Te Aroha & District Community Hospital

Profile & contact details

Premises details
Premises nameTe Aroha & District Community Hospital
Address 72 Stanley Avenue Te Aroha 3320
Total beds46
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameTe Aroha & District Health Services Charitable Trust - Te Aroha & District Community Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence12 July 2018
Certification period24 months
Provider details
Provider nameTe Aroha & District Health Services Charitable Trust
Street address 72 Stanley Avenue Te Aroha 3320
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: 18 May 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The organisation plans to ensure Māori receive services commensurate with their needs.One Māori resident did not have Māori values and beliefs documented in the resident file. Ensure cultural values and beliefs are identified for Māori residents. PA LowReporting Complete01/06/2017
Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.i) Chemicals were found in unlocked cupboards under benches and on shelves in the hair salon, in resident toilets, in the flower room and in the ward kitchen. ii) A dressing trolley being stored in an area the residents could access, had wound cleaning solutions (including betadine) left on the bottom shelf of the trolley. i-ii) Ensure that all chemicals are stored securely. PA ModerateReporting Complete15/08/2016
The service is able to demonstrate that written consent is obtained where required.Six of seven consent forms had not been signed by the resident or EPOA to indicate they have or have not given consent. Ensure that the resident and/or EPOA sign the consent form. PA LowReporting Complete01/06/2017
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)Two of six resident files sampled (one rest home and one hospital), did not have the initial assessment or initial care plan completed within the required timeframes. ii)Three of six resident files sampled (one rest home and two hospital) did not have the long-term care plan documented within twenty-one days of admission. iii) Four of five files (three rest home and one hospital) had an interRAI assessment review completed, but not in the required timeframes. iv) In three of the ARC files re… (this text has been trimmed due to space limits).(i-iii) Ensure that all initial assessments, initial care plans, long-term care plans and interRAI assessments and reviews are completed in the required timeframes. (iv) Ensure that all InterRAI assessments are completed before the LTCPs are developed so that they inform the care plans PA ModerateIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.The following shortfalls were identified around reactive maintenance; i) In the hospital: a) the shower walls and ceilings have numerous areas where the paint is flaking, or chipped. b) One hospital shower has mould growing on the ceiling and has a crack in the lino-join in the corner of the shower. c) There are holes in the shower and toilet walls. d) There are swollen and exposed timber surfaces around the hand basins. e) The under-bench cupboards in the flower room and sluice room, ha… (this text has been trimmed due to space limits).i-iii) Ensure that all outstanding maintenance is completed. PA ModerateReporting Complete01/06/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.i) Corrective action plans are not regularly being developed where opportunities for improvement are identified. ii) Where corrective action plans are documented, there is a lack of consistent evidence of these plans being implemented, with sign-off by the person(s) responsible. i) Ensure corrective action plans are established where opportunities for improvements are identified. ii) Ensure that established corrective action plans are implemented and are signed-off by the person(s) responsible. PA LowReporting Complete02/06/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Quality data is not being trended and analysed. Staff are not kept informed regarding trends in adverse events. Ensure that the quality data collected is trended and analysed, and that this information is shared with staff. PA LowReporting Complete02/06/2017
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.One rest home resident with a stage-two pressure injury did not have an accident/incident form completed. Ensure all pressure injuries are documented on an accident/incident form. PA LowReporting Complete02/06/2017
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff attendance at eight mandatory in-services in 2015-2016 was less than 50%. The facility manager and clinical nurse manager are aware of this shortfall and they are implementing strategies to address it. Ensure that all staff attend mandatory in-service training. PA LowReporting Complete02/06/2017
All records are legible and the name and designation of the service provider is identifiable.i) One continence assessment and two long-term care plans were not signed or dated. ii) Six of seven wound care plans had not been signed by the registered nurse. Ensure all residents’ assessments wound care plans and long-term care plans are signed and dated. PA LowReporting Complete02/06/2017
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) Staff were observed administering medications without prior reference to the medication chart. ii) Four of 14 medication charts (rest home) did not have photo identification on the medication profile. i) Ensure that all staff who administer medication follow acceptable medication administration practices, guidelines and legislative guidelines. ii) Ensure that all medication charts evidence resident photo identification. PA ModerateReporting Complete07/06/2017
The facilitation of safe self-administration of medicines by consumers where appropriate.Two rest home resident’s self-administering inhalers had not had the required competency assessment completed in the past 12 months. Ensure that all residents self-administering medication complete the required competency assessments. PA LowReporting Complete07/06/2017
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.i) One of 14 medication charts reviewed did not have the route or dose time charted for a controlled drug. This was corrected on the day of audit. ii) Nine of fourteen medication charts reviewed did not have indications for use charted for all ‘as required’ medication. i) Ensure that all medication is prescribed according to all contractual and legal requirements. ii) Ensure that all ‘as required’ medication has indications for use charted. PA ModerateReporting Complete07/06/2017
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.i) One rest home resident admitted in August 2015 did not have an InterRAI assessment completed. ii) One hospital resident had not had their InterRAI assessment reviewed with a change in health condition. iii) Two rest home and one hospital residents with pain (as noted in the progress notes and medical notes) did not have pain assessments completed. iv) One hospital resident did not have any risk assessments completed on admission. v) Three residents (two hospital - including the hospita… (this text has been trimmed due to space limits).i-ii) Ensure that the use of the InterRAI tool complies with all contractual requirements. iii) Ensure that pain assessments are completed for all residents reporting pain. iv) Ensure that all required risk assessments are completed on admission. v) Ensure that the medical admission assessments are fully documented. vi) Ensure that all sections of additional risk assessment forms are completed. vii) Ensure that residents are reassessed with a change in heath condition. PA ModerateReporting Complete07/06/2017
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.Three residents (one rest home, two hospital - including one young person with disability) had not had their InterRAI assessments reviewed six monthly. Ensure that all aspects of assessments and care plans are completed within the required timeframes. PA LowReporting Complete07/06/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) One hospital resident had their care plan completed before all the risk assessments had been completed. ii) One rest home resident long-term care plan had not been amended following a change in assessed care level. iii) Short-term care plans were not documented for one rest home resident with a urinary tract and a chest infection, and one hospital resident with a skin infection. iv) Wound care documentation was not fully completed for the current wounds: a) five of seven initial wound… (this text has been trimmed due to space limits).i) Ensure that the assessment process is used to provide information to inform the care plan ii) Ensure that the long-term care plan is reviewed following a change in care level iii) Ensure that care plans are documented for all acute changes in health condition iv) Ensure that all wound documentation is fully completed v) Ensure that interventions are fully documented for all assessed care needs PA ModerateReporting Complete07/06/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.The registered nurses report that they do not consistently have sufficient clinical supplies including wound dressing supplies, or the correct syringes required for the resident on a PEG feed. Ensure that there are adequate medical and dressing supplies to meet the assessed care needs of the resident. PA LowReporting Complete07/06/2017
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.i) One hospital resident did not have an activities assessment completed on admission. ii) Four of the five residents (two hospital, one YPD, one rest home) who were due for a six monthly activities care plan review had not had the activities care plan reviewed against the identified goals or a review completed six monthly. i) Ensure that all residents have an activities assessment and activities care plan completed on admission. ii) Ensure that the activities care plan is evaluated against the resident goals within the required timeframes. PA LowReporting Complete07/06/2017
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.i) Three of five (two rest home and one hospital) long-term care plans due for review not been reviewed six monthly. i) Ensure that all long-term care plans are reviewed at least six monthly or when there is a change in health condition. PA LowReporting Complete07/06/2017
An appropriate 'call system' is available to summon assistance when required.On two separate occasions during the audit, six residents who could not mobilise were sitting in chairs in the hospital lounge/dining area with no staff in attendance and no ability to summon assistance or with access to call bells. Ensure that residents always have access to their call bell or a method to summon assistance. PA LowReporting Complete07/06/2017
Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).Two-hourly monitoring of restraint use was not reflected on the restraint monitoring forms for the two residents’ files reviewed. Ensure monitoring forms reflect documented evidence of restraint use being monitored. PA LowReporting Complete07/06/2017
The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.Towels and flannels were stored in a number of the communal bathrooms in the hospital and Lawrence block. Ensure that all linen is stored correctly. PA LowReporting Complete07/06/2017
Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.The amendments made in 2015 to clause D13.3 of the ARRC contract, regarding refund timeframes are not included in the admission agreement currently in use by the service. Ensure that the current admission agreement aligns fully to the ARRC contract. PA LowReporting Complete07/06/2017
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.Three of five (two rest home and one hospital) long-term care plans due for review, had been reviewed six-monthly. This previous finding remains open. Ensure that the long-term care plan is reviewed at least six-monthly. PA ModerateIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.Three of three rest home residents who were self-medicating, had not completed the three-monthly competency reviews as required by the organisational policy. Ensure that all residents who are self-medicating complete all required documentation and competency reviews. PA ModerateIn Progress
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.i) Six of twelve medication charts (two rest home and four hospital- including one YPD and one long-term chronic resident) did not have indications for use charted for ‘as required’ medications. ii) Three of three hospital residents on anticoagulation therapy did not have the anticoagulant correctly charted. i-ii) Ensure all ‘as required’ medications have indications for use charted and all medication is correctly charted and complies with all legal, contractual and professional guidelines. PA ModerateIn Progress
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.Four of four resident files reviewed (two rest home and two hospital- including the tracer) with pain, as noted in the progress notes and medical notes, did not have ongoing pain assessments documented. Ensure that all residents reporting pain have a pain assessment documented. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) One hospital resident admitted in January did not have a long-term care plan completed till the day of audit. ii) In five of six files reviewed (three rest home and two hospital-including one resident admitted under the long term chronic and one resident admitted under a young person with disability), the care plan interventions did not fully guide staff in the management of: risk of aspiration; management of seizures; care requirements for quadriplegia; suprapubic catheter; indwelling cath… (this text has been trimmed due to space limits).i) Ensure that all residents have a long-term care plan documented. ii) Ensure care plan interventions are documented for all assessed care needs and documented in sufficient detail to guide the care staff. iii) Ensure that all equipment in use is documented in the care plan PA ModerateIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.Not all required maintenance had been completed or scheduled on the day of audit. Ensure that all reactive maintenance is completed. PA LowIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Four of four activity care plans due for review (two rest home and two hospital- including the tracer) did not have the activity care plan reviewed at the same time as the review of the long-term care plan and the activity plan was not reviewed against the identified resident goals. Ensure that the activity care plans is reviewed at the same time as the review of the long-term care plan and reviewed against the identified resident goals. PA LowIn Progress

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.

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