Summerset at Karaka
Profile & contact details
|Premises name||Summerset at Karaka|
|Address||67 Hingaia Road Karaka Papakura 2580|
|Service types||Medical, Rest home care, Geriatric|
|Certification/licence name||Summerset Care Limited - Summerset at Karaka|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||29 September 2018|
|Certification period||24 months|
|Provider name||Summerset Care Limited|
|Street address||Level 12, State Insurance Tower 1 Willis Street Wellington Central Wellington 6011|
|Post address||PO Box 5187 Lambton Quay Wellington 6145|
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: 10 April 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|All buildings, plant, and equipment comply with legislation.||Partial Provisional: A code of compliance has not yet been issued. Rails adjacent to the toilets have not yet been installed.||Ensure a building code of compliance is issued and handrails are installed next to each toilet before admitting residents to these areas.||PA Low||Reporting Complete||07/09/2016|
|An appropriate 'call system' is available to summon assistance when required.||Partial Provisional: The call bell system requires final testing and sign-off before it can be deemed fully operational||Partial Provisional: Ensure the call bell system is signed off as fully operational before accepting residents in the new wings||PA Low||Reporting Complete||07/09/2016|
|Where required by legislation there is an approved evacuation plan.||Partial Provisional: An approved updated evacuation plan has not been received. The call bell system requires final testing and sign-off before it can be deemed fully operational||Ensure the updated fire evacuation plan is approved||PA Low||Reporting Complete||07/09/2016|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||Partial Provisional : A fire evacuation drill is scheduled for the first week of September||Ensure a fire drill is completed prior to occupancy||PA Low||Reporting Complete||07/09/2016|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Partial Provisional: The main nursing station is a significant distance away (approximately 44 meters) from the new wing. A nurses’ station (hot desk) is planned to be installed just outside of the doors leading to the new care facility wing.||Ensure a nurses’ station is placed in close proximity to the new wing in the care facility.||PA Low||Reporting Complete||07/09/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i)Neurological observations had not been implemented for three residents with unwitnessed falls including one with laceration to the eye, (ii) two sets of neurological observation commenced had not been completed as per protocol. (iii) There was no evidence of dietitian input for the two rest home residents with weight loss||(I) and (ii) Ensure neurological observations are completed for all unwitnessed falls and known head injury. (iii) Ensure dietitian input is considered for residents with weight loss.||PA Moderate||Reporting Complete||06/12/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i)Two rest home resident care plans did not document interventions for diabetic management (one insulin dependent and one on oral medication). (ii)One rest home resident care plan did not describe interventions for wandering as recorded on the accident/incident form. (iii) There were no documented interventions for one rest home resident with weight loss (link tracer) and no weekly weighs for one hospital resident as per care plan. (iv) Interventions to manage the risks associated with the u… (this text has been trimmed due to space limits).||Ensure care plans reflect the resident current needs and supports.||PA Moderate||Reporting Complete||06/12/2016|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||i) The risks associated with the use of a restraint or an enabler were not fully documented as part of the assessment process for one hospital resident using a restraint and one hospital resident using an enabler. ii) One hospital resident (recently admitted) using a restraint had not had an assessment for the use of the restraint fully completed or the consent for use of a restraint signed.||i) Ensure that all sections of the restraint assessment form are completed and the risks associated with the use of the restraint or enabler are documented as part of the assessment process. ii) Ensure that the assessment and consent for the use of a restraint are fully completed for all residents using a restraint.||PA Low||Reporting Complete||17/01/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Two of six staff files selected for audit (the relieving clinical manager and property manager who transferred from another Summerset site to Karaka in March), could not be located on the day of audit. Documented evidence of the recruitment, orientation training, performance management and site specific orientation processes for these staff could not be located either on-site or at head office.||Ensure a copy of the relevant staff information (recruitment, qualifications, orientation training, performance management) is available on-site for all staff.||PA Low||Reporting Complete||17/01/2017|
|An appropriate 'call system' is available to summon assistance when required.||The call bell system is not yet operational.||Ensure the call bell system is signed off as fully operational.||PA Low||Reporting Complete||19/06/2017|
|Where required by legislation there is an approved evacuation plan.||An approved updated evacuation plan has not been received that includes the new serviced apartment block.||Ensure the updated fire evacuation plan is approved.||PA Low||Reporting Complete||19/06/2017|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||A fire evacuation drill is scheduled for the new serviced apartment block.||Ensure a fire drill is completed prior to occupancy.||PA Low||Reporting Complete||19/06/2017|
|Consumers are provided with safe and accessible external areas that meet their needs.||Paths and stairs from the exit doors are still being completed.||Ensure paths are completed for safe exits and areas still being landscaped are fenced off.||PA Low||Reporting Complete||19/06/2017|
|All buildings, plant, and equipment comply with legislation.||(i) A code of compliance has not yet been issued; (ii)The nurses’ station areas are yet to be fully completed; (iii) The lift is not yet operational and the connecting walkway is not yet open.||(i) Ensure a building code of compliance is issued; (ii) Ensure the nurses’ station areas are fully completed; (iii) Ensure the lift is fully operational and walkways between buildings are open.||PA Low||Reporting Complete||19/06/2017|
|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)The treatment room was observed to be in an untidy state with medication not all stored away including (but not limited to) medication and containers on the bench, medication stained sink and bench and a large box of medications on the bench due for pharmacy return; (ii) The medication room in the serviced apartments was unable to be viewed; (iii) At regular medication administration times, medication to the rest home residents in serviced apartments is transported on a tray from the treatm… (this text has been trimmed due to space limits).||(i) Ensure the medication room is kept tidy and medication/equipment stored away; (ii) Provide evidence of the serviced apartment treatment room prior to occupancy; (iii) Ensure a medication trolley and system is set up for the administration of medication in the downstairs serviced apartments currently being utilised by six rest home residents.||PA Low||Reporting Complete||19/06/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||(i)The service is in the process of employing more RN’s including (but not limited to) one part time, one new graduate and two causals. Management has also advertised for nine more caregivers to ensure sufficient staff to cover the roster. (ii) Laundry continues to be completed by caregiving staff which takes them away from caregiving duties.||(i)Ensure sufficient staff are employed to cover the roster. (ii) With the increase in resident numbers, ensure laundry staff are employed so that caregivers can always be available for resident needs.||PA Low||Reporting Complete||19/06/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) Respite resident rehabilitating following fractured ankle did not have any interventions around care of the cast; (ii) hospital resident with sacral PI Grade II, did not have interventions to manage the PI; (iii) STCPs for the rest home resident in serviced apartment to cover current needs was kept in the care centre and not with the residents file. (iv) STCPs were kept in a separate folder in the care centre and therefore not integrated with the LTCPs.||(i)- (ii) Ensure all interventions are documented to cover all current needs; (iii) – (iv) Ensure STCPs are kept with LTCPs.||PA Moderate||Reporting Complete||21/08/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||There is a boiling water urn on the wall in the open kitchenette that could potentially be a hazard for confused residents.||The service will need to ensure the boiling water tap is managed as part of the hazard register.||PA Low||Reporting Complete||21/08/2017|
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: 10 April 2017
Audit type:Partial Provisional Audit
Audit type:Certification Audit
Audit type:Partial Provisional Audit