Te Whanau Rest Home & Hospital
Profile & contact details
|Premises name||Te Whanau Rest Home & Hospital|
|Address||603 Queen Street East Levin 5510|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Bupa Care Services NZ Limited - Te Whanau Rest Home & Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||05 September 2020|
|Certification period||36 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: 12 July 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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).||The two resident files sampled for residents with enablers did not consistently have monitoring documented in the progress notes.||Ensure Bupa policies are implemented around documenting monitoring of residents with enablers.||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Not all care plans reviewed included interventions to address all resident needs or had not been updated to reflect interventions currently being implemented. (i) One hospital file reviewed did not document management of constipation, or pain management; (ii) One hospital ACC resident file reviewed had not been updated to reflect changes to continence (no longer has a catheter), and the need for use of lap belt restraint when in specialist wheelchair. For the same resident, with a current unst… (this text has been trimmed due to space limits).||Ensure care plans are updated as resident need changes.||PA Low||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Despite recurring issues all facility meetings except restraint have only occurred three-monthly. Staff report not feeling well informed. The service has remained consistently above benchmarks in several areas through late 2016 and 2017 YTD. Corrective action plans, focussing on individual residents have not been reviewed and updated despite being ineffective.||Ensure meetings are held at a frequency to ensure that issues are promptly addressed and that staff are well informed. Where quality data is evaluated and corrective actions initiated; ensure these are reviewed for effectiveness and amended where needed.||PA Low||In Progress|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||(i) During a tour of the facility a resident who is not assessed for an enabler had bed rails up on the bed. (ii) One resident with a lap belt on a wheelchair had not had this identified as a restraint. (iii) One resident who is not competent to consent to an enabler has a bed rail documented and managed as an enabler, not a restraint.||Ensure that restraints are only used when the resident has been assessed and the restraint approved. Ensure that bed rails on beds are not raised when the resident is not approved for a restraint or enabler.||PA Moderate||Reporting Complete||19/10/2017|
|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.||Four medication charts and signing sheets reviewed of residents prescribed a dietary supplement, evidenced gaps in electronic medication signing sheets where the supplement had not been administered as prescribed.||Ensure dietary supplements are documented as administered as prescribed.||PA Low||Reporting Complete||19/10/2017|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||(i) The ‘rest home’ (which includes eight hospital level residents) as evidenced by staff interviews and review of the roster does not always include sufficient staff to support the needs of residents. (ii) When illness or leave create gaps in the roster, staff are frequently not replaced. (iii) When acuity increases there is no evidence of an increase in staffing. This was particularly evident during the recent protracted outbreak. (iv) During the recent outbreak, when the rest home (whi… (this text has been trimmed due to space limits).||Ensure there is sufficient staff with a correct skill mix to meet resident’s needs at all times.||PA Low||Reporting Complete||19/10/2017|
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: 12 July 2017
Audit type:Certification Audit
- Te Whanau Rest Home & Hospital - Jul 2017 (docx, 46.79 KB)
- Te Whanau Rest Home & Hospital - Jul 2017 (pdf, 182.95 KB)
Audit type:Surveillance Audit
- Te Whanau Rest Home & Hospital - Sep 2015 (docx, 34.09 KB)
- Te Whanau Rest Home & Hospital - Sep 2015 (pdf, 136.32 KB)
Audit type:Certification Audit
- Te Whanau Rest Home & Hospital - Jul 2013 (docx, 208.26 KB)
- Te Whanau Rest Home & Hospital - Jul 2013 (pdf, 607.31 KB)
Audit type:Surveillance Audit