Summerset Mountain View
Profile & contact details
|Premises name||Summerset Mountain View|
|Address||35 Fernbrook Drive Hurworth New Plymouth 4310|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Summerset Care Limited - Summerset Mountain View|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||13 November 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: 22 August 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Oxygen therapy had not been prescribed on the medication chart.||Ensure oxygen therapy is prescribed on the medication chart.||PA Low||Reporting Complete||13/12/2016|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Summerset Mountain View did not have a complaints register in place. There was no evidence that any resident/family complaints made since the care centre opened in December 2015 were documented and entered into Sway (“The Summerset Way").||Ensure that there is a complaints register in place. Ensure that any resident/family complaints are documented and entered in to Sway.||PA Low||Reporting Complete||09/01/2017|
|A process to measure achievement against the quality and risk management plan is implemented.||The 2016 internal audit calendar schedule has not always been followed and corrective actions have not always been followed up and completed.||Ensure that the internal audit schedule is followed as per the annual calendar and that corrective actions are followed up and completed.||PA Low||Reporting Complete||09/01/2017|
|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 is developed and im… (this text has been trimmed due to space limits).||There has been no hazard register in place since the care centre opened in December 2015.||Ensure that there is a hazard register in place to capture any worksite accidents or near misses.||PA Moderate||Reporting Complete||09/01/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||The resident-centred care plans/clinical risk plans did not document the resident’s current needs for the following. (i) Two residents with a high risk of pressure injury (one hospital and one rest home respite care), (ii) two rest home residents (one respite care and one under ACC) identified at high risk of falls, (iii) change of supports/needs for one hospital resident following discharge from hospital. The same resident did not have a current pain management plan in place, (iv) the initial … (this text has been trimmed due to space limits).||Ensure all care plans (initial, long term and clinical risk plans) reflect the resident current health status.||PA Moderate||Reporting Complete||09/01/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) The respiration rate had not been taken on admission for one resident admitted under ACC following chest injury. The same resident did not have an investigation completed as instructed on the discharge summary. (ii) Registered nurse progress notes for one respite care resident documented the residents blood pressure was low and for monitoring. There had been no blood pressure recordings completed since the date of report.||Ensure all relevant observations, investigations and monitoring is completed as required or instructed.||PA Moderate||Reporting Complete||09/01/2017|
|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).||1) Two of four restraint assessments reviewed did not identify the risks associated with the restraint use. 2) Three of four residents on restraint did not have interventions to manage the risks documented in the care plans.||1) Ensure restraint assessments are completed, including risks of the restraint use. 2) Ensure interventions to manage the risks are documented in the resident centred care plan.||PA Low||Reporting Complete||10/01/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) There have been no quality improvement meetings (including health and safety, infection control and restraint) completed as per the annual calendar schedule for the period from January to July 2016. (ii) There has been no clinical/quality data and benchmarking analysis discussed at staff meetings for the period from January to July 2016.||(i) Ensure that meetings are held as per scheduled. (ii) Ensure that quality data and benchmarking analysis is discussed at staff meetings.||PA Low||Reporting Complete||10/01/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||The 2016 education/training calendar schedule has not always been followed. Nine of eighteen training sessions have not been completed including (sexuality & intimacy, privacy & dignity, cultural awareness, dementia/challenging behaviour, documentation, wound care, pressure injury prevention, infection control and incontinence).||Ensure that the education/training calendar schedule is followed.||PA Low||Reporting Complete||10/01/2017|
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: 22 August 2016
Audit type:Certification Audit
- Summerset Mountain View - Aug 2016 (docx, 46.08 KB)
- Summerset Mountain View - Aug 2016 (pdf, 179.7 KB)
Audit type:Partial Provisional Audit