medication competencies. Provide evidence that all staff who administer medicines have current medication competencies. PA ModerateReporting Complete07/06/2016
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.Some windows in the bedrooms open widely with a one storey drop. Ensure that windows are safe for residents. PA LowReporting Complete07/06/2016
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Care plan interventions do not consistently contribute to meeting residents’ needs. Ensure all care needs are recorded on the long term care plan and interventions relating to the identified needs contribute to meeting the residents’ needs. PA ModerateReporting Complete06/12/2016
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.Assessment processes do not consistently identify all the needs, outcomes and/ or goals of the residents in the initial care plans. Provide evidence the assessment processes identify all the residents’ needs, outcomes and/ or goals. PA ModerateReporting Complete06/12/2016
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.The service is not coordinated to promote continuity in service delivery. Provide evidence of a coordinated service in the delivery of clinical care. PA ModerateReporting Complete06/12/2016
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.The time frames for service delivery are not adhered to consistently. Provide evidence each stage of service provision is provided within the required timeframes. PA ModerateReporting Complete06/12/2016
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.i) Residents’ photos on medication charts do not record when the photos were taken. ii) There is no record of medication checks when medications arrive at the facility. i) Provide evidence the residents’ photos on medication charts are dated ii) Provide recorded evidence of the medicines being checked when they arrive at the facility. PA LowReporting Complete06/12/2016
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.A comprehensive training plan is not provided annually for staff. Ensure that a comprehensive training plan is provided annually for staff. PA LowReporting Complete06/12/2016
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.Seven of ten incident forms did not include documentation of observations taken or if recorded, these were only taken once after the incident/accident. Four of ten incident forms were not signed off by the manager to indicate that they had been reviewed. i) Ensure that incident forms include documentation of observations taken with these taken for a period of time to determine health of the resident. ii) Ensure that incident forms are signed off by the manager to indicate that they have been reviewed. PA ModerateReporting Complete06/12/2016
Consumers have a right to full and frank information and open disclosure from service providers.Five of ten files did not include documentation that the family had been informed of an incident/accident. Document that family have been informed if their family member has had an incident or accident. PA LowReporting Complete06/12/2016
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Verbal complaints are not recorded on the complaints register. Ensure that verbal complaints are documented on the complaints register with evidence of actions taken to resolve these. PA LowReporting Complete06/12/2016
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Evidence of resolution of issues is not always documented. Document evidence of resolution of issues. PA ModerateReporting Complete28/02/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Meeting minutes do not evidence robust discussion particularly of clinical aspects of the service including discussion of pressure injuries, tabling of graphs of incidents documented on a monthly basis and review of falls from a clinical perspective. Ensure that meeting minutes reflect robust discussion of service delivery at all levels within the service. PA ModerateReporting Complete28/02/2017
Advance directives that are made available to service providers are acted on where valid.Residents do not sign to give consent for transport. Eight of eight files reviewed did not include documentation around competency of a resident to make an advance directive around resuscitation or not for resuscitation. The doctor has signed an advance directive form that indicates if the resident is or is not for resuscitation, whether the resident should be transferred to hospital for life sustaining treatment and whether antibiotics should or should not be used. All files included sign off… (this text has been trimmed due to space limits).Document consent for transport for each resident. Document competency of the resident to make an advance directive. Ensure that advance directives are signed only by the resident deemed competent to make the decision. PA ModerateReporting Complete28/02/2017
Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.Chemicals are stored on shelves in the unlocked sluice rooms and cleaning trolley were left unattended. Ensure all chemicals are safely stored. PA LowReporting Complete18/07/2017
The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.The visual inspection of the environment did not reflect the cleaning audit schedule. Ensure more regular cleaning audits are implemented and a cleaning schedule is adhered to. PA LowReporting Complete18/07/2017
The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.Section 31 forms were not completed for one grade four pressure injury. The facilities manager must ensure appropriate documentation is completed to meet the statutory and regulatory reporting obligations. PA ModerateReporting Complete18/07/2017

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: 19 April 2017

Audit type:Surveillance Audit

Audit date: 03 March 2016

Audit type:Certification Audit

Audit date: 04 December 2014

Audit type:Surveillance Audit

Audit date: 23 July 2014

Audit type:Partial Provisional Audit

Audit date: 07 March 2013

Audit type:Certification Audit

Audit date: 08 November 2012

Audit type:Surveillance Audit

Audit date: 12 April 2012

Audit type:Partial Provisional Audit

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