Tainui Resthome

Profile & contact details

Premises details
Premises nameTainui Resthome
Address 96 Clawton Street Westown New Plymouth 4310
Total beds60
Service typesRest home care, Geriatric
Certification/licence details
Certification/licence nameTainui Home Trust Board
Current auditorThe DAA Group Limited
End date of current certificate/licence14 May 2018
Certification period36 months
Provider details
Provider nameTainui Home Trust Board
Street address 96 Clawton Street Westown New Plymouth 4310
Post addressPO Box 5016 Westown New Plymouth 4343

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: 13 October 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Advance directives that are made available to service providers are acted on where valid.The policies on resuscitation and informed consent do not clearly define what constitutes an advance directive, roles and responsibilities in relation to these directives, or how they will be facilitated at Tainui Resthome. Policies and procedures are in place which ensure that the advance directives of residents are acknowledged, incorporated into care planning where valid, and acted on. PA LowReporting Complete16/06/2015
The organisation has a quality and risk management system which is understood and implemented by service providers.There is no quality plan as required by these standards and the provider’s contract with the DHB (ARC D19.4). There is evidence, confirmed at interview, that a quality plan has been maintained in the past. Develop a quality plan which guides the current quality activities and ensures there is senior management and Board oversight of the quality management systems within the organisation. PA ModerateReporting Complete16/06/2015
All records are legible and the name and designation of the service provider is identifiable.The designations and/or names of service providers making entries into the clinical record are not legible and/or the provider designation is not identifiable. The name and designation of all service providers making entries into the clinical record is clearly identifiable. PA LowReporting Complete16/06/2015
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.Three residents had not been medically reviewed within three months of the previous medical review. None of the 13 clinical files reviewed contained written evidence as to GP requirements for the frequency of the resident’s medical review. Two lifestyle care plans were not developed within three weeks of the resident being admitted to the service. Two of the clinical files reviewed had not been evaluated within a six-month period. All residents have regular medical reviews at least three monthly. The clinical record of each resident contains written instructions from their GP as to the frequency of medical reviews. All residents have a lifestyle care plan developed within three weeks of their admission to the service. Life style care plans are reviewed at least six monthly and earlier if clinically indicated. PA ModerateReporting Complete16/06/2015
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Four of the 13 clinical plans reviewed contain insufficient detail on the support and/or interventions required to address the needs identified in the assessment process. For example, two residents were identified as being at very high risk of falling. While their care plans noted this, there was little information as to how to prevent or minimise falls. The care plan of a resident with significant weight loss did not include the supports/interventions necessary to address that clinical issue. F… (this text has been trimmed due to space limits).Detailed care plans are developed that include the support/interventions required to meet all the resident’s identified needs. Care plans are updated, or short term care plans developed, to reflect changes in residents’ requirements. PA ModerateReporting Complete16/06/2015
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.Resident progress towards meeting identified outcomes is not recorded in sufficient detail in six of the ten care plans reviewed. Evaluations of residents’ progress is not completed on a timely basis. Ensure that appropriate detail is recorded of residents’ progress towards meeting identified outcomes Ensure that evaluations are completed at least six monthly, or earlier if a resident’s needs change. PA LowReporting Complete16/06/2015
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).There is no record of a formal assessment process taking place which meets the requirements of this criterion. In the absence of the restraint coordinator it was not clear whether this occurs but is not recorded, or whether it does not occur at all. Ensure that there is a record of the assessment of the need for restraint use and all requirements of this criterion are included. PA ModerateReporting Complete16/06/2015
Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).While there is evidence that the use of restraints and enablers for individual residents is reviewed regularly, there is no evidence or reported quality review of overall restraint use by the facility. Undertake regular quality reviews of restraint use at Tainui to meet the requirements of this criterion, in addition to the reviews of restraint use by individual residents. PA ModerateReporting Complete16/06/2015
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Analysis of quality data is inconsistent and basic, resulting in trends not able to be identified. There is no evidence in the meeting minutes reviewed for RN/EN meetings and health and safety meeting minutes and the one general staff meeting of reporting and discussion of analysis and trending of data at these meetings. Provide documented evidence that quality data is comprehensively analysed to identify trends and reported back to all staff on a regular basis. PA LowReporting Complete14/12/2016
Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).Quality reviews of restraint use across the facility was not evidenced. The quality manager reported there was no tool available to audit restraint. A high number of hospital level care residents are using restraint and although there is individual evaluation of restraint, there was no evidence to indicate that the facility is actively reducing the use of restraint. Provide documented evidence that: (i) a quality review of restraint use is developed and implemented that includes items (a) to (h) under this criterion; (ii) the facility is actively minimising the use of restraint. PA ModerateReporting Complete11/01/2017
Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).The template for evaluation of individual use of restraint does not include items (a) to (k) as required under this criterion. Develop and implement an evaluation form that includes all the items (a) to (k) as required. PA LowReporting Complete11/01/2017
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).The template for the assessment of restraint does not include items (a) to (h) as required by this criterion. Expand the assessment template for restraint to include all the elements as stipulated under this criterion. PA LowReporting Complete11/01/2017
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.The existing curtain does not provide adequate privacy for the resident whose bed is nearest the door when there are visitors or the other resident enters the bedroom. Install a curtain railing and curtain so that the privacy of the resident nearest the door is not compromised. PA LowReporting Complete11/01/2017
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.Food items in the chiller and freezer are not consistently labelled and/or dated. All food items in the chiller and freezer are labelled and dated. PA LowReporting Complete11/01/2017
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.When resident progress is different from expected, or new needs are identified, service delivery plans are not consistently updated to reflect this. Service delivery plans are updated when resident progress is different from expected, or new needs are identified. PA ModerateReporting Complete11/01/2017
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.Resident progress towards meeting identified outcomes was not recorded in sufficient detail in four of the care plans reviewed. Resident progress towards meeting identified outcomes is comprehensively recorded in all care plans. PA ModerateReporting Complete11/01/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Care plans do not include sufficient detail on the support and/or interventions required to address identified needs. The documentation related to the safe use of restraint/enablers was incomplete in two care plans and completely absent in a third. Care plans include appropriate detail on the support and/or interventions required to address identified needs. When residents are using a restraint or enabler, care plans are developed which include detailed strategies related to their safe use. PA ModerateReporting Complete11/01/2017
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.InterRAI assessments/reassessments are not completed within required timeframes and there is inconsistent evidence of assessment outcomes then informing care planning. All required assessments are completed within required timeframes and the outcomes of those assessments are consistently used to inform care planning. PA ModerateReporting Complete11/01/2017
All records are legible and the name and designation of the service provider is identifiable.The designation and/or names of service providers making entries into the clinical records were not legible and/or the provider is not identifiable. The name and designation of the service provider is legible in all clinical documentation. PA LowReporting Complete11/01/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective action plans are not being completed following relative and resident satisfaction surveys and meeting minutes apart from health and safety, do not document the staff member responsible for the corrective action, the timeframes and any sign off that the action has been completed. Provide documented evidence that: (i) corrective action plans are developed, implemented and reviewed following all deficits identified; (ii) meeting minutes state who is responsible for the corrective action, the timeframes for completion and sign off once the corrective action has been completed. PA LowReporting Complete11/01/2017
Advance directives that are made available to service providers are acted on where valid.The resuscitation policy does not include a statement that resident’s advance directives are incorporated into care planning and are acted on. Policy and processes are in place to acknowledge advance directives and incorporate these into care planning, where valid and are acted on. PA LowReporting Complete11/01/2017

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: 13 October 2016

Audit type:Surveillance Audit

Audit date: 05 March 2015

Audit type:Certification Audit

Audit date: 11 March 2014

Audit type:Surveillance Audit

Audit date: 14 March 2013

Audit type:Certification Audit

Audit date: 15 September 2011

Audit type:Surveillance Audit

Audit date: 01 March 2010

Audit type:Certification Audit

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