Tasman Care Home
Profile & contact details
|Premises name||Tasman Care Home|
|Address||4 Wadier Place Henderson Auckland 0610|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Bupa Care Servces NZ Limited - Tasman Care Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||12 December 2017|
|Certification period||24 months|
|Provider name||Bupa Care Services NZ Limited|
|Street address||Level 2 109 Carlton Grove Road Newmarket Auckland 1023|
|Post address||PO Box 113054 Newmarket Auckland 1149|
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: 15 November 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.||Two Glucagon injections were found stored in the medication fridge on level two, which had expired in September 2016. These were returned to the pharmacy on the day of audit.||Ensure that there is a process implemented to ensure that medications remain within their expiry date.||PA Low||Reporting Complete||14/03/2017|
|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.||The following shortfalls were noted on level 1. (i) Short course medication was prescribed for five days, but only documented as administered for one day. (ii) As required medication was being administered for six weeks on a regular basis. Although the GP visit occurred during this time, a medication review was not completed. (iii) Non-packed regular medication was not always signed as given.||(i) Ensure that medications are administered as prescribed. (ii) Ensure that ‘prn’ medications are reviewed if they are administered regularly. (iii) Ensure that medications are signed as administered and reason for non–administration is recorded.||PA Moderate||Reporting Complete||18/01/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) One resident file under the interim care scheme was reviewed. The resident was admitted to receive short-term hospital level care and the care plan was developed prior to entry by the referring agency. The care plan included the instruction to complete daily neuro observations and daily monitoring of vital signs. A review of documents identified that neuro observations were recorded four days after admission and there were documented gaps between recordings of three to four days. Vital s… (this text has been trimmed due to space limits).||Ensure that care plan interventions are implemented.||PA Moderate||Reporting Complete||29/02/2016|
|Consumers have a right to full and frank information and open disclosure from service providers.||(i)Two of twelve incident forms reviewed did not have family notification identified. (ii) Residents meetings have not taken place as per policy. (iii) Two of five families interviewed stated the communication with them was inadequate.||(i) Ensure family are notified of incidents as per policy. (ii) Facilitate resident and family meetings as per policy. (iii) Ensure families receive appropriate and timely communication.||PA Low||Reporting Complete||21/03/2016|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans have not been routinely developed where benchmarking data exceeds targets.||Ensure corrective action plans are implemented from analysis of benchmarking data/trends.||PA Low||Reporting Complete||21/03/2016|
|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.||(i) Two residents admitted to the service after 1 July 2015 did not have an InterRAI assessment. (ii) One hospital resident was admitted on 21 August and the first InterRAI assessment was completed on 9 October. (iii) Two hospital resident’s did not have a care plan completed within 21 days.||Ensure that InterRAI assessments and nursing care plans are completed within required timeframes.||PA Low||Reporting Complete||21/03/2016|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Currently the activities programme is provided on one level in the morning and across two levels in the afternoon. To access activities, residents at times are required to be transferred one level to another. Interview with staff confirmed that this has not always been facilitated due to staff commitment to provide resident care first.||Revise the activities programme across the three floors to ensure a more easily accessible programme.||PA Low||Reporting Complete||21/06/2016|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The service provides dual services across three floors. Currently on the first floor, there is one hospital resident and 11 rest home residents. There are two caregivers rostered on morning, two on the afternoon and one at night. There are three hours after lunch when there is only one caregiver. Caregivers interviewed stated they have to access a RN from the floor above or the clinical manager when needed. Interviews identified that RNs are not always available when needed due to work commi… (this text has been trimmed due to space limits).||Due to the layout of the facility (three levels) and the acuity of the residents, staffing levels need to be reviewed to meet individual resident’s needs.||PA Moderate||Reporting Cancelled||15/06/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||A comprehensive range of quality and risk data is collected and collated each month but evidence of the data being trended or analysed is missing.||Ensure quality and risk data reflects any trends and analysis to assist in identifying areas for improvement.||PA Low||Reporting Complete||15/05/2017|
|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).||A trained health and safety officer has not been appointed to the service. The hazard register is overdue for review.||Ensure a health and safety officer is appointed, who receives training on this role and its responsibilities. Ensure the hazard register is reviewed a minimum of annually.||PA Low||Reporting Complete||15/05/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Evidence of completed orientation programmes was missing in four of five caregiver staff files. (Note: sample size expanded). Caregivers confirmed that the orientation programme was robust.||Ensure all caregivers submit their orientation workbooks within the first three months of their employment.||PA Low||Reporting Complete||15/05/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The night shift does not always have at least one staff member with a current first aid/CPR certificate on duty.||Ensure a minimum of one staff is available 24/7 with a current first aid/CPR certificate.||PA Moderate||Reporting Complete||15/05/2017|
|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.||(i) An InterRAI assessment was not evidenced to be completed for a resident who had been admitted in September 2016. (ii) The care plan for one resident with a 5.8% weight loss in one month had not been updated to reflect the current interventions. However staff were observed implementing weight loss strategies including smoothies, adding cream to desserts and breakfast cereal and the completion of a food chart and weekly weight recordings. Therefore this has been identified as low risk. … (this text has been trimmed due to space limits).||(i) Ensure InterRAI assessments are completed within the required timeframe. (ii) Ensure care plans are updated to reflect the current interventions being implemented.||PA Low||Reporting Complete||23/05/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Three initial wound assessments did not fully describe the wound.||Ensure wound assessments are fully completed for all wounds, and that all wounds are entered onto the wound register.||PA Low||Reporting Complete||23/05/2017|
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: 15 November 2016
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Partial Provisional Audit